Diagnostic and Laboratory Examinations

COMPLETE BLOOD COUNT Date Ordered: December 5, 2013

Description: A Complete Blood Count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test panel requested by a doctor or other medical professional that gives information about the cells in a patients blood. It was given to our patient for the provision of an overview on our patients general health status and to determine if there is any infection present. Also, it identifies acute and chronic illness, bleeding tendencies, and white blood disorder.

Procedure: 1. The patient is usually assigned in sitting position with the left or right hand stretch on a platform or table with the palm facing palm facing upward. 2. A tourniquet is applied to the area proximal to the vein (closer to the center of the body that the vein itself) to the antecubital area to facilitate pulling of blood. 3. The skin overlying the vein is cleaned using an alcohol pad. Then a needle is inserted through the area of cleansed skin into the vein below where the tourniquet is applied. 4. The blood is then pulled from the vein via the needle by gently pulling the plunger on the syringe or by a connection of the needle to a special vacuum vial that collects the blood. 5. After that, tourniquet is removed to facilitate venous return. 6. A dry cotton ball was taped on the insertion site upon the removal of needle to block the withdrawal of blood.

Nursing Responsibilities: 1. Explain the procedure to the patient and its rationale. 2. Use aseptic technique by cleansing the skin surface of the venipuncture site. 3. Inform the patient that the puncture may cause little pain. 4. Elevate the venipuncture site and pressure if there is continuous bleeding. 5. Report any results to the requesting HCP, who will discuss the results with the patient.

COMPONENT Hemoglobin Hematocrit WBC 13.8 40.9 11.6

RESULT

NORMAL VALUE (MALE) 13.3-18.0 g/dL 39-54 vol % 4-11 x 103/L

ANALYSIS Normal Normal Increased, due to infection Increased, due to infection Decreased, due to infection Normal Normal Normal

Neutrophils

81.1

54-75%

Lymphocytes

10.2

25-40%

Monocytes Eosinophils Platelet Count

5.3 3.2 293x 10

2-8% 1-4% 150-450 x 109/L

URINALYSIS Date Ordered: December 05,2013 Description: The urinalysis is used as a screening and/or diagnostic tool because it can help detect substances or cellular material in the urine. It is ordered widely and routinely to detect any abnormalities that require follow up. Purpose: Procedure: A urine sample is collected in an unused disposable plastic cup with a tight-fitting lid. A randomly voided sample is suitable for routine urinalysis, although the urine that is first voided in the morning is preferable because it is the most concentrated. The best sample for analysis is collected in a sterile container after the external genitalia have been cleansed using the clean-catch method. To collect a sample using the clean-catch method Females should use a clean cotton ball moistened with lukewarm water (or antiseptic wipes provided with collection kits) to cleanse the external genital area before collecting a urine sample. To prevent contamination with menstrual blood, vaginal discharge, or germs from the external genitalia, they should release some urine before beginning to collect the sample. Males should use a piece of clean cotton moistened with lukewarm water or antiseptic wipes to cleanse the head of the penis and the urethral meatus. Uncircumcised males should draw back the foreskin. After the area has been thoroughly cleansed, they should use the midstream void method to collect the sample.

Nursing Responsibilities: Instruct the patient to void directly into a clean, dry container. Sterile, disposable containers are recommended. Cover all specimens tightly, label properly and send immediately to the laboratory. If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen port with antiseptic before aspirating the urine sample with a needle and a syringe.

Observe standard precautions when handling urine specimens. If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated or have an appropriate preservative added. Result Deep Yellow Normal Light dark yellow; amber Clear 4.5-8 1.005-1.030 None Not Present Not Present Not Present Not Present Not Present Analysis Normal

Component Color

Transparency pH / Reaction Specific Gravity Protein Sugar Pus Cells RBC Mucus Threads Bacteria

Turbid 5.0 1.030 +2 Negative 10-12 2-3 Many Occasional

Due to infection Normal Normal Due to infection Due to infection Due to infection Due to infection Due to Due to infection