12 6 21 LABORATORY EXAMINATIONS AND DIAGNOSTIC PROCEDURES Hhs Case

LABORATORY EXAMINATIONS AND DIAGNOSTIC PROCEDURES
A. LABORATORY EXAMINATIONS
1. Random Blood Sugar Test

 Date and Time Ordered: November 29, 2021 7:00 AM
 Requesting Physician: Joan Cruz, MD
 Brief Description: This is a test for measuring the amount of glucose or sugar
circulating in a patient’s blood at any given point in the day
 Purpose: This test was done to the patient to monitor blood sugar levels and to check
the effectiveness of interventions done
Results:
Procedure Date Found Normal Significance
Value Value
November 29, 2021, 7:00 610 mg/dL 80-140 Increased

Random Blood AM mg/dL
Sugar
AM mg/dL

AM mg/dL

AM mg/dL

AM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL
PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

PM mg/dL

AM mg/dL

AM mg/dL

AM mg/dL

AM mg/dL

AM mg/dL
November 30, 2021, 620 mg/dL 80-140 Increased

6:00 AM mg/dL

AM mg/dL

AM mg/dL

PM mg/dL

PM mg/dL
December 1, 2021, 7:00 610 mg/dL 80-140 Increased

AM mg/dL
December 1, 2021, 600 mg/dL 80-140 Increased

11:00 AM mg/dL

PM mg/dL

PM mg/dL

AM mg/dL

11:00 AM mg/dL

PM mg/dL

10:00 PM mg/dL

AM mg/dL

11:00 AM mg/dL

PM mg/dL

10:00 PM mg/dL

AM mg/dL
December 4, 2021, 140 mg/dL 80-140 Normal

11:00 AM mg/dL
December 4, 2021, 7:00 137 mg/dL 80-140 Normal

PM mg/dL
December 4, 2021, 132 mg/dL 80-140 Normal

10:00 PM mg/dL
Analysis:
The results above show that the glucose level of the patient has been monitored at every
hour for the first 24 hours and randomly for the succeeding days of hospitalization. Throughout
the course of hospitalization, blood glucose levels reached up to more than 600 mg/dL and far
exceeded the normal range which indicates the presence of Hyperosmolar Hyperglycemic
Syndrome (HHS). According to Avichal (2021), the basic underlying mechanism of HHS is a
relative reduction in effective circulating insulin with a concomitant rise in counterregulatory
hormones. He added that the concentration of glucose in the plasma is directly proportional to
the degree of dehydration. Thus, higher concentrations of glucose relate to higher degrees of
dehydration, higher plasma osmolality, and a worse prognosis.
However, due to treatments rendered to the patient, it is also evident in the results that
blood glucose level of the patient gradually decreased reaching the normal value during the last
day of hospitalization, which signifies the effectiveness of the management done. (INSERT
LITERATURE)
NURSING RESPONSIBILITIES RATIONALE

Before the Procedure
Verify the physician’s order as to the patient’s To determine the desired procedure that
name and laboratory procedure to be done need to be done as well as to avoid error
Prepare all materials needed To facilitate smooth flow of the procedure
Confirm the patient’s identity prior to the To ensure that the right procedure is carried
procedure out on the right patient at the right time
Explain the procedure and its purpose to the To gain cooperation regarding the
patient and the significant others and clarify procedure to be undertaken and to allay the
doubts and answer questions accordingly. anxiety of the patient and significant others.
To prevent contamination and to protect

Perform handwashing
self
To be comfortable when doing the
Position the patient in a sitting position
procedure
During the Procedure

To prevent unnecessary injury and protect
Place hand in proper position and disinfect around
of entering organisms from the skin
the injection
surfaces
Prick at the lateral side of the finger To avoid the sensitive area and to prevent
injury
Squeeze the finger and draw a small drop of To get the amount of blood needed for
blood then wiped onto a test strip that will give a testing
glucose reading.
To make sure if the area is has stopped

After puncturing form bleeding
 Place a sterile gauze pad and folded into

a compress tightly over the site
 Secure firmly with tape
 Check the area if the bleeding stops
After the Procedure
Dispose used supplies as per hospital policy To avoid contamination
To prevent contamination and to protect

Perform handwashing
self
For the physician to determine the
Notify physician if results are obtained and attach
appropriate management to be given to the
it to the patient’s chart
patient.
Documentation is done to ensure continuity

Document the procedure done. of care and will serve as basis for future
interventions and legal purposes
Nursing Interventions to normalize blood glucose levels

NURSING INTERVENTIONS RATIONALE
Monitor the patient’s blood sugar level 3 times To have a baseline data for monitoring the
a day and also before sleeping blood sugar level of the patient
Encourage the patient to follow the diabetic

diet recommended to him by eating foods To help maintain the patient’s blood sugar
such as fruits and vegetables. level within the normal range
Instruct the patient to avoid sugar-sweetened To prevent further complications and the
beverages, added sugars, processed meat, increase of blood sugar level in their body.
and other highly processed foods.
Encourage the patient to drink 8-10 glasses of
water daily Drinking enough water may help the patient
keep his blood sugar levels within normal
limits. It also helps the kidneys flush out the
excess sugar through urine.
Administer Metformin as prescribed by the To help control the patient’s blood sugar
physician level
Reinforce to the patient the importance of To help the patient maintain a moderate
regular exercise such as walking, jogging, weight and increase insulin sensitivity.
bicycling and swimming, and to do these at Increased insulin sensitivity means the
home after discharge cells are better able to use the available
sugar in the bloodstream. Exercise also
helps the muscles use blood sugar for
energy and muscle contraction.
2. Serum Osmolality Test

 Brief Description: This is a test done on a sample of blood to measure the levels of
main electrolytes in the body.
 Purpose: This was done to the patient to find the cause of seizures and to check if the
patient has severe dehydration
Results:
Date Test Name Found Value Reference Value Significance
November 29, 2021 Serum osmolality 325 mOsm/kg 285-295 mOsm/kg High
Analysis:
Based on the result, it is evident that the serum osmolality level of the patient is high
(325 mOsm/kg) which means that the patient is dehydrated due to HHS. In connection to this
Adeyinka & Kondamudi (2021) stated that the serum osmolality is very high in HHS. Levels
between 320 to 400mOsm/kg are very common in HHS. Normal serum osmolarity is around 280
-290 mOsm/kg. Higher serum osmolarity is associated with alteration in the level of
consciousness. The fluids from intracellular space go into the extracellular space causing
cellular dehydration, which can lead to coma. Moreover, according to the Health Encyclopedia
(2021), the more diluted blood is, the lower the concentration of particles is. When there is less
water in the blood, the concentration of particles is greater. Thus, serum osmolality increases
when a person is dehydrated.
Verify the physician’s order as to the

To determine the desired procedure that need to be
patient’s name and laboratory procedure
done as well as to avoid error
to be done
Positively identify the patient using at

least two unique identifiers before To ensure you have the right patient
providing care, treatment, or services.
Explain the procedure. Explain that

slight discomfort may be felt when the To gain patient’s cooperation and alleviate
skin is punctured. stress and anxiety.
Instruct the patient to cooperate fully and

to follow directions. Direct the patient to To avoid injury
breathe normally and to avoid
unnecessary movement.
After the Procedure

Monitor the puncture site To check if there is occurred oozing or
hematoma formation
A report of the results will be sent to the To let the physician discuss the results with the
requesting physician patient
Evaluate test results in relation to the To have a basis, because depending on the
patient's symptoms and other tests results of this procedure, additional testing may
performed. be performed to evaluate or monitor progression
of the disease process and determine the need
for a change in therapy.
Documentation is done to ensure continuity of care

Document the procedure done. and will serve as basis for future interventions and
legal purposes
Nursing Interventions to normalize serum osmolality levels
Monitor respiratory rate and depth. Metabolic acidosis secondary to

hyperchloremia may result in deep, labored
breathing with air hunger, which can lead to a
cardiopulmonary arrest if left untreated.
Monitor level of consciousness and muscular Sodium imbalances may cause changes that
strength, tone, and movement. vary from irritability and confusion to seizures
and coma. In the presence of a water deficit,
rapid rehydration may cause cerebral edema.
Monitor intake and output and specific gravity. These parameters are variable, depending on
Weigh patient daily. the fluid status, and are indicators of therapy
needs and effectiveness.
Assess skin turgor, color, and temperature Water-deficit hyponatremia manifests by signs of
and mucous membrane moisture. dehydration.
Provide safety and seizure precaution as Cerebral edema and sodium excess increase
indicated: the risk of convulsions.
 Bed in a low position.
 Use of padded side rails.
Encourage meticulous skin care and frequent Maintains the integrity of the skin.
repositioning.
Teach the patient to avoid foods high in Decreases the risk of sodium associated
sodium such as regular canned vegetables complications such as stroke, heart disease, and
and vegetable juices, processed foods, snack heart failure.
foods, and condiments.
Provide frequent oral care. Avoid the use of Promotes comfort and prevents further drying of
mouthwash containing alcohol. mucous membranes.
Encourage increased oral and IV fluid intake. Replacement of total body water deficit will
gradually restore sodium and water balance.
Monitor serum electrolytes, osmolality, and This will evaluate the therapy needs and
arterial blood gasses, as indicated. effectiveness.
3. Urinalysis
 Brief Description: This is a test done to examine the physical, chemical, and
microscopic characteristics of urine which involves a number of tests to detect and
measure various compounds that pass through the urine.
 Purpose: This was done to the patient to evaluate hyperglycemia and to ensure that
HHS is being managed properly
Results:
Result Reference Indication
Color Dark Yellow Yellow (deep amber) Abnormal
Clarity Cloudy Clear Abnormal

pH level 6.5 5-9 Normal
Specific gravity 1.040 1.010-1.030 Increased
Glucose Positive Negative Abnormal
Protein Negative Negative Normal
Bilirubin Negative Negative Normal
Urobilinogen Negative Negative Normal
Blood Negative Negative Normal
Ketone Negative Negative Normal
Nitrite Negative Negative Normal
Leukocytes 50 WBC/uL 15-40 WBC/uL Increased
Analysis:
Based on the results, the urine is dark yellow in color and is cloudy which means that it
is more concentrated and is commonly due to dehydration (Luo, 2019). Moreover, Khatri (2021)
added that cloudy urine could be due to infections or kidney stones. The results also revealed
elevated specific gravity which is also evidence of dehydration. More so, there is positive
glucose in the urine which usually occurs due to high blood sugar levels. In relation to this,
Stoner (2017) stated that glycosuria may be a sign of uncontrolled diabetes in a patient
presenting with HHS. He added that glycosuria causes greater loss of water than of sodium,
resulting in hyperosmolarity and dehydration. Decreased intravascular volume, often combined
with underlying renal disease, decreases the glomerular filtration rate, thereby decreasing
glucose clearance and further increasing blood glucose levels. Further, the leukocytes are
elevated which may be caused secondary to HHS itself or result from an underlying infection.

Verify the physician’s order as to the patient’s To determine the desired procedure that
name and laboratory procedure to be done need to be done as well as to avoid error
Prepare materials needed and check the

To ensure that the right procedure is carried
specimen form with patient’s name, date, and
out on the right patient at the right time
content of urinalysis
Label the sterile specimen container with the
To ensure correct identification and prevent
date and time, patient’s name, and specimen
error
needed
Explain the procedure and its purpose to the To gain cooperation regarding the
patient and the significant others and clarify procedure to be undertaken and to allay the
doubts and answer questions accordingly. anxiety of the patient and significant others.
Put on clean gloves To prevent contamination
If taking a specimen from a sampling port,

check first whether there is urine in the catheter
This allows urine to collect above the clamp
tubing. If the tubing is empty, apply a clamp
so that a sample can be obtained
approximately 3 inches below the level of the
sampling port.
Clean the sampling port with a prep wipe To reduce the risk of cross infection and
according to policy and allow to dry contamination
Stabilize the tubing by holding it below the level To avoid traction on the catheter
of the sampling port
Insert the syringe tip into the sampling port. Be To prevent from contamination and
careful to protect the sterile syringe tip and alteration of results
disinfected sampling port
Aspirate at least 10 mL of urine and disconnect To obtain specimen needed for the test
the syringe.
Put the urine into a sterile specimen container, To prevent leakage and contamination of
avoiding contact between the syringe and the the specimen.
cup. Ensure the top of the specimen container
is secured.
After the Procedure
Wipe the sampling port with a prep swab and To reduce the risk of cross infection and
allow it to dry. contamination
To allow urine to drain freely. Failure to do

Release clamp if it was used this will cause the bladder to fill and can
result in discomfort.
Remove and dispose gloves and used supplies
To avoid contamination
per hospital policy
Perform handwashing To prevent contamination and to protect self
Label specimen and place in a specimen bag

following policy. Send the sample to the
To ensure accurate results are obtained.
laboratory immediately or refrigerate until it can
be transported
For the physician to determine the
Notify physician if results are obtained and
appropriate management to be given to the
attach it to the patient’s chart
patient.
Documentation is done to ensure continuity

Document the procedure done. of care and will serve as basis for future
interventions and legal purposes
Nursing Interventions to normalize urinalysis results

Monitor the patient’s blood sugar levels To have a baseline data for monitoring
Encourage the patient to follow the diabetic diet

recommended to him by eating foods such as To help maintain the patient’s blood sugar
fruits and vegetables. level within the normal range
Instruct the patient to avoid sugar-sweetened To prevent further complications and the
beverages, added sugars, processed meat, increase of blood sugar level in their body.
and other highly processed foods.
Encourage the patient to drink 8-10 glasses of

water daily Drinking enough water may help the patient
keep his blood sugar levels within normal
limits. It also helps the kidneys flush out the
excess sugar through urine.
Administer Metformin as prescribed by the To help control the patient’s blood sugar
physician level
Reinforce to the patient the importance of To help the patient maintain a moderate
regular exercise such as walking, jogging, weight and increase insulin sensitivity.
bicycling and swimming, and to do these at Increased insulin sensitivity means the
home after discharge cells are better able to use the available
sugar in the bloodstream. Exercise also
helps the muscles use blood sugar for
energy and muscle contraction.
4. HbA1C Test
 Brief Description: A hemoglobin A1c (HbA1c) test measures the amount of blood sugar
(glucose) attached to hemoglobin. It shows what the average amount of glucose
attached to hemoglobin has been over the past three months. It’s a three-month average
because that's typically how long a red blood cell lives.
 Purpose: This test gauges how high the patient’s blood sugar has been in three months
and may be useful in determining whether the acute episode is the culmination of an
evolutionary process in previously undiagnosed or poorly controlled diabetes or a truly
acute episode in an otherwise well-controlled patient.
Results:
November 29, 2021 HbA1C Test 7.8% <7 Increased
Analysis:
 Based on the result, the patient’s HbA1c level has increased. If the HbA1c levels are
high, it means that the blood sugar level in the body is high, and it may be a sign of
diabetes (WebMD, 2020). In line with this Avichal &Blocher (2021) stated that an
elevated HbA1C level may help in determining medication noncompliance or
undiagnosed DM. A normal HbA1C level is useful in determining whether the episode of
HHS is secondary to an underlying acute process (ie, infection, myocardial infarction
[MI]). With the result of 7.8%, since the patient was already diagnosed with DM-type 2 before, it
is confirmed that the patient has poorly controlled diabetes. Moreover, according to Khardori
(2021), the higher the hemoglobin A1c, the higher your risk of having complications
related to diabetes. Hence, the patient has a higher risk of developing a complication.
Nursing Responsibilities Rationale
Before the procedure:
Check the doctor’s order.

To ensure correct procedure to be done
Make sure that the laboratory request form is To inform the medical technologist for the
properly filled up and sent to the laboratory. exact procedure to be done
Approach the patient, introduce self and ask the To confirm if the procedure is
patient to state their full name. administered to the right patient
Explain the procedure to the patient. Explain that

slight discomfort may be felt when the skin is To gain cooperation and allay the anxiety
punctured. of the patient
DURING THE PROCEDURE
To provide support and other needs to the

Assist the patient during the collection of blood by
patient
the medical technician.
Apply manual pressure and dressing over a

To make the puncture site more stable
punctured site.
and to prevent bleeding
AFTER THE PROCEDURE
Monitor the puncture site for oozing or hematoma Monitor the puncture site for oozing or
formation. hematoma formation.
Upon the arrival of the result, refer it to the Upon the arrival of the result, refer it to the
physician, then attach it to the patient’s chart. physician, then attach it to the patient’s
chart.
Carry out doctor’s orders with regards to Carry out doctor’s orders with regards to
management for abnormal results (if present). management for abnormal results (if
present).
Document the procedure done. Document the procedure done.
Nursing Interventions to normalize HBA1C
Monitor for HBA1C levels

To have a baseline data for monitoring
Encourage the patient to follow the diabetic diet To help maintain the patient’s HBA1C
recommended to her and by eating foods with level within the normal range
less trans fats and fewer added sugars like: Fish,
Lean beef, lean pork, chicken (no skin) and fewer
added sugars or naturally low sugar foods such
as: Vegetables and fruits
5. Serum Electrolyte Test

 Brief Description: This is a test done on a sample of blood to measure the levels of
main electrolytes in the body.
 Purpose: This was done to the patient to monitor metabolic abnormalities that may
complicate clinical course of Hyperosmolar Hyperglycemic Syndrome
Results:

Sodium 153 mEq/L 135-145 High
November 29, 2021 Potassium 1.7 mg/dL 3.5-5.0 Low
Phosphorus 4.9 mg/dL 3-4.5 High
Analysis:
Based on the Table above, on March 5, 2021, the sodium is above normal range
suggesting that the patient is experiencing hyponatremia. Sodium disturbances are common in
patients with brain injury because of the major role that the central nervous system plays in the
regulation of sodium and water homeostasis because the neuron’s ability to promote sodium
reabsorption and stimulate renin release is impaired due to the compression of the
hypothalamus (Kumar, 2016).
Results also show that the calcium level of the patient is below normal which is also
known as hypocalcemia. This results from calcium depletion due to acute increase of pro-
inflammatory proteins released by injured cells into the extracellular space after direct trauma
leading to a decrease in calcium levels in the intracellular space (Rios et al., 2017).
However, based on the results of the follow-up blood chemistry on March 7, 2021,
findings show that all electrolytes are back to normal.
To determine the desired laboratory study

Verify the physician’s order as to the patient’s name
to be done to the correct patient and to
and diagnostic procedure to be done
avoid error
To gain cooperation regarding the

Explain the procedure and its purpose to the patient
procedure to be undertaken and to allay
and the significant others and clarify doubts and
the anxiety of the patient and significant
answer questions accordingly.
others.
The laboratory request form will serve as

Check the completeness of the laboratory request
a notice to the medical technologist on
form and send it to the laboratory.
the procedure to be undertaken.
To provide support and address needs of
Assist the patient during the procedure. the patient if there are any, and to allay
anxiety.
Instruct patient to cooperate fully and to follow

To facilitate easier and faster extraction of
directions such as to breathe normally and avoid
the blood specimen.
unnecessary movements throughout the procedure.
Advise the patient and SO to eat foods high in

This is done to aid in normalizing sodium
sodium such as dark leafy greens, low-fat milk,
and calcium levels.
meat, eggs, oranges and carrots.
Place the patient in bed with a flat position, use To provide safety from falls or injury as
padded side rails and maintain a calm quiet patients with sodium imbalances often
environment. are confused.
Educate warning signs and symptoms (such as This is done because prompt care may
paresthesia and muscle weakness) and when to prevent the development of more severe
report them. symptoms.
This is done so that when there are

Refer immediately the results to the physician and
abnormal findings, appropriate orders can
attach the document on the patient’s chart.
be made by the physician.
Documentation is done to ensure

continuity of care and will serve as basis
Document the procedure done.
for future interventions and legal
purposes
6. Arterial Blood Gas Test

 Brief Description: An arterial blood gases (ABG) test measures the acidity (pH) and the
levels of oxygen and carbon dioxide in the blood from an artery. This test determines
how well the lungs can transport oxygen into the bloodstream and eliminate carbon
dioxide.
 Purpose: This was done to determine the level of acidosis the patient had.
RESULTS
Date Test Found Reference Significance
Name Value Value INTERPRETATION
November 29, pH 7.35 7.35 - 7.45 NORMAL
2021 Metabolic acidosis, fully
PCO2 29 35-45 mmHg LOW compensated
HCO3 18 mEq/L 22 to 30 Slightly low

mEq/L
Analysis:
Based on the table, there are two (2) abnormal findings, which are low in pCO2 and
HCO3 is slightly reduced in the blood. The pH (7.35) is normal; however, it falls on the acidotic
side. This suggests that the patient’s metabolic system is also acidotic but the respiratory
system is alkalotic. The problem is with the metabolic system and the respiratory system is
trying to balance out the blood’s acidotic state by decreasing the carbon dioxide level (PaCo2)
to make things more alkaline, which will help increase the blood pH from its acidotic stage.
According to Avichal & Blocher 2021 the pCO might be low from hyperventilation. Acidosis is
mainly a result of dehydration and compromised end-organ perfusion. Hence, it is metabolic
acidosis, fully compensated since the pH is within the normal range.
Before Procedure
Approach the patient, introduce yourself and ask To confirm if the procedure is administered
the patient to state their full name. to the right patient and minimize anxiety of
the patient.
Place the patient on their back, lying flat. Instruct

the patient not to clench his fist, not to hold his To make them more comfortable.
breath or not to cry.
This can change breathing and thus alter
the test result.
During Procedure
Assist the patient during the procedure To provide support and needs
of the patient
After Procedure
Instruct to resume normal activities and diet as To increase awareness

ordered by the Physician.
Check the patient site for bleeding (if necessary,

apply additional pressure) To provide immediate intervention if
bleeding occurs.
To ensure continuity of care and will serve

Document the procedure done. as basis for future interventions and legal
purposes
NURSING RESPONSIBILITIES IN NORMALIZING ABG
Provide seizure or coma precautions and bed in Protect patient from injury resulting from
low position, use of side rails, frequent decreased mentation and convulsions.
observation.
Monitor respiratory rate, rhythm, and depth.

Hyperventilation is a compensatory
mechanism. The respiratory system tries to
balance out the blood’s acidotic state by
decreasing the carbon dioxide level (PaCo2)
Monitor heart rate and rhythm.

Atrial and ventricular ectopic beats and
tachy dysrhythmias may develop.
Record amount and source of output. Monitor
intake and daily weight. Helpful in identifying source of ion loss and
potassium and HCl are lost in vomiting and
GI suctioning.
Provide oral hygiene with sodium bicarbonate

washes, lemon, glycerine swabs Neutralizes mouth acids and provides
protective lubrication.
Administer Sodium bicarbonate or lactate or saline Corrects bicarbonate deficit, but is used
IV as prescribed cautiously to correct severe acidosis (pH
less than 7.2) because sodium
bicarbonate can cause rebound metabolic
alkalosis.
Encourage fluids IV/PO.

Replaces extracellular fluid losses.
Encourage intake of foods and fluids high in

potassium and possibly calcium such as bananas, Useful in replacing potassium losses when
orange, cooked spinach, potatoes, cheese, yogurt, oral intake permitted.
sardines, beans, and leafy greens.
7. Renal Function Test

 Brief Description: This is a test done on a sample of blood to measure the levels of main
electrolytes in the body.
 Purpose: This was done to the patient to monitor metabolic abnormalities that may
complicate clinical course of Hyperosmolar Hyperglycemic Syndrome
Blood Urea Nitrogen 35 mg/dl 8-20 mg/dl High

November 29, 2021
Creatinine 4.5 mg/dL 0.6-1.2 mg/dl High
Analysis:
To determine the desired laboratory study

Verify the physician’s order as to the patient’s name
to be done to the correct patient and to
and diagnostic procedure to be done
avoid error
To gain cooperation regarding the

Explain the procedure and its purpose to the patient
procedure to be undertaken and to allay
and the significant others and clarify doubts and
the anxiety of the patient and significant
answer questions accordingly.
others.
The laboratory request form will serve as

Check the completeness of the laboratory request
a notice to the medical technologist on
form and send it to laboratory.
the procedure to be undertaken.
To provide support and address needs of

Assist the patient during the procedure. the patient if there are any, and to allay
anxiety.
Instruct patient to cooperate fully and to follow

To facilitate easier and faster extraction of
directions such as to breathe normally and avoid
the blood specimen.
unnecessary movements throughout the procedure.
Advise the patient and SO to eat foods high in

This is done to aid in normalizing sodium
sodium such as dark leafy greens, low-fat milk,
and calcium levels.
meat, eggs, oranges and carrots.
To provide safety from falls or injury as

Place patient in bed with flat position, use padded
patients with sodium imbalances often
side rails and maintain a calm quiet environment.
are confused.
Educate warning signs and symptoms (such as This is done because prompt care may
paresthesia and muscle weakness) and when to prevent the development of more severe
report them. symptoms.
This is done so that when there are

Refer immediately the results to the physician and
abnormal findings, appropriate orders can
attach the document on the patient’s chart.
be made by the physician.
Document the procedure done. Documentation is done to ensure

continuity of care and will serve as basis
for future interventions and legal
purposes
8. CAPILLARY BLOOD GLUCOSE TEST
 Check CBG now and record -610 mg/dL

 Brief Description: CBG is a procedure done to rapidly test blood glucose level.
 Purpose: It measures the patient’s glucose levels in the blood. This test is done
regularly, and its results will indicate if diabetes treatments are on target.
 Check temperature and CBG every 4 hours
EXAMINATION DATE AND TIME FOUND NORMAL SIGNIFICANCE

VALUES VALUE
CBG
Monitoring February 24, 2021 260 mg/dL 70-130 mg/dl Increased
@
11:00 AM 252 mg/dL Increased
February 24, 2021
@ 240 mg/dL Increased
6:00 PM
February 25, 2021 234 mg/dL Increased
@
6:00 AM 230 mg/dL Increased
February 25, 2021
11:00 AM
@
6:00 PM 200 mg/dL Increased
February 26, 2021
6:00 AM
@
11:00 AM
February 26, 2021
@
6:00 PM
February 27, 2021
@
6:00 AM
February 27, 2021
@
11:00 AM
@
6:00 PM 130 mg/dL Normal
February 28, 2021
@
6:00 AM
ANALYISIS:
9. Urine GS/CS
 Brief Description: A test is basically a test done to figure out if there are any types of
germs to figure out if there are any types of germs or bacteria in the Urine which could
lead to infection.
 Purpose: This was done to diagnose, and screen for diseases or medical conditions
related to urinary tract infection.
EXAMINATION/ DATE FOUND SIGNIFICANCE

PROCEDURE RESULTS
Specimen-URINE November No growth NORMAL

29,2021 after 48 hours
of incubation
Analysis: The result above is normal, thus the patient has no urinary tract infection.

Verify doctor’s order. To determine the exact procedure
that needs to be done.
Explain procedure to the patient. To gain cooperation.
Instruct the patient to wash and dry the genitals first To reduce the number of transient
before taking the urine specimen. bacteria in the skin that may
contaminate the urine specimen
Provide a specimen bottle with proper instructions.
a. a) Urine should be collected on the first void a) It has more uniform concentration
in the morning, midstream. (after the urine and more acidic pH specimens later
has flowed for several seconds, place the in the day.
collection cup into the stream and collect
about 2 fl oz (60 mL) of this "midstream" urine
without interrupting the flow.
5. b) Put the lid tightly on the container. b) To prevent spillage of

the specimen.
6. Upon receiving the specimen bottle, label with For proper identification.
patient’s name, ward and room number.
7. Notify the laboratory department via the To facilitate the conduct of the
hospital information system. laboratory request.
After the Procedure

8. When the specimen is available, send it To avoid delay in examining the
immediately to the laboratory according to urine and to avoid sedimentation
hospital protocol. and for a more accurate analysis.
9. Refer the result to the physician once So that the physician will be able to
available and attach it to the patient’s chart determine the problems occurring in
afterwards. the patient and determine the
appropriate management to be
done to the patient.
10. Do proper documentation. For legal purposes and to provide
information that the laboratory
examination has been performed.
B. DIAGNOSTIC PROCEDURES
1. CT-SCAN
 Brief Description: CT scanning computerized tomography is a painless, non-
invasive diagnostic imaging procedure that produces cross-sectional images of several
types of tissue not clearly seen on a traditional X-ray. Computed tomography (CT) of the
head uses special x-ray equipment to help assess head injuries, severe headaches,
dizziness, and other symptoms of aneurysm, bleeding, stroke, and brain tumors.
 Purpose: This was done to check if the patient experiences hemorrhagic strokes,
subdural hematomas, subarachnoid hemorrhage, intracranial abscesses, and
intracranial tumor.
CT-SCAN REPORT
 Normal size and configuration of the ventricular system
 No midline shift
 No intra cerebral or extra axial areas of abnormal attenuation values, recent blood
density or enhancing lesions
 Normal appearance of the brainstem and cerebellum
 Scanned para nasal sinuses are clear
CONCLUSION: Normal Study
ANALYSIS: The results above show no abnormalities. Thus, no underlying conditions related
to hemorrhagic strokes, subdural hematomas, subarachnoid hemorrhage, intracranial
abscesses, and intracranial tumor.
CT-SCAN
Verify the doctor’s order. To determine the exact procedure that needs
to be done.
Confirm the patient’s identity prior to the To ensure that the right procedure is carried
procedure. out on the right patient at the right time.
Obtain an informed consent properly signed To meet legality purposes
Explain the procedure to the patient. To gain cooperation and minimize anxiety.
Assess for any history of allergies to iodinated

dye or shellfish if contrast media is to be used. The patient will be at risk for having an adverse
reaction to iodine if he has a shellfish allergy.
Instruct the patient to not to eat or drink for a NPO is often advised as a precautionary
period of time especially if a contrast material measure. The patient could feel nauseous if he
will be used. doesn't have it because he has anything in his
stomach when contrast or sedative is given.
Aspiration occurs when stomach contents
enter the lungs.
Instruct the patient to wear comfortable, To be comfortable during the test
loose-fitting clothing during the exam.
Instruct the patient to remove metal objects,
including jewelry, eyeglasses, dentures and Metal objects may interfere with the Ct-scan
hairpins. result
Instruct the patient to remain still. During the This may indicate allergic reaction with the
examination, tell the patient to remain still contrast media
and to immediately report symptoms of
itching, difficulty breathing or swallowing,
nausea, vomiting, dizziness, and headache.
Inform about the duration of the procedure. To alleviate patient’s anxiety

Inform the patient that the procedure takes
from five (5) minutes to one (1) hour
depending on the type of CT scan and his
ability to relax and remain still.
After the Procedure

Instruct the patient to resume the usual diet It is just a noninvasive procedure so the patient
and activities unless otherwise ordered. can resume his usual diet and activities after
the test.
Encourage the patient to increase fluid intake This is to promote excretion of the dye.
When the results are obtained, notify the For the physician to determine the appropriate
physician and attach it to the patient’s chart. management to be given to the patient.
Do proper documentation. For legal purposes, and to provide information

that the procedure has been rendered to the
patient.
C. TREATMENTS
Vital signs and GCS monitoring
Vital signs every 15 mins

Date and Time Ordered: November 29, 2021 7:00 AM
Requesting Physician: Joan Cruz, MD
Brief Description: Vital signs are measurements of the body's most basic
functions and it helps detect or monitor medical problems. The 4 main vital signs
routinely checked include: body temperature (36.5ºC-37.2 ºC); pulse rate (60-
100bpm); respiration (12-20bpm); blood pressure (120/80mmHg).
Purpose: Vital signs are taken to help assess the general physical health of the
patient, to evaluate the response of the patient to treatment regimen.
GCS monitor every 15 minutes

Date and Time Ordered: November 29, 2021 7:00 AM
Requesting Physician: Joan Cruz, MD
Brief Description: The Glasgow Coma Scale (GCS) is used to objectively
describe the extent of impaired consciousness in all types of acute medical and
trauma patients. The scale assesses patients according to three aspects of
responsiveness: eye-opening, motor, and verbal responses
Purpose: GCS is used to detect the level or extent of impaired consciousness of the
patient.
Before the procedure
Prepare and observe cleanliness of the To prevent transmission of

equipment or materials to be used in getting microorganisms.
the vital signs of the patient. And perform
hand hygiene.
Identify the client by asking him to state her To ensure the right patient for the procedure
full name and verify it by checking her and to prevent documentation error.
wristband.
Explain the procedure to the patient. To gain cooperation and for him to be aware of
the procedures performed to him.
Get the vital signs properly and accurately by To have an accurate baseline data that is
observing the principles in getting vital signs. needed for the continuity of care of the patient
and to prevent complications due to inaccurate
vital signs taken.
Assess and calculate accurately the patient's To have an early detection for deterioration in
GCS by adding together the scores from eye a patient's level of consciousness.
opening, verbal response and motor response.
After the procedure

Record the vital signs of the patient. To serve as baseline data and for legal
purposes.
NPO

 Brief Description: NPO means nothing by mouth. It means that the patient cannot have
anything by mouth.
 Purpose: For the preparation for CT-scan
Verify the Doctor’s Order To ensure the diet intended for the patient.
Explain the purpose of NPO. To gain cooperation of the patient and for the
significant others to be informed.
Document the procedure. For legal purposes.
Monitor patient’s response. To ensure effectiveness and address

complications present.
IFC
 Insert IFC aseptically connected to urine bag

 Brief Description: An IFC is inserted which is inserted into the bladder, via the urethra
and is left in place. The catheter is held in the bladder by a water-filled balloon, which
prevents it from falling out. “Indwelling" means inside your body. This catheter drains urine
from your bladder into a bag outside your body.
 Purpose: This is inserted for the purpose of drainage of urinary bladder to relieve
retention and for monitoring urine output, urine for analysis may be difficult to obtain in a
severely dehydrated patient with HHS. Thus, catheterization of the urinary bladder may be
necessary.
Nursing responsibilities: Rationale

Explain the procedure and its purpose to the This may allay anxiety and to gain his
patient and his significant others. cooperation.
Provide patient’s privacy. To help build and develop trust in the

patient.
Assist the patient in a supine position. To have allow better insertion of IFC
Secure a sterile environment. This prevents secondary infection.
Insert the catheter gently and smoothly. To prevent trauma to the area.
After the procedure
Ensure to position drainage bag properly To prevent backflow of urine or contact with
the floor.
Document all the pertinent data. To serve as an evidence that work is done.
6. O2 Support
 Standby O2 support for SaO2 <95%; may start at 5 lpm via facemask to achieve
SaO2 of >95%
 Brief Description: Oxygen therapy is a treatment that provides the patient with extra
oxygen to breathe in. It can be administered from tubes resting in the nose, a face
mask, or a tube placed in the trachea or windpipe.
 Purpose: The patient was administered with oxygen @5 L/min via face mask to
increase the amount of oxygen sent to the lungs that will be delivered to the blood
and patient’s body tissues.
Perform respiratory assessment To determine the need for oxygen therapy

Verify the doctor’s written order. To double check and prevent mistakes in
the administration and regulation.
Prior to performing the procedure, introduce self To gain his cooperation and also to ensure
and verify the client’s identity. that you’re doing the right procedure to the
right patient.
Explain the procedure to the client and support To allay his anxiety.
systems, what you are going to do, why it is
necessary, the safety precautions that must be
observed and how the client can cooperate.
Explain that oxygen is not dangerous when
safety precautions are observed.
Assist the patient to a semi-fowler’s position. To allow better chest expansion hence,
easier breathing.
Perform handwashing and observe necessary To minimize the number of
infection control measures. microorganisms in your hand and prevent
contamination.
Do proper documentation. For legal purposes, and to provide
information that the procedure has been
rendered to the patient.
7. PNSS
 Start PNSS 1 L fast drip for 1-2 hours then regulate to 10 hours; use gauge 18 IV
cannula.
 Date and Time Ordered: November 29, 2021 7:00 AM
 Requesting Physician: Joan Cruz, MD
 Brief Description: Normal saline is a sterile, non-pyrogenic solution for fluid and electrolyte
replenishment. It contains 9 g/L of Sodium Chloride (NaCl).
 Purpose: The patient was administered with oxygen @5 L/min via face mask to increase
the amount of oxygen sent to the lungs that will be delivered to the blood and patient’s
body tissues.
Intravenous Fluid (IVF) Therapy

Check the doctor's order. To ensure that the right interventions
and procedures will be done to the
right patient.
Perform hand hygiene and observe strict aseptic To prevent the occurrence of
technique. infection.
Prepare equipment at bedside. To save time and effort.

Instruct the patient and significant other about the To be knowledgeable about the drug
purpose of administering the drug. and to promote cooperation and
compliance with the drug therapy.
Select IV site using the non-dominant hand. To promote freedom of movement.

Check the patency of IV line before preparation of To minimize problem in the
medication administration of medication
Cleanse insertion site from starting in the middle of To reduce the transmission of
the site going outward limits. microorganisms.
Apply a tourniquet 5-6 inches above the selected To engorge the vein for easier IV
site. insertion.
Insert the stylet-catheter, with bevel up, at a 20 To ensure proper placement of
to 30-degree angle. Check for blood backflow. catheter, to ensure patency of IV
Loosen stylet and advance catheter into the line, and to secure catheter and
vein until the hub rests on the IV site. Hold the prevent dislodgement.
thumb over the vein above the catheter tip and
release the tourniquet. Quickly release pressure
over the vein and connect the needle adapter of
the IV set to the hub of the catheter. Tape over
the hub of the catheter and secure tubing.
Regulate IVF to the desired flow rate. To prevent hypovolemia or

hypervolemia.
Inspect IV injection site frequently for signs of To avoid complications and
phlebitis. (redness, swelling, warmth, visible red improve patient care. Apply warm
“streaking” on arm, tenderness, rope- or cord- compress, elevate the involved
like structure that feel through the skin) extremity to minimize
inflammation. Gauze dressings
should be changed every 48 hours
on peripheral sites.
Label the venipuncture site with date and time, To ensure proper dispensing of the
type and length of catheter, and nurse’s initials. same solution, thus promoting safe
Label the administration set according to administration. Also, for legal
agency policy: should have a date on which the purposes.
administration set must be changed.
Label solution container with date and time,
drops per hour, and nurse’s initials. (If there is
an additive, a clear label must be applied to the
bag).
After the Procedure

Dispose of used needles and stilets used in a Reduces risk of injury and
nonpermeable, tamper-proof container. prevents the spread of diseases.
Dispose of all paper and plastic equipment in a To prevent contamination.
biohazard container.
Do proper documentation. For legal purposes and to provide
information that the procedure has
been rendered to the patient.
REFERENCES:
Adeyinka & Kondamudi (2021). Hyperosmolar Hyperglycemic Nonketotic Coma.
https://www.ncbi.nlm.nih.gov/books/NBK482142/
Avichal, D. & Blocher, N. (2021). What is the role of hemoglobin A1c measurement in
the diagnosis of hyperosmolar hyperglycemic state (HHS)?
https://www.medscape.com/answers/1914705-6679/what-is-the-role-of-
hemoglobin-a1c-measurement-in-the-diagnosis-of-hyperos molar-hyperglycemic-
state-hhs
Khardori, R. (2021). Type 2 diabetes mellitus treatment & management.
https://emedicine.medscape.com/article/117853-treatment
Health Encyclopedia (2021). Osmolality (Blood).

https://www.urmc.rochester.edu/encyclopedia/content.aspx?
contenttypeid=167&contentid=osmolality_blood.
WebMD (2020). Hemoglobin A1c (HbA1c) Test for Diabetes.

https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c

12 6 21 LABORATORY EXAMINATIONS AND DIAGNOSTIC PROCEDURES Hhs Case

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12 6 21 LABORATORY EXAMINATIONS AND DIAGNOSTIC PROCEDURES Hhs Case

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LABORATORY EXAMINATIONS AND DIAGNOSTIC PROCEDURES

1. Random Blood Sugar Test

November 29, 2021, 7:00 610 mg/dL 80-140 Increased

November 29, 2021, 9:00 613 mg/dL 80-140 Increased

November 29, 2021, 10:00 614 mg/dL 80-140 Increased

November 29, 2021, 11:00 614 mg/dL 80-140 Increased

November 29, 2021, 12:00 614 mg/dL 80-140 Increased

November 29, 2021, 1:00 617 mg/dL 80-140 Increased

November 29, 2021, 2:00 620 mg/dL 80-140 Increased

November 29, 2021, 3:00 625 mg/dL 80-140 Increased

November 29, 2021, 4:00 622 mg/dL 80-140 Increased

November 29, 2021, 5:00 624 mg/dL 80-140 Increased

November 29, 2021, 7:00 628 mg/dL 80-140 Increased

November 29, 2021, 8:00 630 mg/dL 80-140 Increased

November 29, 2021, 9:00 615 mg/dL 80-140 Increased

November 29, 2021, 10:00 650 mg/dL 80-140 Increased

November 29, 2021, 11:00 660 mg/dL 80-140 Increased

November 29, 2021, 12:00 655 mg/dL 80-140 Increased

November 30, 2021, 1:00 645 mg/dL 80-140 Increased

November 30, 2021, 2:00 630 mg/dL 80-140 Increased

November 30, 2021, 3:00 620 mg/dL 80-140 Increased

November 30, 2021, 4:00 615 mg/dL 80-140 Increased

November 30, 2021, 5:00 616 mg/dL 80-140 Increased

November 30, 2021, 620 mg/dL 80-140 Increased

November 30, 2021, 7:00 610 mg/dL 80-140 Increased

November 30, 2021, 11:00 612 mg/dL 80-140 Increased

November 30, 2021, 7:00 614 mg/dL 80-140 Increased

November 30, 2021, 10:00 616 mg/dL 80-140 Increased

December 1, 2021, 7:00 610 mg/dL 80-140 Increased

December 1, 2021, 600 mg/dL 80-140 Increased

December 1, 2021, 7:00 580 mg/dL 80-140 Increased

December 1, 2021, 10:00 570 mg/dL 80-140 Increased

December 2, 2021, 7:00 565 mg/dL 80-140 Increased

December 2, 2021, 563 mg/dL 80-140 Increased

December 2, 2021, 7:00 560 mg/dL 80-140 Increased

December 2, 2021, 520 mg/dL 80-140 Increased

December 3, 2021, 7:00 400 mg/dL 80-140 Increased

December 3, 2021, 350 mg/dL 80-140 Increased

December 3, 2021, 7:00 330 mg/dL 80-140 Increased

December 3, 2021, 270 mg/dL 80-140 Increased

December 4, 2021, 7:00 200 mg/dL 80-140 Increased

December 4, 2021, 140 mg/dL 80-140 Normal

December 4, 2021, 7:00 137 mg/dL 80-140 Normal

December 4, 2021, 132 mg/dL 80-140 Normal

NURSING RESPONSIBILITIES RATIONALE

Prepare all materials needed To facilitate smooth flow of the procedure

To prevent contamination and to protect

During the Procedure

To make sure if the area is has stopped

 Place a sterile gauze pad and folded into

After the Procedure

Dispose used supplies as per hospital policy To avoid contamination

To prevent contamination and to protect

Documentation is done to ensure continuity

Nursing Interventions to normalize blood glucose levels

Encourage the patient to follow the diabetic

2. Serum Osmolality Test

Date Test Name Found Value Reference Value Significance

NURSING RESPONSIBILITIES RATIONALE

Before the Procedure

Verify the physician’s order as to the

Positively identify the patient using at