Critical Care Nursing (2) For Course Coordinator Use

Only
1st semester 2008/2009
Report Number: 24
Daily Clinical Report 24
Submitted on:
Student's Name: Rana Mosa Elayyan Overdue day: Yes No

Day and Date of practice day: Wednesday 24/12/08

Name of Clinical Area: 1st SICU

Case Report (how received, what has been done and the plan of care that should be followed up in the next shift or day)
I was assigned on the same patient in previous clinical report. Patient was received conscious,
oriented, on ensure N.G feeding 40 cc / hour, hypotensive B.P 89/49 mm/hg.

Enteral feeding was hold due to increase amount of residual volume more than 250cc at any time and
complains of anorexia & vomiting.

Patient started on TPN. Intra lipid 20% 250cc & Amino acid 10% 60cc/24 hrs on I.V. fluid dextrose
10% 1500cc. Abdominal X-ray showed slightly distended edematous small bowel without obstruction.

Upper G.I. endoscopy revealed edema dilatation in small bowel, multiple biopsies was done, waiting
for results.

For the next shift, the nurse should encourage pt. with positive interaction with significant others,
calculate total intake & output and provide sterile technique during TPN administration.

Learning activities of any type

 Provide sterile technique during TPN administration.
 Calculate intake & output in the last 24 hrs.
 Review total caloric intake.
 Provide psychological support & coping mechanism to the pt.
 Provide health education about therapeutic management to the pt.
 Care for pt. with iliostomy bag.
 Learn about mechanical ventilator.
 Learn about E.C.G.

______________________________________________________________________________________________________

Comments and reflective remarks

The patient need more support from care providers.

Student's signature: Rana Mosa Elayyan

Only this form is accepted, so make sure you make enough copies of it!