G.

LEVELS OF COMPETEN CIES

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Patterns

Before Illness

During illness Before Hospitalization

a. physical

Mr. Jacinto claimed that he goesHis body becomes weak due

to work as a tricycle driver dailyto the presence of manifestations

except Sunday. He claimed thatof the disease but he claimed that children chores

he help his wife and theirhe was still able to do some like cleaning

in doing householdhousehold chores such as in

inside/helping his wife and children

outside the house and in cuttingcleaning inside and outside the the woods

house. However, he was no his condition.

longer able to go to work due to

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During Illness During Hospitalization

Analysis

His movements were limited due to hisDue to the condition experienced by the independently. Thus, his

condition. He is always lying on bed and hepatient, she was unable to do his physical needs his significant others to assist him inactivities doing some other activities such as her dailyconfinement and chief complaint made her hygiene as well eating. He claimed that hedependent in doing his daily activities can no longer help his wife in doing do household chores.

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Patterns

Before Illness

During illness Before Hospitalization

b. social

According to our client, heHe still interact with his

loves to interact with otherfamily and his friends but not and friends. He often attendsthem. friends, fiestas. and he He became less

people including his familyhis usual interaction with parties with his family andsociable brought about by his alsocondition and he seldom to his condition. participates in their barangayattends social gatherings due

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During Illness During Hospitalization

Analysis

During hospitalization, he still exhibits aDuring illness before hospitalization, our other people. He has a goodcondition. Thus, the illness affected his he was made a

good social interaction with his family andpatient became less sociable due to his with interpersonal relationship with his family,social competency. However, when he was his significant others as well as the otherhospitalized, patients and hospital staffs . relationship with other person

good

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Patterns

Before Illness

During illness Before Hospitalization

andhappening around him. He

c. Mental

He is well oriented as toHe understands what was events, place,

time,

persons very well. He wascan remember dates, persons, family as and he is by welland he was able to make him ngem toy

able to make decision for hisevents, and places very well competent enough mentallydecision on his own. verbalized lumaklakay napigsa memoryak nakon pelang

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During Illness During Hospitalization

Analysis

He understands what was happeningThere was no alteration in the mental of the didnt patient affect before his illness

around him. He can remember dates,aspect

persons, events, and places very well and hethroughout his hospitalization. Thus, his was able to make decision with the help ofcondition his wife and his brother. functioning.

mental

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Patterns

Before Illness

During illness Before Hospitalization

d. Spiritual

He has a good relationshipEven if he seldom goes to still have a good

with God. He attend masschurch due to his condition every Sunday together withhe his family, he claims that herelationship with God. He always pray at night not justalways pray at night not just for himself but also for hisfor himself but also for his family and other people asfamily and others as well. well.

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During Illness During Hospitalization

Analysis

She claimed that she did not put God intoThere is no alteration on the spiritual aspect

blame for anything that happened to her.of the client. Rather, his faith to God and accepted his illness as something givenbelieved that his present condition was to him with purpose. unto him as her supreme being and asked him for her faster recovery.

Instead, her faith with God grew strongerbecame stronger, during hospitalization, he

planned by God. Hence, she put up herself

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Patterns

Before Illness

During illness Before Hospitalization

hospitalization

e. Emotional

He is a happy person and heBefore

loves to be with his familyduring illness, he claimed and friends. He also claimedthat he cry because of his that she can easily expresscondition but he claimed that her feelings to them. he is still feels happy because he knows that his family and his friends are still there to support and comfort her. He can still easily express his feelings to them.

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During Illness During Hospitalization

Analysis

During hospitalization, he became moreThe patient became more emotional when

emotional and more expressive about his he became ill Thus, her condition made him feelings to his significant others. However,more open to his feelings with others, and he didnt become anxious due to hisalso, he was still able to control his condition since he always grasp emotionalemotions with the help of his significant support from his family. According to him,others. he didnt cry anymore.

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H. PYSICAL ASSESSME NT
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I. GENEREAL APPEARANCE
Date: July 28, 2011 Manong Dante was seen lying on bed weak in appearance but still conversant and coherent. With an intact heplock on the left arm infusing well. He was complaining of difficulty of breathing. Wearing blue shirt and checkered shorts. Vital signs taken as follows:
v v v

BP: 120/80mmHG PR: 86 beats/min RR: 24 breath/min

v BT: 4/17/1236.5 c

II.HEAD TO TOE ASSESSMENT

Head
Normocephalic Proportional to body size Can moved in any directions With clean scalp With evenly distributed black hair

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 Eyes
Symmetrically aligned and with coordinated eye

movement
Eye brows equally distributed and symmetrically

aligned
eyelashes are equally distributed Outer canthus in line with the upper border of pinna

of ears
Pale conjunctiva Dark Brown iris With white sclera Can 4/17/12

read the snellen chart with a distance of 20 ft

 Nose
same color as the rest of the face With clean and patent nares Able to differentiate the smell of vinegar from

the smell of alcohol

Ears
same color as the face Symmetrical and attached earlobes Upper border of pinna in line with the outer

canthus of eye

no 4/17/12

lesion noted

Mouth
with dry and dark pink lips soft, smooth lips upon palpation reddish and moist tongue tongue is large but does not extend much past tongue moves freely to any desired direction

the margins of the gums or within normal limits without difficulty

With pinkish gums With 31 teeth

-16 teeth in the upper part -15 teeth in the lower part
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Neck
Proportional to body size and head Able to move side to side, flex, extend and

hyperextended

Chest

color is uniform with the other parts of the body nipples are symmetrical difficulty in breathing noted with crackles auscultated during inspiration on both lower base of the lung With symmetrical chest expansion

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Abdomen
The abdomen is uniform in color with the other

parts of the body

Moves with respiration Abdominal girth of 111 cm Presence of ascites

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Upper Extremities
brown in complexion Bilaterally symmetrical Proportional to body size With capillary refill of 2 secs. With tattoo on right arm With clean and short fingernails with good ROM (can extend, flex, abduct, with pulse rate of 86 bpm with a temperature of 36.5 C (axilla) with 4/17/12

adduct, circumduct and rotate) without difficulty

an intact heplock on the right arm

Lower extremities
brown in complexion Symmetrical and proportional to body size unable to do ROM presence of pain on both feet With clean and short nails With a capillary refill of 2 sec. With peripheral edema on both feet (Pitting

edema:left foot +4; right foot +3)

left feet is not symmetrical size to the right feet shiny, cold and smooth feet upon palpation
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 I. ON GOING APPRAISAL
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July 29, 2011

On the 1st day of appraisal at 7:00 pm, Mr. Valera was seen on bed in semi-fowlers position, wearing a white sleeveless shirt and checkered shorts. With an IVF of D5W 500ml regulated to KVO at a level of 175 cc and with and 02 inhalation of 4 LPM via nasal cannula. He was weak in appearance and with a complaint of difficulty of breathing. He has a pitting edema at the right leg+3 , left leg+4 and ascites. Mr. Valera was on low salt, low fat diet. He was not able to consume all his ration. His total intake for the day was 1300ml and his total 4/17/12 urine output was 1500ml. There were new

Range Vital Sign

v Temperature= 35.5-36.6 v Pulse rate= 88-98 v Respiratory rate= 20-24 v Blood pressure= 100/80- 130/90 v Abdominal girth=111 cm v Weight= 88 kg

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July 30, 2011

On the 2nd day of appraisal at 4:30 pm. Mr. Valera was seen lying on bed with head elevated , wearing a yellow sleeveless shirt and blue shorts. With an intact heplock on right arm and with and 02 inhalation of 2LPM via nasal cannula. He was weak in appearance with still complaint of difficulty of breathing, but his condition is better than of the 1st day of appraisal. He had a pitting edema at the right leg+2, left leg+3 and ascites. Mr. Valera was on low salt low fat diet. He was not able to consume all his ration. His total intake for this day was 990 ml and his total urine output was 1050 ml,there were new orders made by his doctor during his round at 3:00 pm which is to refer results to cardio and to continue monitoring abdominal girth and weight and to have O2 inhalation 2-3 LPM via nasal canula. Medications on this day were all administered and abdominal girth and weight are measured. There was no laboratory procedure that 4/17/12

Range Vital Sign

v Temperature= 35.1-36.6 v Pulse rate= 84-98 v Respiratory rate= 20-22 v Blood pressure= 100/80- 130/90 v Abdominal girth=106 cm v Weight= 87 kg

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July 31, 2011

On the 3rd day of appraisal at 5:00 pm, Mr. Valera was sees sitting on bed, wearing a white sleeveless shirt with a maong shorts. With an intact heplock on right arm and with and 02 inhalation of 2LPM via nasal canula. He was weak in appearance and with a complaint of difficulty of breathing still when exertion but his condition is much better than the 1st day of appraisal. He had a pitting edema on the right leg+2, left leg+3s and ascites. Mr. Valera was on low salt low fat diet. He was not able to consume all his ration. His total intake for this day was 980 ml and his total urine output was 1200ml. During the rounds of his doctor at 1:00 pm there were no new orders made but to refer for 4/17/12 cardio. . Medications on this day were all

Range Vital Sign

Temperature= 35.4-36.5 Pulse rate= 82-98 Respiratory rate= 20-24 Blood pressure= 100/80- 130/80 Abdominal girth=104 cm Weight= 86 kg

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J. DIAGNOSTIC PROCEDURE
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I. URINALYSIS

It is a general screening test for a variety of diseases. It screens for the abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract. It evaluates the color and clarity. It also includes measurements of specific gravity, pH, protein, and ketones plus microscopic examination for casts, RBC, WBC, and epithelial cells. Urinalysis is a battery of test on the clients urine, including measurements of urines physical characteristics and chemical testing. It is a test that assists in establishing 4/17/12 tentative diagnosis as well as the need for

Color

It is an indication how concentrated the urine is. The color of urine normally ranges from pale yellow to deep amber depending on its concentration. The darker the color, the more concentrated the urine is. Excessive urine output is lighter in color, it is less concentrated. Certain drugs color urine and some foods also changes urine color.
pH

It is defined as the hydrogen ion concentration of urine. It is a measurement or parameter of the acid and alkaline. States 4/17/12

Clarity

Fresh void urine is normally transparent. It becomes cloudy on standing but adding a few drops of acid can reverse this. Increases in opacity indicate pathologic condition as a result of presence of bacteria, crystal, and other foreign materials in the urine.

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Urine Specific Gravity

Specific gravity is a measurement of the concentration of urine. As the concentration of minerals, salts, and compounds in the urine increases, the specific gravity increases. Substances contributing primarily to the specific gravity of normal urine are urea and uric acid.
Protein

Normally, a healthy individual excretes small amounts of proteins in urine up to 15 mg per day consisting mainly of albumin and Tamm-Horsfall protein, proteinuria in amounts greater than 15 mg is considered pathologic.
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 Red Blood Cells

Red blood cells are too large to pass through the glomerulus; thus the finding of red blood cells in the urine is considered abnormal. If red blood cells are present, damage to the glomerular membrane or to the genitourinary tract is indicated. There are reasons why red blood cells are seen in the urine. Some of this is renal and genitourinary disorders such as kidney stones, nephritis associated with drug reactions, and glomerulonephritis; and nonrenal disorders such as acute appendicitis, diverticulitis, and malignant hypertension. Strenuous exercise may also cause red blood cells to appear in the urine because of damage to the mucosa of the bladder.
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White Blood Cells

Normally, a few white blood cells are found in the urine. As with red blood cells, white blood cells may enter the urine either through the glomerulus or through damaged genitourinary tissues. In addition, white blood cells may migrate through undamaged tissues to sites of infection or inflammation. White blood cells disintegrate in dilute, alkaline urine and in samples that are allowed to stand at room temperature for more than 1 to 2 hours.

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Epithelial cells
Epithelial cells found in urine samples are derived from three major sources: (1) the linings of the male and female lower urethra and vagina (squamous epithelial cells); (2) the linings of the renal pelvis, bladder, and upper urethra (transitional epithelial cells); (3) the renal tubules themselves. Squamous epithelial cells are large flat cells that are normally present in large numbers in the urine of women. Transitional epithelial cells are 2 to 4 times larger than pus cells and have various forms. Renal epithelial cells are small, round epithelial cells which are mononuclear and slightly larger than leukocytes. If they are found in the cast, their source is probably the uriniferrous tubules, but if there are accompanied only by pus and little albumin, especially if 4/17/12

Urine Hemoglobin
Hemoglobin is a component of red blood cells and is found in the bone marrow and within red cells. When red cells break down, hemoglobin is collected by liver and eliminated through the gastrointestinal tract.

Urine Glucose
Normally, glucose is virtually absent from the urine. Although nearly all glucose passes into the glomerular filtrate, most of it is reabsorbed by the proximal renal tubules through active transport mechanisms. Renal tubules levels vary among individuals, but an average of 180 mg/dl of blood is associated with glucose in the urine.
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Urine Ketones
Ketones are composed of acetone, keto hydroxybutric acid, and acetoacetic acid. These products result from fatty acid metabolism and normally completely metabolized by the liver.

Bacteria
Bacteria are not normally found in the urine but contaminated when passing out in the urethra.

Bilirubin
It is the end product of hemoglobin formed in the reticuloendothelial cells of the spleen, liver and bone marrow and carried in the blood by protein.
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Urobilinogen

It is normally present in the urine. This test is based on Erlichs Aldehyde Reaction or formation of red azo dye from diazonium compound. A negative result is not significant.
Nitrite

Testing urine samples for nitrite is a rapid screening method for determining the presence of bacteria in the specimen. This test is based on the fact that nitrate, which is normally present in urine, is converted to nitrite in the presence of bacteria.
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Leukocyte Esterase

Testing urine samples for the presence of leukocyte esterase is a rapid screening method for determining the presence of white blood cells in the sample. It is based on the fact that the esterase present in neutrophils will convert the indoxyl carboxylic acid ester to indoxyl, which is converted to indigo blue by room air.

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 Indication:

It is done to our client as a general screening test for a variety of diseases.

Date Requested: 07-26-11 Date Processed: 07-26-11 Result Reference Physical exam Color Clarity Specific Gravity Ph Chemical exam Protein Glucose
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Interpretation

Yellow Slightly turbid 1.015 5.0

Straw-dark yellow Clear 1.016-1.022 4.6-6.5

Normal Concentrated Decreased Normal

+2 N

Negative Negative

Increased Normal

Result Nitrite Bilirubin Urobilinogen Leuko Esterase Urinary Cells WBC RBC Epithelial cells Bacteria 0-1/hpf 0-1/hpf Occasional Occasional N -

Reference

Interpretation

Negative 0.1-1 EU/100ml

Normal Normal

Male: 0-4/hpf Male: 0-3 /hpf

Normal Normal

Negative specimen

on

spun

Mucous Threads Renal cells Yeast 4/17/12 Cells

Occasional Occasional Occasional

Result
Urinary Casts Hyaline cast Fine -/LPF 0-1

Reference

Interpretation

granular-/LPF

cast Coarse Granular -/LPF Waxy Cast Urinary Crystals Amorphous urate/Phosphate Calcium OxalatesTriple4/17/12 phosphatesFew -/LPF

Date Requested: 0726-2011 Date Processed: 07-282011 Result

Physical exam Color Yellow Straw-dark yellow Clarity Specific Gravity Ph
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Reference

Interpretatio n

Normal

Slightly turbid 1.015 5.0

Clear 1.016-1.022 4.6-6.5

Concentrated Decreased Normal

Result
Chemical exam Protein Glucose Hgb Ketones Nitrite Bilirubin Urobilinogen Leuko Esterase
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Reference

Interpretation

+2 N +2 N -

Negative Negative

Increased Normal

Negative

Normal

Negative 0.1-1 EU/100ml

Normal Normal

Result
Urinary Cells WBC RBC Epithelial cells Bacteria Mucous Threads Renal cells Yeast Cells 0-1/HPF 0-1/HPF Occasional Occasional Occasional Occasional Occasional

Reference

Interpretation

Male: 0-4/hpf Male: 0-3/hpf

Normal Normal

Negative specimen

on

spun

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Result
Urinary Casts Hyaline cast Fine granular cast Coarse Granular Waxy Cast Urinary Crystals Amorphous urate/Phosphate Calcium Oxalates Triple phosphates
4/17/12 Uric acid

Reference

Interpretation

-/LPF 0-1 -/LPF -/LPF -/LPF

Few -

Analysis:
Nursing Responsibilities Rationale Nursing Responsibilities
1. Check doctors order.

To determine the procedure to be done to

the client. 2. Inform & explain the procedure to theTo gain the clients cooperation. client & significant other/s the reason why the specimen was ordered. 3. Provide a specimen bottle with properSo that the client and significant other/s instructions. will know what to do and to be able to procedure. 4. Fill up laboratory request properly andSo that the medical technologist will know 4/17/12

obtain a proper specimen for the laboratory

Nursing Responsibilities

Rationale

5. Send the specimen (specimen bottle isWithout any proper storage, and letting labeled possible. with patients name) to thestand for a period of time, the bacteria the diagnostic procedure.

laboratory with request slip as soon ascrystallizes therefore altering the result of

6. Read the result once available and refer toSo that the physician will be able to abnormality in the result. Afterwards, attachclient it to the clients chart. and determine the

the physician immediately if there is andetermine the problems occurring in the management to be applied to the client.

appropriate

7. Document
4/17/12

To know that the procedure is already done.

II. Hematology/CBC
This is a screening test known to one of the most frequently ordered laboratory procedures. It consists of several tests that allow for the evaluation of the different cellular components of the blood on a broad spectrum of cells. The items commonly evaluated include Hgb mass concentration, Hct, RBC, RBC indices, WBC differential, platelets and microscopic examination of stained blood smear. The CBC is used for physical examination, preoperative screening, and evaluation of acute disease, and symptoms of anemia and infection. 4/17/12

 Hemoglobin
It is the important component of red blood cell that carries oxygen and carbon dioxide to and from tissue. It likewise acts as a buffer to help maintain acid-base balance. It is also composed of amino acid that forms as a single protein called globin and a compound called heme. Heme contains iron and atoms and the red pigments called porphyrin. Each electrocytes contains approximately 300 million molecules of hemoglobin. This test therefore evaluates blood cells, erythropoietic ability, anemia, and response to therapy. Normally performed as a part of the CBC, this test can be performed individually. The Hgb level is directly related to the RBC count.
4/17/12

Hematocrit

It is a measure of the packed cell volume of red cells expressed as a percentage of the total blood volume. It indicates relative proportion of the plasma and RBCs. This is a measurement of the percentage of RBC in the total value of blood. This blood test, hence, evaluates blood loss, anemia, blood replacement therapy and fluid balance and also screens blood cells.

4/17/12

 Mean Corpuscular Value

It provides an indication of red cell size. It is also stated as the ratio of volume of packed cells to the red cell count.

Mean Corpuscular Hemoglobin

Concentration
It is a measurement of the amount of hemoglobin in an average cell. It is stated as a ration of the weight of the Hgb to the volume of red cells.
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 WBC

and

Differential

Count
White blood cell is one of the formed elements of the circulatory blood. These are the mobile units of the bodys protective system. They are formed partially in the bone marrow and partially in the lymph tissue, but after formation, they are transported in the blood to the different parts of the body where 4/17/12 they are to be used. The renal value

Platelet Count

This blood test evaluates platelet production. The count may be automated but is confirmed by visual estimate if the number of platelets from a stained blood film. The platelet size and shape are not noted. Platelets are non-nucleated, round or oval, flattened disk-shaped structures that are vital to information of a hemostatic plug in vascular injury. The platelet count is one of the most important screening tests of platelet function.
4/17/12

 Indication:
This test is done to our patient to determine significant changes on the different blood components. Date Requested: 07-26-11 Date Processed: 07-26-11

Test
CBC

Result

Reference

Interpretation

Hematology Hemoglobin Hematocrit RBC Mean cell vol. Mean cell Hgb MCHC Concentration
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184.00 0.54 6.000 89.70 30.70 34.20

140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35

H H H

Test
Differential Count Segmenters Lymphocytes Monocytes Eosinophils Basophils Platelet count Chemistry BUN Creatinine Potassium Sodium 4/17/12

Result
0.88 0.04 0.08 0.00 0.00 113

Reference
0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01 150-450

Interpretation
H L

25.66 289.91 5.0 132.00

1.7-8.3 44.2-150.3 3.4-5.3 136-150

H H

Date Requested: 0726-11 Date Processed: 0729-11 Test Result

Hematology CBC Hemoglobin Hematocrit RBC Mean cell vol. Mean cell Hgb MCHC Concentration WBC
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Reference

Interpretation

160 0.48 5.360 89.20 29.20 33.50 9.61

140-175 0.41-0.50 4.5-5.9 80-100 27-32 31-35 4.50-11.00

Test
Differential Count Segmenters Lymphocytes Monocytes Eosinophils Basophils Platelet count Chemistry BUN Creatinine Potassium Sodium 4/17/12

Result
0.82 0.08 0.08 0.02 0.00 140

Reference
0.50-0.70 0.20-0.40 0.02-0.08 0.01-0.04 0.00-0.01 150-450

Interpretation
H L

1.7-8.3 282.09 4.00 44.2-150.3 3.4-5.3 136-150 H

Analysis: Nursing Responsibilities

Nursing responsibilities
1. Check doctors order.

Rationale
the client.

To determine the procedure to be done to

2. Inform the client & significant other/s theTo gain the clients cooperation and in reason why the procedure was ordered andorder for the client to know to be expected how it is to be collected; and that he mayduring the collection of the specimen. experience slight discomfort from the tourniquet and needle puncture. 3. Fill up laboratory request properly andIn order to have the medical technologies completely and send to the laboratory. 4/17/12 properly informed.

Nursing responsibilities

Rationale

4. Instruct client and significant other/s thatTo avoid leakage of blood. apply pressure at the punctured area.

5. Read the result once available and refer toSo that the physician will be able to abnormality in the result. Afterwards, attachclient it to the clients chart. and determine the

the physician immediately if there is andetermine the problems occurring in the management to be applied to the client.

appropriate

6. Document
4/17/12

To determine that the procedure is already done.

III. Lipid Profile

Cholesterol is a steroid alcohol endogenously derived from fat metabolism. It is of great importance in the synthesis of steroid hormone, the formation of the bile salt for fat digestion, and the composition of the cell membrane. The cholesterol synthesized within the body is transported in the plasma as LDL and HDL. The LDL transports cholesterol to 4/17/12

HDL or high-density lipoprotein is often referred as the good cholesterol. Elevated values are associated with a lower risk of coronary artery and peripheral vascular disease. HDL may protect vessel by removing excess cholesterol and preventing it from being deposited on vessel walls. LDL is often referred to as the bad cholesterol. Elevated LDL values are associated with higher risk of coronary artery and peripheral vascular disease. LDL is responsible for the deposition of cholesterol in vessel wall.

4/17/12

 Indication:

This blood test evaluates the risk for coronary artery and peripheral vascular disease. The test measured the blood levels of total Result Reference Interpretation cholesterol, triglycerides, HDL, and Cholesterol 5.51 <5.17mmol/L H LDL.
Triglycerides

Date Requested: 07-26-11 1.51 <2.28mmol/L Date Processed: 07-26-11

1.42 3.36 >1.55mmol/L <3.36mmol/L L

HDL Cholesterol LDL Cholesterol

4/17/12

Analysis:

In normal condition, hepatocytes synthesize cholesterol and use cholesterol to make bile salts. However, because there is damage in the liver as seen in the ALT result, hepatocytes could not assume its function in cholesterol synthesis making them abundant in the blood stream.

4/17/12

Nursing Nursing Responsibilities ResponsibilitiesRationale

1. Check doctors order.

To determine the procedure to be done to

the client. 2. Explain to the client and significantTo gain clients cooperation and in order risk for heart disease or heart attack orthe collection of the specimen. blockage of blood vessels. Tell them how it is to be collected and that he may experience slight discomfort from the tourniquet and needle puncture. 3. Fill up laboratory request properly andTo notify the medical technologist.
4/17/12 completely and send it to laboratory

other/s that this test will help determine thefor the client to know to be expected during

Nursing Responsibilities

Rationale

5. All drugs should be discontinued ifMany drugs may affect serum triglycerides possible for 12 hours before the bloodlevel. sample is taken. 6. Instruct client and significant other/s thatTo avoid leakage of blood. apply pressure at the punctured area.

7. Read the result once available and refer to So that the physician will be able to the physician immediately if there is an abnormality in the result. Afterwards, attached it to the clients chart. 8. Document
4/17/12

determine the problems occurring in the client and determine the management to be applied to the client.

appropriate

To determine that the procedure is already

done.

IV. Abdominal Ultrasound

It is a non-invasive procedure in which a high frequency sound wave are passed into internal body structures and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities. Abdominal ultrasound has no ionizing radiation, no noticeable side effects, relatively low cost, and it has almost immediate results. It cannot be used to examine a structure that lies behind bones because bones prevent sound waves from passing to deeper structures.

4/17/12

Indication: Determine ascites fluid status. Date ordered: 07-26-11 Date processed: 07-28-11

Result

The liver is not enlarged with smooth borders and homogenous parenchymal echopattern. No focal solid or cystic mass noted. The intrahepatic bile ducts and vessels are not dilated. The gallbladder is contracted with thin walls and no definite intraluminal pathology noted. The common bile duct is not dilated. The pancreas and spleen are sonographically normal. Both kidneys normal in sizes with smooth borders and increased parenchymal echopattern. Cortical thickness is within normal. The bilateral central renal echocompolexes are undilated. No hydronphrosis noted nor lithiasis noted. Perinephric regions are unremarkable.
4/17/12

The urinary bladder is adequately filled with thin walls. No

 Impression:
v v v

Mild to moderate ascites Minimal pleural effusions bilateral Echogenic kidneys, bilateral which could be secondary to the ascites or inflammation

4/17/12

Analysis: Nursing Responsibilities

Nursing Responsibilities
1. Check doctors order.

Rationale
the client.

To determine the procedure to be done to

2. Explain and describe the procedure to beTo gain clients cooperation. done. Tell the client who will perform the test, and where it will take place. 3. Tell the client that during the test the lights may be lowered, hell feel only slight pressure and mineral oil or gel, which may feel cool, will be applied to his abdomen. 4. Fill up laboratory request properly andTo notify
4/17/12

To lessen clients anxiety and in order for the client to know to be expected during the test.

Nursing Responsibilities

Rationale

5. Instruct the client and significant other/sTo minimize bowel gas and motility. to fast for 8-12 hours prior to the test. 6. Place the client on the examination tableTo provide privacy. in a supine position. Draped and exposed clients abdomen. 7. Inform client that food intake may be resumed. 8. Read the result once available and refer toSo that the physician will be able to abnormality in the result. Afterwards,client attached it to the clients chart. 9. Document
4/17/12

the physician immediately if there is andetermine the problems occurring in the and determine the management to be applied to the client.

appropriate

To determine that the procedure is already

done.