C.

Diagnostic Procedure

Name

Date

Normal Values

Value Obtained

Interpretation and

of the

Ordered

(according to

(Results of the Test)

Analysis

Proced

hospital

ure
Chest X-

standards)
Normal lung

There is no significant

The patient has chronic

ray

fields, cardiac

interval change in the

Kochs infection

size, mediastinal

Kochs infiltrates

with bronchiecsis

structures,

on both lung fields

Changes. Bilateral lung

thoracic spine,

and the bronchiectasis

fields, radio graphically

ribs and

changes on the right

stable since the1/20/09

diaphragm

mid and lower lung

LAGYAN MO NG

fields and the left

DATE chest

upper lobe compared

radiograph. Mild

with the 1/20/09

cardiomegaly, left

LAGYAN MO NG

ventricular form.

DATE chest

Atheromatous aorta.

radiograph. The heart

Dextro scoliosis,

is minimally enlarged

thoracic spine

with left
ventricular form. The
aortic knob iscale fied.
The diaphragm, sulci

and ribs are intact.

Nursing Responsibilities: Prepare your patient

Inform the patient about the purpose of the procedure, various positions to assume, and the need
to hold his or her breath.
Inform the patient that the procedure takes 5 to 10 minutes.
There are no food or fluid restrictions.
Inform the patient that no pain is associated with the study.
Perform procedure
Instruct the patient to remove clothing and metallic objects from the waist up.
Give the patient a gown and robe to wear.

Remove any wires connected to electrodes, if allowed.

Place patient in a standing, sitting, or recumbent position in front of the x-ray film holder.
Have the patient place hands on hips, extend neck, and position shoulders forward.
Position the chest with the left side against the film holder for a lateral view.

Instruct the patient to inhale deeply, to hold his or her breath while the x-ray is taken, and then
exhale after the film is taken.
Care after the test
Inform the patient of the possible need for additional chest x-rays to evaluate progression of the
disease process or determine the need for a change in therapy.
Determine if the patient or family members have any further questions or concerns.
A physician sends a written report to the ordering health care provider, who discusses results
with the patient

Name of the

Date

Normal Values

Value

Interpretation

Procedure

Ordered

(according to

Obtained

and Analysis

hospital

(Results of the

standards)

Test)

Hematocrit

Male: 40.0-

41.0%

The patients

54.0%

hematocrit is

Female 37.0

within normal

47.0%

values which
mean that the
concentration
of red bloods
cells is normal

Nursing Responsibilities Prepare your patient

Explain that this test helps evaluate if there are enough red blood cells in the blood, or if there is
too much or too little water in the body.
Perform procedure
Collect 7 mL of venous blood in a lavender-top tube.

Alternately, collect the sample in a heparinized capillary tube (red-banded tube) and seal on or
both ends after collection.
Care after test
Observe the patient for signs and symptoms of anemia including pallor, tachycardia, dyspnea,
chest pain, and fatigue. Severe anemia may produce these symptoms from tissue hypoxia
Encourage rest periods for patient experiencing fatigue related to anemia.
Evaluate patients ability to perform activities of daily living.

Discuss with patient or family the significance of hematocrit levels. For example, extreme
increases in red blood cells may trigger a stroke in some individuals. Acute dehydration can start
a sickling crisis.

Name of the

Date

Normal Values

Value

Interpretation

Procedure

Ordered

(according to

Obtained

and Analysis

hospital

(Results of the

Hemoglobin

standards)
12.5 g/dl

Test)
The patients
hemoglobin is
within normal
values which
mean that the
ability of
red blood cells
to carry oxygen
and carbon
dioxide to and
from tissues is
normal.

Nursing Responsibilities Prepare your client

Explain that this test measures a part of the blood that carries oxygen.
Perform procedure
Collect 5-7 mL of venous blood in a lavender-top tube.
Alternately, a finger stick or heel-stick method may be used to collect venous blood ina
heparinized capillary tube.
Care after test
Observe the patient for signs and symptoms of anemia including pallor, dyspnea, chest pain, and
fatigue.
Encourage rest periods for patient experiencing fatigue related to anemia.
Evaluate patient ability to perform activities of daily living.
If a low hemoglobin level indicates the possibility of blood loss or anemia, instruct the patient
or family that further testing will be necessary to identify the cause of thecondition to treatment.

Name of the

Date

Normal Values

Value

Interpretation

Procedure

Ordered

(according to

Obtained

and Analysis

hospital

(Results of the

standards)

Platelet count

141-440

Test)

247

The patients
platelet count is
within normal
range which
means that there
is adequate
coagulating
function.

Nursing Responsibilities Prepare your patient

Explain that this test helps assess the bloods ability to clot
Perform procedure
Collect 7 mL of venous blood in a lavender-top tube.
Apply pressure or a pressure dressing to the venipuncture site.
Care after test
Hold pressure ate the venipuncture site for 5 minutes to prevent hematoma formation.
Assess patient for unusual bruising or prolonged bleeding from venipuncture site.Delayed
clotting is a complication of severely impaired clotting.

Test all body secretions including stool, gastrointestinal aspirate, and tracheal aspiratefor occult
blood. Closely inspect mucous membranes for bleeding.

Teach the patient and family members about bleeding, precautions including using asoft-bristled
toothbrush, using a electric razors, avoiding constipation, avoiding pickingtheir nose, and
avoiding constricting clothing.
Teach the patient and family the signs and symptoms of bleeding including petechiae(small
purplish spots on the skin), bruising, and blood in the urine or stool, vaginal bleeding, and
bleeding from any other sites.

Name of the

Date

Normal

Value Obtained

Procedure

Order

Values

(Results of the

ed

(according

Test)

Interpretation and Analysis

to hospital
standards)

White blood

4.7 10

13.8

cell

The patient has increased levels

of WBC (leukocytosis) which
indicate infections, inflammation,
stress or hemorrhage.

Lymphocyte/

The patient is

Monocytes

compromised because of immune

deficiency. So this type of WBC is

(%)

(x10/1)
Granulocyte

28.0 48.0

18

1.2 5.3

2.5

decreased.

The immune system of the patient

may be poor or an overwhelming

(%)

44.2- 80.2

(x10/1)

82

infection is present.

11

Nursing Responsibilities Prepare your patient

Explain to your patient that this test helps to assess the bodys ability to fightinfection, to tell the
difference between an infection and an allergy, or to find problemswith the way bone marrow
makes blood cells.
Instruct your patient to avoid strenuous physical activity for 24 hours prior to testing,if possible.

Perform procedure
Collect 7 mL of venous blood in a lavender-top tube.
Gently invert the collection tube several times immediately after collection to mix thesample
with the anticoagulant in the tube.
Care after test
If WBC differential indicates an infection, assess patient responses to antimicrobials.
Interventions will include assessment of vital signs, focused physical assessment of body
systems affected, administration and maintenance of fluids, monitoring intake and output, and
assistance with activities of daily living as required.
If WBC differential indicates an allergic or inflammatory response, monitor the clients response
to therapies. Inflammatory responses may worsen or involve more than one body system.
Monitor the patient for worsening of the inflammatory condition, particularly respiratory
compromise.
When decreased bone marrow activity is demonstrated on the WBC differential, instruct your
patient about the importance of obtaining immunizations that may provide some level of
protection (pneumococcal vaccine, flu vaccine, hepatitis B vaccine). Also instruct the patient and
family about the importance of avoiding individuals with acute illnesses and upper respiratory
infections. If the patient lives with young children, it is important to maintain the immunization
schedule of these children to prevent unnecessary exposure of the client to infections.
When an allergic or inflammatory condition is identified, explore possible interventions for
preventions for prevention of recurrences with the patient and family.

Explain the similarities and differences in treatment and management of parasitic, viral, and
bacterial illnesses to the patient and family. Discuss routes of transmission to help the patient and
family identify means of limiting exposure of others.

BLOOD CHEMISTRY

Name of the

Date

Normal

Value Obtained

Procedure

Order

Values

(Results of the

ed

(according

Test)

Interpretation and Analysis

to hospital
Arterialblood

standards)
7.35-

gas

7.45mmHg3 34.3PO:

alow pCO level,and a normal

5-

89.3HCO:

HCO which means that the

45mmHg80

25.6O Sat:

patient is experiencing respiratory

2.8B.E: 97.4

alkalosis. A highO sat and

pH: 7.491 pCO:

he patient has ahigh pH level,

100mmHg2

B.E.level was also noted. The

2-

patient may have

26mEq/L2

fever,hyperventilation and

mEq/L(97%
Nursing Responsibilities :

excessive artificial ventilation.

Prepare your patient

Obtain a history of the patients complaints, including known allergies

Obtain a history of the patients cardiovascular and respiratory systems, any

bleedingdisorders, and results of tests and procedures previously performed, especially

bleedingtime, clotting time, complete blood count, and prothrombin time.

Obtain a list of medications the patient is taking including anticoagulant therapy. It
isrecommended that use of these medications be discontinued 14 days before dental or

surgical procedures.
Note any recent procedures that can interfere with test results

Administer oxygen, if appropriate.

Observe the patient for signs or symptoms of respiratory alkalosis such as

tachypnea,restlessness, agitation, tetany, numbness, seizures, muscle cramps, dizziness,
or tinglingfingertip.

Instruct patient to breathe deeply and slowly; performing this type of breathingexercise
into a paper bag decreases hyperventilation and quickly helps the patients breathing
return to normal

Name of the

Date

Normal

Value Obtained

Procedure

Order

Values

(Results of the

ed

(according

Test)

to hospital
standards)

Interpretation and Analysis

potassium

3.55.1mEq/L

5.1 mEq/L

The patient hasnormal level of

potassium which means that
thereis normalosmotic pressureand
cardiac andneuromuscular
electrical conduction

Nursing Responsibilities
Prepare your patient

Explain that the test is helpful in identifying chemical imbalances, specifically potassium.
Collect 5-10 mL of venous blood in a red-top or green-top tube.
Collect blood form the arm opposite an intravenous infusion of electrolyte solution.
Do not allow patient to pump the arm with a tourniquet in place.URINE
Use a clean 3-L container and no preservative.
Carefully collect a 24-hour urine sample.
Keep the collection container on ice or refrigerated during the collection period.

Care after test

Monitor for signs and symptoms of hypokalemia including weakness,

paralysis,hyporeflexia, ileus, dizziness, thirst, increased sensitivity to digoxin and

cardiacdysrhythmias.
Monitor for signs and symptoms of hyperkalemia including weakness,

paralysis,irritability, nausea and vomiting, intestinal colic, and diarrhea.

Monitor intake and output.

Name of the

Date

Normal

Value Obtained

Procedure

Order

Values

(Results of the

ed

(according

Test)

Interpretation and Analysis

to hospital
sodium

standards)
135-

137 mEq/L

145mEq/L

the patientssodium level iswithin

normalvalues whichmeans there
iswater balanceand extracellular
fluid replacementis functioning

Nursing Responsibilities: Prepare your patient

Explain that this test is helpful in evaluating the balance of chemicals in the
body, particularly sodium. Explain how sodium balance is regulated by the kidneys and

twoglands near the kidneys called the adrenals.

Collect 5-7 mL of venous blood in a red-top tube.
Avoid collecting blood near a vein where saline or electrolyte solutions are

infusing.URINE
Collect 24-hour urine specimen without preservatives.
Keep specimen refrigerated or on ice during the collection period.
Instruct the client that all urine voided in the next 24-hour period must be added to

thecollection container.
Monitor intake and output. Report urine output less than 30 mL/hour in adults, lessthan 1

mL per kg body weight per hour in infant and children.

Monitor urine specific gravity every 8 hours and as indicated.
Monitor vital signs every 4 hours and note changes in blood pressure and pulse.
Weigh daily; assure the clothing, time of day, and scales are consistent.

Assess breathing sounds every 4 hours for presence of rales

Name of the
Procedure

Date

Normal

Value Obtained

Order

Values

(Results of the

ed

(according

Test)

Interpretation and Analysis

to hospital
Glucose

standards)
75-111

102mg/dl

mg/dl

The patientsglucose is
withinnormal valueswhich mean
thatrandomlycollected bloodfrom
the patientyields a normallevel of
sugar

Nursing Responsibilities: Prepare your patient

Explain that this test is to measures the amount of sugar in the bloodstream and isoften

used to look for any sign of sugar diabetes (diabetes mellitus).

Do not give insulin, oral antidiabetic agents or food until after the blood is drawn.
There is no period of fasting for this random analysis of blood glucose.
Perform a venipuncture and collect 5 cc of blood into a red-top or green-top tube.
Patient or staff may instead use a bedside glucometer after obtaining a sample from

afingerstick. Follow the manufacturers directions for usage.

Administer any medications withheld for this test.
Resume patients normal diet immediately to prevent hypoglycemia.
Assess for symptoms such as nausea, light-headedness, hunger, and tremors, whichmay

signify hypoglycemia.
If the blood glucose is extremely low, administer a source of carbohydrates byoffering
crackers, orange juice, or other high-carbohydrate foods to patient who has noalteration

in level of consciousness
Inform the patient and family that continued elevated blood glucose levels mayindicate

sugar diabetes (diabetes mellitus).

Begin or reinforce diabetic teaching as indicated.
Encourage patient to self-monitor blood glucose.
Encourage patient and family to join diabetes support groups

Name of the
Procedure

Date

Normal

Value Obtained

Order

Values

(Results of the

ed

(according

Test)

Interpretation and Analysis

to hospital
standards)

2D echo

Normalappe

LV

Some of thevalves of the patients

arancein the

sizewithhyperthr

heartare thickenedwhich

size,

opied

mayindicate mitralvalve

position,stru

wall(concentricL

prolapse,valvular

cture,andmo

VH)

stenosis,ventricular dysfunction,

vementsof

withadequatecon

pericardialeffusion,valvular

the

tractilityand

insuffiency or regurgitation

heartvalvesv systolicfunction
isualizedand

withDoppler

recoredin

evidence of

acombinatio

impaired

nof

LVrelaxation.2.L

ultrasoundm A, RA,RV,
odes;

MPAand

andnormal

aorticrootdimens

heartmuscle

ion.3.Thickeneda

wallsof

ortic valvecusps

bothventricl

withno

esand

restrictionof

leftatrium,

motionwith

withadequat

aorticannular

e blood

calcificationnote

filling.Estab

lishedwalue

(aorticsclerosis).

s for

4.Thickenedmitr

themeasure

al valveleafted

mentof

withno

heartactiviti

restrictionof

esobtained

motionwith

bythe

mitralannular

studymay

calcificationnote

vary by

physicianan

(mitralsclerosis).

dinstitution.

5.Structurallynor
maltricuspid and
pulmonicvalves.
6.Nointracardiac
thrombus or
pericardialeffusi
onnoted

Nursing ResponsibilitiesPrepare your patient

Inform the patient that the procedure assesses heart function
Inform the patient that the procedure is performed in a special department by
atechnologist and takes approximately 30 to 60 minutes, and that there is no risk of

radiation form the study.

Obtain a list of medication the patient is taking.

Perform procedure
Place the patient in a supine position on a flat table with foam wedges to helpmaintain
position and immobilization. Ask the patient to lie very still during the procedure because

movement will produce unclear images.

Instruct the patient to resume normal activity and diet unless otherwise indicated.
Encourage family and significant others to learn cardiopulmonary resuscitation