DIAGNOSTICS

A. Complete Blood Count 06/25/12 at 4:20AM

Complete Blood Count (CBC)
Hematocrit

Normal findings

Actual findings

Analysis and interpretation

Normal

Nursing Considerations

40.0-52.0%

42.7

Pre-test: Inform the patient that the test is used to evaluate numerous conditions involving red blood cells, white blood cells, and platelets. Obtain a history of the patients complaints, including a list of known allergens (especially allergies or sensitivities to latex), and inform the appropriate health care practitioner accordingly. Obtain a list of medications the Notify med. Techinicians accordingly. Review the procedure with the patient. Explain to the patient that there may be some discomfort during venipuncture.. There are no food, fluid, or medication restrictions unless by medical direction.

Intra-test: Instruct the patient to cooperate and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Remove the needle, and apply a pressure dressing over the puncture site .Promptly Promptly transport the specimen to the laboratory for processing and analysis. Post-test: Observe venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place, or replace with a plastic bandage
RBC 4.70-6.10 x 106 cells/mm3 6.42 Decreased RBC may place the client at risk for anemia because the body is not getting enough oxygen it needs.

WBC Neutrophils Lymphocytes Eosinophils Monocytes Platelet count MCV MCH MCHC Prothrombin Time (PT)

4,800-10,000/mm3 40-74% 19-48% 0-7% 3-9% 150,000-400,000 82-98fl 28-33pg 32-38% 10-14s

7,300 60 29 2 9 312,000 88 31

Normal Normal Normal Normal Normal Normal Normal

Normal 35 14.3s Normal

Prolonged prothrombin time may indicate a deficiency in any of factors VII, X, V, prothrombin, or fibrinogen. It may mean that the patient has a vitamin K deficiency, a liver disease, or disseminated intravascular coagulation (DIC). A.
Leeuwen (2006) Daviss Comprehensive Handbook of Laboratory and Diagnostic Test 2nd ed.

B. Clinical Chemistry

06/25/12 at 6:00AM Exam Blood Urea Nitrogen (BUN) Creatinine Troponin I Sodium Potassium 3.5-5.0mg/dL Normal findings 2.86-8.93 mmol/L 44.2-150.28 umol/L Actual findings 4.90 99.5 Negative 140.5mg/dL 3.2mg/dL Decreased decrease in potassium levels may cause poor heart conduction altering cardiac rate and rhythm.
A. Leeuwen (2006) Daviss Comprehensive Handbook of Laboratory and Diagnostic Test 2nd ed.

Analysis and interpretation Normal Normal Normal

Nursing consideration

C. Capillary Blood Glucose Levels 06/25/12 starting at 11:30AM CBG 11:30AM 80-120mg/dL or 70110mg/dL 163mg/dL Hyperglycemia Elevated blood glucose is due to low insulin circulating around the body which is responsible for carrying out and Normal findings Actual findings Analysis and interpretation Nursing consideration Identify the correct patient Explain the purpose of the procedure. Explain that a venipuncture must be done and a slight discomfort may be experienced. Explain that a blood sample will be obtained in this procedure

transporting glucose into the cells.

A. Leeuwen (2006) Daviss Comprehensive Handbook of Laboratory and Diagnostic Test 2nd ed.

7:00PM 9:30PM

163mg/dL 203mg/dL

D. Chest X-ray Exam Chest PA- Lateral Normal findings Actual findings No definite active infiltrates seen Heart is not enlarged Aortic knob is calcific Included spine shows degenerative changes REMARKS: Atheromatous aorta Analysis and interpretation
Atheromatous aorta means that fatty deposits on the inner walls of the aorta, which is the largest artery of the body carrying blood away from the heart. This narrows the passageway, and can become mineralized and hardened, as in hardening of arteries, or arteriosclerosis.

Nursing consideration
Pretest: Inform the patient that the procedure assesses cardiopulmonary status. Obtain a history of the patients symptoms and complaints, including a list of known allergens. Obtain a list of the medications the patient is taking. Review the procedure with the patient. There are no food, fluid, or medication restrictions unless by medical direction. Instruct the patient to remove dentures, jewelry (including watches), hairpins, credit cards, and other metallic objects. Intratest: Ensure that the patient

has removed jewelry, dentures, all external metallic objects, wires, and the like prior to the procedure. Patients are given a gown, robe, and foot coverings to wear and instructed to void prior to the procedure. Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure. Place the patient in the standing position in front of the x-ray film or detector. Have the patient place hands on hips, extend neck, and position shoulders forward. Ask the patient to inhale deeply and hold his or her breath while the x-ray images are taken, and then to exhale after the images are taken. Post-test: Reinforce information given by the patients health care provider regarding further testing, treatment, or referral to another health care provider. Answer any questions or address any concerns voiced by the patient or family.

E. ECG Exam Normal findings Actual findings Analysis and interpretation Nursing consideration

Chest PA- Lateral

(+) atrial and ventricular tachycardia (+) Ventricular fibrillation

-heart rhythm originates from the sinus node and has a rate of 60bpm. -irregular rhythm, normal P waves are absent and are replaced by f waves. -occasionally irregular; no P waves associated with PVC

(+) Premature Ventricular contractions

Pretest: Inform the patient that the procedure assesses cardiac function. Obtain a list of the medications the patient is taking. Review the procedure with the patient. Record baseline vital signs. No food, fluid, or medication restrictions exist, unless by medical direction. Intratest: Have the patient remove clothing to the waist and shoes and any hosiery. Instruct the patient to lie very still in a relaxed position during the study and to refrain from tensing muscles after electrode placement Place patient in a supine position. Expose and appropriately drape the chest, arms, and legs. Prepare the skin surface with alcohol and remove excess hair Apply the electrodes in the proper position. Place three limb bipolar leads (two electrodes combined for each) on the arms and legs The machine is set and turned on after the electrodes, grounding, connections, paper supply, computer, and data storage device are checked. If the patient has any chest discomfort or pain during the procedure, mark the ECG strip

indicating that occurrence. Post-test: When the procedure is complete, remove the electrodes and clean the skin where the electrode pads were applied. Evaluate the results in relation to previously performed ECGs. Denote cardiac rhythm abnormalities on the strip. Monitor vital signs and compare with baseline values. Protocols may vary from facility to facility. Evaluate test results in relation to the patients symptoms and other tests performed.