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Clinical Journaling

One of my favorite quotes by Nightingale states; “to nurse is a field of which one may safely say: there is no end in what we may be learning every day” ( Nightingale, p. 11). A third Tuesday on the cardiac floor has come to an end. A day filled with remarkable new learning experiences focused on patient care, nursing diagnoses, clinical judgments, therapeutic, professional and direct communication that is so unique to the science of nursing.

The patient’s story & my experience this week: My patient was a 32 years old male, father of three with great psychosocial support at home but still very lonely and very sick. Seven years ago, I did not dear to ask the circumstances and I could not go on his Epic chart; he was bitten by a dog. Ever since then his life took a turn for the worse. He has been fighting particular bacteria that it will never be extinguished from his body completely. Currently he had three deep wounds, between 8cm and 14cm across, different locations on his body, with no hope for healing any time soon. This experience was a great learning opportunity for me to get exposed to the field of wound care. I looked more in depth about amyloidosis and it occurs when abnormal proteins called amyloids build up and form deposits either in the kidney, leading to kidney failure and heart, thickening the walls and causing heart failure. Symptoms can vary in patients but here it lead to kidney and heart failure. He was put on a transplant list but his health was deteriorating pretty fast. The goal now was to limit the production of proteins and somehow bring the patient’s body back to homeostasis. The day that I was there, my patient had no dialyses. He was under fluid restriction, 1500cc/24hrs, and his output was 450cc/9hrs under my care. Why would he still need dialyses? I think it was due to amyloids, lot of protein floating around and very dangerous to his kidney, and his hyperkalemia. Too much potassium destroys his heart that was already weak and failing.
Upon assessment he was dizzy, fatigue, activity intolerance, SOB with any activity, coughing(thick sputum and traces of blood) indicating pulmonary congestion. I heard pulmonary crackles, tachypnea of 24RR, pulse quality was bounding, heart sounds were normal but tachy, jugular veins were distended and I definitely heard dysrhythmias. Due to increased venous pressure his lower extremities had a edema of 3+. Supplemental oxygen was given to decrease the effects of hypoxia. He was on 2 liters and his Oxygenation sat. was 96-100%. Head of the bed was always elevated to promote respiratory function and reduce cardiac overload.
Overall he was very clear, nice to talk to and aware of his illness. Throughout my day I really tried to promote safety for my patient. I tried to reduce infection and promote skin integrity. I tried to check the homodynamic status, VS, every 4 hours, not to miss any signs of complication. I tried to talk to him about his pain and pain tolerance. We talked a lot about his psychosocial issues and what life means for him in general and his delicate conditions. To me he seemed a little depressed, but still happy to be around and see his children grow. He had great

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