1

VII. LABORATORY RESULT

Diagnostic/Laboratory
Procedure
Date Results Indications/Purposes

Results Normal Values
(units used in the hospital)
Analysis /
Interpretation of Results
Hematology


















Clinical
Chemistry

Date Results:
August 7, 2014

















August 7, 2014
Specimens of venous blood are
taken for a CBC which includes
Hemoglobin and Hematocrit
measurements, RBC indices and
diferential white cell count.













Laboratory tests demonstrating
the presence of physiologically
significant substances in the
blood, urine, tissue, and body
fluids with application to the
diagnosis or therapy of disease.
Hemoglobin: 126



Hematocrit:
38


WBC count: 12.8


RBC count: 4.36


Platelet count:
200


Lymphocytes:
0.30

Monocytes:
0.4

Segmenters:
0.66


Cretinine:
87.2


SGPT/ALT:
15.9
120-180 g/L



37-47 volume %



5-10 x 10
9
g/L


4.3-6.1x10x
12
g/L



150-450 x10
9
/L


0.25-0.50


0.2-0.15


0.50-0.80



35.40-150.30 umol/L




> Normal



> Normal


>high due to presence of infection or
inflammation


>Normal



>Normal



> Normal


>Normal


>Normal


> Normal




2

4-41 U/L

>Normal




Diagnostic/
Laboratory
Procedures
Date Ordered
and date
Result/s In
Indication/s or
Purposes
Result/s Normal Values (Units used
in the Hospital)
Analysis and Interpretation of
results
Nursing
Implication

Urinalysis









Sept. 16, 2009
Result:
Sept. 17, 2009

> To determine the
presence of micro
organism, the type of
organism, and the
antibiotics to which the
organism are
sensitive.
> Assess the color,
odor, and consistency
of the urine and the
presence of clinical
signs of UTI. (
frequency, urgency,
dysuria, hematuria,
flank pain, cloudy
urine with foul odor.

Color: yellow



Appearance:
SlightlyTurbid


Pus cells:
1-2


RBC:
1-3



Epithelial cells:

Color:
straw amber transparent

Appearance:
Amber transparent

Pus cells:
0/HPF


RBC:
Red blood cells: 02/HPF


Epithelial cells:
None to few


Normal



Normal


Not Normal, pus cells are present.


Normal



Not Normal, moderate epithelial cells are present.

Before:
>Explain the purpose of the specimen
collection and the procedure for
collection of the specimen. Client mat
experience anxiety about the
procedure, especially if it is perceived
as being intrusive or if they fear
unknown to the result. A clear
explanation will facilitate cooperation
on the part of the client.
>Provide proper instruction if client will
be the one to collect the specimen.

During:
>Provide client comfort, privacy and
safety. Client may experienced
embarrassment or discomfort when
providing a specimen.
>The nurse needs to be judgemental
and sensitive to possible socio cultural
beliefs that might affect clients
condition.
>Use the correct procedure for
obtaining the specimen.
Aseptic technique should be use in
collection to prevent contamination
that can cause inaccurate results.
3

moderate


Mucus threads:
many


Specific gravity:
1.005


Albumin:
-


Glucose:
negative



None



Specific gravity:
1.010-1.020


Albumin:
Negative


Glucose:
Negative




Not Normal, mucus threads are
present.


Normal



Normal




Normal
>Note relevant information on the
laboratory requisition slip like
medications the client is taking that
can affect the result of the specimen.
>As much as possible collect the
specimen at the first void in the
morning.

After:
>Make sure that the specimen label
and the laboratory requisition carry the
correct information.
>Attach the label securely.
>Transport the specimen to the
laboratory promptly. Fresh specimens
provide more accurate results.
>Report abnormal laboratory findings.






Procedure date result Impression
Chest AP Suppine

>reserved for very ill
patients who cannot
stand erect.
August 7,2014 no definite active lung infiltrate
The heart is not grossly enlarge,
undilated aorta
the mediastinum, diaphragm, costophrenic sulci and visualized bones show no findings
of note.
No significant chest
finding.
4

PELVIC ULTRA SOUND
A pelvic ultrasound
uses sound waves to
make a picture of the
organs and structures
in the lower belly
(pelvis).
A pelvic ultrasound looks at
the bladder and:
The ovaries, uterus,
cervix, and fallopian
tubes of a woman
(female organs ).
August 7,2014 Transabdominal sonogram at 32 and 3/7 postmenstral weeks shows a single NONVIABLE
intrauterine fetus in breech presentation,
No cardiac activity or somatic motion is demonstrated.
No vascular flow is demonstrated in the fetal circulation and heart on color flow mapping.




Fetal Growth Parameters:

measurement Sonographic age
BPD = 69mm 20W OD
HC = 256mm 27W 5D
FL = 51mm 27W 1D
AC = 232mm 27W 3D

Composite age:
Amniotic fluid index = 2.3 + 1+1.9+0.7= 5.8cm (n=6 cm and above)

Diminished amniotic fluid

Fundal and posterior placenta


Single intrauterine fetal
demise

IX. DRUG STUDY
University of Luzon
College of Nursing
Dagupan City


Patients Name: Anisah Lumna Age: 33 Ward/Area: Obstetrics & Gynecology Hospital: Luzon medical Center
Chief Complain: Nape pain/ DOB Diagnosis Impression: Attending Physician: Dra. Pastoral


D R U G S T U D Y
5


Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicati
on
Nursing
Implications
Patient
Teaching

Hydrazaline
Hydrochlorid
e


Apresoline
,
10mg
via IV
every 8
hours

To reduce
after load in
severe CHF (
with
nitrates); and
severe
essential
hypertension
(parenteral to
lower
blood
pressure
quickly).
Directly
relaxes
arteriolar
smooth
muscle.
No adverse
reactions noted,
such as;
>head ache
>vomiting

No interaction
with other drug
Not contra-
indicated to the
patient
>Monitor patients Vital signs
and body weight frequently.
>Some clinicians combine
hydralazine therapy with
diuretics agents to decrease
sodium retention and
tachycardia, and to prevent
anginal attacks.
>Watch patient closely for
signs of lupus erythematosus-
like syndrome (sore throat,
fever, muscle and joint aches,
skin rash).
>Teach patient about
his disease and
therapy. >Explain the
importance of taking
this drug as
prescribed, even when
hes feeling well.
>Inform the patient that
orthostatic hypotension
can be minimized by
rising slowly and
avoiding sudden
position Changes





Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicatio
n
Nursing
Implications
Patient
Teaching
Magnesium
Sulfate

Sulfamag

2.5 mg deep IM
on each buttocks
Prevention or
control of
seizures in
preeclampsia
or
eclampsia
May decrease
acetylcholine
released by
nerve impulses,
but its
anticonvulsant
mechanism is
unknown..
No adverse
reaction noted.
No drug
interaction noted
Not
contraindicated
to the patient
>Use cautiously in
impaired renal function,
myocardial damage,
and heart block, and in
women in labor.
>I.V. use: Monitor vital
signs every 15 mins
>Monitor I & O. urine
output should be 100ml
or more in 4 hr period
before each dose.
Inform
patient
about
short-
term need
for drug,
and
address
any
questions
or
concerns.



6

Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindication Nursing
Implications
Patient
Teaching
Cefuroxime

Zinacef 500mg
1ta every
12hours
Gynaecologic
Infections
Interferes with
bacterial cell
wall, causing
cell to die.
No adverse
reaction noted.
No drug
interaction noted
Not
contraindicated
to the patient
>Explain the action and scientific
explanation of drugs to the patient and
family members
>Assess pts condition at starting
therapy & regularly thereafter to
monitor the drugs effectiveness.
>Monitor patient closely for toxicity
such as tremor, palpitations, increased
heart rate, decreased BP, seizures,
hypokalemia, muscle cramps, headache,
and hyperglycemia.
>Proper disposal of syringe and other
waste materials
>Check for infiltrations and
thrombophlebitis
Advise
patient to
take with
meals to
enhance
absorptio
n. If
tablet
must be
crushed,
mix with
food or
beverage
.


Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contra
indicat
ion
Nursing
Implications
Patient
Teaching
Ketorolac Toradol 30mg
> via IV
Ketorolac is
indicated for
short-term
managemen
t of
pain (up to
five days
maximum).
The primary mechanism of action
responsible for ketorolac's
antiinflammatory,
antipyretic and
analgesic effects is the inhibition of
prostaglandin synthesis by competitive
blocking of the the enzyme cyclooxygenase
(COX). Like most
NSAIDs, ketorolac is a non-selective
COX inhibitor.
As with other NSAIDs, the
mechanism of the drug is associated
with the chiral S form. Conversion of
No
adverse
reaction
noted.
No drug
interaction
noted
Not
contrai
ndicat
ed to
the
patient
>Document indications for therapy,
onset, location, pain intensity/level,
and characteristics of the symptoms

>If given on p.r.n. basis, base the
size of a repeat dose on duration of
pain relief from previous dose. If the
pain returns within 3-5 hours, the
next dose can be increased by up to
50% (as long as the total daily dose
is not exceeded). If the pain does not
return for 8-12 hr, the next dose can
be decreased by as much as 50% or
> inform the
patient that
Ketorolac
may cause
some people
to become
dizzy or
drowsy


7

the R enantiomer into the S enantiomer has
been shown to occur in the metabolism of
buprofen; it is unknown whether it occurs in
the metabolism of etorolac.

the dosing interval can be increased
to q 8-12 hr.


Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contrain
dication
Nursing
Implications
Patient
Teaching
Nicardipine
Drip
Cardene 1D5W
90ml + 10
mL
antihyperte
nsives for
essential
hypertensio
n.
Inhibits the transport
of calcium into
myocardial and
vascular smooth
muscle cells,
resulting in inhibition
of excitation-
contraction coupling
and subsequent
contraction.
Therapeutic Effects:
Systemic
vasodilation
resulting in
decreased blood
pressure. Coronary
vasodilation
resulting in
decreased
frequency and
severity of attacks of
angina.
No adverse
reaction noted
such as;
dizziness
,shortness of
breath
No interaction
noted with
cefuroxime
Not
contraindi
cated to
the
patient
>Establish baseline data before
treatment is started including BP,
pulse, and lab values of liver and
kidney function.

>Monitor BP during initiation and
titration of dosage carefully.
Hypotension with or without an
increase in heart rate may occur,
especially in patients who are
hypertensive or who are already
taking antihypertensive medication.

>Avoid too rapid reduction in either
systolic or diastolic pressure during
parenteral administration.

>Discontinue IV infusion if
hypotension or tachycardia develop.

>Observe for large peak and trough
differences in BP. Initially, measure
BP at peak effect (12 h after dosing)
and at trough effect (8 h after dosing).

>Advise patient to
avoid grapefruit and
grapefruit juice during
therapy.

> Caution patient to
change positions slowly
to minimize orthostatic
hypotension

>Record and report any
increase in frequency,
duration, and severity
of angina when
initiating or increasing
dosage. Keep a record
of nitroglycerin use and
promptly report any
changes in previous
anginal pattern.
Increased incidence
and severity of angina
has occurred in some
patients using
nicardipine.





Generic Brand Dosage, Indicatio action Adverse Interactions Contraindicatio Nursing Patient
8

Name Name Route, &
Frequency
n Reaction n Implications Teaching
Metronidazol
e
noritad
e
500mg
via IV
every
*hours
Amebicid
e in the
managem
ent of
amebic
dysentery
>Disrupts
DNA and
protein
synthesis
in
susceptibl
e
organisms
>Bacterici
dal, or
amebicidal
action
No
adverse
reaction
noted
No
interaction
noted with
cefuroxime
Not
contraindicated
with the patient

>assess pts. Infection
>watch carefully for edema
because it may cause
sodium retention
>assess skin for severity
areas of localadverse
reactions
>record number and
character of stools
>assess pts and familys
knowledge of drug therapy

r>instruct pt. to take oral form with
meals to minimize reactions

>instruct to complete full course of
therapy

>tell pt. not to use alcohol or drugs
that contain alcohol
.>tell pt. that metallic taste and
dark or red brown urine may occur
>may cause dizziness/ light
headedness





Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindication Nursing
Implications
Patient
Teaching
Clindamyci
ne
Cleocin
HCl,
1 capsule
every 8
hours
Treating
serious
infections
caused
by certain
bacteria
used to treat
a wide
variety of
bacterial
infections. It
is an
antibiotic that
works by
stopping the
growth of
bacteria.
No adverse
reaction
noted such
as;
Nausea,
vomiting,
or
diarrhea
no interaction
noted
not contraindicated
to the client
Administer oral drug with a
full glass of water or with food
to prevent esophageal
irritation.
Do not give IM injections
of more than 600 mg; inject
deep into large muscle to avoid
serious problems.
Do not use for minor
bacterial or viral infections.
Monitor renal and liver
function tests, and blood
counts with prolonged therapy.

>inform patient that she
may experience these
side effects: Nausea,
vomiting (eat frequent
small meals);
superinfections in the
mouth, vagina (use
frequent hygiene
measures; request
treatment if severe).
> tell patient to Report
severe or watery diarrhea,
abdominal pain, inflamed
mouth or vagina, skin rash
or lesions.


9





Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindication Nursing
Implications
Patient
Teaching
Mefenamic Apo-
Mefenamic
500mg
1 capsule
every 6
hours
Relief of
moderate
pain when
therapy will
not exceed 1
wk

Anti-
inflammato
ry,
analgesic,
and
antipyretic
activities
related to
inhibition of
prostaglan
din
synthesis
No adverse
reaction
noted such
as ;
Rash,
pruritus,
sweating,
dry mucous
membranes
no interaction
noted
Not
containdicated to
tha patient
>Give with milk or food
to decrease GI upset.

>Arrange for periodic
ophthalmologic
examination during long-
term therapy.

>Institute emergency
procedures if overdose
occurs: gastric lavage,
induction of emesis,
supportive therapy.
Advice patient to:
>Take drug with food; take only the
prescribed dosage; do not take the
drug longer than 1 wk.

>Dizziness, drowsiness can occur
(avoid driving or the use of
dangerous machinery).

>Report sore throat, fever, rash,
itching, weight gain, swelling in
ankles or fingers; changes in
vision; black, tarry stools; severe
diarrhea.



Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicatio
n
Nursing
Implications
Patient
Teaching
Acedofenac clanra 100Mg
every 12
hours
It eases pain
and reduces
inflammation.
Some prostaglandins
are produced at sites
of injury or damage,
and cause pain and
inflammation. By
blocking the effect of
COX enzymes, fewer
prostaglandins are
produced, which
means pain and
inflammation are
No adverse
reaction noted
such as;
Diarrhea, nausea,
headache,
indigestion,
heartburn,
abdominal pain,
flatulence, feeling
sick, dizziness and
rash.
No
interaction
with other
drug
Not
contraindicated
to the patient

tell patient to

>Taking Preservex with
food and drink

>Preservex must be
taken preferably with or
after food.

10

eased.






Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicatio
n
Nursing
Implications
Patient
Teaching
dulcolax
Bisacodyl

1
suppository
NOW
Bisacodyl is
used for the
temporary
relief of
occasional
constipation
and irregular
bowel
movements.
It works by stimulating
the bowel muscles and
also accumulates water
in the intestines. This
helps to soften the stool
and produce a bowel
movement more quickly.
The tablets should be
taken at bedtime to
produce a bowel
movement the next
morning. The
suppositories usually
take about 15 minutes to
1 hour to work
No adverse
reaction
noted.
No drug
intertion
noted
Not
contraindicate
d to the patient
>Evaluate periodically
patient's need for
continued use of drug;
bisacodyl usually
produces 1 or 2 soft
formed stools daily.

>Monitor patients
receiving concomitant
anticoagulants.

>Indiscriminate use of
laxatives results in
decreased absorption
of vitamin K.
Inform the client to
:
>Add high-fiber
foods slowly to
regular diet to
avoid gas and
diarrhea.
>Adequate fluid
intake includes at
least 68
glasses/d.
?Do not breast
feed while taking
this drug without
consulting
physician.

Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicatio
n
Nursing
Implications
Patient
Teaching
Nifedipine adalat
gitz
1 tab
once a day
hypertension causes blood-
pressure
lowering
through
peripheral
vasodilation. It
can cause an
uncontrollable
decrease in
No adverse
reaction
noted.
No drug
interaction
noted
Not
contraindicated
to the patient
> Monitor BP and
pulse before
therapy, during
dose titration and
periodically during
the therapy.

>Adalat should
never be
>instruct patient on technique
for monitoring pulse. If heart
rate is below 50 beats per
minute

>Instruct the patient to avoid
concurrent use of alcohol or
OTC medications and natural
or herbal products especially
11

blood pressure,
reflex
tachycardia,
and a steal
phenomenon in
certain vascular
beds.
administered with
grapefruit juice.
As it can increase
the level of the
medicine in the
blood and thus
increase its effect
on the blood
pressure.
cold preparations, without
consulting the doctor.he
physician should be notified.

>Advise patient to take
medication exactly as
directed. Missed doses
should be taken as soon as
remembered unless almost
time for next dose.


Generic
Name
Brand
Name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindication Nursing
Implications
Patient
Teaching
Nebirolol Nebilet 5mg
1 tab,
once a day
hypertension Blocks beta receptors.
Factors that may be
involved in mechanism
of action include
decreased heart rate
and myocardial
contractility, diminished
tonic sympathetic
outflow to the periphery
from cerebral
vasomotor centers,
suppressed renin
activity, and decreased
peripheral vascular
resistance. Lacks
intrinsic
sympathomimetic
activity at
therapeutically relevant
doses.
No adverse
reaction noted
Interted with
nifedipine
Not
contraindicated to
the patient
Closely monitor
patients receiving
anesthetic agents
that depress
myocardial
function. When
discontinuation of
nebivolol is
planned, carefully
observe patients
and advise them to
minimize physical
activity. Closely
monitor patients
suspected of
developing
thyrotoxicosis when
nebivolol therapy is
to be withdrawn.
>Advise patients
that this medicine
may be taken with
or without food.
>Caution patients
to avoid sudden
position changes
to prevent
orthostatic
hypotension.






12


Generic
Name
Brand
name
Dosage,
Route, &
Frequency
Indication action Adverse
Reaction
Interactions Contraindicati
on
Nursing
Implications
Patient
Teaching
bromocript
ine
Parlodel 2.5mg
1 tab
3 times a
day
mTo stop milk
production after
an abortion or
miscarriage or in
women after a
delivery who
should not
breastfeed for
medical reasons.
Bromocriptine
blocks the release
of a hormone
called prolactin
from the pituitary
gland. Prolactin
affects the
menstrual cycle
and milk
production.
No adverse
reaction
noted.
No drug
intertion
noted
Not
contraindicate
d to the
patient
>Monitor vital signs
closely during the first
few days and
periodically throughout
therapy.

>Lab tests: Periodic
CBC, liver functions
and renal functions
with prolonged therapy.
Inform patient that,
>taking
bromocriptine to
suppress
postpartum
lactation may have
temporary rebound
breast enlargement
and pain following
drug withdrawal.

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Date: Date: