PROCEDURE AND DESCRIPTION OF PROCEDURE SIGNIFICANCE/PURPOSE OF SIGNIFICANT FINDINGS IMPLICATION
DATE PERFORMED THE PROCEDURE
Electrocardiogram It is a simple non-invasive test to record electrical activity of the heart. Used to detect abnormal Normal sinus Normal heart
February 10 2024 heart rhythm. rhythm rhythm
Better Health Channel (n.d) ECG Test
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/ecg-
test
PROCEDURE AND DATE DESCRIPTION OF PROCEDURE SIGNIFICANCE/PURPOSE OF SIGNIFICANT FINDINGS IMPLICATION
PERFORMED THE PROCEDURE
Chest X-ray It is an imaging test to look at organs and its structures. To determine how well the Both lungs are Lungs are normal, no
February 10 2024 The size, shape as well as organ’s location. organs are working. This can normoaerated atelectasis noted
show fluid accumulation, No active lung No presence of
John Hopkins Medicine (2019) Chest X-ray lesions in the lungs and detect opacities pulmonary
Https://www.hopkinsmedicine.org/health/treatment/ lung collapse. inflammation
test-and-therapies/chest-xray Heart is unenlarged Heart is within normal
size and shape
Pulmonary vascular No presence of
markings are within pneumothorax or
normal vascular congestion
a
PROCEDURE AND DATE DESCRIPTION OF PROCEDURE SIGNIFICANCE/PURPOSE OF THE SIGNIFICANT FINDINGS IMPLICATION
PERFORMED PROCEDURE
Complete Blood count It measures the number of your It is used to detect or monitor Hemoglobin: 139 g/L There is adequate
February 10 2024 blood component such as WBC, RBC, different health condition such as Normal range: 120-160 g/L oxygenation with
Hgb, Hct etc. anemia and systemic infection. Hematocrit:0.41 L/L appropriate number of
Normal range: 0.37-0.47 RBC,WBC and platelet
UCSF Health Org. (2022) Complete L/L present and no significant
Blood Count WBC count:6.47 /L sign of active infection in
Https://www.ucsfhealth.org/medical- Normal range: 5.0-10.0/L the body.
tests/cbc-blood-test o Neutrophil: 63%
Normal range: 50-
70%
o Lymphocyte: 27%
Normal range: 20-
40%
o Monocyte: 7%
Normal range: 0-
10%
o Eosinophil: 2%
Normal range: 0-
7%
o Basophil: 1%
Normal range: 0-
1%
RBC count: 4.15/L
Normal range:4.04-5.48/L
Platelet: 213/L
Normal range: 150-400/L
PROCEDURE AND DATE DESCRIPTION OF PROCEDURE SIGNIFICANCE/PURPOSE OF SIGNIFICANT FINDINGS IMPLICATION
PERFORMED THE PROCEDURE
Blood Chemistry It is a test done to measure the amount of certain It gives important information Blood Urea Nitrogen: There is no sign of
February 10 2024 substance like electrolyte, fats, sugar and enzymes. about how well the kidneys, 5.10 mmol/L liver damage nor
liver and other organs are Normal range: 2.80- kidney disease
NIH (N.D) Blood Chemistry Test working. 7.20mmol/L
Https://www.cancer.gov/publications/dictionaries/ Creatinine: 52.80
cancer-term umol/L
Normal range: 53-106
umol/L
SGOT/AST: 26.72 u/L
Normal range: 0-30
u/L
SGPT/ALT: 34.55 u/L
Normal range: 0-30
u/L
PROCEDURE AND DATE DESCRIPTION OF PROCEDURE SIGNIFICANCE/PURPOSE OF THE SIGNIFICANT FINDINGS IMPLICATION
PERFORMED PROCEDURE
Urinalysis It is a test that uses urine sample to detect It can determine GU infection and Color: Light yellow The kidney is filtering body
February 10 2024 substance in your urine. kidney function waste appropriately and no
Transparency: Clear genitourinary infection seen.
Nationale Kidney Foundation (n.d)
Urinalysis (Urine Test) Specific gravity: 1.005
https://www.kidney.org/atoz/content/what- Normal range: 1.00-1.005
urinalysis pH: 6.0
Normal range: 5.0-6.5
Creatinine: 4.40 mmol/L
Normal range: 4.4-17.7
mmol/L
Pus cell: 0/HPF
RBC: 0/HPF
Yeast cell: 0/HPF
Bacteria: 0/HPF
Mucus thread: 0/LPF
Amorphous Material:
0/LPF
Uric acid: 0/LPH
Calcium oxalate: 0/LPF
Squamous Epithelial
Cells:0/LPF
Glucose: Negative
Ketone: Negative
Urobilinogen: Negative
Bilirubin: Negative
Erythrocyte: Negative
Assessment Explanation of the problem Objectives Nursing intervention Rationale Evaluation
Objective: The patient has uterine STO: Dx: STO: Goal Met
Urinary incontinence protrusion that displaced After 1 hour of nursing 1. Identified conditions 1. This identifies direction for After 1 hour of nursing
Bladder distention pelvic organ leading to intervention, the patient will that may contribute further evaluation and intervention, the patient
Frequency of urinary urethral kinking that makes be able to: to impairment of treatment was able to:
elimination the urine unable to pass and A. Adhere to a urinary elimination. A. Adhere to a prescribed
pooling of urine in the urinary prescribed fluid 2. Noted age and gender 2. Age and gender is fluid intake and voiding
bladder. intake and voiding important indicator that can schedule
Nursing Diagnosis: schedule contribute to the current
Impaired urinary elimination LTO: problem. LTO: Goal Met
related to anatomical After 24 hours of nursing 3. Determined usual 3. To determine hydration After 24 hours of nursing
abnormalities Source: intervention, the patient will fluid intake status intervention, the was able
Doenges, et.al (2019) Nurse’s be able to: 4. Ascertained pattern of 4. To have a baseline data for to:
Pocket Guide F.A Davis A. Demonstrate proper elimination evaluation A. Demonstrate proper
Company bladder emptying Tx: bladder emptying
techniques 1. Had the client keep a 1. Baseline data for the techniques
B. Demonstrate record of voiding severity of the problem B. Demonstrate behaviors
behaviors to prevent frequency and output to prevent urinary tract
urinary tract infection 2. Assisted in developing 2. To rehabilitate normal infection.
a toilet training voiding patter
schedule
3. IFC to deflate bladder To prevent possibility of
as ordered. recurrent infection
4. Assisted in promoting 4. To alleviate discomfort
comfort measure such related to the current
as warm pads for problem.
spasm
EDx:
1. Educated about 1. To prevent nosocomial
proper care of IFC and infection
drainage bag
2. Encouraged to 2. To maintain renal function
increase oral fluid and prevent GU infection
intake to 1500 ml to
2000 ml of water
3. Instruct to verbalize
any persistent 3. For prompt intrvention
discomfort
Chief complaint: Patient is on her follow-up care due to vaginal discharge probably due to uterine protrusion about 2.6 cm from the external opening of vaginal canal, hence admission.
