Diagnostic Test

Examination: CHEST PA
November 10, 2015 11:37PM

Present study done in AP high back position

Haziness is seen in the right paracardiac area.

The heart is not enlarged.
Note degenerative spurs along the edges of the
thoracic vertebrae.
The rest of the included structures are
unremarkable.

Impression: Right basal pneumonitis

Nursing Responsibility

1.) Explain the procedure to the patients why it

is needed (Rationale: it promotes cooperation of
the patient to the said laboratory procedure).
2.) Make sure that the patient is calm and
relaxed (Rationale: this will facilitate the flow of
the procedure).
3.) Instruct the watcher to remove all jewelries of
the client before the said procedure (Rationale:
this will facilitate the flow of the procedure).
4.) Instruct watcher to let patient wear loose
fitting clothing (Rationale: To easily gain access
to the part that will be examined).

Examination: Lumbosacral APL

November 11, 2015 3:33PM

The vertebral bodies, facets, pedicles and disc

spaces are intact.
No fracture demonstrated.
The usual lumbar lordosis is maintained.
No evidence of spondylolisthesis.
Paravertebral soft tissues are unremarkable.
No other significant findings.

Impression: Negative Study.

Nursing Responsibility

1.) Explain the procedure to the patients why it

is needed (Rationale: it promotes cooperation of
the patient to the said laboratory procedure).
2.) Make sure that the patient is calm and
relaxed (Rationale: this will facilitate the flow of
the procedure).
3.) Instruct the watcher to remove all jewelries of
the client before the said procedure (Rationale:
this will facilitate the flow of the procedure).
4.) Instruct watcher to let patient wear loose
fitting clothing (Rationale: To easily gain access
to the part that will be examined).

Examination: Pelvis AP
November 11, 2015 1:04PM

Complete acetabular fracture is noted in the right.

Overlying soft tissue swelling is noted. Complete fractures
in the left superior and inferior pubic rami are also noted.
The pubic symphysis and bilateral sacroiliac joints are
intact.
No abnormal soft tissue shadows demonstrated.
No other significant findings.
Impression:
Complete Acetabular Fracture, Right
Complete Fractures, Superior and Inferior Pubic Rami, Left

Nursing Responsibility

1.) Explain the procedure to the patients why it

is needed (Rationale: it promotes cooperation of
the patient to the said laboratory procedure).
2.) Make sure that the patient is calm and
relaxed (Rationale: this will facilitate the flow of
the procedure).
3.) Instruct the watcher to remove all jewelleries
of the client before the said procedure
(Rationale: this will facilitate the flow of the
procedure).
4.) Instruct watcher to let patient wear loose
fitting clothing (Rationale: To easily gain access
to the part that will be examined).

Hematology (blood typing)

November 11, 2015 6:53AM

is the branch of medicine concerned with the

study, diagnosis, treatment, and prevention of
diseases related to the blood. Used to identify
the blood type of a person including his/her Rh
factor
Exam Name

Result

Blood Type

A Rh Positive

Nursing Responsibility

1.) Explain the procedure to the patients watcher as

to why it is needed (Rationale: it promotes
cooperation).
2.) Encourage avoiding stress if possible (Rationale:
altered physiologic status influences and changes
normal hematologic values).
3.) Inform patients watcher that the test requires
blood sample. Inform patients watcher as to who will
perform the blood extraction. (Rationale: This may help
to make the patients watcher feel comfortable when
blood is extracted from the child).
4.) Assess vital signs. (Rationale: To have baseline data
and to determine present condition of the client).

Hematology (CBC)

is the branch of
study, diagnosis,
diseases related
routine diagnostic

EXAM NAME

RESULT

RESULT

11/11/15

11/14/15

medicine concerned with the

treatment, and prevention of
to the blood. Most common
lab exam done in the hospital.
UNIT

NORMAL RANGE

Hemoglobin

77

114

g/L

140-180

Erythrocytes

2.61

3.81

10^12/L

4.5-5.0

INTERPRETATION
Can be associated with a
disease or condition that
causes the body to have
too few red blood cells or
Anemia
Decrease;
associated
with a condition like
anemia, chronic renal
failure, failure of marrow
production, hemorrhage.

EXAM NAME

RESULT RESULT

NORMAL

UNIT

RANGE

INTERPRETATION

11/11/15

11/14/15

MCH

29.5

29.9

Pg

28-33

Normal

MCV

89.3

88.1

Fl

82-98

Normal

MCHC

33.0

33.9

g/L

33-36

Normal

Leucocytes

7.0

8.4

10^g/L

4.8-10.8

Normal

Neutrophils

66

64

40-70

Normal

Lymphocyte

28

23

19-48

Normal

Monocyte

3-9

Normal

Eosinophil

2-8

Normal

Basophils

0-0.5

Normal

Hematocrit

0.23

0.34

0.40-0.45

Can be due to anemia,

bleeding

Thrombocytes

204

223

10^g/L

150-400

Normal

Nursing Responsibility

1.) Explain the procedure to the patients watcher as

to why it is needed (Rationale: it promotes
cooperation).
2.) Encourage avoiding stress if possible (Rationale:
altered physiologic status influences and changes
normal hematologic values).
3.) Inform patients watcher that the test requires
blood sample. Inform patients watcher as to who will
perform the blood extraction. (Rationale: This may help
to make the patients watcher feel comfortable when
blood is extracted from the child)
4.) Assess vital signs. (Rationale: To have baseline data
and to determine present condition of the client).

Chemistry
November 11, 2015
12:54PM

A creatinine blood test measures the level of

creatinine in the blood. Creatinine is a waste
product that forms when creatine breaks down.
Creatine is a substance found in muscle.
Creatinine levels help determine how well your
kidneys function.
Exam Name

Result

Unit

Normal Range

Creatinine

105.3

Umol/L

53- 115

Nursing Responsibility

1.) Explain the procedure to the patients watcher as

to why it is needed (Rationale: it promotes
cooperation).
2.) Encourage avoiding stress if possible (Rationale:
altered physiologic status influences and changes
normal hematologic values).
3.) Inform patients watcher that the test requires
blood sample. Inform patients watcher as to who will
perform the blood extraction. (Rationale: This may help
to make the patients watcher feel comfortable when
blood is extracted from the child).
4.) Assess vital signs. (Rationale: To have baseline data
and to determine present condition of the client).

Blood Chemistry Serum

November 11, 2015

A chemistry test is a blood test that measures the levels of

several substances in the blood such as electrolytes. To
help the doctor plan changes in the meal plan or lifestyle.
To look for problems, such as a low or high blood glucose
level that may be causing a specific symptom.
To follow a specific health condition and check how well a
treatment is working.
Exam Name

Result

Normal Range

Sodium

140.8

136-145 mmol/L

Potassium

4.30

3.5-5.1 mmol/L

Calcium

2.19

2.12-2.52mmol/L

Nursing Responsibility

1.) Explain the procedure to the patients watcher as

to why it is needed (Rationale: it promotes
cooperation).
2.) Encourage avoiding stress if possible (Rationale:
altered physiologic status influences and changes
normal hematologic values).
3.) Inform patients watcher that the test requires
blood sample. Inform patients watcher as to who will
perform the blood extraction. (Rationale: This may help
to make the patients watcher feel comfortable when
blood is extracted from the child).
4.) Assess vital signs. (Rationale: To have baseline data
and to determine present condition of the client).

Coagulation Test
November 12, 2015 6:35AM

Coagulation tests measure your bloods ability to

clot and the amount of time it takes to do so.

PROTIME
PROTIME CONTROL:

13.9 sec

PROTIME TEST:

14.5 sec

INR:

1.049

% ACTIVITY:

97.4%

Nursing Responsibility

1.) Explain the procedure to the patients watcher as to

why it is needed (Rationale: it promotes cooperation).
2.) Encourage avoiding stress if possible (Rationale: altered
physiologic status influences and changes normal
hematologic values).
3.) Inform patients watcher that the test requires blood
sample. Inform patients watcher as to who will perform
the blood extraction. (Rationale: This may help to make the
patients watcher feel comfortable when blood is extracted
from the child).
4.) Assess vital signs. (Rationale: To have baseline data and
to determine present condition of the client).

Cholesterol Test
November 13, 2015 8:37AM

A complete cholesterol test (also called a lipid

panel or lipid profile) measures the amount of
good and bad cholesterol and the level of
triglycerides in your blood.
Test Name

Result

Ref. Interval

Units

Glucose

5.9

4.1-5.9

mmol/L

Cholesterol

4.6

0.0-5.2

mmol/L

LDL-Cholesterol

3.1

0.0-3.4

mmol/L

Rev Triglycerides

1.06

0.00-1.70

mmol/L

HDL-Cholesterol

0.99

0.90-1.55

mmol/L

Nursing Responsibility

1.) Explain the procedure to the patients watcher as to why

it is needed (Rationale: it promotes cooperation).
2.) Encourage avoiding stress if possible (Rationale: altered
physiologic
status
influences
and
changes
normal
hematologic values).
3.) Inform patients watcher that the test requires blood
sample. Inform patients watcher as to who will perform the
blood extraction. (Rationale: This may help to make the
patients watcher feel comfortable when blood is extracted
from the child).
4.) Should not eat or drink (other than water) for between 9
and 12 hours before the test
5.) Assess vital signs. (Rationale: To have baseline data and to
determine present condition of the client).

Clinical Microscopy
November 13, 2015
10:33AM

A urinalysis tests the urine for color, clarity (clear or

cloudy), odor, concentration, and pH (acidity or alkalinity).
It also checks for abnormal levels of protein, sugar, and
blood cells or other substances that, if found in the urine,
may mean an illness or disease somewhere in the body.
Parameter

Result

Normal Range

Interpretation

WBC

29

0-11/uL

there is inflammation
in the urinary tract or
kidneys

RBC

17

0-11/uL

Bladder,
kidney
infection,
kidney
disease, injury

Urine flow cytometry

Parameter

Result

Normal Range

Interpretation

Epithelial cells

11

0-11//uL

Cast

0-1/uL

Bacteria

0-111/uL

Color

yellow

yellow

Normal

Clarity

Clear

Clear

Normal

Reaction

5.0

4.5 - 8

Normal

Specific Gravity

1.030

1.005 1.025

Glucose

Negative

Negative

Normal

Protein

++

Negative

sign
of
kidney
disease, proteinuria,
diabetes,
hypertension, fever

Normal
Infections,
dehydration,
inflammation
Normal

Physical Exam

High values may be

due to significant
amounts of protein or
ketoacids.

Chemical Analysis

Nursing Responsibility

1. Explain the procedure to the patient why it is

needed because it promotes cooperation.
2. Make sure that the patient is calm and relaxed
as this will facilitate in the flow of the procedure.
3, Instruct the patient to void directly into a
clean,
dry
container.
Sterile,
disposable
containers are recommended. Women should
always have a clean-catch specimen if a
microscopic examination is ordered. Feces,
discharges, vaginal secretions and menstrual
blood will contaminate the urine specimen.
4. Cover all specimens tightly, label properly and
send immediately to the laboratory.