II.

DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/Laboratory Procedures

Date ordered/Date result in Ordered February 23, 2010

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of the result

Mr. CVA undergone chest xray to check if there are pulmonary

There are no pulmonary infiltrates, cardiac size and configuration are normal. The diaphragm, sulci and ribs are intact.

A normal chest x ray will show normal structures for the age and medical history of the patient. Findings, whether normal or abnormal, will be provided to the referring physician in the form of a written report.

The results show that Mr. CVAs heart is not enlarged.

Result February 24, 2010

infiltrates, check the cardiac size and configuration dynamic precordium was noted upon admission which is an indicator of enlarged heart.

Nursing Responsibilities: Prior : After: Explain to pt that the results of a chest x-ray can be available almost immediately for review by the physician Explain the procedure to the pt why it is indicated. A chest x-ray examination itself is a painless procedure

Diagnostic/ Laboratory Procedures CT scan

Date ordered/Date result in

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of the result

February 23, 2010

Mr. CVA undergone CT scan to have multiple axial views of the head to distinguish the cause of the signs and symptoms present.

Plain multiple axial views of the head using incremental CT reveals a small hypodense Foci on the anterior limb on the left internal capsule and the left putamen.

N.A.

The test indicates that there is presence of an infarct at left lobe of the brain explaining right sided weakness

There is also a hypodense focus on the left parietal cortex.

The ventricles and cistern are not dilated The middle line structures are not displaced.

The sella furica posterior fossal and basal skull structures are intact.

Impression: Acute infarct, anterior limb or left internal capsule left putamen and left parietal cortex.

Nursing Responsibilities: Explain the procedure to the pt. and why it is indicated. Explain that this test is done to take excellent pictures of the brain to locate any problem areas if they exist. Assess the client for allergies to iodine, seafood and contrast medium. Evaluate the client for restlessness. Clients unable to remain still 30-90 minutes during the scan may need a sedative. Ensure an informed consent has been obtained if contrast medium is used. Remove metal objects such as jewelries, glasses, and dental bridges from the head and neck before the procedure. Restrict food and fluids for 8 hours before the scan if contrast medium is injected. Do not restrict food, fluids, or medications when contrast medium is not used for scan.

Diagnostic/ Laboratory Procedures

Date ordered/ Date result in

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of the result

Blood Chemistry

May 27,2010

-This test was ordered to measure and monitor the amount of sugar in Mr. CVA s blood. This is a more accurate determinant than RBS.

Glucose (FBS) 5.37mmol/L 4.22 6.10

Fasting plasma glucose level above 7.0 mmol/L indicates that Mr. CVA has Hyperglycemia

May 31,2010

This test was ordered to monitor Mr. BATES renal function, specifically the ability of the kidney to excrete urea and protein.

BUN 4.76 mmol/L

2.5-7.5 mmol/L

This indicates that Mr. BATES renal function is well, specifically expressed through the ability of his kidneys to excrete urea and protein.

This test was ordered to monitor Mr. BATES renal function, specifically the ability of the kidney to excrete urea and protein.

Crea 108.54mmol/L

44.2-115mmol/L

Creatinine level is slightly elevated but within normal range. This indicates that Mr.BATES kidneys doesnt clear creatinine that may possibly result

from kidney disease.

This test was ordered to check for Mr. BATES water balance.

Na

139

137-145

Sodium level is within in the normal range that does not directly affect cardiac function.

This test was order to Mr. BATES to measure acid base balance and normal muscle activity. This test was ordered to Mr. BATES to determine the total cholesterol in his blood.

3.4mmol/L

3.6-5.4

Cholesterol 5.24mmol/L 3.90-5.22

Mr. BATES cholesterol is above the normal range that may result to cholesterol blockage due to narrowed blood vessel. 0.45 1.81

- This test was ordered to Mr. BATES to determine the triglyceride or the glycerol esterified with three fatty acids in the blood -this is also a test which assesses the risk of developing heart disease and stroke

Tryglycerides 1.85

Triglycerides are linked to the thickening of the arterial wall caused by fatty materials deposition. The result may rule out atherosclerosis as the cause of the Mr. BATES

stroke LDL does not aid in the LDL 4.1mmol/L - This test was ordered to Mr.CVA to determine measures the amount of LDL or the bad cholesterol in the blood -assess the risk of developing heart disease and stroke 0.0-3.8 transportation of cholesterol out of the body, instead it deposits cholesterol and triglycerides into the cell. This result indicates that Mr. BATES is more likely to form deposits of cholesterol onto his vessel walls. HDL 0.89mmol/L 0.91 1.68 Having a low level of HDL(High density - This test was ordered to Mr.BATES to determine measures amount of HDL or good cholesterol in the body -To determine risk of developing heart disease and stroke Lipoprotein), there is a decreased protective action. It is less likely that cholesterol is being transported away from the tissues and cells of the arterial wall to the liver for excretion.

Nursing Responsibilities: Prior : After: Apply brief pressure to prevent bleeding Apply warm compress if Hematoma will develop at the venipuncture site. For creatinine, assess fluid and nutritional status of client for clues of renal impairment and other diseases causing changes in creatinine levels. Continuously monitor fluid balance through daily weights and intake and output recordings. For glucose, ensure the client receives food promptly in accordance with the ordered diet. Explain the procedure to the pt. and why it is indicated Inform the patient that fluid and food restriction is required especially for FBS which is a 12 hour fast. Inform the patient that a blood sample will be taken. Tell the patient that he may experience transient discomfort from the needle pincture Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen. For glucose, do not give their insulin/anitdiabetic agents until blood is drawn.

During the procedure: For cholesterol, seat the client at least 5 minutes before the venipuncture is performed to reduce fluctuations in serum levels associated with postural changes. Inform the patient that pain may be felt through prick in the needle Instruct the patient to calm down to avoid uneasiness.

Diagnostic/ Laboratory Procedures Hemo Glucose Test

Date ordered/Date result in

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of the result

May 27, 2010 12mn 6am May 28, 2010 Mr. BATES has undergone Blood glucose monitoring to identify intervention to maintain his blood 12nn glucose within an acceptable 6pm range as determined by their May 30, 2010 6pm May 31, 2010 6pm 12mn June 2, 2010June 4, 2010 June 5, 2010 12mn 6am June 6, 2010 12nn 109 119 Refused doctors. This is a more immediate and convenient way to test his blood glucose. Refused Refused Refused No fund 121 mg/L 118 126 115 Refused Blood glucose level normal range 80120mg/dl The results of Mr. BATES Hemo Glucose Test is within the normal range.

Nursing Responsibilities: Prior : After: Diagnostic/ Laboratory Procedures Hematology Date ordered/ Date result in February 24, 2010 -To evaluate the hemoglobin content (iron status and O2 carrying capacity) of erythrocytes by measuring the no. of grams of hemoglobin /dl of blood - Measures the volume of Hematocrit 0.46 0.40-0.54 Hemoglobin 153 140-180 g/l Indication or Purpose Results Normal Values Analysis and Interpretation of the result Mr. BATES result is within the acceptable range. This could indicate that Mr. BATES red blood cells freely carry oxygen to the body Mr. BATES result is Apply brief pressure to prevent bleeding. Observe for signs and symptoms of hyperglycemia or hypoglycemia. Explain the procedure to the pt. and why it is indicated Inform the patient that a blood sample will be taken. Tell the patient that he may experience transient discomfort from the needle pincture

During the procedure: Inform the patient that pain may be felt through prick in the needle Instruct the patient to calm down to avoid uneasiness.

RBCs in whole blood expressed as a percentage.

within the acceptable range. A lowered hematocrit can indicate hemorrhage thus the result may indicate that hemorrhage is not the cause of his CVA Mr. BATESs result is within the acceptable range. A decrease in the RBCs could indicate hemorrhage thus the results may indicate that hemorrhage is not the cause of his CVA Elevated WBC count

-Measures the number of RBCs

RBC

5.1 X10 12/L

4.5 6.5 X 10 12/L

-Measures the number of WBCs

indicates that Mr. WBC 17.7 X10 9/L 5- 10 X 10 9/L BATESs body is currently fighting off an infection

-To provide a numeric estimate of the clients

Neutrophils

0.83

0.55- 0.65

There is an increased level of

immune status.

neutrophils. This could indicate that his body is currently fighting off a bacterial infection.

-To determine immune function, provides a gross measure in nutritional status. Lymphocytes 0.11 0.25-0.35

Decreased level of lymphocytes may indicate sepsis. The result is within the acceptable

-To provide a numeric estimate of the clients immune status.

range. This could Eosinophils Monocytes 0.02 0.04 0.02-0.04 0.02-0.06 indicate that his body is not currently fighting off a parasitic infection. The patient has an increased platelet

-Measures the number of platelets (Thrombocytes) per mm3 of blood. Platelet 386 X10 9/L 150-400 X 10g/L

count that is once activated by blood vessel wall injury or ruptures of atherosclerotic plaque, platelets,

undergo chemical changes that may form a thrombus.

Nursing Responsibilities: Prior : After: Apply brief pressure to prevent bleeding Apply warm compress if Hematoma will develop at the venipuncture site. If BUN levels are >40mg/dl without signs and symptoms of dehydration, monitor intake and output, complete dietary assessment, and check with health care provider regarding protein restriction. Monitor for lethargy, confusion, and change in mental status. Provide necessary safety precautions. Observe for signs and symptoms GI bleeding, which is associated with decreased red blood cells. Explain the procedure to the pt. and why it is indicated Inform the patient that fluid and food restriction is not required Inform the patient that a blood sample will be taken. Tell the patient that he may experience transient discomfort from the needle pincture Fill up laboratory request form properly and send it to the laboratory technician during the collection of sample/specimen.

During the procedure: Inform the patient that pain may be felt through prick in the needle Instruct the patient to calm down to avoid uneasiness.

Diagnostic/Laboratory Procedures

Date ordered/Date result in

Indication or Purpose

Results

Normal result

Analysis and Interpretation of the result

Urinalysis

May 27, 2010 Urinalysis is done to Mr. BATES to observe urine color and clarity and measure urine acidity and specific gravity Character- cloudy PH- 6 S.G.- 1.020 CHON- trace Color- dark yellow Pale, straw color to amber Transparent 4.6-8.0 1.01 1.03 none

Diagnostic/Laboratory Procedures

Date ordered/Date result in

Indication or Purpose

Results

Normal result

Analysis and Interpretation of the result

Fecalysis

May 27, 2010 Color- Brown ConsistencyWatery Microscopic Puscells- Few RBC- Few Yeast- Few Brown Soft, formed