Discharge plan (M.E.T.H.O.D.

):
Medication Instruct client to continue take her prescribed medications Orient the client about the name of drugs, their actions, the exact dosage, the frequency and the route of administration. Instruct client to follow the instruction when administering medication. Advice the significant others not to leave the client during medication Explain to the client the side effects and adverse effects of the drugs she takes by prescribing its manifestations. Advice client not to stop intake of prescribed medications, unless approved by the physician. Exercise Instruct client to balance activities with adequate rest periods. Educate client on proper body mechanics to prevent muscle strain and enable client to relax. Encourage client to ambulate and assume normal Encourage deep breathing exercise Treatment Educate client the importance of drug compliance. Discuss to the client the complication of the condition because knowledge about the condition supports learning that will decrease deficit and anxiety To promote healing, eat a balanced diet rich in fresh fruits and vegetables. Hygiene Keep your incision sites clean and dry. Do not douche or put anything in your vagina, such as a tampon, until your doctor tells you otherwise. Encourage client to do daily hygiene Encourage client to ask assistance if needed Outpatient orders Call the doctor if any of the following occurs: Develop a fever. Become dizzy and faint. Experience nausea and vomiting.

Become short of breath. Have heavy bleeding. Have leakage from the incision or the incision opens up. Have pain when you urinate. Have swelling, redness, or pain in your leg. Have questions about the procedure or its result.

Diet To promote healing, eat a balanced diet rich in fresh fruits and vegetables. Depending on how much blood loss occurred during surgery, you may require a daily iron supplement. Eat foods that are rich in carbohydrates and protein. Sufficient intake of fluids. Eat high-fiber foods, drink plenty of water, and if necessary, use stool softeners. Instruct client to eat foods that are high in protein and vitamins and minerals. Spirituality Instruct client to pray and seek for the lords guidance.

HEALTH TEACHING
Inform the patient about the importance of complying with the prescribed medication. Emphasize the proper dosage of the medications taken. Educate the client about the importance of proper nutrition. Encourage the client to have the prescribed diet for his condition. Encourage the patient to drink plenty of water and avoid being dehydrated. Rest and relax. No heavy lifting, strenuous exercise, sex, tampons or douching. The patient should not have intercourse or drive until postpartum check. Encourage the patient to love and take good care of self. Avoid or quit smoking. Quitting smoking will improve health and the health of those around you.

Diagnosti c/ Laborator y Procedur Diagnosti e c/ Laborator Lymphocyt es y Procedur e

Date ordered/re sult in Date ordered/re sult in 09/07/11

Indication purposes

Result

Normal Values

Analysis and interpretat ion Analysis and interpretat There is an ion increased count of lymphocytes , which there is indicates decrease in inflammatio hemoglobin, n or indication infection for disease There is an increased count of Result is monocytes, within which normal indicates range, inflammatio indication of n or optimal infection health Result was within normal level no indication Has of increased malfunction WBC of clotting indication of reflex infection or inflammatio n. Result was within normal level no indication of malfunction of clotting reflex There is an increased count of segmenters, Result was which within indicates normal level inflammatio no indication n or of infection malfunction of clotting reflex

Indication purposes Determines any chronic bacterial infection or viral infection

Result 0.11

Normal Values 0.2-0.4

09/07/11 1.CBC HgB Monocytes

Pre-operation assessment of the patient.

Determines any acute bacterial infection

11.9 gm/dl 0.07

1216gm/dl 0.02-0.05

09/07/11

09/07/11 09/07/11

Pre-operation assessment of the patient.

Used to measure platelet count to assess for malfunction of clotting reflex

0.35 0.37-0.47 232x10 150 450 9 /L x109/L

Hct Platelet count

09/07/11 2.WBCC Leukoytes Bleeding time 09/07/11

Determines any inflammation or infection

12.1 4-11 x 10^9/L 030900

300 Determines Determines any bleeding time acute bacterial Infection -

09/07/11

0.82 430

Neutrophil s Clotting time Segmenter

09/07/11 09/07/11 To asses for any infection or Determines inflammation Clotting time

4001500 0.50 0.70

09/07/11 Prothrombi n Measures of the extrinsic pathway of coagula tion. To determine the clotting tendency of blood, in the measure of warfarin dosage, 011.1 11016

Clinical microscopy (macroscopy) Color

Result

Purpose

Evaluation

Yellow

To know the hydroxygenation of the urine To know the transparancy To know if the patient has sugar in urine To assess for proteinuria

Normal urine output color, no indication of inflammation or infection Normal transparency The patient has (-) result. No glucose in the urine The patients kidney if functioning well Acidic urine is normal after delivery The patient is (-)pregnant

Transparency Sugar

Slightly turbid (-)

Protein

(-)

pH

5.0 To assess the pH balance of the patients body

Frequency test

(-) specimen used for test : serum To know if the patient is pregnant

Clinical microscopy (microscopic) WBC 2-4/HPF To assess for bacterial infection It is within normal range, indication of no serious infection The patient has blood in his urine, indication for infection Few cells were found which is normal

RBC

0.2/HPF

To assess for hematuria

Epithelial

few To know if there is infection in the urinary tract

Clinical microscopy (microscopic) Amorphous urates / Phosphates Bacteria

Few Few

To assess if the patient may develop crystals To identify any

Has little chance of forming crystals Has few, a good

09/07/2011
Indication To evaluate kidney function or monitor the effectiveness of dialysis an d other treatments related to kidney disease or damage used to help diagnose the cause of recurrent kidney stones and to monitor people with gout for stone formation. Result Range Result Range Evaluation

BUN

5.0

2.5 6.4

14.01

7 18.0

Normal results, indication of normal function of the kidney

Uric acid

354

155428

5.94

2.6-7.2

Normal results, indication of normal function of the kidney

Creatini ne

assess kidney function.

89

53-115

1.01

0.06-1.3

Normal results, indication of normal function of the kidney Normal results, indication of normal function of the liver Has above normal result, indication of cell perfusion of

AST(SG OT)

aspartate aminotransfer ase (AST) to assess the liver function Lactate dehydrogenas e is used to assess celluar respiration

31

15-37

31

15-37

LDH

272

81-234

272

81-234

glucose

09/05/2011
Indication To assess the amount of glucose bound to a hemoglobi n Result Referrence range Evaluation

Glycohemogl obin
(HbA1c, A1c)

6.8%

4.2-6.1%

Result is high, indication of diabetes mellitus

Nursing Responsibilities During Different Laboratory Procedures

White Blood Cell Count Before

Explain to the patient that the WBC test is used to detect an infection or inflammation. 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 slight discomfort from the needle puncture and the tourniquet.

Inform the patient that he should avoid strenuous exercise for 24 hours before the test. Also tell him that he should avoid eating a heavy meal before the test.

If the patient is being treated for an infection, advise him that this test will be repeated to monitor his progress.

Notify the laboratory and physician of medications the patient is taking that may affect test results: they may need to be restricted.

During

Ensure subdermal bleeding has stopped before removing pressure.

After

If a hematoma develops at the venipuncture site, apply warm soaks. If the hematoma is large, monitor pulses distal the venipuncture site.

Inform the patient that he may resume his usual diet, activity and medications discontinued before the test, as ordered.

A patient with severe leucopenia, they have little or no resistance to infection and requires protective isolation.

Red Blood Cell Count Before

Explain to the patient that RBC count is used to evaluate the number of RBCs and to detect possible blood disorders.

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 slight discomfort from the needle puncture and the tourniquet.

Inform the patients that he need not restrict foods and fluids

During

Ensure subdermal bleeding has stopped before removing pressure.

After

If a hematoma develops at the venipuncture site, apply warm soaks.

Hemoglobin Before

Explain to the patient that the hbg test is used to detect anemia or polycythemia or to assess his response to treatment.

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 slight discomfort from the needle puncture and the tourniquet.

During

Ensure subdermal bleeding has stopped before removing pressure.

After

If a hematoma develops at the venipuncture site, apply warm soaks.

Hematocrit Before

Explain to the patient that hct is tested to detect anemia and other abnormal conditions 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 slight discomfort from the needle puncture and the tourniquet.

Inform the patients that he need not restrict foods and fluids

During

Ensure subdermal bleeding has stopped before removing pressure.

After

If a hematoma develops at the venipuncture site, apply warm soaks.