Medical Management diagn. test

8/12/2019 Medical Management diagn. test

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MEDICAL MANAGEMENT

A. DIAGNOSTIC AND LABORATORY TESTComplete Blood count

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Result

General

Description

Indication or

Purpose

Results Normal

Values

Analysis

Interpreta

Complete

Blood Count

(CBC)

Date

Ordered:

Date

Performed:

The CBC test

isolates and

counts the 7

types of cells

found in the

blood:

neutrophil,

eosinophil,

basophil, red

blood cell,

lymphocyte,

monocyte, and

platelet. It is a

screening test,

used to

diagnose and

manage

numerousdiseases. This

can reflect

problems with

fluid volume

To identify if

there is presence

of infection,

Hemoglobin:

130mg/L

Female:

115-

155g/L

The patien

hemoglob

level is wi

normal ran

WBC :

14 x 109/L

5-10 x

109/L

There is a

white bloo

count. It c

indicate th

an

inflammat

and infecti

Hematocrit:

39%

Female:

0.38-

0.48%

The patien

hematocrit

count is w

normal ran

Lymphocytes:

0.38

0.20-

0.35%

There is a

lymphocyt

level deno

that the cli


2/23

(such as

dehydration)

or loss of

blood. It can

show

abnormalities

in the

production,

life span, and

destruction of

blood cells. It

can reflect

acute or

chronic

infection,

allergies, and

problems with

clotting.

may have

or bacteria

infection.

Neutrophils

0.64

0.02-0.06 The patien

neutrophil

within nor

range.

Monocytes

0.02

0.45-0.65 The patien

monocytes

within nor

range.

Platelet count

377

150- 400

x 109/L

The patien

platelet co

are within

normal ran

Nursing Responsibilities:

Before:


3/23

1. Explain test procedure. Explain that slight discomfort may be felt when the skin ispunctured.

2. Encourage to avoid stress if possible because altered physiologic status influences andchanges normal hematologic values.

3. Explain that fasting is not necessary. However, fatty meals may alter some test results asa result of lipidemia.

During:

1. Monitor vital signs before, during and after procedure.After:

1. Apply manual pressure and dressings over puncture site on removal of dinner.2. Monitor the puncture site for oozing or hematoma formation.3. Instruct to resume normal activities and diet.


4/23

Sodium, serum

Diagnostic

and

Laboratory

Procedures

Date Ordered

Date

Performed

General

Description

Indication

or Purpose

Results Normal

Values

Analysis an

Interpretati

Sodium,

serum

Date ordered:

Date

Performed:

This test

measures

serum levels

of sodium in

relation toamount of

water in the

body. It

evaluates

fluid

electrolyte

and acid base

balance and

related

neuromuscula

r, renal, and

adrenal

functions

because

sodium is the

major

extracellular

cation which

affects bodys

To monitor

the

electrolytes

and check for

imbalancesany

imbalance in

the fluid and

electrolytes.

140.9

mmol/L

135. 0-

145.0

mmol/L

The sodium

electrolyte lev

is within norm

range.


5/23

water

distribution,

maintains

osmotic

pressure of

extracellular

fluids, helps

neuromuscula

r function;

helps

maintain acid-

base balance,

and

influences

potassium and

chloride. Due

to

extracellular

sodium ithelps in

kidneys to

regulate body

water

(decreased

sodium levels

promotes

water

excretion and

increased

level promote

retention),


6/23


Before:

1. Explain to the mother that the serum sodium test determines sodium content in the blood.2. Tell mother that the test requires a blood sample. Explain who will perform the

venipuncture and when.

3. Explain to the mother that her baby may feel slight discomfort from the tourniquet andthe needle puncture.

4. Inform mother that the baby need not restrict food and fluids.5. Notify the laboratory and physician of drugs the patient is taking that may affect result; it

may be necessary to restrict them.

During:

1. Perform venipuncture and collect the sample in a 3 or 4-ml activator tube.2. Handle gently to prevent hemolysis.

After:

1. Apply direct pressure to the venipuncture site until bleeding stops.

serum level

are evaluated

by the amount

water in the

body.(Lippinc

ott William &

Wilkins,

2006)


7/23

Potassium, serum

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Results

General

Description

Indication or

Purpose

Results Normal

Values

Analysis

Interpret

Potassium,

serum

Date

Ordered:

Date

Performed:

Measures serum

levels of

potassium, a major

intracellular cation

that helps maintain

cellular osmostic

equilibrium;

regulates muscle

activity, enzyme

activity and acid

balance, and

influences renal

function.

Serum

Calcium is

being checked

to observe for

any imbalances

with serum

electrolytes

4.03 3.50-5.50 The serum

level of

potassium

within no

limit

Nursing Responsibilities

Before:

1. Explain to the patient that the serum potassium test determines the potassium blood.2. Tell the patient that the test requires a blood sample. Explain who will perform the

venipuncture and when.

3. Explain to the patient that he may experience slight discomfort from the tourniquet andfrom the needle puncture.

4. Inform patient that he need not restrict food and fluids.5. Notify the laboratory and physician of drugs the patient is taking that may affect result; it

may be necessary to restrict them.


8/23

During:

1. Perform venipuncture and collect the sample in a 3 or 4-ml activatortube.2. Handle gently to prevent hemolysis.

After:

1. Apply direct pressure to the venipuncture site until bleeding stops.Instruct patient to resume any medication stopped before the procedure


9/23

Cranial Ultrasound

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Results

General

Description

Indication

or Purpose

Results Normal

Values

Analysis

Interpret

Date

Ordered:

Date

Performed:

Cranial

ultrasound

uses

reflected

sound waves

to produce

pictures of

the brain and

the inner

fluid

chambers

(ventricles)

throughwhich

cerebrospinal

fluid (CSF)

flows

Cranial

ultrasound

may also be

done to

evaluate a

baby's large

or

increasing

head size,

detect

infection in

or around

the brain(such as

meningitis),

or screen

for brain

problems

that are

present

from birth.

Cranial ultrasound

via open anterior

showed the

following features:

There isincrease

echonogenicity of

the brain

parenchyma.

The cistern,

ventricles, sulci are

normal in size,

shape, &configuration.

No evidence of

hydrocephalus,

intra or extra-axial

hemorrhage.

IMPRESSION:

Consider

meningitis

The size and

shape of the

brain appear

normal.The

size of the

brain's inner

fluid

chambers

(ventricles)is

normal.

Brain tissue

appears

normal. Nobleeding,

suspicious

areas

(lesions),

abnormal

growths, or

evidence of

infection are

present.


10/23

Calcium,serum

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Results

General

Description

Indication or

Purpose

Results Normal

Values

Analysis

Interpret

Potassium,

serum

Date

Ordered:

Date

Performed:

Measure the total

calcium in the

blood

Serum

Calcium is

being checked

to observe for

any imbalances

with serum

electrolytes

4.36

mEq/L

3.5-5.5

mEq/L

The serum

level of

potassium

within no

limit


Before:

Check the doctors order

1. Explain the procedure2. Explain the purpose and what to expect3. No food or fluid restrictions

During1. Do not take the blood sample from hand or arm with receiving IVF2. The tourniquet should be less on a minute3. Do not squeeze the punctured site rightly


11/23

4. Wipe away the first drop of blood

After1. Observed and record vital signs.2. Check injection sites for bleeding, infection, tenderness or thrombosis.3. Report untoward reaction to the physician.4. Apply warm compress to ease discomfort, as ordered.5. Interpret results and provide counsel appropriately. Provide health teachings regarding

proper lifestyle changes and symptoms that may warrant immediate medical attention.


12/23

Lumbar Puncture

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Results

General

Description

Indication or

Purpose

Results Normal

Values

Analysis

Interpret

Potassium,

serum

Date

Ordered:

Date

Performed:

Permits

sampling of

cerebral spinal

fluid (CSF) for

qualitative

analysis

To measure

cerebrospinal

fluid pressure

as an aid to

detect has an

infection in

the CSF

around the

brain.

Color:

Colorless

Color:

Colorless

The CSF

is within

normal r

Transparency:

Clear

Transparency:

Clear

The CSF

transpare

within n

range.

Differential

count:

All

lymphocytes

Increase

different

count ind

infection

Sugar

1-1.3 mmol

mmol/L

Sugar:

2.754.125

mmol/L

Decrease

glucose m

result fro

infection

Protein

No reagent

Protein

6.3-8.3 g/L

It may in

rapid CS

producti

Gram Stain

No

Microorganism

No organism

No

microorg

found in

lumbar

puncture


13/23

Acid base

bacilli

Negative

Acid base

bacilli

Negative

Negative

Acid bas

bacilli


Before

1. Explain the procedure to the mother2. Explain when and where the procedure will occur (e.g., the bedside or the treatment

room) and who will be

3. Explain that it will be necessary to lie in a certain position without moving for about 15minutes. A slight pinprick will be felt when the local anesthetic is injected and a

sensation of pressure as the spinal needle is needed.

During

1. Support and monitor the client throughout:a. Stand in front of the client and support the back of the neck and knees if the client

needs help remaining still.

b. Reassure the client throughout the procedure by explaining what is happening.Encourage normal breathing and relaxation.

c. Observe the clients color, respirations, and pulse during the procedure.2. Handle specimen tubes appropriately:

a. Wear gloves when handling test tubes.b. Label the specimen tubes in sequence.c. Send the CSF specimens to the lab immediately.

3. Place a small sterile dressing over the puncture site.4. Ensure the clients comfort and safety:

a. Assist the client to a dorsal recumbent position with only one head pillow5. The client remains in this position for 1 to 12 hours, depending on the primary care

provider orders.


14/23

6. Advised mother to breastfeed , unless contraindicated, to help restore the volume of CSF.

After

Observe for swelling or bleeding at the puncture site

. Monitor changes in neurologic status.

Document the procedure on the patients chart: Include date and time performed; the primary

care providers name; the color, character, and amount of CSF; and the number of specimens

obtained.

Also document CSF pressure and the nurses assessments and interventions.


15/23

Urinalysis

Diagnostic

and

Laboratory

Procedures

Date

Ordered

Date

Performed:

General

Description

Indication or

Purpose

Results Normal

Values

Analysis and

Interpretation

Urinalysis Date

Ordered:

Sept 1,

2012

Date

Performed:

Sept 1,

2012

A routine

urinalysis test

for urinary and

systemic

disorders. This

test evaluates

physical

characteristics

(color, odor,

turbidity, and

opacity) of the

urine;determines

specific

gravity and

pH; detects

and measures

protein,

glucose, and

ketone bodies;

and examines

sediments for

blood cells,

casts, and

To screen for

abnormalities

within urinary

system

problems that

may manifest

through the

urinary tract.

Color:

Yellow Straw to dark

yellow

The color of the

urine of the

patient is

normal

Transparency:

Turbid Clear

The urine of

patient is

slightly turbid.

Turbid urine

may contain

RBCs, WBCs,

and bacteria an

may reflectinfection.

pH:

6.0 4.5-8

The pH of

patients urine

ranges to the

normal limits.

Specific

gravity:

1.070 1.010-1.035

The specific

gravity is

normal.

Epithelial

cells:

moderate

Rare; 0-5 /

The result of

epithelial cells

in the urinalysis


16/23


Before:

1. Explain that this analysis helps to diagnose renal disease and to evaluate overall bodyfunction.

2. Inform the patient that he may not need to restrict food and fluids.3. Notify the laboratory and physician of drugs the patient is taking that may affect

laboratory results.

crystals. high-power

field

is normal.

Albumin:

Negative Negative

There is no

presence of

protein in the

urine

Sugar:

Negative Negative

There is no

presence of

sugar in the

urine.Pus cells:

18-20 cells /

hpf

5 to 10 pus

cells/hpf

Presence of hig

levels of pus

cells in the urin

may also be a

sign of infection

Bacteria:

Light None

Bacteria in the

urine sediment

may reflect

infection.


17/23

During:

1. Instruct the patient to void directly into a clean, dry container. Sterile, disposablecontainers are recommended.

2. Collect a random urine specimen of at least 15ml. Obtain a first voided morningspecimen if possible.

3. Cover all specimens tightly, label properly and send immediately to the laboratory.After:

1. Inform patient that he may resume to his usual diet and medications.2. Observe standard precautions when handling urine specimens.3. If the specimen cannot be delivered to the laboratory or tested within an hour, it should

be refrigerated or have an appropriate preservative added.


18/23

B. IVFMEDICAL

TREATMENT

DATE

ORDERED

AND

STARTED:

GENERAL

DESCRIPTION

INDICATION/

PURPOSE

CLIENTS

RESPONSE

Side effects:

This solution is

used to provide

lost nutrients in

the body

It was given to

the patient to

maintain fluid

balance in the

body and to

prevent

dehydration

The patient did

not manifest

dehydration. His

hydration was

maintained, and

no electrolyte

imbalance noted.


Before:

1. Verify with the doctors order.2. Explain the indication to the mother.

During:

1. Label the IVF bottle and tubings indicating the date and time it was started with theordered regulation.

2. Maintain and regulate at the rate prescribed.3. Handle IVF site aseptically.4. Change solution and IVF tubings as per hospital policy.

After:

1. Check the site for any signs/symptoms of infection


19/23

C. OGTMEDICAL

MANAGEMENT

DATE

ORDERED

DATE

PERFORMED

GENERAL

DESCRIPTION

INDICATIONS CLIENTS

RESPONSE

OGTThe process of

placing a soft

plastic tube

through a patient's

mouth, past the

pharynx and downthe esophagus into

a patient's

stomach.

Oro- gastric tubes

are inserted to

deliver substances

directly into the

stomach, or to

remove substances

from the stomach

or as a means of

testing stomach

function or

contents.

It is used to

deliver milk

formulas to the

babys stomach.

The patient

didnt

experience

aspiration.


Before


20/23

Verify doctors order. Inform the SO. Explain the purpose of OGT. Practice strict asepsis.

During:

Do hand washing. Prepare the materials needed for the procedure.

After:

Check for the patency.


21/23

D. OXYGEN THERAPYE. DRUG STUDY

NAME OF DRUG

DOSAGE AND

FREQUENCY

ROUTE OF

ADMINISTRATION

GENERAL

ACTION

INDICATION DATE

ORDERED

DATE

PERFORMED

DATE

CHANGED

CLIENT'S

RESPONSE TO

TREATMENT

SIDE EFFECTS

Generic Name:

Ampicillin

Brand Name:

Stock Dose:

Inhibits cell wall

synthesis during

bacterial

multiplication.

Treatment for

sepsis and

meningitis.

Date Ordered: Client responded

well and had no

adverse reaction to

drug.


Check for the doctors order and medication chart Before giving drug ask the mother about allergic reactions to certain drugs such as

penicillin. A negative history of the drug allergy is not a guarantee against a future

allergic reaction. Check for any hypersensitivity reaction (Skin testing was not indicated

because it is believed that a neonate would not develop any hypersensitivity reaction to a

certain drug until 6 months of age due to his/her natural antibody

Inform patient to notify prescriber if rash, fever or chills develop. A rash is a mostcommon allergic reaction.


22/23

NAME OF DRUG

DOSAGE AND

FREQUENCY

ROUTE OF

ADMINISTRATION

GENERAL

ACTION

INDICATION DATE

ORDERED

DATE

PERFORMED

DATE

CHANGED

CLIENT'S

RESPONSE TO

TREATMENT

SIDE EFFECTS

Generic Name:

Cefotaxime 125 q8o

Inhibits synthesis

of bacterial cell

wall

Treatment for

sepsis and

meningitis.


Check for any hypersensitivity reaction (Skin testing was not indicated because it isbelieved that a neonate would not develop any hypersensitivity reaction to a certain drug

until 6 months of age due to his/her natural antibody

Check for the patency of the IV site Maintain sterility during the preparation Give the drug slow IV Maintain sterile technique during the administration Monitor for any untoward reaction Document the time or any reaction. Continue antibiotic therapy in full length of treatment.


23/23

NAME OF DRUG

DOSAGE AND

FREQUENCY

ROUTE OF

ADMINISTRATION

GENERAL

ACTION

INDICATION DATE

ORDERED

DATE

PERFORMED

DATE

CHANGED

CLIENT'S

RESPONSE TO

TREATMENT

SIDE EFFECTS

Generic Name:

Phenobarbital

It is a barbiturate

that has anti

seizure activity

that depresses

CNS, reticular

activating system.

It was given to

decrease episodes

of seizure.

The infant didnt

experienced any

episodes of seizure.


Assess pulse, respiration after administration. Review history of seizure disorder Observe frequently

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Medical Management diagn. test