CBC Test Hemoglobin Normal Result Remark Rationale Values 115.0- 137.0 Normal Hemoglobin carries 155.

0 oxygen to and removes carbon dioxide from red blood cells. It measures total amount of hemoglobin in the blood Hematocrit 0.360.52 0.42 Normal Hematocrit measures the percentage of red blood cells in the total blood volume RBC 4.2-6.1 4.47 Normal Measures the number o RBCs per cubic millimeter of the whole blood. WBC 5.010.0 14.1 High Determines the number of circulating WBCs per cubic millimeter of the whole blood. Elevated levels Within normal range The patient may feel discomfort when blood is drawn from a vein. Within normal range Interpretation Within normal range Nursing Responsibilities There is very little risk associated with taking blood from a vein in the arm, although there is a slight risk of infection anytime the skin is broken. Strict asepsis should be observed

Bruising may occur at the puncture site, or the may be caused by person may feel dizzy or acute infections faint. Pressure should be tuberculosis, pneumonia, meningitis, applied to the puncture site until the bleeding

tonsillitis, appendicitis, colitis, etc. Neutrophil 55-75 74 Normal Phagocytes engulfing bacteria and cellular debris. It prevents or limits bacterial infections. Lymphocytes 20-35 21 Normal Cells present in the blood and lymphatic tissue that provide the main means of immunity for the body. There are three types of lymphocytes: the natural killer (NK), thymus-derived lymphocytes (T cells), and bone marrow-derived lymphocytes (B cells). NK cells are found in the blood, red bone marrow, lymph nodes and spleen and are able to destroy many kinds of infected Within normal range Within normal levels.

stops to reduce bruising. Warm packs can also be placed over the puncture vsite discomfort to relieve

Instruct patient in dietary sources of iron such as red meat, organ meats, clean green vegetable and fortified grains

Protect the patient from potential sources of infection, monitor for signs of infection. Provide soft, bland diet high in protein, vitamins, and calories. Meticulous hand washing and strict asepsis are mandatory

body cells and tumor cells. The T cells and B cells are involved in specific immune responses. Monocytes 2-10 4 Normal This type of granular leukocyte functions in the ingestion of bacteria and other foreign particles Eosinophil 1-8 1 Normal Functions in allergic responses and in resisting infections. Eosinophils mount on attack against parasitic invaders by attacking to their bodies and discharging toxic molecules from their cytoplasmic granules. Platelet 150.0400.0 278 Normal A test that direct count of platelets in whole blood. Platelets number from 100,000-500,000 per cubic millimeter and are Within normal range Within normal range Within normal range

Institute isolation

protective measures

immediately if there is neutrophil disorder. Also instruct the patient to observe aseptic

technique and to take caution most especially if immunocompromised. Inflammatory responses involve more than one body system. Monitor

the patient for worsening of the inflammatory particularly

condition, respiratory

compromised.

Encourage patient to rest between activities. Encourage patient to

important in triggering the sequence of events that leads to the formation of blood clots.

plan ahead and save energy for the most important activities. Encourage patient to void or stop activities that make short of breath or make heart beat faster. Encourage patient to Eat a diet with adequate protein and vitamins. Drink plenty of noncaffeinated and nonalcoholic fluids.

Urinalysis - Urinalysis is a physical, microscopic, or chemical examination of the urine. It is done to detect urinary tract infection. It also measures the level of ketones, sugar, protein, blood components and many other substances

May 8, 2010 TEST Glucose RESULT Negative NORMAL <50mg/dL CLINICAL SIGNIFICANCE Glucose is the type of sugar found in blood. Normally there is very little or no glucose in urine. When the blood sugar level is very high, as in uncontrolled diabetes. Glucose can also be found in urine when the kidneys are damaged or diseased. Protein Negative <30mg/dL Protein is normally not found in the urine. Fever, hard exercise, pregnancy, and some diseases, especially kidney disease, may cause protein to be in the urine. Bilirubin Negative <1mg/dL This is a substance formed by the breakdown of red blood cells. If it is present, it often means the liver is damaged or that the flow of bile from the gallbladder is blocked. Wash hands to make sure they are clean before collecting the urine. If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers. Clean the area around your genitals. NURSING RESPONSIBILITIES Advise Patient to:

Begin urinating into the toilet or urinal. Finish urinating into the toilet or urinal. Carefully replace and tighten the lid on the cup then return it to the lab. After the urine has flowed for several seconds, place the collection cup into the urine stream and collect "midstream" urine without stopping your flow of urine. Do not touch the rim of the cup to your genital area. Do not

get toilet paper, pubic hair, stool (feces), menstrual blood, or anything else in the urine sample.

pH

4.5-8

Urine pH is used to classify urine as either a dilute acid or base solution. The lower the pH, the greater the acidity of a solution; the higher the pH, the greater the alkalinity. The glomerular filtrate of blood is usually acidified by the kidneys from a pH of approximately 7.4 to a pH of about 6 in the urine

Blood

Negative

<510RBC/mL

Red blood cells in the urine may be caused by kidney or bladder injury, kidney stones, a urinary tract infection (UTI), inflammation of the kidneys (glomerulonephritis), a kidney or bladder tumor, or systemic lupus erythematosus (SLE).

Leukocytes

25

<25WBC/m L

Leukocyte esterase shows leukocytes in the urine. WBCs in the urine may mean a UTI is present. Urine is normally clear. Bacteria, blood, sperm,

Clarity

Clear

Clear

crystals, or mucus can make urine look cloudy. Specific gravity 1.010 1.010-1.030 This checks the amount of substances in the urine. It also shows how well the kidneys balance the amount of water in urine. The higher the specific gravity, the more solid material is in the urine. Color Yellow Pale to dark yellow Many things affect urine color, including fluid balance, diet, medicines, and diseases. How dark or light the color is tells you how much water is in it. Vitamin B supplements can turn urine bright yellow. Some medicines, blackberries, beets, rhubarb, or blood in the urine can turn urine red-brown.

Blood Chemistry - A number of tests performed on blood serum (liquid portion of the blood). It determines certain enzymes that may be present (including lactic dehydrogenase [LDH], certain kinase [CK], aspartate aminotransferase [AST], and alanine aminotransferas [ALT]), serum glucose, hormones such as thyroid hormone and other substances such as cholesterol and triglycerides. These tests provide valuable diagnostic cues.May 9, 2010

TEST Total Bilirubin

RESULT 8.3

REFERENCE 2.0 21.0

REMARK Normal

RATIONALE It occurs when bilirubin production exceeds the liver's excretory capacity. This may occur because (1) too much bilirubin is being produced, (2) hepatocytes are injured and cannot metabolize or excrete bilirubin, or (3) the biliary tract is obstructed blocking the flow of conjugated bilirubin into the intestine

Direct Bilirubin

0.9

0.0 3.4

Normal

Increases in conjugated bilirubin are highly specific for disease of the liver or bile ducts

Inderct Bilirubin

7.4

2.0 17.0

Normal

Increase in unconjugated bilirubin may be caused by hepatic disease, cholestasis, and hemolysis

SGPT

.9

0.0 34.0

Normal

SGPT is released into blood when the liver or heart is damaged; thus, this is to determine liver disease.

SGOT

55.6

0.0 31.0

High

SGOT is an enzyme found in high amounts in heart muscle and liver and skeletal muscle cells. Elevated levels may be caused by liver or heart disease

Pro- Thrombin

11.3

12- 16 secs

LOW

Prolonged by deficiency of factors I, II,V, VII, and X, fat malabsorption,severe liver disease, coumaDin anticoagulant therapy. Present cbc shows normal Prothrombin time

Medical sonography (ultrasonography) is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Ultrasound has been used by sonographers to image the human body for at least 50 years and has become one of the most widely used diagnostic tools in modern medicine.

12/28/10 Impression:

Veterans Memorial Medical Center

obstructive cholelithiasis Ultrasonically normal liver, intrahepatic ducts, pancreas, spleen, aorta, paraaortic areas, kidneys and urinary bladder

Nursing Responsibilities: Explain the procedure and purpose of the test Provide a gown without snaps, and ask the patient to remove all jewelry Take ultrasound if the patients bladder is fluid filled for better results