V.

MEDICAL MANAGEMENT

a. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic and Date Ordered

Analysis and
Laboratory General Description Indication or Purpose Results Normal Values
Date Results in Interpretation
Procedures

LDH Date Ordered: The lactate dehydrogenase (LDH) The LDH test is used to identify 158 U/L 208-414 U/L

September 20, laboratory test includes examining tissue damage, keep track of
2023
blood samples to determine the conditions that cause tissue damage,
Date Results
concentrations of LDH, an and assess the therapeutic effect of
September 20,
enzyme present in many human chemotherapy.
2023
tissues. This test is frequently LDH levels are monitored in diseases

used to identify and track like anemia, liver disease, lung

problems like heart attacks, disease, and specific infections,

anemia, liver diseases, and providing important information on

particular malignancies. Increased how these conditions are

LDH levels in the blood can progressing.

 signify tissue damage, which is

important information for medical

practitioners in the diagnosis and

monitoring of diseases.

HBsAG Date Ordered: Hepatitis B surface antigen, often The presence of HBsAg indicates NONREACTIVE

September 19, known as HBsAg, is a protein that that the person is infectious, except
2023
may be seen on the hepatitis B when it might be transiently positive
Date Results
virus's surface. A person has an within 30 days after a dose of
September 19,
2023 active hepatitis B infection if hepatitis B vaccine (HepB). The

HBsAg appears in their blood. body normally produces antibodies

This antigen is a crucial marker to HBsAg as part of the normal

used in hepatitis B diagnostic immune response to infection. A

testing, assisting medical "positive" or "reactive" HBsAg test

professionals in determining those result indicates that the subject is

with the infection. The hepatitis B infection. This test can

bloodstream's HBsAg actually identify the "surface

concentration signals continued antigen" of the hepatitis B virus in

 viral replication and possible your blood.

spread to other people.

RPR Date Ordered: The RPR (Rapid Plasma Reagin) RPR (Rapid Plasma Reagin) testing NONREACTIVE

September 19, test is a diagnostic method for detects syphilis by identifying anti-
2023
syphilis, a sexually transmitted cardiolipin antibodies in the blood,
Date Results
infection, to be detected. It indicating an active infection. During
September 19,
2023 functions by identifying blood the test, blood is mixed with a

antibodies that the body makes in cardiolipin reagent, causing

response to the bacteria that clumping if syphilis antibodies are

causes syphilis. During the present. It is a crucial initial

procedure, a patient's blood screening tool; positive results

sample is drawn and mixed with a require confirmation with further

reagent containing cardiolipin, a tests like TPPA or FTA-ABS.

cellular component. When Timely testing is vital for early

syphilis antibodies react to the test diagnosis and appropriate treatment,

substance, a noticeable preventing disease progression and

agglutination or clumping reaction

 results. Since the test results are

frequently available quickly,

complications.
healthcare professionals can

quickly identify syphilis.

A urinalysis provides a wide The following are the variety of Physical  pH: 4.5-8
Date Ordered:
Urinalysis spectrum of data from which components of the urinalysis to be Examination: mean 6
September 21,
2023 tentative diagnoses can be made. evaluated: • Color  Specific

(10:35 PM) The urinalysis may indicate the Dark Yellow gravity:

need for further studies. Kidney • Transparency 1.010-1.030;

Date Results  Color/ appearance
and urinary tract infections can be Turbid usually about
September 21,  Transparency
2023 screened. Diseases unrelated to • pH: 1.015-1.025
 Specific gravity
the kidney 5.0  Protein:
 Pus Cells/ HPF
• Specific gravity usually
 RBC/ HPF 1.030 negative
 Cast / LPF • Pus cells  Sugar: usually
 Albumin 30-35 negative (may

be trace in
 Sugar • RBC normal

 Bile Test More than 50 pregnancy)

 Ketones • Cast/ LPF  Ketone:

None negative
 Epithelial Cells
• Albumin  Microscopic
 Mucus Threads
Trace sediment:
 A. Urates
• Sugar  Crystals: little
 A. Phosphate
Negative significance
 Crystals:
• Bile Test  Casts: more
Calcium oxalates
None are
Uric Acid
• Ketones pathological
 Bacteria in the urine
None (some hyaline
 Bacteria in the urine
• Epithelial Cells casts normal)
 Uncontrolled diabetes, starvation
Moderate RBCs:
 Tumor, calculus, occasional less
• Crystals: than 2-3 per
glomerulonephritis high power.
• Calcium oxalate
 Infection
  Kidney disease None

 T. Vaginalis Bacteria • Uric Acid

None

• T. Vaginalis

Bacteria

None

The CBC is a frequently ordered Normal Values

Hematology Date Ordered The Complete Blood Count outpatient and inpatient basic • Hemoglobin for adults:
Test:
September 20, (CBC) is a combination report of screening and diagnostic test that 128 g/L
Complete Blood 2023 • Hemoglobin
Count a series of tests of the peripheral provides information about the • WBC ct.
Date Result F: 120-160 g/L
blood. The quantity, percentage, hematological system and many 10.1
September 20, • WBC
2023 variety, concentrations, and other systems. It is used in routine • Bleeding Time 4-10

quality of blood cells are physical examination and in the 2 “00” Differential

identified. The tests usually diagnosis of a wide range of • Clotting Time Count:

included in a CBC are hematocrit, conditions and diseases of children 4 “00” • Neutrophils

hemoglobin, red cell count, red and adults (note: refer to individual Differential 55-65%

blood cell indices, white cell tests for a specific clinical Count: • Lymphocytes

count, and differential white blood implication). • Neutrophils 25-35%

cell count. Red blood cell (RBC) 77 • Monocytes

indices consist of the following • Lymphocytes 3-6%

tests: MCV, MCHC, MCH, 18 • Eosinophils

stained red cell examination, and • Monocytes 2-4%

platelet count. The differential 5 • Basophils

white blood cell count consists of • Eosinophils 0.1%

neutrophils, eosinophils, 0.00 • Band

basophils, lymphocytes, and

 monocytes. The individual test • Basophils 2-6%

comprising a CBC are described 0.00 • Hematocrit

in detail within this text. T • Band F: 0.37-0.43

0.00 M: 0.40-0.50

• Hematocrit • RBC ct.

0.39 F: 4.0-5.4

• RBC ct. M: 4.5-6.2

4.32

• Platelet Count

Normal Values

An analyte lab test is a diagnostic in adult:

or screening test that analyzes his diagnostic test provides a device • FBS • FBS

Analyte test Date Ordered: specific compounds or for determining the concentration of None 74- 106 mg/dl
September
20,2023 components in a patient's an analyte like glucose, cholesterol,
 biological sample, such as blood, free fatty acids, triglycerides, • BUN S.I.
(11:00 AM)
urine, or tissue. These tests are proteins, ketones, phenylalanine or None 4.1-5.9 mmol/L
Date Results in:
performed to evaluate a patient's enzymes, in a physiological or • Creatinine • BUN
September 20,
2023 health, diagnose medical aqueous fluid like blood, serum, 0.5 M: 9-20 mg/dl

disorders, monitor disease plasma, saliva, urine, interstitial S.I. F: 7-17 mg/dl

development, or evaluate the and/or intra-cellular fluid, the device 46.0 S.I.

effectiveness of treatments. having an integrated calibration and • UA M: 3.2-7

quality control system suitable for • Cholesterol mmol/L

dry reagent test strips with a very None F: 71-

small sample volume of about 0.5 μL • 133mmol/L

based on to a new sample • SGOT • Creatinine

distribution system. The production 15.0 M: 0.8-1.5

of the inventive analyte test element • SGPT mg/dl

involves only a small number of 9.0 F: 0.7-1.5 mg/l

uncomplicated production steps • Amylase S.I.

enabling an inexpensive production None M: 71-133

of the strips. • CKMB umol/L

None F: 62.106

• Sodium umol/L

None • UA

• Potassium M: 3.5- 8.5

None mg/dl

• Chloride F: 2.5-6-2 mg/dl

None S.I.

• Ionized Calcium M: 208-506

None umol/L

F: 149-369

umol/L

• Cholesterol

< 200 mg/dl

S.I

<5.2 mmol/L
• Glycerife

<150 mg/dl

S.I

1.7 mmol/L

• TDL

> 40 mg/dl

S.I

> 1.0 mmol/L

• SGOT

M: 17-59 u/L

F: 14-36 u/L

• SGPT

M: 21-72 u/L

F: 9-52 u/L

• Amylase

30-110 mmol/L
• CKMB

Up to 16 u/L

• Sodium

135-148

mmol/L

• Potassium

3.5-5.3 mmol/L

• Chloride

98-107
Nursing Care and Responsibilities (LDH):

Before test

Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse

should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During Test

Adhere to standard precautions or sterile technique if necessary. The nurse should provide

emotional support to the patient; and monitor the patient’s response during the procedure. Ensure

the correct labeling, storage, and transportation of the specimen.

After test

Apply pressure to the venipuncture site. Explain that some bruising, discomfort, and

swelling may appear at the site and that warm, moist compresses can alleviate this. Monitor for

signs of infection. In this period, nursing care revolves around observations and follow-up

activities for the patient. Report the results to the physician (or the appropriate members of the

health care team).

*The nurse must also consider that infants and children will need assistance in remaining still

during the venipuncture and age-appropriate comfort measures following the test.

Nursing Care and Responsibilities (HBsAg):

Before test

Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse

should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During Test

Adhere to standard precautions or sterile technique if necessary. The nurse should provide

emotional support to the patient; and monitor the patient’s response during the procedure. Ensure

the correct labeling, storage, and transportation of the specimen.

After test

Apply pressure to the venipuncture site. Explain that some bruising, discomfort, and

swelling may appear at the site and that warm, moist compresses can alleviate this. Monitor for

signs of infection. In this period, nursing care revolves around observations and follow-up

activities for the patient. Report the results to the physician (or the appropriate members of the

health care team).

*The nurse must also consider that infants and children will need assistance in remaining still

during the venipuncture and age-appropriate comfort measures following the test.

Nursing Care and Responsibilities (RPR):

Before test

Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse

should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During Test

Adhere to standard precautions or sterile technique if necessary. The nurse should provide

emotional support to the patient; and monitor the patient’s response during the procedure. Ensure

the correct labeling, storage, and transportation of the specimen.

After test

Apply pressure to the venipuncture site. Explain that some bruising, discomfort, and

swelling may appear at the site and that warm, moist compresses can alleviate this. Monitor for
signs of infection. In this period, nursing care revolves around observations and follow-up

activities for the patient. Report the results to the physician (or the appropriate members of the

health care team).

*The nurse must also consider that infants and children will need assistance in remaining still

during the venipuncture and age-appropriate comfort measures following the test.

Nursing Care and Responsibilities (Urinalysis):

Before test

Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse

should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During Test

Adhere to standard precautions or sterile technique if necessary. If any urine is accidentally

discarded or contaminated with feces, discard entire specimen, and begin the test again.

After test

Document urine quantity, date, and exact hours of collection on requisition.

*The nurse must also consider a collection bag or insertion of a straight catheter is likely

needed for infants and toddlers.

Nursing Care and Responsibilities (CBC test):

Before test
Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse
should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During test

Adhere to standard precautions or sterile technique if necessary. The nurse should provide

emotional support to the patient; and monitor the patient’s response during the procedure. Ensure

the correct labeling, storage, and transportation of the specimen.

After test
Apply pressure to the venipuncture site. Explain that some bruising, discomfort, and swelling

may appear at the site and that warm, moist compresses can alleviate this. Monitor for signs of

infection. In this period, nursing care revolves around observations and follow-up activities for

the patient. Report the results to the physician (or the appropriate members of the health care

team).

*The nurse must also consider that infants and children will need assistance in remaining still

during the venipuncture and age-appropriate comfort measures following the test.

Nursing Care and Responsibilities (Analyte Test):

Before test

Explain the test procedure and the purpose of the test to the patient. Assess their knowledge of

the test. Prepare the equipment and supplies needed. If a consent form is required, the nurse

should prepare it. If the patient’s guardian asks questions, provide information about the

procedure to help them provide comfort to the patient.

During test
Adhere to standard precautions or sterile technique if necessary. The nurse should provide

emotional support to the patient; and monitor the patient’s response during the procedure.

After test
Apply pressure to the venipuncture site. Explain that some bruising, discomfort, and swelling

may appear at the site and that warm, moist compresses can alleviate this. Monitor for signs of

infection. In this period, nursing care revolves around observations and follow-up activities for

the patient. Report the results to the physician (or the appropriate members of the health care

team).

*The nurse must also consider that infants and children will need assistance in remaining still

during the venipuncture and age-appropriate comfort measures following the test.
 B. IVF, THERAPY, DRUGS ETC.

Date
Route of
Administration Dosage
Ordered
Medical and Frequency of
Administration General Description Indication or Purpose Client’s Response
Management Date

Started

Date Changed
Route of Administration: Hydralazine is used to treat high blood Hydralazine is an antihypertensive
Date Ordered:
Intravenous IV
pressure (hypertension). It is also used agent used for the management of
Fluid Infusion September 20,
2023
to control high blood pressure in a essential hypertension or severe
Hydralazine Dosage: 5mg
Date Started
mother during pregnancy (pre- hypertension associated with conditions
September 20,
2023 Frequency of eclampsia or eclampsia) or in requiring immediate action, heart

Administration:
emergency situations when blood failure, and pre-eclampsia or eclampsia.

pressure is extremely high

 (hypertensive crisis). A

combination product with isosorbide

dinitrate is indicated as an adjunct

therapy in the treatment of heart failure.

Date

Ordered Route of General Description Indication or Purpose

Administration Dosage
Medical Date and Frequency of Client’s Response
Management Administration
Started

Date Changed
Intravenous Date Ordered: Route of Administration: Normal saline is a cornerstone of This intravenous solution is indicated
Fluid Infusion
September 20, IV intravenous solutions commonly used in
for use in adults and pediatric patients
Saline Solution: 2023
the clinical setting. It is a crystalloid
mgSay 4g dicuk as a source of electrolytes and water for
in 50 cc PNSS Date Started Dosage: 4g fluid administered via an intravenous
5Iup
hydration. Also, designed for use as a
Septemb solution. Its indications are sources of

er 20, Frequency of hydration and electrolyte disturbances. diluent and delivery system for
2023 Administration: It can come in various concentrations; intermittent intravenous administration

30 minutes the two specifically addressed are 0.9%

of compatible drug additives it is also
and 0.45%.
used to clean out an intravenous (IV)

catheter, which helps prevent blockage

The following are primary indications
and removes any medicine left in the
for the use of normal saline infusion

that have been approved by the FDA: catheter area after you have received an

A. Extracellular fluid replacement IV infusion.

(e.g., dehydration, hypovolemia,

hemorrhage, sepsis)

B. Treatment of metabolic alkalosis

in the presence of fluid loss

C. Mild sodium depletion

 Date

Ordered Route of General Description Indication or Purpose

Administration Dosage
Medical Date and Frequency of Client’s Response
Management Administration
Started

Date Changed
Date Ordered: Route of Administration: N/A
Intravenous Dexamethasone accelerates maturation Dexamethasone is a corticosteroid,
Fluid Infusion September 20, IM
2023 of fetal lungs, decreases number of which is a type of drug. It is commonly
Dexamethasone

Date Started Dosage: 6mg: 4 doses neonates with respiratory distress used to treat inflammation and edema in

September 20, syndrome and improves survival in the body. It can be administered
2023
Frequency of
preterm delivered neonates. Optimal throughout pregnancy to assist prevent
Administration:
gestational age for use of preterm delivery by encouraging fetal

dexamethasone therapy is 31 to 34 lung development. Depending on the

weeks of gestation. patient's demands, the drug can be

administered via injection or consumed

 orally.

C.MEDICATIONS

Date

Ordere Route of Administration General Description Indication or Purpose

Dosage and Frequency
d of Administration
Medical
Managemen Date Client’s Response
t
Started

Date
Changed
Date Ordered: Date Ordered: Methyldopa is a centrally acting
Methyldopa Methyldopa can help reduce
September 20, September 20, 2023 alpha-2 adrenergic agonist used to
250 mg
2023 pregnancy issues such as
manage hypertension alone or in
Date Started
Date Started combination with hypertension (high blood pressure)
September 20, 2023
Septem hydrochlorothiazide, and to treat and a related disease known as pre-

ber 20,
eclampsia. Preterm birth, low birth
 2023 hypertensive crises.
weight in the newborn, and illness in
Methyldopa crosses the placenta and
both the mother and the baby, which
may cause mild hypotension in

neonates of treated mothers. Because can be dangerous, are examples of

it has been safely and successfully these difficulties.

used to treat hypertension during

pregnancy, some experts consider it

to be the drug of choice for the

D. DIET

Type of Diet Date General Description Indication/ Purpose Specific Foods Taken Client’s Response

Ordered

Date

Started

Date

Change
 d

Diet as Date Diet as tolerated is "Diet as tolerated" is a meal plan that Foods allowed include broiled,

tolerated Ordere frequently prescribed is frequently provided to patients in baked, or boiled trimmed

d: regarding surgery. healthcare settings, especially in meats/fish, chicken/turkey

Septemb Individuals are only hospitals or after surgery. It indicates without skin, nonfat and low-

er 20, provided liquids such as that the patient should eat or drink fat milk products, fruits and

2023 water once a surgical according to their comfort and ability vegetables, most breads,

operation is completed. to do so without causing discomfort, pastas, rice, caffeine, and salt

The diet evolves to solid pain, or other negative effects. is allowed

foods in the form of

purees, chunks, and,

finally, a conventional

diet. Diet as tolerated is a

word that denotes that the

gastrointestinal tract is

tolerating meals and is

ready to progress to the

 next stage.

TYPE OF ACTIVITY GENERAL DESCRIPTION INDICATION OR PURPOSE NURSING RESPONSIBILITIES

Bed rest can help the patient recover N/A

Resting in bed at home, limiting
Bed Rest from an injury, surgery, or illness. As
activities, or being monitored in the
well as prevent further damage to your
hospital if the patients was advised to
body after an injury or illness.
stay in bed.

Controlled and appropriate physical Exercise improves cardiovascular N/A

 activity such as jogging, walking, fitness and decreases blood pressure.

Zumba and yoga can help regulate It protects against preeclampsia and
Recreational Physical Activities
blood pressure. Properly managed other hypertensive illnesses by

exercise can contribute to maintaining lowering oxidative stress, increasing

healthier blood pressure levels, vascularity and placental

decreasing oxidative stress,

stimulating vascularity and placental

growth. Patients with preeclampsia

can engage in light to moderate

activities with their healthcare

provider's guidance.
References

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https://go.drugbank.com/drugs/DB01275
Hydralazine (Oral Route). (2023, February 7).
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20064201#:~:text=Hydralazine%20is%20used%20to%20treat,extremely%20high
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Tonog, P. (2022, October 16). Normal Saline. StatPearls - NCBI Bookshelf.
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https://go.drugbank.com/drugs/DB00968
Gupta, M. (2023, July 10). Methyldopa. StatPearls - NCBI Bookshelf.

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%20medication%20used,in%20the%20management%20of%20hypertension.

What Is the Meaning of "Diet As Tolerated"? (2021, January 11). Healthfully.

https://healthfully.com/205546-what-is-the-meaning-of-diet-as-tolerated.html

Lab Tests Online. (2021). LDH: The Test. American Association for Clinical Chemistry.

https://labtestsonline.org/tests/ldh

Lactate dehydrogenase (LDH) test. (n.d.). https://medlineplus.gov/lab-tests/lactate-

dehydrogenase-ldh-test/#:~:text=An%20LDH%20test%20is%20most,and%20some

%20types%20of%20infections.

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testing/en/

Detailed STD facts - Syphilis. (n.d.). https://www.cdc.gov/std/syphilis/stdfact-syphilis-

detailed.htm