Nursing Assessment RESULT UNIT REFERENCE INTERPRETATION

upon Admission in
Medical Unit
Revealed:
VITAL SIGN

Temperature 38.4 °C 37.5 °C A temporary rise in body temperature is

usually called a fever that is a common side effect of
illness . A fever is usually a sign that your immune
system is busy fighting an infection or other illness
(Iftikhar. N, 2019).
Pulse Rate 103 bpm 60- 100 bpm Heart rates that are consistently above 100, even
when the person is sitting quietly, can sometimes be
caused by an abnormal heart rhythm. A high heart
rate can also mean the heart muscle is weakened by
a virus or some other problem that forces it to beat
more often to pump enough blood to the rest of the
body (Harvard Health Publishing, 2021).
Respiratory Rate 22 br/min 14- 20 br/min Rapid, shallow breathing, also called tachypnea,
occurs when you take more breaths than normal in
a given minute. It can be caused by several things
including infections, choking, blood clots, and more
(Kahn. A, 2019).
Blood pressure 140/100 mmHg 120/80 mmHg High blood pressure (also referred to as HBP, or
hypertension) is when your blood pressure, the
force of blood flowing through your blood vessels, is
consistently too high (Heart.org, 2021)
O2Sat 95 % 95- 100% Within the normal range

COMPLETE BLOOD COUNT

Hb 12 mg/dL 12- 16 mg/dL Within the normal range

 Hct 41 % 36- 48% Within the normal range

WBC 11,000 mm3 4, 500- 11, 000 mm3 Within the normal range

Platelets 360,000 uL 150,000- 450,000 uL Within the normal range

FBS 130 mg/dL 70- 99 mg/dL Elevated levels are associated with diabetes and
insulin resistance, in which the body cannot
properly handle sugar, ( Cleveland clinic.org, 2021)
BASIC METABOLIC PANEL

K 3.9 mEq/L 3.5- 5.0 mEq/L Within the normal range

Na 142 mEq/L 135- 145 mEq/L Within the normal range

Ca 10 mg/dL 9- 11 mg/dL Within the normal range

BUN 23 mg/dL 7- 20 mg/dL High BUN level means your kidneys aren't

working well. But elevated BUN can also be due to:
dehydration, resulting from not drinking enough
fluids or for other reasons such as urinary tract
obstruction and taking certain medications, such as
some antibiotics, (Rodwell VW, et al., 2018).
Serum Creatinine 2.12 mg/dL 0.6- 1.2 mg/dL Elevated creatinine level signifies impaired kidney
function or kidney disease. As the kidneys become
impaired for any reason, the creatinine level in the
blood will rise due to poor clearance of creatinine by
the kidneys, (Davis. C, 2021).
Liver Function Test (LFT)

ALT 52 U/L 7- 56 U/L Within the normal range

 AST 43 U/L 5- 40 U/L High AST level is a sign of liver damage, but it can
also mean you have damage to another organ that
makes it, like your heart or kidneys, (Robinson. J,
2021)
ALP 121 U/L 40-120 U/L Elevated ALP levels are generally a sign of a
liver or bone condition. An obstruction of the liver
or damage to it will cause ALP levels to rise. This
will also occur if there is an increase in bone cell
activity. Abnormal ALP levels usually indicate one
of the following conditionssuch as overuse of
medications harmful to the liver, (Lou.K, 2018).
Albumin 5.9 g/dL 3.4- 5.4 g/dL High serum albumin levels could mean that
you’re dehydrated or eat a diet rich in protein.
However, a serum albumin test usually isn’t
necessary to diagnose dehydration, (Nall.R, 2019).

Total Protein 8.4 g/dL 6.2- 8.2 g/dL

Elevated total protein is found in people who are
dehydrated, the real problem is that the blood
plasma is actually more concentrated.Certain
proteins in the blood may be elevated as your body
fights an infection or some other inflammation.
People with certain bone marrow diseases, such as
multiple myeloma, may have high blood protein
levels before they show any other symptoms, (Oza,
A., et al., 2015). 

Bilirubin 1.1 mg/dL 0.1- 1.2 mg/dL Within the normal range

GGT 57 U/L 0- 30 U/L Results show higher than normal levels of GGT, it
may be a sign of liver damage. The damage may be
 due to one of the following conditions: diabetes,
congestive heart failure and side effect of a drug.
Certain medicines can cause liver damage in some
people. The results can't show which condition you
have, but it can help show how much liver damage
you have. Usually, the higher the level of GGT, the
greater the level of damage to the liver. (Hinkle J.,et
al., 2014)
ABG result revealed:

pH 7.32 7.35- 7.45 Within the normal range

PaCO2 39 mmHg 35- 45 mmHg Within the normal range

PaO2 92 mmHg 80- 100 mmHg Within the normal range

HCO3 20 mEq/L 22- 26 mEq/L Within the normal range

Blood sugar 142 mg/dL 80-120 mg/dL High blood sugar or hyperglycemia is an
abnormally high blood sugar (blood glucose) level in
the blood. Hyperglycemia is a hallmark sign of
diabetes, (Stoppler.M, 2020).

Output 180 ml w/in 6 hrs 2000 ml w/in 24 hrs Normal urine output ranges 0.5 to 1.5 ml/kg/hour
Therefore, 0.5ml × 51kg =25.5/hr × 6hrs = 153 ml a
patient should be urinating at least every 6 hours.

URINALYSIS
 INTERPRETATION

COLOR Amber Amber-colored urine can indicate dehydration, (Smith.K, 2018).

TRANSPARENCY Turbid If  urine looks cloudy instead of its usual clear, yellowish color, it could
be due to infections, kidney stones, or other changes in the health.
Sometimes pain or other symptoms go along with it, (Watson. S, 2021).

PH/REACTION 4.8 (7.35- 7.45) If the urine sample has a lower-than-normal pH, this could indicate
an environment conducive to kidney stones. Other conditions that
prefer an acidic environment are: acidosis. diabetic ketoacidosis, which
occurs when ketones build up in the body, (Nall. R, 2021).
CELLS/HPF

RBC 5(<2) A higher than normal number of RBCs in the urine may be due to:
bladder, kidney, or urinary tract cancer, kidney and other urinary
tract problems, such as infection, or stones and kidney injury,
(Krishnan A., et al, 2020).
Moderate Leukocyte esterase w/ WBC 11mm3
If doctor tests the urine and finds too many leukocytes, it could be a
sign of infection. Leukocytes are white blood cells that help your body
fight germs. When you have more of these than usual in your urine, it's
often a sign of a problem somewhere in your urinary tract.Some of the
most common reasons for leukocytes in urine, and other symptoms you
might see with them, include: Urinary Tract Infection (UTI), (Watson.
S, 2019).
 At present (Day 3 since admission) RESULT UNIT REFERENCE INTERPRETATION

VITAL SIGN

Temperature 37.6 °C 37.5 °C Within the normal range

Pulse Rate 99 bpm 60-100 bpm Within the normal range

Respiratory Rate 19 br/min 14-20 br/min Within the normal range

Blood pressure 140/90 mmHg 120/80 mmHg In comparison to the prior

result the diastolic is slightly
decreased but still above normal.
The higher your blood pressure
levels, the more risk you have for
other health problems, such as
heart disease, heart attack, and
stroke (cdc 2021).

O2Sat 96 % 95-100% Within the normal range

COMPLETE BLOOD COUNT

 Hb 12 mg/dL 12- 16 mg/dL Within the normal range

Hct 42 % 36- 48% Within the normal range

WBC 9, 800 mm3 4, 500- 11, 000 mm3 Within the normal range

Platelets 340, 000 uL 150,000- 450,000 uL Within the normal range

FBS 152 mg/dL 70-99 mg/dL The fasting blood sugar level
has increased significant
compare to the earlier result. A
high level of fasting blood sugar
indicates that the body has been
unable to lower the levels of
sugar in the blood.
BASIC METABOLIC PANEL

K 3.9 mEq/L 3.5- 5.0 mEq/L Within the normal range

Na 145 mEq/L 135- 145 mEq/L Within the normal range

Ca 10.2 mg/dL 9- 11 mg/dL Within the normal range

BUN 20 mg/dL 7- 20 mg/dL Within the normal range

Serum Creatinine 1.62 mg/dL 0.6- 1.2 mg/dL Elevated creatinine levels
usually indicate that the kidneys
 are not working as they should
and other factors can
temporarily raise creatinine
levels above normal these
include dehydration and
consuming large amounts of
protein (Sherrell. Z, 2021).
Liver Function Test (LFT)

ALT 51 U/L 7-56 U/L Within the normal range

AST 45 U/L 5-40 U/L High amount of AST in the

blood indicate health problem
and can be associated with liver
injury. AST levels increase when
there's damage to the tissues and
cells where the enzyme is found
(Burke, 2018).
ALP 119 U/L 40-120 U/L Within the normal range

Albumin 5.6 g/dL 3.4- 5.4 g/dL Compared to the prior result,
the albumin level are slight
decreasing but still above
normal. Higher than normal
levels of albumin may indicate
dehydration and other certain
drugs (MedLinePlus, 2020).
Total Protein 8.1 g/dL 6.2- 8.2 g/dL Within the normal range

Bilirubin 1.2 mg/dL 0.1- 1.2 mg/dL Within the normal range
 GGT 56 U/L 0- 30 U/L From the previous result the
GGT level decreased but still in
above normal. High levels of
GGT in the blood could indicate
that the enzyme is leaking out of
the liver cells and into the blood,
suggesting damage to the liver or
bile ducts, (Galan 2019).
ABG result revealed:

pH 7.35 7.35- 7.45 Within the normal range

PaCO2 44 mmHg 35- 45 mmHg Within the normal range

PaO2 94 mmHg 80- 100 mmHg Within the normal range

HCO3 22 mEq/L 23- 26 mEq/L Within the normal range

Input 2,800 ml 2500ml According to the result only

half of the input was being
Output 1,600 ml 2000ml excreted or the output. A
positive fluid balance indicates
that the patient's fluid input is
higher than their output. The
condition describing excess fluid
is known as hypervolemia or
fluid overload, (Bannerman,
2018) .

URINE C AND S TEST

TEST RESULT INTERPRETATION

(＋) E. coli Sensitive to ciproflaxin Ciprofloxacin is an antibiotic agent in the fluoroquinolone class
used to treat bacterial infections such as urinary tract infections and
Ciprofloxacin is the most potent against gram-negative bacilli
bacteria such as E.coli. Ciprofloxin is to treat bacterial infection
notably infectious caused by E.coli, (Ogbru, 2019).

URINALYSIS
INTERPRETATION
COLOR Amber The color of urine is the same to the prior results that indicate severe
dehydration becoming the urine color is amber. Dehydration, which can
concentrate your urine and make it much deeper in color, can also make
your urine appear orange (MayoClinic.org, 2020).
TRANSPARENCY Minimally turbid The transparency of the urine is slightly change compared to the
previous result. Minimally turbid urine may occur occasionally due to
mild dehydration; when it occurs in the absence of symptoms and goes
away rapidly, it is usually of little consequence. Urine causing it to
persistently appear cloudy or foamy due to infections anywhere in the
urinary tract (Stoppler, 2019).
PH/REACTION 5.7 (7.35- 7.45) PH urine level is acidic and a bit elevated compared to the first result
and one of the major factors affecting urine pH is the person’s diet it also
might indicate a medical condition, (Nall, 2018).
CELLS/HPF
 RBC 4 (<2) When compared to the prior result of RBC in the urine it decreased
from 5 to 4. A normal result is 4 red blood cells per high power field
(RBC/HPF) or less when the sample is examined. A higher than normal
number of RBCs in the urine may be due to urinary tract problems, such
as infection, or stones (Krishnan et al., 2019)
Leukocyte esterase w/ 9.5 mm3 The WBC is result significantly decreased compared to the previous
WBC result and elevated levels of leukocytes in the bloodstream may indicate an
infection. This is because WBCs are part of the immune system, and they
help fight off disease and infection, (Roland, 2019.)