Date Ordered

Diagnostic Test and Normal Range of Values Urinalysis

Result

Clinical Significance/Rationale

Nursing responsibilities

June 25, 2013

Findings: Color:

Dark yellow

Dehydration is a common diagnosis in a patient who experiences dark yellow urine. Dark yellow urine could also be an indicant of conditions of the liver such as jaundice, hepatitis or cirrhosis.

-provide patient with urine container with lid -instruct patient to collect sample of urine preferably arising -woman should avoid collecting urine during menstruation -the lid must be sealed completely and the container must be labeled properly

Appearance

cloudy

Cloudy urine can be caused by a variety of conditions, dehydration, certain autoimmune disorders, as well as infection, inflammation, or other conditions of the urinary tract. It can also be a characteristic of underlying conditions such as liver disease, kidney stones, cystitis or STIs.

Chemical: Protein Negative

Normal, no indication of proteinuria that may diagnose kidney disease or damage

Glucose

Negative

Normal, no indication of hyperglycemia and Diabetes Mellitus.

pH urine Flowcytometry: RBC N: 0-11 u/L 31 (HIGH)

Blood in your urine requires additional testing, as it may be a sign of kidney damage, kidney or bladder stones, kidney or bladder cancer or blood disorders, among other conditions.

WBC N: 0-17 u/L

1
Normal, no indication of infection or inflammation in the kidney or bladder.

Epithelial Cells N: 0-17

1
Normal, no indication of inflammation or contamination within the bladder.

Cast N: 0-17

1
Normal, no indication of renal disease or damage.

CBC + PLT Hemoglobin N: 120-140g/L 84.0 g/L (LOW)

Low Hemoglobin count may indicate anemia, bleeding, leukemia, malnutrition and other nutritional deficiencies in iron, folate, Vitamin B12, B6.

- identify patient and check for the requisition form with the patients identification bracelet Prior to taking the blood sample, the nurse should inform the patient or the watcher or significant other of the patient about the test(s) to be performed and the preparation for the test. You should: 1.define and explain the test

Hematocrit N: 0.36-0.48

2.state the specific purpose of the test 0.27 (LOW)

Low Hematocrit count may indicate anemia, acute or chronic bleeding from the digestive tract, Nutritional deficiencies such as iron, folate or B12 deficiency

3.explain the procedure 4.discuss test preparation, procedure, and posttest care

Red Blood Cells N: 4.20-6.10

2.75 (LOW)

Low RBC may mean Anemia, malnutrition, chronic inflammation and acute or chronic blood loss. Nutritional deficiencies including those of iron, copper, vitamin B12, or vitamin B6 could also

cause the red blood cell count to dwindle.

WBC count N: 5.0- 10.0

13.65 (HIGH)
High WBC count may indicate infection, inflammation, hematologic malignancy, leukemia, tuberculosis.

Lymphocytes N: 20-35

8.6 (LOW)
Low levels of lymphocytes may indicate viral infection, certain cancers or autoimmune diseases, or decrease bone marrow function

Neutrophils Normal: 55- 75

84 (HIGH)
Increased in count my indicate bacterial infection, severe burns, rheumatic fever, ketoacidosis, cancer.

Monocytes Normal: 2-10

11 (HIGH)
Increased level of monocytes may indicate acute infection, inflammation, tuberculosis, syphilis.

Eosinophils Normal: 1-8

1
Normal, no indication of skin diseases, allergic reactions to drugs, allergies, rheumatoid arthritis.

Basophils Normal: 0-1

0
Normal, no indication of allergic reactions and asthma, dermatitis, intestinal inflammation, sinus infections.

Platelet N: 150-400

209

Normal, no indication of bleeding tendencies, Disseminated intravascular coagulation, Vitamin K deficiency

MCH N: 25.60-32.20

24.00 (LOW)
May be because of blood loss over time, too little iron in the body, or microcytic anemia. (Microcytic anemia is a condition in which abnormally small red blood cells are present)

MCV N: 79.40- 94.8

97.1 (HIGH)
High levels of MCV may indicate liver disease, specifically cirrhosis that destroys the liver. Another cause can be alcohol abuse.

MCHC N: 32.2-35.5

31.5 (LOW)
Low levels of MCHC may indicate blood loss over time, too little iron in the body, or hypochromic anemia(condition in which the red blood cells have a decreased amount of hemoglobin.)

BLOODCHEM: Creatinine N: 53- 115 umol/L 23.00 (LOW)

Low blood creatinine levels can mean lower muscle mass caused by a disease, such as muscular dystrophy, or by aging. Low levels can also mean some types of severe liver disease or a diet very low in protein. Pregnancy can also cause low blood creatinine levels.

Explain to the patient that the blood chemistry test is used to determine blood creatinine, sodium, potassium, SGPT. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. Explain to the patient that he may experience discomfort from the tourniquet and needle puncture.

Sodium N: 136.00-155

133.50 (LOW)

Low levels or sodium called hyponatremia. This may be due to Addisons disease, dehydration, vomiting, An increase in total body water seen in those with heart failure, certain

Inform the patient that he need not restrict food and fluids.

kidney diseases, or cirrhosis of the liver.

Potassium N: 3.5-5.5

2.94 (LOW)
Low levels of potassium may indicate Gastrointestinal disorders associated with diarrhea and vomiting, hyperaldosteronism

SGPT N: 14.0-53.6

55.40 (HIGH)

High levels of SGPT may indicate liver damage, lead poisoning, necrosis, Many medicines, such as statins, antibiotics, chemotherapy, aspirin, narcotics, and barbiturates.

PROTHROMBIN TIME:

Test/ Control N: 11.2-15.5 seconds

15.7 sec (HIGH)

Prolonged PT means that the blood is taking too long to form a clot. This may be caused by conditions such as liver disease, vitamin K deficiency, or a coagulation factor deficiency

INR N: 0.8-1.2

1.4 (HIGH)

If your INR is higher than this range, that means your blood clots more slowly than desired that may indicate liver problems, inadequate levels of protein, vitamin K deficiency

APTT Test N: 25.4- 36.4 secs 40.1 sec (HIGH)

Prolong APTT time may indicate Liver disease due to: - Malabsorption of vitamin K - Decreased synthesis of clotting factors - An acquired

>The doctor will explain the procedure to the patient >Let the patient sign a consent if the procedure includes the use of contrast dye.

dysfibrinogenemia due to changes in the sialic acid content of the fibrinogen.

>Confirm for allergies to Iodine >Ask the patient to remove all jewelries, clothing and all other objects >If given contrast by mouth, monitor for diarrhea or constipation after the procedure.

Control N: 24.2-30.0 secs

28.1 secs
Normal, but since the APTT takes longer than the control sample, it then may indicate decreased clotting in the intrinsic pathway.

CT scan of the whole Abdomen Consider chronic inflammatory liver disease. To r/o tuberculosis etiology. Massive splenomegaly, moderate ascites, incidental note of basal pneumonia with minimal pleural effusion, left.
The CT scan gave a probable result that may help in determining the diagnosis of the patient and it aided in giving detailed information about what the real problem is.

>The doctor will explain the procedure to the patient.

>Instruct the patient to not eat or

drink anything from midnight the night before the test until the test is completed >Ask the patient to change into a hospital gown. > Assure the patient that there is virtually no discomfort during the test. If a full bladder is required for the test, inform them that they may feel some discomfort when the probe is applied.

Ultrasound of the whole abdomen

>moderate ascites >moderate fatty liver with calcific densities in the right hepatic lobe probably due to infectious process >contracted gallbladder >splenomegaly >para-aortic LymphadeNopathies >bilateral isoechoic renal parenchymal echopattern.
Just like the CT scan, the ultrasound procedure contributed in determining the diagnosis of the patient and both procedures somewhat had a similar result that may be the real diagnosis of the patient.