HEMATOLOGY RESULT
Test Result Reference values Analysis
Hemoglobin
Reduce RBC
Mass 95 135-180 g/L
production
Concentration
Erythrocyte Reduce RBC
.33 0.40-0.54
Volume Fraction production
Mean
Corpuscular 166 150-400x109/L Normal
Volume
Leukocyte
Number 6.0 4.5-11x109/L Normal
Concentration
WBC DIFFERENTIAL COUNT
Neutrophils .72 .35-.65 Due to infection
Lymphocytes .28 .20-.40 Normal
CLINICAL CHEMISTRY SECTION
Potassium 4.45 3.5-5.4mmo/L Normal
Calcium 1.23 1.05-1.30mmo/L Normal
LABORATORY RESULT
HEMATOLOGY RESULT
(Date)
NORMAL RANGE ACTUAL ANALYSIS
FINDINGS
Hemoglobin Female: 120-160 140 Normal
M.C.
Erythrocyte VF 0.38-0.47 0.39 Normal
ENC 4.5-6.0x10 g/L 4.62x10 g /L Normal
TNC 150-400x10 / L 253x10 g / L Normal
MCV 80-100 fL 84 Normal
MCH 26-32% 30 Normal
MCHC 32-36% 36.2 Normal
Leukocyte # 4.5-11x10 g/L 6.10 Normal
concentration
DIFFERENTIALS:
NORMAL RANGE ACTUAL ANALYSIS
FINDINGS
Nuetrophils 0.35-0.65 41 Normal
Lymphocytes 20-40 47 Increased
Monocytes 2-8 7.9 Normal
Eosinophils 0-5 3.6 Normal
Basophils 0-1 0.2 Normal
CLINICAL MICROSCOPY
(Date)
URINALYSIS NORMAL ACTUAL ANALYSIS
RANGE FINDINGS
Color Yellow Yellow Normal
Transparency Clear Clear Normal
PH 6.5-7.5 6.5 Normal
Specific 1.010-1.025 1.010 Normal
Gravity
CLINICAL CHEMISTRY SECTION
(November 9,2007)
NORMAL RANGE ACTUAL FINDINGS
Aspartate 15-37 16 U/L
Aminotransferase
Alanine 30-65 28 U/L
Aminotransferase
CLINICAL CHEMISTRY SECTION
(November 10,2007)
NORMAL RANGE ACTUAL FINDINGS
Aspartate 15-37 17 U/L
Aminotransferase
Alanine 30-65 28 U/L
Aminotransferase
CLINICAL CHEMISTRY SECTION
(November 8,2007)
NORMAL RANGE ACTUAL FINDINGS
Blood Urea Nitrogen 3.3-6.7 2.17 mmol/L
Creatinine 53-115 50 umol/ L
Aspartate 15-37 18 U/L
Aminotransferase
Alanine 30-65 35 U/L
Aminotransferase
TUMOR MARKERS
(November 06,2007)
TEST RESULT METHOD NORMAL RANGE
B-HCG 10.37 ELFA Women Cyclic: Less
than 5.0 mIU/ ml
Menopause Women:
>10 mIU/ ml
X-ray and Ultrasound
Impression
>Cardiomegaly with congestion or pneumonia
R
>Pleural effusion,
>Atherosclerotic aorta (calcified)
>Radiodensity, R lung base,comparison with previous film is
suggested, if any.
COURSE IN THE WARD
DOCTOR’S ORDER RATIONALE NURSING
RESPONSIBILITY
08/08/08
>Admit to CVMC Male >For management or >Assisted the patient on going to
Charity Ward (Medical) treatment bed
>Consent for admission >For legal purposes >Witnessed and explained to the
patient and SO the significance
of the consent
>V/S q hr until stable >To monitor vital signs any >Monitored vital signs of the
abnormal findings patient and recorded
>IVF D5W 1L x KVO >To restore body fluids >Checked for blood clot and IVF
infusion rate and kept patent
>Low salt diet and low fat >To prevent possible >Instructed patient to have a low
diet occurrence of hypertension. salt and low fat diet and
To prevent further explained the importance of the
obstruction of fats in the diet.
lumen of blood vessels to
prevent complications of
heart failure.
>Dx - ECG-done, CXR- >To monitor heart stability. >Ensured patient’s request form
done and prepared the patient for such
Do Serum, Ca+1, K+, procedure.
CBC
>Tx -Furosemide 20mg IV q >To aid in lowering blood >Taught patient about drug
12 hr, hold if BP≤110 mmhg pressure. action and adverse reaction.
-Captopril 25 TID, hold Observed the 10 rights in
if BP≤110 mmhg administering drugs.
-ISMN 3g ½ tab BID,
hold if BP≤110
>O2 3Lpm >To give sufficient oxygen >Explained the purpose of he
for the lungs and for the procedure and how it is done.
body. Regulated oxygen tank. Assisted
client in oxygenation.
>High back rest >To facilitate better lung >Monitored client’s condition.
expansion Performed high back rest.
>Refer Meds to Dr. J >For further proper >Referred
management
>CBR without BRP >To aid in energy >Advised client to simply stay on
conservation. bed and not to have bathroom
activities.
4:30pm
>For RBS >To monitor blood sugar >Secured consent.
level
>Fecalysis with occult blood >To test stool for presence of >Advised patient to submit a
any unusual content and to sample of his stool.
determine any internal
problems.
>Monitor V/S hourly >To have a basis for client’s >Monitored v/s hourly and
present condition monitored patient’s condition.
>I&O q shift >To check if patient has as >Monitored client’s intake and
equal amount of output with output.
his intake and to check if he
has normal intake and output.
08/09/08
>Facilitate administration of >To aid in lowering his blood >Taught patient about drug
Furosemide pressure and to maintain action and adverse reaction.
stability of good condition. Observed the 10 rights in
administering drugs.
>For ABG >Ensured patient’s request form
and prepared the patient for such
procedure.
>CBR >For patient to conserve >Advised client to have
energy for fast recovery sufficient rest and explained the
purpose and reason why he has to
stay on bed all the time.
08/11/08
>Continue meds >For health maintenance >Continued giving his
medications as ordered.
>Start Levofloxacin >Antibiotic >Taught patient about drug
750mg/tab OD action and adverse reaction.
Observed the 10 rights in
administering drugs.
>IVF TF D5W ½ L x KVO >To have an immediate site >Checked for the patency of the
for IV drugs the needs to act IVF and regulated at appropriate
immediately for the client. rate
08/11/08 10:30pm
>Furosemide 40mg/IV now >To facilitate decrease of >Taught patient about drug
then q 8 hrs. blood pressure. action and adverse reaction.
Observed the 10 rights in
administering drugs.
>Cont. management >For client monitoring and >Continued giving nursing care
health improvement. for the client.
>Facilitate administration of >For patient’s antibiotic >Taught patient about drug
Levofloxacin action and adverse reaction.
Observed the 10 rights in
administering drugs.
>V/S q hr >To monitor client’s present >Monitored v/s and monitored
condition and to look for any client.
possible problems.
>MGH >Client is well enough to care >Performed discharge planning.
for self at home.
>Home meds. >To aid in health >Taught patient about drug
-Levofloxacin improvement, maintenance action and adverse reaction.
750mg/tab 1 tab OD x 7 and stability. Observed the 10 rights in
days administering drugs.
-Imdur 60mg/tab ½
tab OD
-Captopril ¼ tab 3x a
day
-Aldazide 1 tab OD x
3 days
>Advised patient to come >For further monitoring even >Instructed patient to come back
back on Aug.20, 2008 at if patient is not in the after 1week for check-up.
1:00pm hospital.
DOCTORS ORDER RATIONALE NX RESPONSIBILITY
November 7, 2007
Please admit to
OB ward under
Dr. T/A
Secure consent To prevent legal Check if consent
for admission bearings is signed by the
patient or SO.
TPR q shift and For baseline data Monitor and refer
record for any deviation
from the normal
To achieve Advised patient
DAT maximum to eat nutritious
nutrition. foods such as
foods rich in
vitamin c.
To assess a
Dxtics: CBC, compensatory Prepare lab
APC, U/A, increase in forms.
SGOT, SGPT, hematocrit,
BUN, CREA, B- Hemoglobin and
HCG, CxRPN erythrocyte
count.
For treatment of
Txtics: Start gestational
chemotherapy choriocarcinoma, Monitor vital
with with signs and other
methotrexate chorioadenoma, side effects of the
0.5 ml OD x 5 destruents and h- drugs. Administer
days mole. drugs following
To optimize the 10 golden
MVS tab OD health at its rules.
maximum level. Advise patient to
For Hormonal take MVS
OCP tab OD balance. regularly.
Administer
For continuous regularly.
V/S q shift monitoring of
baseline data Monitor and refer
for any deviation
Refer
November 8, 2007
7:50 am For maximum
Full diet nutrition
Start
Methotrexate
once SGOT,
SGPT result is
available To treat
Continue oral underlying
meds conditions Advised patient
to take medicines
For baseline data regularly
Monitor V/S
Refer To achieve
November 9, 2007 maximum
8:15 am nutrition
Full diet To treat
underlying
Continue nutrition
Methotrexate For continuous
Continue oral monitoring of
meds baseline data
Monitor V/S q
4o
To achieve
Refer maximum
November 10, 2007 nutrition
8:30 am To treat
Full diet underlying
Continue nutrition
Methotrexate For continuous
Continue oral monitoring of
meds baseline data
Monitor V/S q
4o and record
Refer
November 11, 2007
7:20 am
Full diet
Continue
Methotrexate
For repeat
BUN,
UREA,SGOT, To note for
SGPT relevant changes
Conitnue oral
meds
Monitor V/S q
4o and record
Refer
To treat
November 12, 2007 underlying
8 am treatment
MGH after the
last dose of To note for any Advised patient
Methotrexate deviation to go back for
OPD ff. up, check-up
11/26/07 Advised patient
to continue
Continue OCP taking oral meds
and MVS at
home
Advised
For further
monitoring and
November 13, 2007 evaluation
4:30 pm For continuous
MGH as treatment
ordered