81037602 laboratory and diagnostic exam

7/29/2019 81037602 Laboratory and Diagnostic Exam

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mfayLABORATORY TESTS RESULTS AND DIAGNOSTIC EXAMINATIONS

Gat Andres Bonifacio Memorial Medical CenterHematology ExaminationDate: November 02, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONHemoglobin 120-180gm/l114 gm/l Decrease in hemoglobinresults in blood loss fromthe cellular injury whichdisrupts blood flow fromentering the cells andtissues of the body thusdecrease in tissueperfusion from decreaseblood volume or reducedcirculating erythrocytes. Administer IV fluids asordered to improve tissueoxygenation. Prepare for Bloodtransfusion if massive bloodloss occurs to increaseblood volume. Monitor vital signs andpulse oximeter readingsclosely.

Assess for signs andsymptoms of hypovolemicshock. Promoting rest and comfortto decrease oxygendemand. Proper positioning toprevent any complication. Provide O2 therapy asordered to increase oxygenin the blood.Hematocrit 0.370-0.540 0.339 Due to acute massiveblood loss causingdisruption of blood fromentering the cells andtissues of the body.Segmenters 0.60-0.70 0.48 Decrease in segmentersis due to blood losscause by the response to Observe and report signsof infection.


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cellular injury. Assess temperature. Note and report laboratoryvalues (e.g., white bloodcell count and differential,serum protein, serumalbumin, and cultures). Encourage a balanced diet,emphasizing proteins tofeed the immune system. Encourage fluid intake andadequate rest to bolster theimmune system. Administer antibiotics, asordered.Lymphocytes 0.20-0.40 0.52 High lymphocytes countindicates the responseto cellular changes byrelease of chemicalmediators as aninflammatory response.Platelet count 150-450 x109/L332 x 109/L NORMAL Observe for any changes inany laboratory values. Monitor vital signs. Document findings.Blood type N/A Type A RhpositiveN/A N/A

Hematology ExaminationDate: November 02, 2011 (due at 2 pm)

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONHemoglobin 120-180gm/l89 gm/l Decrease inhaemoglobin results inblood loss from thecellular injury whichdisrupts blood flow fromentering the cells andtissues of the body. Administer IV fluids as

ordered to improve tissueoxygenation. Prepare for Bloodtransfusion if massive bloodloss occurs to increase


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blood volume. Monitor vital signs andpulse oximeter readingsclosely. Assess for signs andsymptoms of hypovolemicshock. Promoting rest and comfortto decrease oxygendemand. Proper positioning toprevent any complication. Provide O2 therapy asordered to increase oxygenin the blood.Hematocrit 0.370-0.540 0.250 Due to acute massiveblood loss causingdisruption of blood fromentering the cells andtissues of the body

ECGDate: November 03, 2011

DIAGNOSTICPROCEDUREFINDINGS ANALYSIS NURSINGINTERVENTIONECG A tall R wave (greater than 25mm in V5 or V6) or R plus Sgreater than 35 mm).A deep S in V1 or V2.Inverted T waves in V5 or V6and ST depression.Left axis deviation is present.

QRS is slightly prolonged.Left ventricularhypertrophy Providepositioning withthe head of bedthe elevated(Fowler'sposition). Give adequateoxygen supply. Monitor vitalsigns regularlyand beforemedications if


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indicated. Identify earlysigns orworsening signsof CHF, such asreduced oxygensaturations,pedal edema,heartirregularities,heart rate,increased workof breathing,rapid weightchanges, etc.and notify thephysician ifchanged frombaseline. Monitor intakeand output.

Plain Cervical CT-ScanDate: November 03, 2011

DIAGNOSTICPROCEDUREFINDINGS ANALYSIS NURSING INTERVENTIONPlain CervicalCT-Scan

Thickened nasopharynxlikely inflammatory innature.The thickenednasopharynx is probablydue to the inflammatoryprocess caused by thetrauma made to the Monitor vital signs. Cleanse the wound of thepatient. Assist in exploration of thewound of the patient to


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Collapsed right pyriformsinus.Engorged thyroid glandright neck. Theinflammatory processreaches to the adjacentareas to localized theinflammation.The right pyriformssinus collapsed is dueto the surgery done onthe right side of theneck causing collapse tothe right pyriform sinus.examine for foreign bodiesor injuries underneath theskin. Administer intravenousfluids, as ordered. Assist in laceration repairfor stabbed wound. Administer anti-inflammatory medicationsfor pain. Administer antibiotics toprevent infections.which may relate to edema. The edema of thethyroid gland is causedby too much forceoutside the capillariescausing it to leak intothe surrounding tissues.For Normal Findings: Observe for any changes inany laboratory values. Monitor vital signs. Document findings.Subcutaneous emphysemaleft side of the neck.This excess fluid causes

the tissues to swell. Inthis case, the force isthe trauma taken by thecapillaries in the zone 2on the left side of theneck.Parotid and submandibularSubcutaneousemphysema can resultfrom a puncture of apart of the respiratorysystem. Particularly inthe neck, air may


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glands are non remarkable.Soft tissue densities arenoted in both carotid canal,jugular, anterior andposterior triangle of theneck.The sternocleidomastoidmuscles are thickened andirregular.The proximal commoncarotid arteries until thethyroid are grossly normal.The bifurcation internal,external carotid and jugularveins are obscured byhematoma or collapsed /injured.become trapped as aresult of penetratingtrauma. trauma such asstabbed wound.NORMALSoft tissue density is dueto trapped air as a resultof injury to a part of theairway. Carotid, jugularand the posteriortriangle of the neck isaffected because it ispositioned in the zone 2of the neck.The sternoclaidomastoidmuscle is thickenedbecause of theinflammatory processcaused by trauma. Theirregular shape is causeby the tissue i

njury.NORMALDue to the tissue injury,blood vessels in thetissue are affected


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Doppler studies may be ofcausing it to leak outsidehelp for further evaluationthe blood vessels. Thisand the rest are non blood is usually collectedremarkable. in liquid form withinthetissue.NORMAL

Hematology ExaminationDate: November 08, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS FINDINGS NURSING INTERVENTIONHemoglobin 120-180gm/l80 Decrease in hemoglobinis a reflection of thepost-op blood loss afterthe surgery and ainflammatory responseto inflammation causedby the injury. Administer IV fluids asordered to improve tissueoxygenation.

Monitor vital signs andpulse oximeter readingsclosely. Promoting rest andcomfort to decrease oxygendemand. Proper positioning toprevent any complication. Provide O2 therapy asordered to increase oxygenin the blood. Provide nutritional supportto increase blood cells.Hematocrit 0.370-0.540 0.233 Decrease in hematocritis a reflection of thepost-op blood loss afterthe surgery and ainflammatory responseto inflammation causedby the injury.

Neck Ultrasound


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Date: November 23, 2011

DIAGNOSTICPROCEDUREFINDINGS ANALYSIS NURSING INTERVENTIONNeck Mass is cystic with itsRight neck mass is Monitor increased ICP dueUltrasound superficial wall more thick. Itmeasures 2.8x2.3x1.7cm. Itexhibits pulsations and isadjacent a vein (internaljugular?)caused by posttraumatic venousaneurysm as a result ofprior exploratorylaparotomy procedureon bilateral neck.to neck mass. Position patient on semifowlers. Instruct patient to avoidneck flexion,hyperextension androtation. Nurses should takemeasures to preventpatients from coughing,vomiting, shivering,tremoring, posturing, andstraining for bowelmovements.

Jose Reyes Memorial Medical CenterHematology ExaminationDate: December 03, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONHemoglobin 135-180 g/dL 116 g/dl A decrease in thehaemoglobin content in theblood is due to the decrease

in the red blood cell. The red Elevate head of bedespecially at night. Instruct to avoidstrenuous activity.


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blood cell contains the Instruct patient to eathaemoglobin. Hemoglobin isfood rich in iron.directly proportional with the Promote adequatered blood cell therefore a bed rest.decrease in the red blood cellis also a decrease in thehaemoglobin and vice versa. Encourage quiet andrestful atmosphere.Hematocrit 0.40-0.54 0.36 A decrease in the hematocritof the blood is due to thedecrease in the red bloodcell. The hematocrit, alsodetermines the percentage ofred blood cells in theplasma. Hematocrit isdirectly proportional with thered blood cell therefore adecrease in the red blood cellis also a decrease in thehematocrit and vice versa. Assess for his/herability to toleratephysical activity. Assess the extent ofthe patient'sweakness and fatigueon exertion whenplanning physicalcare activities. Encourage thepatient to eat foodsthat are high inprotein and iron, suchas liver,egg yolk,

beef, and dried fruitssuch as prunes andapricots. Instruct the client totake ironsupplements, asordered. Give health teachingon when to take ironsupplements andwhat substances


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interfere with ironabsorption.Red Blood 4.6-6.2 x 3.99 x The decrease in the amount Administer IV fluidsCells 10^12/L 10^12/L of red blood cells in the bloodis due to the accumulation ofthe cell in the injured site asa part of the inflammatoryprocess.as ordered. Monitor vital signsand pulse oximeterreadings closely. Promote rest andcomfort. Provide O2 therapy,as ordered. Provide nutritionalsupport.MCV (Mean80 96 fL 91 fL NORMAL Observe for anycorpuscularchanges in anyVolume) laboratory values. Monitor vital signs. Document findings.MCH (Mean27 31 g/L 29 g/L NORMAL Observe for anyCorpuscularchanges in anyHemoglobin) laboratory values. Monitor vital signs. Document findings.

MCHC (MeanCorpuscularHemoglobinConcentration)33-36 g/dL 32 g/dL The decrease in the meancorpuscular haemoglobinconcentration is due to thedecrease of haemoglobin inthe body. The MCHC isdirectly proportional to theamount of haemoglobin theperson has. If thehaemoglobin increase, the Elevate head of bedespecially at night. Instruct to avoidstrenuous activity. Instruct patient to eatfood rich in iron. Promote adequatebed rest.


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MCHC also increases viceversa. Encourage quiet andrestful atmosphere.RDW CV 11.0 16.0% 14.2% NORMAL Observe for any(Red Bloodchanges in anyCell laboratory values.Distribution Monitor vital signs.Width) Document findings.White Blood 5 10 x 9.03 x NORMAL Observe for anyCell Count 10^9/L 10^9/L changesin anylaboratory values. Monitor vital signs. Document findings.Neutrophils 54-62% 74.5% The increase in theneutrophils is one of thebodys first inflammatoryresponse due to ischemicdamage.Neutrophilsaccumulate at the site ofischemic damage producingneutrophil extracellular trapin order to engulf anyoffending organism and toremove cellular debris aswell. The immunologicresponse signals the bonemarrow to produce moreneutrophilsto provide thebody with greater ability tofight infection hence theincrease of neutrophils in theblood. Observe and reportsigns of infection. Assess temperature. Note and reportlaboratory values(e.g., white bloodcell count anddifferential, serum

protein, serumalbumin,and cultures). Encourage abalanced diet,emphasizing proteinsto feed the immunesystem. Encourage fluidintake and adequate


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Lymphocytes 25-30% 18.9% The decrease in lymphocytesis the inflammatory responseof the body due to ischemicdamage. Killer T cells searchthe body for cells infected byantigens. When a killer T cellrecognizes an antigen(ischemic clot) attached to acell of the body, it attachesitself to the surface of theinfected cell. It then secretestoxic chemicals into the cell,killing both the antigen andthe infected cell. Thedecrease lymphocyte is dueto the accumulation orwalling of on the damagearea to prevent the spread ofinfection.rest to bolster theimmune system. Before and aftergiving care to clientuse proper handwashing techniques. Use goggles, gloves,and gowns whenappropriate. Use sterile techniquein catheterization. Use careful techniquewhen changing andemptying urinarycatheter bags; avoidcrosscontamination. Use careful steriletechnique whereverthere is a loss of skinintegrity. Ensure client'sappropriate hygieniccare with hand

washing; bathing;and hair, nail, andperineal care. Administerantibiotics, asordered.Basophils 0.4-1% 0.1% The decrease in basophils isthe inflammatory responsedue to ischemic damage.They are the one who isresponsible for secretinghistamine which cause theEARLY changes invasodilation and vascularpermeability. The basophils ispresent at the time ofdevelopment of inflammationcausing it to become lowerwhen the inflammationprocess is through.


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Monocytes 0 9% 4.3% NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Eosinophils 1 3% 2.2% NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Platelet Count 150-450 x10^9/L129 x 10^9/L The decrease in platelets isdue to the accumulation ofplatelet cells at the site oftissue injury. The platelet inthe body goes to thesite ofthe injury probably produceby the ischemic clot leavingthe blood volume with adecrease in platelet cells. Instruct client toavoid activities thatmight result in injury. Instruct client to usean electric razor forshaving. Instruct client tobrush with a soft-bristle toothbrush. Instruct client to

avoid othermedications that mayweaken platelets.These include:-Acetylsalicylic-acid andproducts thatcontainacetylsalicylic-acid-Ibuprofen andother non


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steroidal anti-inflammatorymedications(NSAIDs)-Warfarin Avoid rectalsuppositories orenemas forconstipation and donot use a rectalthermometer.Mean Platelet 7.5 11.5 fL 8.9 fL NORMAL Observe for anyVolume (MPV) changes in anylaboratory values. Monitor vital signs. Document findings.

Clinical ChemistryDate: December 3, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTION

Creatinine 45 104mol/L77.67mol/LNORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Sodium 135 143mmol/L138.2mmol/LNORMAL Observe for anychanges in anylaboratory values. Monitor vital signs.


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Document findings.Potassium 3.41 4.82mmol/L3.63 mmol/L NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.

Arterial Blood GasDate: December 03, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONpH 7.350- 7.450 7.402 In order to compensate forthe respiratory alkalosis, pHlevel should adjust to theborderline of alkalinity. Encourage patient tobreathe slowly anddeeply. Speak in alow, calm tone ofvoice; providesafe environment. Demonstrateappropriate breathing

patterns,if appropriate. Provide comfortmeasures. Promotes relaxationand reduces stress.Control and reductionof fever reducespotential for seizuresand helps reducerespiration rate.PO2 80.0- 100.0 195.5(+)mmHgIncreased when inspiredhigher oxygen levels.PCO2 35.0- 45.0 25.5mmHg (-) PCO2 is decreased in

Respiratory Alkalosis.SO2 75.9- 99.0 99.6 % (+) Breathing oxygen-enriched air will increaseSO2 level.HCO3 22- 26 15.5 mmHg HCO3 is decreased inRespiratory Alkalosis.


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Plain Cranial CT-ScanDate: December 03, 2011

DIAGNOSTI FINDINGS ANALYSIS NURSING INTERVENTIONCPROCEDUREPlain cranial There is an area of Cerebrovascular Accident Teach the patient toidentify riskCT-Scan hypodensity involvingcan produce hypodensefactors and necessary life-stylethe right frontoareasin region that is cutmodifications, such as diet, stresstemporo- parietaloff from blood flow. reduction, and smokinglobes with cessation.effacement of the Maintain a patent airway toadjacent cortical sulcipromote adequate oxygenation.and follows the right Maintain bed rest to minimizeterritorial distribution metabolic requirements.of the right middlecerebral artery. Begin bedside range-of-motionexercise to preserve mobility andprevent deformities.

UrinalysisDate: December 04, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONColor Light yellowto amberAmber NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Appearance Clear Turbid The turbid appearance of Observe for any


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the urine is probably due tochanges in anythe RBC, WBC ketones and laboratory values.bacteria present in the urine Monitor vital signs.making it cloudy / turbid. Document findings.PH 5 - 6 6 NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Specific1.010 1.025 1.025 NORMAL Observe for anyGravity changes in anylaboratoryvalues. Monitor vital signs. Document findings.Chemical (-) (-) NORMAL Observe for any(sugar,changes in anyprotein,laboratory values.bilirubin, Monitor vital signs.nitrite etc.) Document findings.Ketones (-) (+) Ketonuria occurs instarvation states, low or nocarbohydrate diet and highfat and protein in diet. Inabsence of glucose, cellsmetabolize fats for energy.Ketone bodies accumulate inplasma and are excreted inurine. Assess the client. Advise the client to

increase carbohydrateand lessen fat andprotein in his diet. Continuously monitorany changes inlaboratory results. Report if there arecertain changes, asnecessary.


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RBC 0 2 hpf 1 hpf NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.WBC 0 - 5 hpf 3 hpf NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs.Document findings.Crystals(AmorphousUrates)None None NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.EpithelialCellsNone None NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Bacteria None Few Bacteria in urine sedimentreflect GUT or contaminationof external genitalia. Advise client toregularly cleangenitalia to preventcontamination. Give medications, asordered to fightbacterial infectionCasts None None Normal Observe for anychanges in anylaboratory values. Monitor vital signs.


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Document findings. Document findings.Hematology ExaminationDate: December 05, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONProthrombinTimePT ControlPT INRPT %ActivityAPTTAPTTControl11.3 15.3sec

70 100 %28 -37 sec13.8 sec12.8 sec1.10 sec96.0 %33.9 sec33.9 secNORMALNORMALNORMAL Observe for anychanges in anylaboratory values. Monitor vital signs.

Document findings.

UrinalysisDate: December 13, 2011

LABORATORYEXAMINATIONNORMALVALUESRESULTS ANALYSIS NURSING INTERVENTIONColor Light yellowto amber

Light Yellow NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Appearance Clear Clear NORMAL Observe for any


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changes in anylaboratory values. Monitor vital signs. Document findings.PH 5 6 6 NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Specific1.010 1.025 1.015 NORMAL Observe for anyGravity changes in anylaboratoryvalues. Monitor vital signs. Document findings.CrystalsNone Few The amorphous urates in Practice clean(Amorphousthe urine depict how cleantechnique in collectingUrates) the techniqueis. It signifiesthe dirt present in theurine once it is collected.There is no internalsignificance.urine to minimizeamorphous urates inthe urine. Use an intermittentcatheter if available toprovide the sterility ofthe urine.

Clinical ChemistryDate: December 14, 2011

LABORATORYEXAMINATINORMALVALUESRESULTS ANALYSIS NURSING INTERVENTION


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ONFasting BloodSugar4.1 5.09mmol/L4.02 mmol/L There is a minimal decreasein the blood sugar probablydue to the fasting requiredto gain the laboratory result.The body increases itsmetabolism to compensatefor the fasting needed in theFBS leading to a minimaldecrease. Advice the client to goback to the usualroutine of eating. Monitor for baselinedata as soon as theclient goes back to theusual routine ofeating. Document findings.Total Protein 66 - 83 72.73 NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Albumin 35 52 g/L 41.74 g/l NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs.

Document findings.Globulin 11 - 33 31 NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.Albumin /Globulin Ratio1.5 3.0 1.5 NORMAL Observe for anychanges in anylaboratory values. Monitor vital signs. Document findings.


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81037602 laboratory and diagnostic exam

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