Manuel S.

Enverga University Foundation

Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
Pre-Op
(March
7,2019)
Component Result Normal Range Interpretation Implication Nursing
Responsibiliti
es
WBC 11.76 x 4,000-10,000 Increased Level Can be sign of  Provide
10^9/L infection or stress positive
reinforceme
nt when the
client seeks
out others.
 Assess
physical and
mental status
Provide safe
and conducive
environment
Neutrophils 80.0% 50.0 - 60.0 Increased level Can be sign of
infection or stress • Prevent
infection

•Promote oral
care

•Promote
hygiene

Lym% 15.0 % 35.0 - 45.0 Decreased level Lymphocytopenia • Minimize the

risk of
infection
• Observing
for signs of
infection.
• Provide
patient
emotional
support
Mon% 5.0 % 2.0 - 4.0 Increased level Can be sign of
infection or stress • Prevent
infection

•Promote oral
care
•Promote
hygiene
Eos% 0.0 % 2.0 - 5.0 Decreased level Sign of infection. •Rest
between
activities.

•Plan
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

ahead and
save your
energy for
the most
important
activities.

•Avoid or
stop
activities
that make
you short
of breath
or make
your heart
beat
faster.
Bas% 0.0% 0.0 - 1.0 Normal Results
RBC 5.64 4.00 - 5.50 Increased level • Low oxygen •Assess vital
X10^12/L level signs,
respiratory and
cardiovascular
systems,
and level of
consciousness
HGB 16.6g/dl 12.0 - 16.0 Increased level •Polycythemia •Medication to
decrease blood
cells.
• Therapy to
reduce
itching. 
HCT 46.2% 40.0 - 54.0 Normal Results
MCV 82.0 fl 80.0 - 100.0 Normal Results
MCH 29.5 pg 27.0 - 34.0 Normal Results
MCHC 35.9g/dl 32.0 - 36.0 Normal Results
RDW-CV 11.7 % 11.0 - 16.0 Normal Results
RDW-SD 40.1 fl 35.0 - 56.0 Normal Results
PLT 371 x10^9/L 150 - 450 Normal Results
MPV 8.3 fl 6.5 - 12.0 Normal Results
PDW 16.0 9.0 - 17.0 Normal Results
PCT 0.308 % 0.108- - 0.282 Increased level •Low risk of • Monitor
sepsis client’s
temperature
•Administer
antipyretic as
ordered
•Adjust
environmental
factors as
indicated

J. LABORATORY DIAGNOSTIC EXAM

 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
HEMATOLOGY

Component Result Normal Range Interpretation Implication Nursing

Responsibilities
Creatinine 1.03mg/dl 0.3-1.3
Urea UV 20.6 mg/dl 7 -18 Increased level •Uremia •maintaining a
healthy blood
pressure
taking steps to
maintain
cardiovascular
health
•not smoking
•maintaining a
healthy diet and
exercise plan to
avoid obesity

Pre-Operative(March 7,2019)

K. Impression/Diagnosis
Computed Tomography:
Findings:
Multiple enlarged pararectal lymph nodes are seen with the largest on the left
measuring 1.5 cm in short axis diameter.
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
The liver is in normal size with smooth margins and homogenous parenchyma. No
focal lesions are detected. There is no intrahepatic or extrahepatic biliary ductal
dilatation.

The gallbladder shows normal volume with no intraluminal filling defects. The
gallbladder walls are not thickened.

The pancreas is normal in size and density with no focal lesions. The pancreatic duct
is not dilated. A well-defined nodule is seen medial to the superior pole, likely
representing a splenule. The spleen and adrenal glands are normal in size and
configuration.

The kidneys are rotated anteriorly. Both lower poles are pointing medially and is seen
fused at the level of L4 across the midline by an isthmus. Ureters arise from the
kidneys anteriorly. Two ureters unite before emptying into the bladder on both sides.
Both kidneys are normal in position and size. No parenchymal lesions are detected.
The pelvocalyceal systems and visualized ureters are not dilated. No lithiasis are
noted along the urinary tract.

The urinary bladder is well distented and shows no abnormal wall thickening. There
are no enlarged retrocural, retroperitoneal, mesenteric, or pelvic lymph nodes. No
ascites is detected.
No abnormalities are noted within the uterus. Bilateral hypodense structures are seen
in both adnexae, likely representing ovaries.

The visualized vascular and osseous structures are grossly unremarkable.

The included lung bases are clear.

Impression:
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

COURSE IN THE WARD

Component
Date Result Normal
Medical Range
Management InterpretationNursing
Implication Nursing
Rationale
Interventions Responsibilities
SODIUM 134.1 135-148 mmol/dl Decreased
3 -7-19 >Admit to surgery Ward Level>assessment of the >to give the best
POTASSIUM
8:34pm 4.46 3.50 -5.30mmol/dl
>IVF of D5LR 1L x 8x Normal Results
patient care, needs nursing care for the
(K)
CHLORIDE
>NPO 98 - 107mmol/dl
based on his patient and assess the
CALCIUM >Labs/diagnostics
0.80 - 1.20mmol/dl perception of the patient’s condition
CREATININ ECG, Chest0.6 -X-ray,
1.1mg/dl illness is essential for
E (STAT) Creatinine, BUN, Na, RBS, the provision of high
BUN (STAT) urinalysis, K level
7-18mg/dl quality nursing care >to replace fluid loss
HbA1C(HPL >Insertion 4.2
of -NGT
6.2% >regulate IVF at >to have a further
C)
>Monitor V/S q4 prescribe rate check on the patient’s
RBS
>I and O q8 >instructed not to eat condition accurately
>Meds: until the procedure is >to avoid vomiting
HNBB 10mg IV done during the procedure
Omeprazole 40mg IV OD >secure patient >to provide accurate
>refer consent and explain information for the
the procedure to the drug medication
patient >for health care
>inform the patient provider awareness to
about the medicine provide safety
and its uses precautions to patient
>observe the 10R’s and to avoid other
>watch for any complications
discrepancies >to prescribed another
order for patient’s
treatment
>refer to ROD
3-7-19 >Admit >assessment of the >to give the best
9:10pm >Secure consent patient care, needs nursing care for the
>NPO based on his patient and assess the
>IVF: D5LR 1L x8 perception of the patient’s condition
>Dx: CBC with Pc illness is essential for >for health care
> Abdominal X-RAY upper the provision of high provider awareness to
quadrant/supine quality nursing care provide safety
>Chest X-Ray: PA >secure patient precautions to patient
> Na, K, consent and explain and to avoid other
>Urinalysis the procedure to the complications
>RBS patient >replaced fluid loss
>BUN >regulate IVF at >check patient’s
>Crea prescribe rate condition accurately
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
Tx: ceftriaxone 2g IV then 1g >secured consent and >to provide accurate
IV q12 ANST explain the procedure information for the
Metronidazole 500mg IV q8 >>inform the patient drug medication
ANST about the medicine >for health care
Omeprazole 40mg IV OD and its uses provider awareness to
> For E-Lap Appendectomy >observe the 10R’s provide safety
>inform OR/Anesthesiologist >watch for any precautions to patient
>I and O qShift discrepancies and to avoid other
>Refer PRN >monitored I and O complications
>FD 500cc of PNSS then shift >secured consent and >Baseline reference,
to D5LR 1L x 6hrs explain the procedure >provide information
>insert Folly catherter about the procedure
and gain rapport
3-8-19 >NPO >instructed not to eat >to avoid vomiting
1am >medications: until the procedure is during the procedure
Ondansetron 4mg tab PRN done >to provide accurate
Omeprazole 40mg cap PRN >inform the patient information for the
>Refer about the medicine drug medication
and its uses
>observe the 10R’s >to prescribed another
>refer to ROD order for patient’s
treatment
POST OP
3-8-19 >NPO for 5 days >instructed not to eat >>to avoid vomiting
1:10 pm >continue: Ceftriaxone 1gm IV until the procedure is during the procedure
q12 done >help to ensure that
-Combivent 100mg IV q8 >assess location, the patient receives
-Omeprazole 40mg IV OD duration, frequency effective pain relief
-Ketorolac 30gm IV q8 ANST and severity of pain >impaired swallowing
>Assess gag reflex may cause aspiration
- Tramadol 100mg IV q8 for and swallowing >for legal
pain >baseline reference documentation
>monitor SP pain q8 WOF for the entire chain of
>Maintain NGT IFC for 5 days healthcare accurate
>Repeat CBC with ABO blood documentation
typing, crea, K , Na
3
3-8-19 ANOTHER POST OP ORDER >monitor vital signs > to monitor if there
2pm >S/P exlap enlarged >provide safety are any changes
cholecystectomy, >>baseline reference >to prevent further
Appendectomy, extended right for the entire chain of injury
__ ileo-colon anastomosis, JP healthcare accurate >for legal
Drain__, __ converted to documentation documentation
GETA >placed patient flat on >check patient’s
>To PACU bed condition accurately
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
>Flat on bed until 6pm >regulate IVF at >to relieved comfort
>NPO for 3 days prescribe rate >for prescribed
>monitor V/S q15 mins. >administer pain another order for
untilstable then q4hrs medication as ordered patient treatment
>present IVF to run for 8hrs >refer to ROD
Component Result Normal Range
>IVF to ff. D5LR 1L x 8hrs for Interpretation Implication Nursing
Responsibilities
3 cycles
SODIUM 136.4 135-148 mmol/dl Normal results
POTASSIUM 4.34>Antibiotic as-5.30mmol/dl
3.50 ordered Normal Results
(K) >Pain Medication:
CHLORIDE -Ketorolac98 30mg IV q6 for 7
- 107mmol/dl
CALCIUM more doses 0.80 - 1.20mmol/dl
CREATININ -Tramadol 0.650mg
- 1.1mg/dl
IV q6hrs
E (STAT) PRN for severe pain
BUN (STAT) 7-18mg/dl
HbA1C(HPL
-Ambivent 1 neb q6hrs for
4.2 - 6.2%
st
C) 3doses, 1 dose at PACU
RBS > watch out for any __
types/symptoms>Refer
accordingly
3-8-19 >Oxygen via facial mask at
3:35pm 3L/min.
>encourage deep breathing
exercise
>refer accordingly
3-9-19 >NPO
>General Liquid diet
>cont. IVF/ monitor
>______
>refer

Post-operative (March 8,2019)

 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES
Post-Op
(March
8,2019)
Component Result Normal
Manuel S.Range Interpretation
Enverga University Implication
Foundation Nursing
Responsibiliti
Lucena City es
WBC 11.76 x 4,000-10,000 Increased Level Can be sign of  Provide
10^9/L Granted Autonomous Status infection or stress positive
reinforceme
CHED CEB Res.076-2009 nt when the
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES client seeks
out others.
 Assess
physical and
mental status
Provide safe
and conducive
environment
Neutrophils 80.0% 50.0 - 60.0 Increased level Can be sign of
infection or stress • Prevent
infection

•Promote oral
care

•Promote
hygiene

Lym% 15.0 % 35.0 - 45.0 Decreased level Lymphocytopenia • Minimize the

risk of
infection
• Observing
for signs of
infection.
• Provide
patient
emotional
support
Mon% 5.0 % 2.0 - 4.0 Increased level Can be sign of
infection or stress • Prevent
infection

•Promote oral
care
•Promote
hygiene
Eos% 0.0 % 2.0 - 5.0 Decreased level Sign of infection. •Rest
between
activities.

•Plan
ahead and
save your
energy for
the most
important
activities.

•Avoid or
stop
activities
that make
you short
of breath
or make
your heart
beat
faster.
 Manuel S. Enverga University Foundation
Lucena City
Granted Autonomous Status
CHED CEB Res.076-2009
COLLEGE OF NURSING & ALLIED HEALTH SCIENCES

Post-Op (March 8,2019)

Component Result Normal Range Interpretation Implication Nursing

Responsibilities
Creatinine 1.03mg/dl 0.3-1.3
Urea UV 20.6 mg/dl 7 -18 Increased level •Uremia •maintaining a
healthy blood
pressure

•taking steps to
maintain
cardiovascular
health

•not smoking

•maintaining a
healthy diet and
exercise plan to
avoid obesity