LOG BOOK

Medical surgical nursing department

Index
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1 Title page 1
2 Index 2
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What is a logbook?

Log book is a day record of the clinical and academic work done by the trainee.

Instruction for filling log book:

1. Entries must commence from the start i.e. DAY ONE of the training
program.
2. Trainees are advised to make the required entries on the day of the event and
get it signed by the supervisor.
For validating the entries in logbooks, a "consultant" is an individual who
has observed / supervised the procedure documented by the trainee.
3. It is the responsibility of the trainee to get the logbook signed by the
approved supervisor as soon as the entries on one page are completed.

Level of competency

i. Level one assistant status.

ii. Level two need direct supervisor.
iii. Level three need indirect supervision.
iv. Level four competent, UN supervised.
Objectives

At the end of semester, the student would acquire the following skills.
1. Ability to take full medical history and assess patient's vital signs.
2. Acquisition of the skills that enable students to perform nursing care
plan.
3. Identify patient problems physical, psychological, and social.
4. Plan for integrated and holistic patient's care in general medical words.
5. Implement nursing care according to identified and constructed plan.
6. Use methods of self-learning to promote abilities and building self-
competence capacity.
Introduction of the course/ course description:-
Nursing administration course is designed to provide the student nurse with the
theoretical knowledge and practical skills focusing on application nursing
administration components using the leadership process. It is consists of theoretical
part in addition to clinical rotation which designed to prepare graduate nurses with
knowledge and skills to be competent in improve nursing services, communication,
comprehensive nursing management to maintain staff development, management
of nursing staff problems in hospitals board as well as using nursing assignment to
improve quality of patients care and plan to achieve the organization goal.
The theoretical education started four weeks earlier before the clinical
training in order to give chance for the students to equip the different scientific
aspects bases up on which clinical training is based. Different items of
administration used in the nursing services and other department also precede this.
The students are evaluated through oral, written, and practical examination
by using observation checklist and the active discussion participation.
Method of evaluation
1. Observe the students' performance using chick list.
2. Nursing administration sheet.
3. Nursing records.
4. Attendance.
5. Uniform.
6. Interpersonal communication with staff and other students.
7. Preparation and presentation of conferences.
8. Counseling and application of administration components.
9. Practical exam.
 Comprehensive history
Demographic data
Patient's name:-………………………………………………………………………
Age :-…………………….……………………………………………....
Gender :-…………………………………..…………………………………
Occupation :-…………………………………………………..…………………
Resident :-………………………………………………………………..……
Marital status :-……………………………………………………………………...
Race :-…………………………………………………………………….
Religion :-…………………………………………………………………….
Date of admission:-…………………………………………………………………..
Source of referral:-…………………………………………………………………...
Source of history:-…………………………………………………………………...
Ward :-……………………………………………………………………..

Chief complaint:
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………

Present illness
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
o Past history
 Childhood illnesses:
Measles Rubella Rheumatic fever
Mumps polio Whooping cough
Chickenpox Scarlet fever
 Adult illnesses:
Diabetes Hypertension Asthma
Stroke Kidney disease Tuberculosis
Arthritis Anemia Allergy
o Hospitalization
………………………………………………………………………………………
………………………………………………………………………………………
o Operations:
………………………………………………………………………………………
………………………………………………………………………………………
o Accident and injures
………………………………………………………………………………………
………………………………………………………………………………………

o Blood transfusion
………………………………………………………………………………………
………………………………………………………………………………………

o Long-term medication
………………………………………………………………………………………
………………………………………………………………………………………
o Allergies list if any
…………………………………………………………………………………………….
o Current medication
………………………………………………………………………………………
………………………………………………………………………………………
 Allergies list if any
 …………………………………………………………………………………………….
o Family history
Diabetes Hypertension Heart diseases
Asthma Kidney diseases Hypercholesterolemia
Epilepsy Cancer mental illness
The age and heath or age and cause of death, of each immediate family member:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Psychological history:
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Home situation:
………………………………………………………………………………………
………………………………………………………………………………………
Environmental hazard:
………………………………………………………………………………………
………………………………………………………………………………………
Use of safety measures:
………………………………………………………………………………………
………………………………………………………………………………………
Life style:
Diet
Usual daily intake:
………………………………………………………………………………………
………………………………………………………………………………………
Dietary restriction or supplements:
………………………………………………………………………………………
………………………………………………………………………………………
Sleep patterns:
………………………………………………………………………………………
………………………………………………………………………………………
 Exercise and leisure activities:
………………………………………………………………………………………
………………………………………………………………………………………
Personal habits:
Tobacco:
1. Cigarettes Amount…………Duration………………
2. Chewing tobacco or snuff Amount…………Duration………………
3. Alcohol, drugs, and Related Amount…………Duration………………
Amount…………Duration………………
Amount…………Duration………………
Screening test:
…………………………………………………………………………….
Immunizations:
Tetanus pertussis diphtheria hepatitis B

Polio Rubella measles pneumococcal

Homophiles influenza

Systemic review:
General

Usual weight recent Wight change weakness

Fatigue fever

Skin

Rashes lumps sores

Color changes changes in hair changes in nails

Itching dryness
Head:
Headache head injury

Eyes:
Vision glasses contact lenses pain
redness excessive tearing spots glaucoma
cataract flashing lights duple vision specks
Blurred vision

Last eyes examination……………………………………………………………….

Ears:
Hearing Tinnitus Earaches

Infection hearing aid discharge

Nose and Sinuses:

Frequent cold Nasal stuffiness itching

Nose bleeds sinus trouble

Mouth and throat:

Condition of teeth bleeding gums
Frequent sore throat sore tongue
Dry mouth
Last dental examination…………………………………………………
Neck:
Lumps pain discomfort

Breast self-examination nipple discharge

Respiratory system:
Cough asthma bronchitis hemoptysis

Pleurisy pneumonia wheezing Emphysema

Last chest X-ray………………………………………………..tuberculosis

Sputum (color and quantity)………………………………………………………

Cardiac:
Tachycardia high blood pressure chest pain

Palpitation Rheumatic fever orthopnea

Edema heart murmurs

Paroxysmal nocturnal dyspnea

Past electrocardiogram or other test result

………………………………………………………………………………………
………………………………………………………………………………………

Gastrointestinal tract:
Nausea Vomiting

Heartburn Appetite

Vomiting of blood Regurgitation

Troubling swallowing Color and size of stool

Hemorrhoid Constipation

Abdominal pain Jaundice

Hepatitis Frequency of bowel movement

Rectal bleeding or black tarry stool Change in bowel habits

Diarrhea Excessive belching or passing of gas

Food intolerance Liver or gallbladder trouble

Urinary system:
Frequency of urination

Nocturia Hesitancy

Incontinence Urinary infection

Polyuria Hematuria

Dysuria Stones

Genital system:
Swelling Pain Redness

Tenderness Stiffness Weakness

Limitation of motion or activity

Neurological:
Fainting Weakness Blackout

Paralysis Seizure

Tingling or pain and needles movements

Tremors or other involuntary movements

Numbness or loss of sensation

Hematology:
Past transfusion and any reaction to them

………………………………………………………………………………………
………………………………………………………………………………………

Easy bruising or bleeding

Anemia

Endocrine:
Thyroid trouble Excessive sweeting

Excessive thirst or hunger Heat or cold intolerance

Diabetes Polyuria

Psychiatric:
Nervousness Tension

Mood including Depression

Memory loss Aggressive behavior

 Investigation sheet

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

investigation Result comments Time and date Signature

 Medical sheet

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Drug name Route Dose Start at Discontinue at Time and Signature

date
Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Intake output Time Signature

oral parenteral Urine Others

Total intake= Total output=

Comment:

………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
 Nursing note

Patient's name…………………………………..………… Age……………..

Diagnosis………………………………………………………………………

Nursing diagnosis Nursing goal Nursing intervention Nursing evaluation

Good luck