Clinical log

Day, Date & time

Practicum

Hours

Cumulative

hours

Provide brief demographic information, diagnosis and status of client/patient

Clinical practice activities carried out and achieved objective (s) of the week.

Monday 26/04/2021 (1500H– 1900H)

4 hours

36 hours

Name : Mrs Y

Age : 63 years old

Gender : Female

Nationality : Malaysian

Race : Chinese

Religion : Christian

Occupation : Tailor

Marital status : Married

Diagnosis : Breast carcinoma

1.Collect subjective data by interviewing Mrs Y regarding:

· Demographic data

· Reason for seeking treatment

· Family history

· Present illness history

· Past health history

· Holistic aspects including cultural, spiritual, physical, psychosocial

· Review of systems

· Activities of living before and after becoming ill-using Roper, Logan, and Tierney’s model of nursing.

2. Collect objective data by doing focus assessment of the breast by using inspection, palpation, and full physical assessment on Mrs Y.

3.Identify normal and abnormal findings from the objective findings and the document data.

4.Formulate an accurate diagnosis of nursing according to the objective findings and subjective data upon assessment completion. (Toney-Butler, 2020).

5.Provide and discuss the objective data findings to the medical officer in charge for further analysis and management.

6.Able to demonstrate adherence to the responsibilities of professional practice within the ethical and legal framework of nursing and maintain confidentiality of patient’s information.

7.Acknowledged the necessity of working and collaborating as a cooperative group member with the rest of the healthcare workers throughout assessment.

Tuesday

27/04/2021

(1500H – 1900H)

4 hours

40 hours

Name : Mr C

Age : 40 years old

Gender : Male

Nationality : Malaysian

Race : Chinese

Religion : Christian

Occupation : Restaurant owner

Marital status : Married

Diagnosis : Acute cholecystitis

1.Collect subjective data by interviewing Mr C regarding:

· Demographic data

· Reason for seeking treatment

· Family history

· Present illness history

· Past health history

· Holistic aspects including cultural, spiritual, physical, psychosocial

· Review of systems

· Activities of living before and after becoming ill-using Roper, Logan, and Tierney’s model of nursing.

2. Obtain the objective information by performing focus assessment of the abdomen by using inspection, auscultation, percussion, palpation, and full physical assessment on Mr C.

3.Recognize normal and abnormal findings from the document and objective data accordingly.

4.Formulation of an accurate nursing diagnosis according to the subjective data and objective finding.

5.Provide and discuss the objective data findings to the medical officer in charge for further analysis and management.

6.Able to demonstrate adherence to the responsibilities of professional practice within the ethical and legal framework of nursing and maintain confidentiality of patient’s information.

7.Acknowledged the necessity of working and collaborating as a cooperative group member with the rest of the healthcare workers throughout assessment.

Wednesday

28/04/2021 (1500H – 1900H)

4 hours

44 hours

Name : Mrs K

Age : 52 years old

Gender : Female

Nationality : Malaysian

Race : Malay

Religion : Islam

Occupation : Florist

Marital status : Married

Diagnosis : Haemorrhoid

1.Collect subjective data by interviewing Mrs K regarding:

· Demographic data

· Reason for seeking treatment

· Family history

· Present illness history

· Past health history

· Holistic aspects including cultural, spiritual, physical, psychosocial

· Review of systems

· Activities of living before and after becoming ill-using Roper, Logan, and Tierney’s model of nursing.

2.Obtain the objective data by performing focus assessment of anus and rectum by using inspection, palpation, and physical examination from head to toe on Mrs K.

3. Recognize the normal and abnormal findings through objective data and subjective data.

4.Formulate nursing diagnosis that is accurate according to the objective findings and subjective data (Nost, Andre,2015).

5. Discuss and provide the objective data findings to the medical officer in charge for further analysis and management.

6.Able to demonstrate adherence to the responsibilities of professional practice within the ethical and legal framework of nursing and maintain confidentiality of patient’s information.

7.Acknowledged the necessity of working and collaborating as a cooperative group member with the rest of the healthcare workers throughout assessment

Friday

30/04/2021 (1500H – 1900H)

4 hours

48 hours

Name : Miss F

Age : 23 years old

Gender : Female

Nationality : Malaysian

Race : Indian

Religion : Hindu

Occupation : Salesperson

Marital status : Single

Diagnosis : Axillary abscess

1.Collect subjective data by interviewing Miss F regarding:

· Demographic data

· Reason for seeking treatment

· Family history

· Present illness history

· Past health history

· Holistic aspects including cultural, spiritual, physical, psychosocial

· Review of systems

· Activities of living before and after becoming ill-using Roper, Logan, and Tierney’s model of nursing.

2.Obtain the objective information by performing focus assessment of the axilla by using inspection, palpation, and complete physical examination on Miss F.

3.Recognize normal and abnormal findings from the document and objective data accordingly.

4.Make an accurate nursing diagnosis according to the subjective data and objective findings.

5.Provide the objective data findings to the medical officer in charge for further investigation and management

6.Able to demonstrate adherence to the responsibilities of professional practice within the ethical and legal framework of nursing and maintain confidentiality of patient’s information.

7.Acknowledged the necessity of working and collaborating as a cooperative group member with the rest of the healthcare workers throughout assessment.

Mrs. Y is working as a home-based tailor, and she gets paid as per order basis. She lives with her husband and children in a terrace home at Penang. Patient’s highest level of education is

primary school level, till standard six. She is a non-smoker, but patient consumed alcohol, beer

during her younger days. She consumed beer for around 20 years occasionally during social

gatherings. However, patient stopped drinking alcohol at the age of 40 after being advised by

doctor.

Pati Patient is a Christian and she prays regularly, and never fails to visit church on Sundays. She believes love has healing power and it has the potential to change our life and perspective. She hopes that her love towards god gives her the strength to go through all challenges in life.

Maintain a safe environment :

Mrs Y can walk and move by herself without assistance, has short sightedness and using glasses on

a regular basis. She can hear well and able to maintain surrounding safety well by herself.

Communication :

Mrs Y is trilingual, she converses fluent Mandarin, English, and Malay. She has good mental capacity, hearing, and speech ability, and not using any communication aids.

Breathing :

She has clear airway, non-smoker, and has no pain on breathing. Mrs Y inhales and exhales regularly

by her own and she does not use oxygen aids.

Eating and drinking :

Patient has drastic, unintentional loss of weight of 6 kilogram over 3 months duration. She however

has good appetite, able to chew and swallow food, and drink liquid by herself without help.

Patient has adequate nutrition and hydration.

Elimination :

Patient has no issues passing urine and she passes stool once a day normally.

Washing and dressing :

Mrs Y looks appropriately dressed, her clothes, nails and appearance look clean and tidy. Patient able

to get herself groomed and cleaned up by herself daily. She normally showers twice a day.

Controlling temperature :

She can maintain a normal body temperature and there was no hypothermia or hyperthermia.

Mobilization :

Patient has stable and normal gait. She does not need usage of walking aids, and can move and handle

things well.

Working and playing :

Patient is working full time as a tailor and she leads a sedentary lifestyle. She does not do any form of

sports. Her hobby is watching television.

Expressing Sexuality :

Patient is married and her husband is her only sexual partner. She has no issues with her normal

sexual functioning.

Sleeping :

Mrs Y has a normal sleeping pattern and sleeps 6 hours in the night and takes afternoon nap of one

hour. She does not take any medications or activities to promote sleep.

Death and dying :

Mrs Y believes that death is a part of life’s natural cycle and it is all predetermined. Patient have not

write down her will yet, however she said her next of kin would be her two children.

E. History of present illness (e.g. OLDCARTS

or PQRSTU )

F. Past medical and surgical history

Onset : Patient noted a sudden onset of lump at right breast

about 3 months ago.

Location : The lump was located at the upper outer quadrant

of the right breast.

Duration : The swelling was initially the size of 20 cents

coin and over 3 months increased to size of a tennis ball.

Character : Patient felt the lump was hard in consistency but

painless.

Associated factor : The swelling was associated with 3

episodes of blood nipple discharge for past one week duration.

She also had unintentional loss of weight of 6kg in 3 months,

which was noticed by patient’s children.

Radiation : The lump was localised at upper outer quadrant

of right breast, and no other lumps noted anywhere else on

breast.

Timing : The episode of nipple discharge was intermittent in

nature, as patient noticed blood on her clothes with a 2 day

interval.

Severity : She said the severity score of her symptoms was

currently 8/10, as patient has become more anxious after the

three episodes of blood nipple discharge. Her loss of weight

being noticed by her friends and family has also limited her

social interaction with them, as she wants to avoid their

questions.

· Mrs Y was diagnosed with hypertension and

diabetes mellitus at 43 years old during an

annual medical screening.

· She has one history of hospital admission,

due to hypertensive urgency at 46 years old, in

Island Hospital for 3 days.

· She delivered both her children via lower

segment caesarean section at 32 and 36 years

old, with indication of macrocosmic baby.

G. Pertinent family history

(genogram if possible)

H. Allergies, immunisation and medication

Maternal Paternal

Grandfather Grandmother Grandfather Grandmother

Old age Old age Old age Old age

(Unknown) (Unknown) (Unknown) (Unknown)

Mother Father

79 years old 61 years old

Breast Ca CKD,HPT

65 years old 41 years old Mrs. Y 65 years old

Breast Ca MVA Breast Ca

Son Daughter

31 years old 27 years old

Allergies : Seafood cause itchiness all over the body.

Immunization : Patient was vaccinated according to Malaysian vaccination schedule. However, she did not

take the HPV vaccine.

Medication : So far, no medication allergies.

Current medication : Mrs Y is currently taking

Tablet Amlodipine 10mg OD for her hypertension and

Tablet Metformin 500mg BD for her diabetes mellitus.

I. General survey

J. Vital signs and measurement

(+nutritional status)

Physical appearance : Mrs Y looks alert, conscious, and

orientated to time place and person. She is an elderly woman developed suitable for her age and gender. Patient is dressed

well and clean, with neat appearance. Patient’s facial is

symmetry and proportional to her body shape. Patient has

pale skin. No obvious wound, laceration, skin disorder,

bruises and swelling seen.

Behaviour : Mrs Y has a friendly nature and was easy to talk

with. She answered all questions and was cooperative during assessment. Patient talks very politely. Though her mood was

low, but she conversed well with understandable speech.

Body structure : Patient looks underweight but no visible

physical deformities seen such as mumps, scoliosis and

kyphosis. All her body parts are intact, and she maintained

stable, and good posture throughout assessment.

Mobility : Mrs Y can move by her own, and her gait was

steady with a slow pace no involuntary movement are seen.

Patient looks pain free while walking, sitting, and standing in

erect posture. Patient moved her upper and lower limbs

equally with normal power.

Temperature : 36.5’C

Pulse : 66 bpm, regular rhythm, good volume

Respiration rate : 15 breaths/min

Blood pressure : 121/78 mmHg

SPO2 : 98 %

Pain score : 0/10 (NRS)

Weight : 44 kg

Height : 155 cm

Body mass index : 18.3 kg/m2 ( underweight BMI)

Nutritional status :

Mrs. Y is underweight according to her BMI. Patient

appears pale, which might signify micronutrient

deficiency. Though she complained of weight loss,

she has no signs of wasting and cachexia, no

macronutrient deficiency. According to her dietary

history, she consumes all classes of food

that means she has a balanced diet.

Full blood count (FBC)

Hemoglobin: 9.9 g/dL (LOW)

WBC: 5.8 K/uL (normal)

Neutrophil: 50 % (normal)

Impression: Low haemoglobin level signifies

patient is anaemic.

Renal function test

Urea: 8.2 mmol/L (HIGH)

Na: 132 mmol/L (LOW)

Impression: Patient has hyponatremia which

can be due to her weight loss. She has raised

level of urea which may be due to dehydration

Ultrasound of right breast

Oval shaped poorly defined lesion seen

measuring 3.1x2.8x2.6 cm. Solid component,

no vascular invasion, no lymph nodes

enlargement.

TRU CUT BIOPSY

Invasive ductal carcinoma of right breast

General: She has weight loss of 6kg, but no fatigue, body weakness, malaise, pain, no episode of

fever, has normal activity.

Head and neck: She have no headache, dizziness, seizure, neck stiffness, no thyroid issues.

Vision: She has short sightedness and wearing glasses. There is no cataract, glaucoma, redness,

burning, and discharge of eyes.

Ear: She have no hearing issues, ear pain, discharge. She has never undergone any hearing

assessment before.

Nose and sinus: She has good ability of smell. There is no running nose, no colds, nose blockage,

voice change and epistaxis.

Mouth and throat: No history of mouth or throat cancer, bleeding and swollen gums. Never done

dental assessment before

Cardiovascular: No chest pain, palpitations, did ECG last year and results were normal.

Respiratory: No wheezing, sputum production, cough, no TB contact.

GIT: No loss of appetite, nausea, constipation, diarrhoea, change in stool colour.

Genitourinary: No pain and change in urination, nocturia, incontinence, urgency

Hematology: No bleeding disorders, regular blood transfusions, easy bruising

Neurological: No tremor, loss of sensation and coordination, numbness, and no stroke or brain injury

Endocrine: No polydipsia, polyuria, no changes in body hair and body fat distribution

Musculoskeletal: No deformity, change in strength, history of muscle injury

Peripheral vascular: Mrs Y has no peripheral oedema, claudication, ulcer, and peripheral vascular

disease.

Skin & hair: No history of skin, hair, and nail disease. There is no itching, pigmentation change,

no thick or yellow nails, and no hair loss.

O&G: Attained menopause 15 years ago, no uterine or ovarian cancer. Had 2 pregnancies and 2

children. Never done pap smear before.

Anus and rectum: No history of haemorrhoids, and rectal cancer.

Mental health: Has no history of having psychiatric illness and no psychiatric symptoms.

Breast examination

Inspection:

I asked patient to sit on bed with arms at her side, then hands clasped overhead and tensed, then I asked her

to put hands on hips and then lean forward.

Breast

Left and right breasts are same size, pendular shape, and symmetrical. The colour of left and right

breast was normal, and visible lump was seen in the upper outer quadrant of right breast, with no overlying

skin lesion, no oedema, dilated veins, dimpling, no orange peel skin, surgical scars, retraction, and bruises.

Nipple and areola

The left and right nipple looks pink, symmetrical both nipple in same direction, no retraction, inversion,

no nipple lump noted, no supernumerary nipples. There is presence of bloody nipple discharge of right

breast.

Axilla

Right and left axilla looks normal colour, no lesions, equal hair distribution.

Palpation:

I asked patient to lie in supine position and I first examined the non-affected left breast. I did light, medium,

and deep palpation in a circular motion. I palpate the breast in overlapping vertical strips and continue until

covered the entire breast including the axillary. I palpated around areola by pressing nipple gently between

thumb and index finger. I then lowered patient’s arm and palpate for axillary lymph nodes.

Breasts

Left breast has normal texture, soft consistency, no tenderness, and no mass were palpated. The right breast

has a normal texture, firm consistency, non-tender, and mass was palpated in the upper outer quadrant of

right breast. Mass is oval shape, 3x3cm, asymmetrical surface, hard consistency, irregular border, non-tender

and immobile.

Nipple and areola

The left nipple and areola have normal elasticity, no tenderness, and no discharge. The right nipple has

reduced elasticity, non-tender and has bloody nipple discharge.

Lymph nodes

I examined the lymph nodes assessing their size, shape, symmetry, consistency, mobility, borders, and

tenderness. The anterior cervical, supraclavicular, infraclavicular, axillary, and epitrochlear lymph nodes are

not palpable.

· Reflection–on-action and clinical learning:

a) Describe 2 ways your nursing health assessment skills expanded during this experience

· I am more well versed now to perform breast examination on patients as I have the skills and experience. Moreover, by practicing this assessment I able to plan a proper nursing care for my patient.

· I have improved my communication skills, since now I can enquire deeper personal details of patient in a proper way.

b) Name 2 things you might do differently if you encounter this kind of situation again

· I will advise female patients to do regular breast examination by themselves at home, and if they discovered a lump, I would ask them to get it checked by a doctor immediately so that we can intervene at an early stage to prevent widespread of disease.

· I will ask patient’s female family members such as her niece and cousins to get screened, as this breast cancer is a genetic disease running in her family.

c) What additional knowledge, information and skills do you need when encountering this kind of situation or similar situation in the future?

· I should learn about different examination techniques, positions, and ways to check patients of different ages, body habitus, and body types. I must know about the differential diagnosis of breast swelling to correctly diagnose patient.

d) Describe any changes in your values or feelings as a result of this experience.

· I learnt about the importance of always keeping our health in check, anyone is predisposed to all kinds of diseases, hence I realized that we must always check our body, pay attention to it, and try to keep ourself healthy by doing regular checkups.