MEDICAL MANAGEMENT A.

DIAGNOSTIC AND LABORATORY TEST Complete Blood count

Diagnostic and Laboratory Procedures

Date Ordered Date Result Date

General Description

Indication or Purpose

Results

Normal Values

Analysis

and

Interpretation

The CBC test isolates and counts the 7

To identify if there is presence of infection, Hemoglobin: 130mg/L Female: 115155g/L

The patients hemoglobin level is within normal range.

Complete Blood Count (CBC)

Ordered:

Date

types of cells

Performed: found in the blood: neutrophil, eosinophil, basophil, red blood cell, lymphocyte, monocyte, and platelet. It is a screening test, used to diagnose and manage numerous diseases. This can reflect problems with fluid volume Lymphocytes: 0.200.38 0.35% Hematocrit: 39% Female: 0.380.48% WBC : 14 x 109/L 5-10 x 109/L There is a high white blood cell count. It could indicate there is an inflammation, and infection The patients hematocrit count is within normal range. There is a high lymphocyte level denotes that the client

(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. Platelet count 377 150- 400 x 10 /L
9

may have viral or bacterial infection.

Neutrophils 0.64

0.02-0.06

The patients neutrophils are within normal range. The patients monocytes are within normal range. The patients platelet count are within normal range.

Monocytes 0.02

0.45-0.65

Nursing Responsibilities: Before:

1. Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured. 2. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values. 3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a 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.

Sodium, serum

Diagnostic and Laboratory Procedures Sodium, serum

Date Ordered Date Performed

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

Date ordered:

This test measures

To monitor the electrolytes and check for imbalances any imbalance in the fluid and electrolytes.

140.9 mmol/L

135. 0145.0 mmol/L

The sodium electrolyte level is within normal range.

Date Performed:

serum levels of sodium in relation to amount 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

water distribution, maintains osmotic pressure of extracellular fluids, helps neuromuscula r function; helps maintain acidbase balance, and influences potassium and chloride. Due to extracellular sodium it helps in kidneys to regulate body water (decreased sodium levels promotes water excretion and increased level promote retention),

serum level are evaluated by the amount water in the body.(Lippinc ott William & Wilkins, 2006)

Nursing Responsibilities: 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 and the 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.

Potassium, serum

Diagnostic and Laboratory Procedures Potassium, serum

Date Ordered Date Results Date Ordered:

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

Measures serum levels of

Serum Calcium is

4.03

3.50-5.50

The serum level of potassium is within normal limit

potassium, a major being checked Date intracellular cation to observe for

Performed: that helps maintain any imbalances cellular osmostic equilibrium; regulates muscle activity, enzyme activity and acid balance, and influences renal function. with serum electrolytes

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 and from 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.

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

Cranial Ultrasound

Diagnostic and Laboratory Procedures

Date Ordered Date Results Date Ordered:

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

Cranial ultrasound uses

Cranial ultrasound

Cranial ultrasound via open anterior

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. No bleeding, suspicious areas (lesions), abnormal growths, or

may also be showed the done to evaluate a baby's large There is increase or increasing head size, detect infection in or around the brain (such as echonogenicity of the brain parenchyma. The cistern, ventricles, sulci are normal in size, shape, & configuration. following features:

Date

reflected

Performed: sound waves to produce pictures of the brain and the inner fluid chambers (ventricles) through which

cerebrospinal meningitis), No evidence of fluid (CSF) flows or screen for brain problems that are present from birth. IMPRESSION: Consider meningitis hydrocephalus, intra or extra-axial hemorrhage.

evidence of infection are present.

Calcium,serum

Diagnostic and Laboratory Procedures Potassium, serum

Date Ordered Date Results Date Ordered:

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

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 is within normal limit

Date Performed:

Nursing Responsibilities Before: Check the doctors order 1. Explain the procedure 2. Explain the purpose and what to expect 3. No food or fluid restrictions

During 1. Do not take the blood sample from hand or arm with receiving IVF 2. The tourniquet should be less on a minute 3. Do not squeeze the punctured site rightly

4. Wipe away the first drop of blood

After 1. 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.

Lumbar Puncture

Diagnostic and Laboratory Procedures Potassium, serum

Date Ordered Date Results Date Ordered:

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

Permits sampling of cerebral spinal

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 color is within normal range.

Date

fluid (CSF) for

Transparency: Clear

Transparency: The CSF Clear transparency is within normal range.

Performed: qualitative analysis

Differential count: All lymphocytes Sugar 1-1.3 mmol mmol/L Sugar: 2.75 4.125 mmol/L

Increased in differential count indicate infection Decreased glucose may result from infection.

Protein No reagent

Protein 6.3-8.3 g/L

It may indicate rapid CSF production.

Gram Stain No Microorganism No organism

No microorganism found in lumbar puncture

Acid base bacilli Negative

Acid base bacilli Negative

Negative for Acid base bacilli

Nursing Responsibilities Before 1. Explain the procedure to the mother 2. 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 15 minutes. 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 pillow 5. The client remains in this position for 1 to 12 hours, depending on the primary care provider orders.

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.

Urinalysis

Diagnostic and

Date Ordered

General Description

Indication or Purpose

Results

Normal Values

Analysis and Interpretation

Laboratory Date Procedures Urinalysis Performed: Date Ordered: Sept 1, 2012 A routine urinalysis test To screen for abnormalities 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 and may reflect infection. pH: 6.0 4.5-8 The pH of patients urine ranges to the normal limits. Specific gravity: 1.070 Epithelial cells: moderate Rare; 0-5 / The result of epithelial cells in the urinalysis 1.010-1.035 The specific gravity is normal.

for urinary and within urinary systemic system

disorders. This problems that Date Performed: Sept 1, 2012 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 may manifest through the urinary tract.

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 high levels of pus cells in the urine may also be a sign of infection

Bacteria: Light None

Bacteria in the urine sediment may reflect infection.

Nursing Responsibilities:

Before: 1. Explain that this analysis helps to diagnose renal disease and to evaluate overall body function. 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.

During: 1. Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. 2. Collect a random urine specimen of at least 15ml. Obtain a first voided morning specimen 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.

B. IVF MEDICAL TREATMENT DATE ORDERED AND STARTED: 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 Side effects: The patient did not manifest dehydration. His hydration was maintained, and no electrolyte imbalance noted. GENERAL DESCRIPTION INDICATION/ PURPOSE CLIENTS RESPONSE

Nursing Responsibilities 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 the ordered 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

C. OGT MEDICAL MANAGEMENT DATE ORDERED DATE PERFORMED OGT The process of placing a soft plastic tube through a patient's mouth, past the pharynx and down the 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. GENERAL DESCRIPTION INDICATIONS CLIENTS RESPONSE

Nursing Responsibilities Before

 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.

D. OXYGEN THERAPY E. DRUG STUDY NAME OF DRUG DOSAGE AND FREQUENCY ROUTE OF ADMINISTRATION GENERAL ACTION INDICATION DATE ORDERED DATE PERFORMED DATE CHANGED Generic Name: Ampicillin Brand Name: Inhibits cell wall synthesis during bacterial multiplication. Stock Dose: Treatment for sepsis and meningitis. Date Ordered: Client responded well and had no adverse reaction to drug. SIDE EFFECTS CLIENT'S RESPONSE TO TREATMENT

Nursing Responsibilities 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 most common allergic reaction.

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.

Nursing Responsibilities: 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 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.

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.

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