Level 3

CASE PRESENTATION

1st Semester SY 2010-11

I. Statement of Objectives

A. General Objectives

This case analysis aims to increase the understanding and knowledge of student nurses

on how to care for patients with Diabetes Mellitus type II, Hypertension effectively and

efficiently.

B. Specific Objectives

Specifically, this case analysis aims to:

1. define Diabetes Mellitus type II , Hypertension and its effects to the body as a whole;

2. illustrate the pathophysiology of Diabetes Mellitus type II secondary to Hypertension and in relation to

the signs and symptoms specifically observed in the client

3. describe and identify the common signs and symptoms of Diabetes Mellitus type II, Hypertension;

4. discuss the medical and surgical interventions for the management of Diabetes Mellitus type II,

Hypertension;

5. formulate appropriate nursing care plans suited for the client based on the assessment findings;

6. identify care measures to be given to the patient and family to promote continuity of care

and independence after discharge.

II. Client’s Profile

Name : Patient XX

Age : 17 years old

Birth date : December 31, 1993

Sex : Male

Ethnic Background : Tagalog

Civil Status : Single

Address : Dili, Bauang, La Union

Religion : Roman Catholic

Occupation : Student
 Admitting Diagnosis : Acute abdominal pain

Final/Principal Diagnosis : Cholelithiasis

Admitting Physician : Dr. Cheryll Pagnas MD

Date and Time Admitted : December 31, 2010 at 7:00pm

III. Chief Complaint

Abdominal pain with vomiting

IV. Present History of Illness

The client’s condition started few hours prior to admission wherein he felt pain in his abdomen

while he was celebrating the New Year with his family. The pain was not radiating to the other parts of the body but

was localized. He also verbalized that his abdomen felt hard when he tried to massage it. The patient also claimed

that the pain was sometimes accompanied by vomiting.

The patient verbalized that he was able to tolerate the said symptoms for quite a long time. He

took a tablet of paracetamol to relieve the symptoms but his condition did not improve. After about an hour, the pain

became intolerable that he and his family decided to seek medical attention and hence admitted to the institution.

V. Past History of Illness

The client had no history of any major abdominal problem and claimed that this was his first. The

client stated that he only had few cases wherein he was admitted to the hospital. One of such was when he was

confined due to convulsion when he was still an infant and another was when he had a dog bite when he was 12. He

also reported that he had no allergy to any medication as far as he knows.

Further discussion revealed that he had experienced abdominal pain when he was in high school

but the pain was tolerable, not long and was relieved by simple means.

VI. Family Health History

The client claimed that he doesn’t know of anyone from their family who suffers from any disease.

He verbalized that, as far as he knows, no illness such as Hypertension, Diabetes Mellitus, Kidney problem or Cancer

affected any of their family members. As of now, none of his family members suffer from any illness as claimed by

the client.
VII. Developmental History

The client is the firstborn of the 3 siblings, which is composed of 2 females and a male. He is a 17

year old single man who is living his life as it is. According to Erik Erikson’s Developmental Theory, he is experiencing

Identity vs. Role Confusion. He verbalized that he had no problem with himself in matters of self-image and stated

that he doesn’t have any problem with him being the firstborn in the family. He stated that his goals were simple

such as finishing his studies. He also said that he enjoys mingling with friends and loves going out with them. He

added that he and his friends enjoy playing billiards and computer games and sometimes just hang out in the plaza

spotting girls. He is currently living with his parents and siblings and helps his parents in their livelihood.

VIII. Social and Environmental History

As verbalized by the client, he claimed that he does not smoke and that he drinks alcoholic

beverages occasionally. No other vices were identified aside from those mentioned. He lives with his family and

siblings near from the center of the city where central business take place.

The house where they stay is made up of cement and metal. They value privacy as evidenced by

separate bedrooms. Water used daily is being supplied by NAWASA from which they also take their drinking

water.

The client verbalized that he last attended school when he was in 4 th year high school but stopped

during that year making him unable to graduate. This was due to financial problems his family experiences.

The client claimed that his parents only finished vocational courses and that making charcoal is

their family’s source of income. Because of this, their family can rarely afford to have access to medical services.

The family prefers to consult his grandmother who is a “manghihilot” and rely on home remedies. They only go

to the hospital in emergency situations and/or if they failed to treat the illness at home.

IX. Lifestyle and Health Practices

The client is unaware about the risks that lifestyle poses to his overall health. He states that he is

contented on what he has. He completes two to three meals in a day usually with snacks. He is not much into sports

thus views his daily chores as his form of exercise. He often eats food in eateries which serves home-cooked meals.

He is fond of eating flavorful food such as those that are spicy, salty and sweet. Fluid intake is 1-2 liters a day

coming from carbonated beverages, juice and water. The client stated that he sleeps for 7-9 hours every night.
X. Health Assessment

A. General Survey

The client was received awake, lying on bed with a moderate high back rest elevation. Client with ongoing

IVF’s of PLRS I L x KVO with a side drip of Cefipime 500mg in 500 cc D 5W to run for 20 hours infusing well on the left

arm.

Client appears weak. She wears a neat gown, and maintains proper hygiene. Client is conversant, speech is

well formulated, oriented to the self and others around her, able to determine the time and date and is aware that

she stays in a private room for quite a long time now.

Client is an endomorph. She verbalized that he is 5’ tall and weighs 43 kilograms.

B. Head to Toe Assessment

1.Head Normocephalic. Hair is white and black, evenly distributed, no visible lesions

and lice, no complaints of pain upon palpation.

2. Eyes The upper and lower eyelids meet completely when closed and pinkish

conjunctiva, and is free of swelling and foreign bodies, with no difficulty of

distinguishing colors and no blurring of vision, pupils equally round, reactive to

light and accommodation, mucous membranes are moist and light pink. With a

visual acuity score of 20/20 based on the Snellen scale.

3. Ears Equal in size bilaterally, no lesions, lumps or nodules. Canals appear pink with

minimal cerumen build-up, hearing is not impaired.

4. Nose and Sinuses Nasal structure is smooth and symmetric. Client is able to sniff through each

nostril while other is occluded. Nasal mucosa is dark pink, moist and free of

exudates. Nasal septum is intact. No tenderness upon palpation of sinuses.

5. Mouth Lips are moist without swelling. Client doesn’t use dentures on upper and lower

teeth. Oral mucosa is dry, no lesions noted. Tonsils are not inflamed, uvula

located in the midline.

6. Neck ROM intact, able to change direction of head without complaints of pain, carotid

pulses are bilaterally symmetrical. Jugular vein is not distended. Lymph nodes

are not enlarged. No tenderness upon palpation of lymph nodes. Thyroid is

located midline, no enlargement noted, trachea is located midline.

7. Chest Appears symmetrical with ribs sloping downward. Scapula is symmetric and

non- protruding. Respiratory rate ranges from 18-20 cpm. No tenderness noted

upon palpation. No adventitious sounds heard upon auscultation.

8. Cardiac Apical pulse with regular rate and rhythm. No murmurs were heard upon

auscultation. With a BP of 120/80 mmHg and PR of 85 bpm.

9. Breast (-) mastitis. Areolas are dark pink in color. Nipples are not inverted, and are

equal bilaterally in size. No palpable masses and no discharges noted.

10. Abdomen Flat, with normoactive bowel sounds heard in all the quadrants, soft, no direct
 or rebound tenderness upon palpation, no organomegaly. Shape of the

abdomen is round and has a lighter color compared to the rest of the body.
11. Genitals Client does not complain of pain during urination. With no abnormal discharges

nor foul odor noted.

12. Musculoskeletal Upper and lower extremities are symmetric without lesions, nodules,

deformities, or swelling. Client is able to perform ADLs independently. Client

does not report any weakness or fatigue.

13: Integumentary Skin generally appears normal. Skin is warm to touch. Good skin integrity. Nails

are smooth and trimmed. Good capillary nail bed refill of 1-2 seconds.
XII. Pathophysiology

cholesterol secretion Bile stasis Hemolysis Liver malfunction Infection

bile salt secretion

Cholesterol supersaturation Formation of biliary sludge Accumulation of Calcium salts Accumulation of bilirubinate and fatty acids

Solute crystallization

Formation of gallstones

Common bile & cystic duct obstruction

Sharp pain in the right part of the abdomen Gallbladder distention

Impaired venous and lymphatic drainage Bacteria proliferation Localized irritation/infiltration or both Localized ischemia

Gallbladder inflammation
XIII. Treatment/Management

A. Drugs

Name Classification Mechanism of action Nursing implication significance

Dosage
Generic: Antihypertensive >Completely blocks > Assess drug > To reduce the

Carvedilol Beta-blocker alpha-beta and allergies patient’s high blood

Brand: ½ tab, 50 mg adrenergenic receptors >Give drugs with pressure.

Dilatrend BID and has some meal

symphathomimetic >Avoid use of over

Activity at beta2 the counter

receptors. Both alpha medications

and beta blocking actions >Monitor BP

contribute to the BP- regularly.

lowering effects.
Generic : Intermediate > Insulin is a hormone >Give maintenance > To lower the level of

isophane insulin acting insulin that, by receptor dose SC, rotating glucose in the blood.

suspension (NPH) mediated effects, injection sites

Brand : Depends on promotes the storage of regularly to decrease

 Humulin N patient’s HGT body’s fuel, facilitating incidence of

result the transport of lipodystrophy,

metabolites, and ions >do not give insulin

through all membranes injected

and stimulating the concentrated IV,

synthesis of glycogen to severe anaphylactic

glucose of fats from reactions can occur

lipids and proteins from >advice patient to

amino acids. store insulin in cool

place away from

direct sunlight

>monitor urine or

serum glucose level

frequently to

determine

effectiveness of drug.
Generic: antipyretics   It reduces fever through its >do not exceed the > To lower the body's

acetaminophen 500 mg 1 tab PRN action on the heat- recommended dosage temperature when the

for temp. > to regulating center of the >give drug with food temperature is
Brand: Paracetamol 37.8. brain. Specifically, it tells elevated.
>assess drug
the center to lower the
allergies.
body's temperature when

the temperature is elevated.

Generic Name: Cephalosporin >inhibits synthesis of >assess drug >to treat the UTI or to

cefepime 500 mg IV bacterial cell wall causing allergies. prevent infections

hydrochloride cell death. >report severe caused by bacteria.

Brand: diarrhea, DOB and

Maxipime pain at injection site.

>advise patient not

to drink alcohol while

taking this drug.

Generic Name: Fluoroquinolone >Bactericidal; interferes >Continue therapy >to treat UTI and to

ciprofloxacin with DNA replication in for 2 days after signs prevent any other

susceptible bacteria and symptoms of infection caused by

Brand: Ciloxan preventing cell infection are gone. bacteria.

reproduction. > Ensure that the

patient is well

hydrated.

> Encourage patient

to complete full

course of therapy.

Give antacids at least

2 hours after dosing.

Generic: clopidogrel Antiplatelet; >Inhibits platelet > advise to take daily >To prevent risk for

Brand: Plavix Adenosine aggregation by blocking as prescribed. ischemic events such

diphosphate ADP receptor on >Provide small as myocardial

receptor platelets, preventing frequent meals if GI infarction.

antagonist clumping of platelets. upset occurs.

75 mg PO daily >Provide comfort

measures and

arrange for analgesics

if headache occurs.
B. IV Fluids

Name Classification Component/s Use & Effects Significance

Plain Lactated Isotonic It contains 6mg/mL of Lactated Ringer’s is typically This medication is an

Ringers’ Solution Sodium Chloride, 310 mg used to replace lost fluid, intravenous (IV)

of Sodium Lactated blood, or both. Due to the solution used to

Anhydrous, 30 mg of sodium content, it is typically supply water and

Potassium Chloride, and not used as an ongoing fluid electrolytes (e.g.,

20 mg of Calcium replacement, but instead is calcium, potassium,

Chloride Dihydrate. frequently used when large sodium, chloride),

volumes of fluid must be either with or

given, known as fluid without calories

resuscitation. (dextrose), to the

 body. It is also used

as a mixing solution

(diluents) for other

IV medications.

XIV. Nursing Care Plans

A. Prioritization of Problems

1. List of Problems

a. Ineffective tissue perfusion related to interruption of blood flow as manifested by unstable blood pressure.

b. Imbalanced nutrition less than body requirements related to inability to utilize nutrients as evidenced by change in

weight and weakness.

c. Impaired urinary elimination related to urinary tract infection as manifested by the presence of WBC and pus cells

in the urine and pain during urination.

d. Risk for fluid volume deficit related to uncontrolled diabetes mellitus as manifested by increased urine output and

decreased skin turgor.

e. Risk for injury related to decreased hemoglobin level as manifested by dizziness.

2. Basis of Prioritization

Maslow’s Hierarchy of Needs

 Nursing Diagnosis and Rank Rationale
1. Ineffective tissue perfusion related to This must be prioritized first because according to ABC’s

interruption of blood flow as manifested by of prioritization, circulation must be prioritized first and

the most important among all diagnosis.

unstable blood pressure
2. Imbalanced nutrition less than body This is a problem that must be prioritized secondly

requirements related to inability to utilize nutrients because according to Maslow’s Hierarchy of Needs, food

or nutrients is our physiological needs. This means that

as evidenced by change in weight and weakness.
we need it primarily to be able to survive.
4. Risk for fluid volume deficit related to This problem must be the fourth priority because aside

uncontrolled diabetes mellitus as manifested by from it is a potential problem, it should prioritized first

than risk for fluid volume deficit as a nurse one of our

increased urine output and decreased skin turgor.
role is to protect client to any further injury which can

aggravate the condition of the client or to avoid further

complication.
5. Risk for injury related to decreased hemoglobin This must be the last priority because it is a potential

level as manifested by dizziness. problem and it does not require an immediate

intervention. This is a diagnosis which requires

prevention and it does not harm the client at the

moment.
XV. List of References

Medical Surgical Nursing 10th Edition- Brunner and Suddarth

Clinical Chemistry Principles, Procedures, Correlations- Michael L. Bishop, Edward P. Fody, Larry E. Schoeff
Expanded Medical Blue Book 3rdEdition- Willie Ong,M.d, Anna Liza Ong, M.D, Juan Martin J. Magsanoc, M.D, Rhoda R.

Redulla, R.N

Principles of Anatomy and Physiology, Atlas and Registration Card, 11th Edition- Tortora, Derrickson

Medical-Surgical Nursing: Clinical Management for Positive Outcomes, Single Volume / Edition 7 by Joyce Black, Jane

Hokanson Hawks

http://bloodindex.org/blood_chemistry_tests.php

http://en.wikipedia.org/wiki/Diabetes_mellitus

http://care.diabetesjournals.org/content/26/suppl_1/s109.full

http://surgery.about.com/od/aftersurgery/qt

http://web2.airmail.net/uthman/lab_test.html
Ineffective Tissue Perfusion
Assessment Explanation of The Problem Outcomes Criteria Nursing Intervention Rationale Evaluation
S> “I urinate frequently but in Due to Diabetes Mellitus STO: Dx: STO:
minimal amount.” which causes the viscosity of After 8hours of effective >Monitor vital signs. >For baseline data. Goal met if after 8
blood and old age which nursing intervention, the client
hours of effective nursing
O> decreased urine output causes the blood vessels to will demonstrate >Note customary baseline >Provides comparison with
intervention, the client will
>restlessness thicken called arteriosclerosis, behaviors/lifestyle changes to data (e.g., usual blood current findings.
demonstrate
>vital signs of: hypertension is expected. Due improve circulation (e.g., pressure, weight mentation,
behaviors/lifestyle changes
T-37.9 oC to hypertension, the flow of exercise, dietary program, ABGs, and other appropriate
RR-22 bpm the blood is fast causing relaxation techniques). laboratory study values). to improve circulation.

PR-85 bpm insufficient distribution of

BP-150/90 mmHg
A>Ineffective tissue perfusion
related to interruption of blood
flow as manifested by
unstable blood pressure
oxygen to tissues and cells.
LTO:
After 3 days of effective
nursing intervention, the client
will increase tissue perfusion
as appropriate to her
condition.
>Review results of diagnostic
studies.
>Auscultate blood pressure,
ascertain client’s usual range.
Tx:
>Measure urine output on
regular schedule.
>To determine
location/severity of condition.
LTO:
>Because decreased
Goal met if after 3 days
glomerular filtration rate-GFR-
of effective nursing
may increase rennin release
and raise blood pressure.
intervention, the client will
demonstrate increased
tissue perfusion as
>To compare the client’s appropriate.
output.

>Provide diet restriction as >Restriction of carbohydrate

indicated while providing helps limit BUN.
adequate calories to meet the
body’s needs.
>To improve tissue

Imbalanced Nutrition less than body requirements
Assessment
S> “I feel weak and dizzy.”
O> weak in appearance
>pallor noted
>needs assistance in
Explanation of the Problem
In Diabetes Mellitus Type
2, the insulin is either resistant
or not normally secreted by
the pancreas causing the
dysfunction of the beta cells.
Because of this dysfunction,
Outcome Criteria
STO:
After 2 hours of
effective nursing
intervention, the client will
verbalize understanding of
>Assist with treatment of
underlying conditions (e.g.,
medications).
Edx:
>Encourage discussion of
feelings regarding effects of
condition.
>Encourage use of relaxation
exercises.
Nursing Intervention
Dx:
>Monitor vital signs.
>Monitor daily weight.
perfusion/organ function.
>Open expression allows
client to deal with feelings and
begin problem solving.
>To decrease tension level.
Rationale Evaluation
STO:
>For baseline data. Goal met if the client
will verbalize understanding
>To detect abnormalities of her condition and
and establish baseline cooperation.
performing activities of the beta cells cannot keep up her condition and parameter.
daily living with the high level of insulin cooperation.
causing the glucose level to
>weight loss >Monitor dietary intake. >To detect deficiencies. LTO:
rise. In this situation glucose
Previous wt: 48kgs Goal met if the client
is not transported to the cells
Present wt: 47.2kgs LTO: Tx: will manifest improvement
which will serve as its energy.
>pale in color After 72 hours of >Promote adequate fluid >To reduce possibility of of condition such as gaining
This will lead to imbalanced
nutrition less than body effective nursing intake. early satiety. of weight.

requirement intervention, the client will

A>Imbalanced nutrition manifest improvement of >Weight regularly. >To monitor effectiveness
less than body condition such as gaining of efforts.
requirements related to of weight.
inability to utilize nutrients >Promote safe and >To protect the client from
as evidenced by change in comfortable environment. injury.
weight and weakness.
>Limit fiber intake. >Fiber may lead to early
satiety.
Edx:
>Re-emphasize importance >To boost client’s immune
of well-balanced and system.
nutritious intake of food.

>Encourage use of >To stimulate salivation.

lozenges.

>Encourage client to >To stimulate appetite

choose food/have family

Impaired Urinary Elimination
Assessment Explanation of the Problem
S> “Mahapdi pag umiihi Urinary tract infection (UTI)
ako.” is a common burden in
>pain rating of 3/10. patients with diabetes
mellitus. Due to the
O> facial grimacing colonization of bacteria in
>frequent urination the lower urinary tract of
>Urinalysis result: the client, WBCs thrive in
WBC: TNTC the site of bacterial
Pus Cells: 6-10 colonization. WBCs attack
the bacteria causing the
member bring food that
seem appealing.
Outcome Criteria Interventions Scientific Rationale Evaluation
STO: Dx: STO:
After 2 hours of >Assess urinary elimination >To evaluate progress of Goal met if client will
nursing interventions, the pattern, frequency and condition. be able to enumerate ways
client will be able to volume. on how to prevent further
enumerate ways on how to complications of urinary
prevent further >Review lab results. > To determine abnormal infection such as avoiding
complications of urinary findings. soft drinks.
infection such as avoiding
soft drinks. >Review medication >To assess causative
regimen. factors.

A> Impaired urinary
elimination related to
urinary tract infection as
manifested by the presence
of WBC and pus cells in the
urine and pain during
urination.
production of
prostaglandins which then LTO: >Monitor intake and output > To evaluate function of LTO:
signals the sensation of After 72 hours of of the client. the kidney. Goal met if the client
pain when urinating. nursing interventions, the will be able to verbalize a
client will be able to Tx: absence in the sensation of
verbalize absence in the >Assist client during >To promote patient pain when urinating.
sensation of pain when positioning. comfort.
urinating.
>Re-enforce oral intake. >To lessen concentration
of toxins in urine.
>Perform bedside care. >To promote rest and
comfort.
>Administer antibiotics as >To inhibit bacterial
prescribed. growth.
Edx:
>Encourage client to >To lessen the
increase fluid intake. concentration of toxins in
the urine.
>Explain the importance of >To reduce bacterial
the client’s compliance to colonization and for
 medication intake. continuity of care.

>Instruct client of proper

hygiene.
>Discuss possible dietary
restrictions such as coffee
and carbonated drinks
>To prevent further
complications of the
infection.
>To assist in treating and
preventing urinary
alteration.

Risk for fluid volume deficit

Assessment
S> “I always pee and I’m
always thirsty.”
O>frequent urination
>decreased skin turgor
>weight loss
Previous wt: 48kgs
Present wt:47.2 kgs
>dry mucous membranes
>with capillary refill of 3
Explanation of the Problem Outcome Criteria Nursing intervention Rationale Evaluation
Due to failure of the STO: Dx:
pancreas to produce After 2 hours of >Assess vital signs. >To evaluate degree of
effective nursing fluid deficit.
insulin it will now result
intervention, the client will
to elevation of blood
>Assess presence of physical >To evaluate degree of
glucose. The glucose
signs(dry mucus membranes, fluid deficit.
will now increase the poor skin turgor, delayed
osmolality resulting to capillary refill)
polyuria which is a
manifestation of >Note change in >This signs indicate
mentation/behavior/functiona sufficient dehydration to
Diabetes Mellitus. Due
l abilities such as confusion, cause poor cerebral
to uncontrolled DM
seconds there is decrease falling, loss of ability to carry perfusion and/or
>pale in color intravascular, interstitial out usual activities, lethargy, electrolyte imbalance.
and dizziness.
and intracellular fluid
without change in
>Observe urinary output, >To more accurately
sodium.
A>Risk for fluid volume color and measure amount. determine replacement
deficit related to needs.
uncontrolled diabetes
mellitus as manifested by Tx:
increased urine output and >Provide beverages and >Rehydration over time
decreased skin turgor. foods with high fluid content prevents peaks/valleys in
such as orange, water melon fluid level.
and apple.

>Limit intake of alcohol or >It tends to exert a

caffeinated beverages. diuretic effect.

>Reinforce oral intake. >Restore fluid loss.

>Change position frequently. >To promote comfort and

safety.

>Weigh daily. >Weight is the most

accurate determination of
fluid loss.
>Provide safety measures. >To promote comfort and
safety.

Edx:
>Discuss to client the factors >Early identification of risk
related to occurrence of factors can decrease
deficit. occurrence and severity of
complications associated
with hypovolomia.

>Instruct client in ways to >To provide adequate

meet specific nutritional fluids and nutrients to
needs. correct deficiencies.

>Educate client on how to >To know what possible

identify actions that she may measures she must do in
take to correct deficiencies. order to prevent or correct
the occurrence of deficit.

>To monitor fluid status

>Instruct client or significant regularly.
others on how to measure
and correct input and output.
Risk for injury
Assessment Explanation of the Problem
O: The client is risk for
>dizziness injury due to her decrease
>Hemoglobin amount of hemoglobin
determination test result: level. This insufficient
95mg/dL amount causes imbalance
supply of oxygen to the
body tissues therefore
causing her to feel dizzy.
This dizziness might cause
her to fall when ambulating
or standing for a long
period of time.
A: Risk for injury related to
decreased hemoglobin level
as manifested by dizziness.
Outcome Criteria
STO:
After 2 hours of
nursing interventions the
patient will be able to
verbalize understanding of
individual factors that
contribute to possibility of
injury
LTO:
After 72 hours of
nursing intervention, the
patient will be able to,
modify environment as
indicated to enhance safety
Nursing Implication
Dx:
>Assess muscle strength
fine and motor coordination
>Review the patients
history noting age, weight,
nutritional status and
physical status
>Note client’s age, gender
developmental stage,
decision making ability,
level of cognition or
competence
>Review laboratory result
Tx:
>Provide bedside care
>Provide peaceful and
quite environment
>Attend to client’s needs
Rationale
>to identify risks falls
>condition like hypoxia can
predispose patient to injury
>risk factor affects client’s
ability to protect self and
influence choice of
interventions on teaching
on the part of the nurse
>to detect alteration
>to promote patient
comfort and safety
>to promote client rest
Evaluation
STO:
Goal met if , the patient
was able to enumerate
factors that could possibly
lead to injury such as
neurological changes, gait
and muscle weakness
LTO:
Goal met if, patient was
able to modify environment
as indicated to enhance
safety due to her ability to
tolerate certain activities
Edx:
>Discuss important of self-
monitoring condition that
could contribute to
occurrence of injury
>Encourage demonstration
of relaxation techniques
>Provide info regarding
condition that may result in
risk of injury
To provide therapeutic
management
>to be able to identify risk
factors
>to manage stress
>to promote safe physical
environment and individual
safety
 XI. Diagnostics

Significance/
Description
Diagnostic Purpose of Date of Findings Normal values
of the Implications
Procedure the Procedure
Procedure
Procedure
Urinalysis Analysis of It is done August Color-light Color- pale Normal Findings.
volume and because it is a 2,2010 yellow yellow to
physical, general health amber
chemical and screening to
microscopic detect renal Transparency- Transparency- May be caused by the
properties of and metabolic Turbid Clear to presence of blood cells,
urine. diseases. It is slightly hazy yeast, and bacteria.
also done to
diagnose Specific Gravity- Specific gravity-
diseases of the 1.010 1.015-1.025 Indicates renal Failure.
kidney and
urinary tract pH- 6.5 pH- 4.5-8.0
and also for Normal Findings.
monitoring Albumin- Albumin-
diabetic client. negative negative
Normal Findings.
Sugar- Sugar-
negative negative Normal Findings

WBC- TNTC WBC- negative

or rare Caused by infection (UTI).

RBC- 0-2/ HPF RBC- negative

or rare Normal Findings

Epithelial cells- Epithelial cells-

Rare few Normal Findings.
Amorphous
Urates-
Amorphous negative Normal Findings
Urates- Few

August Color-light Color- pale Normal Findings.

5,2010 yellow yellow to
amber

Transparency- Transparency- May be caused by the

Turbid Clear to presence of blood cells,
slightly hazy yeast, and bacteria.

Specific Gravity- Specific gravity-

1.013 1.015-1.025 Indicates renal Failure.

pH- 6.5 pH- 4.5-8.0

Normal Findings.
Albumin- Albumin-
negative negative
Normal Findings.
Sugar- Sugar-
negative negative Normal Findings

WBC- TNTC WBC- negative

 or rare
Caused by infection (UTI).
RBC- negative RBC- negative
or rare
Normal Findings
Epithelial cells- Epithelial cells-
Rare few
Normal Findings.
Amorphous Amorphous
Urates- Few Urates-
negative Normal Findings
Clinical Clinical Assess a wide August 2, Potassium= 3.50- 5.30 Decreased due to excessive
Chemistry chemistry range of 2010 3.0mEq/L mEq/L urination.
uses chemical condition and
processes to function of Sodium= 135.4-141.44 Decreased due to excessive
measure organs. 97.0 mmoL/L mmoL/L urination.
levels of
chemical Creatinine= 1.8 0.5-1.1 mg/dL
components mg/dL Increased due to renal
in the blood. failure.
The most Random Blood 110 mg/dL
common Sugar= Increased due to diabetes.
specimens 210 mg/dL
used in
clinical August 5, Potassium= 3.50- 5.30 Decreased due to excessive
chemistry are 2010 3.3mEq/L mEq/L urination.
blood and
urine. Sodium= 135.4-141.44 Decreased due to excessive
105.0 mmoL/L urination.
mmoL/L
0.5-1.1 mg/dL Increased due to renal
Creatinine= 1.3 failure.
mg/dL
200 mg/dL Increased due to diabetes.
Random Blood
Sugar=
205 mg/dL
Hematology Hematology is Hematology August 5, Routine CBC
the study of tests can help 2010 Hemoglobin= 110-150 g Normal Findings.
blood and its diagnose 119 g
disorders. anemia,
hemophilia, RBC count = 4.00-5.5x 10g/L Normal Findings.
blood-clotting 5.38
disorders, and
leukemia. WBC count= 4.30-10.00x Elevated due to infection.
14.7 10g/L

Hematocrit = 0.38-0.48 Normal Findings.

0.38

Differential
Count
Eosinophil= 0.00-0.05 Normal Findings.
0.02

Monocyte = 0.00-0.04 Indicates a recovery to

0.06 acute infection.
 Segmenters= 0.50-070 Increase due to infection.
0.80

Lymphocyte= 0.20-0.40
0.09
August 5, Routine CBC
2010 Hemoglobin=
123 g 110-150 g Normal Findings.

RBC count = 4.00-5.5x 10g/L Normal Findings.

5.40

WBC count= 4.30-10.00x Elevated due to infection.

13 10g/L

Hematocrit = 0.38-0.48 Normal Findings.

0.38

Differential
Count
Eosinophil= 0.00-0.05 Indicates a recovery to
0.03 acute infection.

Monocyte = 0.00-0.04 Indicates a recovery to

0.07 acute infection

Segmenters= 0.50-070 Increase due to infection.

0.80

Lymphocyte= 0.20-0.40 Decrease due to infection.

0.15
Fasting It is the To determine August 128 mg/dL 110mg/dL Increased due to diabetes.
Blood Sugar amount of diabetes 4,2010
glucose
(sugar)
present in the
blood of a
human in
fasting state
of about 8
hours.