Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬

Faculty of Nursing ‫كلية التمريض‬

Master Nursing Program
‫برنامج ماجستير التمريض‬

Advanced Adult Nursing Course (1)

Weekly Clinical log

Student’s Name: Alaa saad

Week/Date: / /

Name of Clinical Area: ER-Arab medical center

Objectives for the week:

Bone fracture

To deal with patient has bone fracture in ER

To do physical assessment to the patient that has Bone fracture
To observe and identify the treatment that initiating in ER
To identify the blood test required and what the abnormal finding
To identify the image that will be requested and what the abnormal finding
To identify special procedure that will be performed
To identify the ER nurses role in Bone fracture

Learning activities for the clinical day
(planned or unplanned):
I Discussed with ER doctor about the tibia
fracture (sign, special physical examination and
the abnormal finding)
And we compare it to the case that we are
working with it in ER
I observed the triaging process in the ER
I work with the patient that she has tibia fracture
from the time he arrived to ER till she admitted
in oncology ward
I identify the treatment plan and the guideline.
Evaluation of outcome and the whole
clinical day, including reflecting
remarks and/or comments, and
recommendations:
The clinical day was good:
I work with patient has tibia fracture from
arrival to ER till admission to medical
surgical ward including the triaging and
the nursing care , I got information about
the reason for all blood lab test ,images
that requested to the patient.
From my discussion with the ER doctor I
get a lot of information regarding the
tibia fracture

I identify the blood test required and what the The team was cooperative
abnormal finding
Good knowledge and practice had
I identify the image that requested and what the obtained.
abnormal finding.

1
Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬
Master Nursing Program
‫برنامج ماجستير التمريض‬

I recommend that the ER nurses should

I identify the medication used in this case have education about the fracture types
and how to deal with it.
I identify if and special procedure should be
performed

Emergency case

Dx: tibia fracture

Past medical history: free medical and surgical history.

Present illness: A 24 years old male presents to the emergency room post trauma
on his left leg, while playing football, complaining of left leg pain, swelling, fatigue,
tenderness and bruising in your left leg. Inability to bear weight on left leg, Inability
to move the hip and knee on the left leg

Systematic physical exam:

Systematic physical exam:

Vital sign : HR: 88b/m, temp 37.1 C° orally, RR 19 b/min, BP 110/70 mmhg

Position: he lies on the bed supine (this position was comfortable with the patient)

Physical appearance: The patient appears to his stated age, weakness, fatigue, in
pain can’t walk

skin color pink, warm, intact with no lesions. Appropriate hair distribution.

Nails: smooth, regular, pink color.

Head: No any kind of headache, dizziness no head trauma.

2
Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬
Master Nursing Program
‫برنامج ماجستير التمريض‬

Eyes: symmetric, no redness, swelling or discharge, no eye pain.

Ear: hearing acuity was adequate, no scare or trauma, the patient not using hearing
aid instrument.

Nose: The patient has a good sense of smell, no trauma or scare, no abnormality was
detected.

Mouth and throat: no sore throat or lesion, no gum bleeding, the patient hasn’t
denture, no tongue lesion or mouth ulcer.

Neck: No lumps, no neck pain or stiffness, no limitation of movement, no lymph

node enlargement or swollen.
.
Respiratory: the patient can breathe easy, nothing obstructing the air way, the chest
expansion symmetric bilaterally. Furthermore, no tenderness, no lumps, no lesions,
or masses through palpation. Resonant sound over the lung fields.

Cardiovascular: no chest pain, no dyspnea, no cyanosis or pallor, no edema no past

cardiac history. No history of murmur.S1, S2 heard.no defect was assessed.

Abdomen: flat, soft, high pitch normal bowel sound presented about 20
times/minute in RLQ. No bruits, no vascular sound or a friction rub heard over the
four quadrants.
General abdominal wall is tympanic sound predominates in all four quadrants. The
liver span is10 cm in the right mid clavicle line. The splenic dullness is 6 cm located
at 10th intercostal space in left maxillary line. No tenderness and the test for fluid
wave negative.

Peripheral vascular: right leg pain, swilling on right legs, no swelling in arms, no
lymph node enlargement. No varicose veins or DVT, the patient has pain, numbness,
warmness in left leg, no history of Phlebitis or ulceration,

Musculoskeletal: No history of gout or arthritis in the joints. The patient has pain
(verbal numerical pain scale 7/10), stiffness, and swelling, left leg tibia fracture.
he has general weakness, fatigue.

Neurology: The patient has free history from any neurological disease
But he has right leg pain, She is conscious GCS 15/15, oriented *3 (time, person,
place), The patient has no history of seizure, he has normal cognitive function
without any memory disorder. No paralysis. In sensory function, also, there is no
history of mental status disability, no mode changing or depression or hallucinations

Diagnostic procedures and studies:

3
Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬
Master Nursing Program
‫برنامج ماجستير التمريض‬

CBC: ( to assess any sign of anemia, bleeding or infection )

Result: Hb: 14.5 g/dl , WBCs: 13*10^3 /UL ( leukocytosis) , Plt: 330*10^3 /UL

Blood chemistry and kidney function: (to check if there is any electrolyte
imbalance or disturbed in kidney function )
Result: urea: 21 mg/dL, creatinine: 0.9mg/dL, Na: 138 mmol/L, K: 3.7 mmol/L,
Ca: 9.3 mg/dL

Pelvic and left leg x ray: (to check if there is pelvic or fracture in his left leg bones),
Result: so the finding was left tibia fracture stable fracture

Interventions

1. keep the patient bed rest

2. monitoring vital signs
3. physical assessment
4. Splint the left leg
5. Peripheral line gage 18 inserted.
6. The requested blood sample sent to the lab
7. Tramal 100 mg IV given to decrease the pain and continues assessment for
the pain.
8. IV fluids are given to maintain a normal blood pressure and to hydrate the
patient, Normal saline 0.9, (500 ml) was given
9. The requested image (X rays ) done
10. antibiotics Cefazolin 500 mg IV given in order to prevent severe infection
in the bone.
11. Complete cast (from the left feet up to above the knee) was applied on by
orthopedic doctor
12. Decrease the patient and his family stress and anxiety
13. The treatment plan and the follow up visit date was explained to the patient
14. Instruction and health education was given to the patient and instruction to
not walk on his left leg and to keep it elevated, and in case any cyanosed or
decrease sensation or any complication to come back to ER immediately
15. Full documentation was recorded.
16. The patient discharged to home with follow up appointment and on
antibiotic and pain reliever.

Student’s signature:……………. HN/CN signature: ……….

4
Al-Zaytoonah University of Jordan ‫جـامعـة الـزيتـونــــة األردنيــة‬
Faculty of Nursing ‫كلية التمريض‬
Master Nursing Program
‫برنامج ماجستير التمريض‬

Course coordinator: …………………………….