Laboratory Results

Urinalysis Results
Characteristic Normal finding/s Actual Finding Implication Interpretation
Color Yellow, amber, nearly
colorless or transparent
Yellow
Checking the color and
clarity of the urine sample is
the first test performed. The
urine sample is visually
examined for color, with
"yellow," "straw," or "nearly
colorless" being typical
normal values. Abnormal
colors are possible: orange
can be a side effect of a
prescription medication,
brown and pink may indicate
the presence of blood, and
dark yellow can mean
dehydration.
Based on the actual
findings, the patients urine
color is normal.
Appearance Clear Clear
Infection may cause urine to
become cloudy, giving it a
hazy appearance.
Based on the actual
findings, the patients urine
appearance is normal.
Sugar Negative negative
Finding glucose in the urine
is not a normal finding.
Typically, it is found in
patients with diabetes.
Based on the actual findings
the patients urine is
negative for sugar, which is
a normal finding.
Mucous Negative negative
Mucus in the urine indicates
Bacterial Infection.
Based on the actual finding,
the patient is negative for
mucous, which is a normal
findings.
Pus cells Negative negative
Pus cells in the urine
indicate infection.
The patients urine is
negative for pus cells, which
is a normal finding.
RBC Negative negative
Significant numbers of RBC
in the urine typically indicate
the presence of infection.
The patients urine is
negative for RBC, which is a
normal finding.

Bacteria Negative negative
The presence of bacteria
may indicate an infection or
contamination of the sample.
The patients urine is
negative for bacteria, which
is a normal finding.
pH 7.35-7.45 7.48
Urine become increasingly
acidic as the amount of
sodium and excess acid
retained by is increasing.
Encourage the patient to
increase fluid intake and
food intake such us citrus
fruits and green leafy
vegetables.
Specific gravity 1.010-1.025 1.020
This portion of the test
determines how
concentrated the urine is. If
the patient is dehydrated, for
example, the specific gravity
will be high. If the person is
very well hydrated, a lower
result is expected.
Based on the actual
findings, the patients urine
specific gravity is in normal
range.
Albumin Negative negative
Finding protein in the urine
is not a normal finding.
Seriously, elevated levels
may indicate that there is a
problem with kidney
function.
Based on the actual
findings, the patient is
negative for albumin, which
is a normal finding.

Hematology Results
Characteristics Normal Finding/s Actual Finding/s Implication/s Interpretation
Hgb Concentration 135 - 160 135 g/L
A decrease Hgb indicates
anemia, severe
hemorrhage, cancer, kidney
disease and splenomegaly.
Increased Hgb indicates
polycythemia vera,
dehydration, COPD and
high altitudes.
Based on the actual
findings, patients
hemoglobin concentration is
within normal range.
Leucocytes 4.5 10 10.2
Elevated leucocytes usually Based on the normal
indicates infection, tissue
inflammation or tissue
necrosis. A decreased
leucocyte indicates a
decrease in production or
an increased destruction of
the cells.
findings, the patients
leucocytes are slightly
elevated but it should be
referred to the attending
physician immediately,
especially if the patient will
undergo a surgery.
Segmenters 0.55 - 0.65 0.47
Segmenters increases
during a bacterial infection.
Decrease Segmenters
increases the risk of
bacterial infection.
The patient had decreased
Segmenters. This abnormal
finding should be referred to
the patients attending
physician because decrease
Segmenters increases the
risk of bacterial infection.
Lymphocytes 0.25 - 0.40 0.44
Elevated lymphocyte
indicates a viral infection
and chronic infection.
Lowered lymphocytes
usually indicate
immunodeficiency disease.
The patient had increased
lymphocytes. This abnormal
finding should be referred
immediately to the patients
attending physician because
this may indicate that the
patient had an infection or
ongoing infection.
Monocytes 0.02 - 0.06 0.08
Elevated Monocytes
indicates inflammatory
disorders: viral infection
such as mononucleosis,
tuberculosis, chronic
ulcerative colitis and
parasites such as those
associated with malaria.
Monocytes can be
decreased in prednisone
therapy, overwhelming
infections, aplastic anemia
and HIV infection.
The patient had increased
Monocytes. This abnormal
finding should be referred
immediately to the patients
attending physician because
this may indicate that the
patient had an infection.
Eosinophils 0 - 0.04 0.01
Elevated eosinophils indicate
parasitic infections, allergic
reaction, eczema, leukemia
and autoimmune diseases.
Based on the actual
findings, the patients
eosinophils are within
Eosinophils will decrease if
there is an increase of
adrenosteroid production.
normal range.
Thrombocytopenia 150 300 238 g/L
Increased thrombocytopenia
indicates polycythemia vera,
post Splenectomy
syndrome, rheumatoid
arthritis and can occur in
malignant disorders.
Decrease thrombocytopenia
indicates hemorrhage and
can occur in idiopathic
thrombocytopenic Purpura,
leukemia, chemotherapy,
DIC and increased use or
destruction of platelet.
Based on the actual
findings, the patients
thrombocytopenia is within
normal range.
Hematocrit 0.39 0.49 0.46
Low hematocrit indicates
anemia, normal pregnancy,
hemorrhage and leukemia.
Elevated Hct indicates
polycythemia vera,
Eclampsia, dehydration and
burns.
Based on the actual
findings, the patients
hematocrit is within normal
range.








SYNTHESIS OF CLIENTS CONDITION
Criteria Good Fair Poor Justification
Family Support




The rating is good because patient Js wife
is very supportive, especially when he
decided to undergo a surgery.
Environment


According to what he had observed, the
place where they live has a clean
environment but some areas in their
community are not that clean.
Financial



The rating is good because they can afford
all the expenses in the hospital because
Patient J has a lending business with an
income of at least 15,000 a month.
Age



Patient Js age belong to middle
adulthood. It is rated fair because in this
stage he is already mature physically,
mentally, emotionally and spiritually and
could tolerate the surgery but in this stage,
Middle-aged adults often show visible
signs of aging such as loss of skin
elasticity and graying of the hair. Physical
fitness usually wanes, with a 510 kg (10
20 lbs.) accumulation of body fat,
reduction in aerobic performance and a
decrease in maximal heart rate. Strength
and flexibility also decrease throughout
middle age and these may be factors to
develop risks during the surgery.
Onset of Illness




The rating in this criterion is fair because
patient J waited for two months before he
consulted a physician but the good thing is
he consulted a physician before it become
severe and creates complications.
Duration of Illness






The rating of this criterion is fair because
like what is stated in the previous criterion
he waited for two months before he
consulted a doctor but when the time he
consulted the doctor he immediately
suggest to remove the lump (fibroma) in
his perineal area to prevent it from
growing, which may result to
complications.
Compliance of
Medication



The rating is good because Patient J is
very cooperative. He is able to comply and
tolerate all his medicines prescribed.

Legends:
Good 3pts. Fair 2pts Poor - 1pt

Rating:
Good: 2.4 3 Fair: 1.7 2.3 Poor: 1 1.6

Computation:
Good: 3 x 3 = 9 Fair: 2 x 4 = 8 Poor: 1 x 0 = 0

Total: 17/7 = 2.43



GENERAL PROGNOSIS
Based on the result, the overall prognosis of the patient is good because after he consulted a physician, he immediately suggested
removing the fibroma in his perineal area to prevent it from growing larger, which may result to complications. The patients health
status is progressing after the surgery and therapeutic regimens are effective and well tolerated. He can afford the expenses in the
hospital and medications prescribe by the attending physician. His wife is also supportive to him and very concern in terms of his
health. Therefore, the patient achieved a state of good care given by the healthcare professionals.
RECOMMENDATION

Patient J must sign the consent form before undergoing the procedure. According to his laboratory results, he had an infection so
he must take antibiotics prescribe to him and finish the course of medicine until the prescribed time of administration. The patient
must not have a full stomach when undergoing surgery, so, the patient is not on NPO but he must not eat much or drink much
before surgery. The patient must know about the procedure to avoid anxiety about the procedure. The patient must have calm state
of mind, so, patients cooperation especially during patient education is necessary.