8/12/2019 Medical Management diagn. test
1/23
MEDICAL MANAGEMENT
A. DIAGNOSTIC AND LABORATORY TESTComplete Blood count
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Result
General
Description
Indication or
Purpose
Results Normal
Values
Analysis
Interpreta
Complete
Blood Count
(CBC)
Date
Ordered:
Date
Performed:
The CBC test
isolates and
counts the 7
types of cells
found in the
blood:
neutrophil,
eosinophil,
basophil, red
blood cell,
lymphocyte,
monocyte, and
platelet. It is a
screening test,
used to
diagnose and
manage
numerousdiseases. This
can reflect
problems with
fluid volume
To identify if
there is presence
of infection,
Hemoglobin:
130mg/L
Female:
115-
155g/L
The patien
hemoglob
level is wi
normal ran
WBC :
14 x 109/L
5-10 x
109/L
There is a
white bloo
count. It c
indicate th
an
inflammat
and infecti
Hematocrit:
39%
Female:
0.38-
0.48%
The patien
hematocrit
count is w
normal ran
Lymphocytes:
0.38
0.20-
0.35%
There is a
lymphocyt
level deno
that the cli
8/12/2019 Medical Management diagn. test
2/23
(such as
dehydration)
or loss of
blood. It can
show
abnormalities
in the
production,
life span, and
destruction of
blood cells. It
can reflect
acute or
chronic
infection,
allergies, and
problems with
clotting.
may have
or bacteria
infection.
Neutrophils
0.64
0.02-0.06 The patien
neutrophil
within nor
range.
Monocytes
0.02
0.45-0.65 The patien
monocytes
within nor
range.
Platelet count
377
150- 400
x 109/L
The patien
platelet co
are within
normal ran
Nursing Responsibilities:
Before:
8/12/2019 Medical Management diagn. test
3/23
1. Explain test procedure. Explain that slight discomfort may be felt when the skin ispunctured.
2. Encourage to avoid stress if possible because altered physiologic status influences andchanges normal hematologic values.
3. Explain that fasting is not necessary. However, fatty meals may alter some test results asa result of lipidemia.
During:
1. Monitor vital signs before, during and after procedure.After:
1. Apply manual pressure and dressings over puncture site on removal of dinner.2. Monitor the puncture site for oozing or hematoma formation.3. Instruct to resume normal activities and diet.
8/12/2019 Medical Management diagn. test
4/23
Sodium, serum
Diagnostic
and
Laboratory
Procedures
Date Ordered
Date
Performed
General
Description
Indication
or Purpose
Results Normal
Values
Analysis an
Interpretati
Sodium,
serum
Date ordered:
Date
Performed:
This test
measures
serum levels
of sodium in
relation toamount of
water in the
body. It
evaluates
fluid
electrolyte
and acid base
balance and
related
neuromuscula
r, renal, and
adrenal
functions
because
sodium is the
major
extracellular
cation which
affects bodys
To monitor
the
electrolytes
and check for
imbalancesany
imbalance in
the fluid and
electrolytes.
140.9
mmol/L
135. 0-
145.0
mmol/L
The sodium
electrolyte lev
is within norm
range.
8/12/2019 Medical Management diagn. test
5/23
water
distribution,
maintains
osmotic
pressure of
extracellular
fluids, helps
neuromuscula
r function;
helps
maintain acid-
base balance,
and
influences
potassium and
chloride. Due
to
extracellular
sodium ithelps in
kidneys to
regulate body
water
(decreased
sodium levels
promotes
water
excretion and
increased
level promote
retention),
8/12/2019 Medical Management diagn. test
6/23
Nursing Responsibilities:
Before:
1. Explain to the mother that the serum sodium test determines sodium content in the blood.2. Tell mother that the test requires a blood sample. Explain who will perform the
venipuncture and when.
3. Explain to the mother that her baby may feel slight discomfort from the tourniquet andthe needle puncture.
4. Inform mother that the baby need not restrict food and fluids.5. Notify the laboratory and physician of drugs the patient is taking that may affect result; it
may be necessary to restrict them.
During:
1. Perform venipuncture and collect the sample in a 3 or 4-ml activator tube.2. Handle gently to prevent hemolysis.
After:
1. Apply direct pressure to the venipuncture site until bleeding stops.
serum level
are evaluated
by the amount
water in the
body.(Lippinc
ott William &
Wilkins,
2006)
8/12/2019 Medical Management diagn. test
7/23
Potassium, serum
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Results
General
Description
Indication or
Purpose
Results Normal
Values
Analysis
Interpret
Potassium,
serum
Date
Ordered:
Date
Performed:
Measures serum
levels of
potassium, a major
intracellular cation
that helps maintain
cellular osmostic
equilibrium;
regulates muscle
activity, enzyme
activity and acid
balance, and
influences renal
function.
Serum
Calcium is
being checked
to observe for
any imbalances
with serum
electrolytes
4.03 3.50-5.50 The serum
level of
potassium
within no
limit
Nursing Responsibilities
Before:
1. Explain to the patient that the serum potassium test determines the potassium blood.2. Tell the patient that the test requires a blood sample. Explain who will perform the
venipuncture and when.
3. Explain to the patient that he may experience slight discomfort from the tourniquet andfrom the needle puncture.
4. Inform patient that he need not restrict food and fluids.5. Notify the laboratory and physician of drugs the patient is taking that may affect result; it
may be necessary to restrict them.
8/12/2019 Medical Management diagn. test
8/23
During:
1. Perform venipuncture and collect the sample in a 3 or 4-ml activatortube.2. Handle gently to prevent hemolysis.
After:
1. Apply direct pressure to the venipuncture site until bleeding stops.Instruct patient to resume any medication stopped before the procedure
8/12/2019 Medical Management diagn. test
9/23
Cranial Ultrasound
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Results
General
Description
Indication
or Purpose
Results Normal
Values
Analysis
Interpret
Date
Ordered:
Date
Performed:
Cranial
ultrasound
uses
reflected
sound waves
to produce
pictures of
the brain and
the inner
fluid
chambers
(ventricles)
throughwhich
cerebrospinal
fluid (CSF)
flows
Cranial
ultrasound
may also be
done to
evaluate a
baby's large
or
increasing
head size,
detect
infection in
or around
the brain(such as
meningitis),
or screen
for brain
problems
that are
present
from birth.
Cranial ultrasound
via open anterior
showed the
following features:
There isincrease
echonogenicity of
the brain
parenchyma.
The cistern,
ventricles, sulci are
normal in size,
shape, &configuration.
No evidence of
hydrocephalus,
intra or extra-axial
hemorrhage.
IMPRESSION:
Consider
meningitis
The size and
shape of the
brain appear
normal.The
size of the
brain's inner
fluid
chambers
(ventricles)is
normal.
Brain tissue
appears
normal. Nobleeding,
suspicious
areas
(lesions),
abnormal
growths, or
evidence of
infection are
present.
8/12/2019 Medical Management diagn. test
10/23
Calcium,serum
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Results
General
Description
Indication or
Purpose
Results Normal
Values
Analysis
Interpret
Potassium,
serum
Date
Ordered:
Date
Performed:
Measure the total
calcium in the
blood
Serum
Calcium is
being checked
to observe for
any imbalances
with serum
electrolytes
4.36
mEq/L
3.5-5.5
mEq/L
The serum
level of
potassium
within no
limit
Nursing Responsibilities
Before:
Check the doctors order
1. Explain the procedure2. Explain the purpose and what to expect3. No food or fluid restrictions
During1. Do not take the blood sample from hand or arm with receiving IVF2. The tourniquet should be less on a minute3. Do not squeeze the punctured site rightly
8/12/2019 Medical Management diagn. test
11/23
4. Wipe away the first drop of blood
After1. Observed and record vital signs.2. Check injection sites for bleeding, infection, tenderness or thrombosis.3. Report untoward reaction to the physician.4. Apply warm compress to ease discomfort, as ordered.5. Interpret results and provide counsel appropriately. Provide health teachings regarding
proper lifestyle changes and symptoms that may warrant immediate medical attention.
8/12/2019 Medical Management diagn. test
12/23
Lumbar Puncture
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Results
General
Description
Indication or
Purpose
Results Normal
Values
Analysis
Interpret
Potassium,
serum
Date
Ordered:
Date
Performed:
Permits
sampling of
cerebral spinal
fluid (CSF) for
qualitative
analysis
To measure
cerebrospinal
fluid pressure
as an aid to
detect has an
infection in
the CSF
around the
brain.
Color:
Colorless
Color:
Colorless
The CSF
is within
normal r
Transparency:
Clear
Transparency:
Clear
The CSF
transpare
within n
range.
Differential
count:
All
lymphocytes
Increase
different
count ind
infection
Sugar
1-1.3 mmol
mmol/L
Sugar:
2.754.125
mmol/L
Decrease
glucose m
result fro
infection
Protein
No reagent
Protein
6.3-8.3 g/L
It may in
rapid CS
producti
Gram Stain
No
Microorganism
No organism
No
microorg
found in
lumbar
puncture
8/12/2019 Medical Management diagn. test
13/23
Acid base
bacilli
Negative
Acid base
bacilli
Negative
Negative
Acid bas
bacilli
Nursing Responsibilities
Before
1. Explain the procedure to the mother2. Explain when and where the procedure will occur (e.g., the bedside or the treatment
room) and who will be
3. Explain that it will be necessary to lie in a certain position without moving for about 15minutes. A slight pinprick will be felt when the local anesthetic is injected and a
sensation of pressure as the spinal needle is needed.
During
1. Support and monitor the client throughout:a. Stand in front of the client and support the back of the neck and knees if the client
needs help remaining still.
b. Reassure the client throughout the procedure by explaining what is happening.Encourage normal breathing and relaxation.
c. Observe the clients color, respirations, and pulse during the procedure.2. Handle specimen tubes appropriately:
a. Wear gloves when handling test tubes.b. Label the specimen tubes in sequence.c. Send the CSF specimens to the lab immediately.
3. Place a small sterile dressing over the puncture site.4. Ensure the clients comfort and safety:
a. Assist the client to a dorsal recumbent position with only one head pillow5. The client remains in this position for 1 to 12 hours, depending on the primary care
provider orders.
8/12/2019 Medical Management diagn. test
14/23
6. Advised mother to breastfeed , unless contraindicated, to help restore the volume of CSF.
After
Observe for swelling or bleeding at the puncture site
. Monitor changes in neurologic status.
Document the procedure on the patients chart: Include date and time performed; the primary
care providers name; the color, character, and amount of CSF; and the number of specimens
obtained.
Also document CSF pressure and the nurses assessments and interventions.
8/12/2019 Medical Management diagn. test
15/23
Urinalysis
Diagnostic
and
Laboratory
Procedures
Date
Ordered
Date
Performed:
General
Description
Indication or
Purpose
Results Normal
Values
Analysis and
Interpretation
Urinalysis Date
Ordered:
Sept 1,
2012
Date
Performed:
Sept 1,
2012
A routine
urinalysis test
for urinary and
systemic
disorders. This
test evaluates
physical
characteristics
(color, odor,
turbidity, and
opacity) of the
urine;determines
specific
gravity and
pH; detects
and measures
protein,
glucose, and
ketone bodies;
and examines
sediments for
blood cells,
casts, and
To screen for
abnormalities
within urinary
system
problems that
may manifest
through the
urinary tract.
Color:
Yellow Straw to dark
yellow
The color of the
urine of the
patient is
normal
Transparency:
Turbid Clear
The urine of
patient is
slightly turbid.
Turbid urine
may contain
RBCs, WBCs,
and bacteria an
may reflectinfection.
pH:
6.0 4.5-8
The pH of
patients urine
ranges to the
normal limits.
Specific
gravity:
1.070 1.010-1.035
The specific
gravity is
normal.
Epithelial
cells:
moderate
Rare; 0-5 /
The result of
epithelial cells
in the urinalysis
8/12/2019 Medical Management diagn. test
16/23
Nursing Responsibilities:
Before:
1. Explain that this analysis helps to diagnose renal disease and to evaluate overall bodyfunction.
2. Inform the patient that he may not need to restrict food and fluids.3. Notify the laboratory and physician of drugs the patient is taking that may affect
laboratory results.
crystals. high-power
field
is normal.
Albumin:
Negative Negative
There is no
presence of
protein in the
urine
Sugar:
Negative Negative
There is no
presence of
sugar in the
urine.Pus cells:
18-20 cells /
hpf
5 to 10 pus
cells/hpf
Presence of hig
levels of pus
cells in the urin
may also be a
sign of infection
Bacteria:
Light None
Bacteria in the
urine sediment
may reflect
infection.
8/12/2019 Medical Management diagn. test
17/23
During:
1. Instruct the patient to void directly into a clean, dry container. Sterile, disposablecontainers are recommended.
2. Collect a random urine specimen of at least 15ml. Obtain a first voided morningspecimen if possible.
3. Cover all specimens tightly, label properly and send immediately to the laboratory.After:
1. Inform patient that he may resume to his usual diet and medications.2. Observe standard precautions when handling urine specimens.3. If the specimen cannot be delivered to the laboratory or tested within an hour, it should
be refrigerated or have an appropriate preservative added.
8/12/2019 Medical Management diagn. test
18/23
B. IVFMEDICAL
TREATMENT
DATE
ORDERED
AND
STARTED:
GENERAL
DESCRIPTION
INDICATION/
PURPOSE
CLIENTS
RESPONSE
Side effects:
This solution is
used to provide
lost nutrients in
the body
It was given to
the patient to
maintain fluid
balance in the
body and to
prevent
dehydration
The patient did
not manifest
dehydration. His
hydration was
maintained, and
no electrolyte
imbalance noted.
Nursing Responsibilities
Before:
1. Verify with the doctors order.2. Explain the indication to the mother.
During:
1. Label the IVF bottle and tubings indicating the date and time it was started with theordered regulation.
2. Maintain and regulate at the rate prescribed.3. Handle IVF site aseptically.4. Change solution and IVF tubings as per hospital policy.
After:
1. Check the site for any signs/symptoms of infection
8/12/2019 Medical Management diagn. test
19/23
C. OGTMEDICAL
MANAGEMENT
DATE
ORDERED
DATE
PERFORMED
GENERAL
DESCRIPTION
INDICATIONS CLIENTS
RESPONSE
OGTThe process of
placing a soft
plastic tube
through a patient's
mouth, past the
pharynx and downthe esophagus into
a patient's
stomach.
Oro- gastric tubes
are inserted to
deliver substances
directly into the
stomach, or to
remove substances
from the stomach
or as a means of
testing stomach
function or
contents.
It is used to
deliver milk
formulas to the
babys stomach.
The patient
didnt
experience
aspiration.
Nursing Responsibilities
Before
8/12/2019 Medical Management diagn. test
20/23
Verify doctors order. Inform the SO. Explain the purpose of OGT. Practice strict asepsis.
During:
Do hand washing. Prepare the materials needed for the procedure.
After:
Check for the patency.
8/12/2019 Medical Management diagn. test
21/23
D. OXYGEN THERAPYE. DRUG STUDY
NAME OF DRUG
DOSAGE AND
FREQUENCY
ROUTE OF
ADMINISTRATION
GENERAL
ACTION
INDICATION DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
CLIENT'S
RESPONSE TO
TREATMENT
SIDE EFFECTS
Generic Name:
Ampicillin
Brand Name:
Stock Dose:
Inhibits cell wall
synthesis during
bacterial
multiplication.
Treatment for
sepsis and
meningitis.
Date Ordered: Client responded
well and had no
adverse reaction to
drug.
Nursing Responsibilities
Check for the doctors order and medication chart Before giving drug ask the mother about allergic reactions to certain drugs such as
penicillin. A negative history of the drug allergy is not a guarantee against a future
allergic reaction. Check for any hypersensitivity reaction (Skin testing was not indicated
because it is believed that a neonate would not develop any hypersensitivity reaction to a
certain drug until 6 months of age due to his/her natural antibody
Inform patient to notify prescriber if rash, fever or chills develop. A rash is a mostcommon allergic reaction.
8/12/2019 Medical Management diagn. test
22/23
NAME OF DRUG
DOSAGE AND
FREQUENCY
ROUTE OF
ADMINISTRATION
GENERAL
ACTION
INDICATION DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
CLIENT'S
RESPONSE TO
TREATMENT
SIDE EFFECTS
Generic Name:
Cefotaxime 125 q8o
Inhibits synthesis
of bacterial cell
wall
Treatment for
sepsis and
meningitis.
Nursing Responsibilities:
Check for any hypersensitivity reaction (Skin testing was not indicated because it isbelieved that a neonate would not develop any hypersensitivity reaction to a certain drug
until 6 months of age due to his/her natural antibody
Check for the patency of the IV site Maintain sterility during the preparation Give the drug slow IV Maintain sterile technique during the administration Monitor for any untoward reaction Document the time or any reaction. Continue antibiotic therapy in full length of treatment.
8/12/2019 Medical Management diagn. test
23/23
NAME OF DRUG
DOSAGE AND
FREQUENCY
ROUTE OF
ADMINISTRATION
GENERAL
ACTION
INDICATION DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
CLIENT'S
RESPONSE TO
TREATMENT
SIDE EFFECTS
Generic Name:
Phenobarbital
It is a barbiturate
that has anti
seizure activity
that depresses
CNS, reticular
activating system.
It was given to
decrease episodes
of seizure.
The infant didnt
experienced any
episodes of seizure.
Nursing Responsibilities:
Assess pulse, respiration after administration. Review history of seizure disorder Observe frequently