LABORATORY EXAMINATIONS

Examination Date of Results Normal Values

Done Examination Relevance/Significance to Patient Condition

(Why was it done to the client? what is the significance of

the result to the client’s condition?)

2 Dimensional Apr 5, 2022 LEFT ATRIUM LEFT ATRIUM

Echo Doppler AO Root Diam = 2.6 AO Root Diam = The patient has a small AO Root Diam. Having a small
Report cm 3.0 - 3.5 cm aortic root was associated with increased ischaemic
cardiovascular events and mortality.

REGURGITATION REGURGITATION
(GRADE) (GRADE)
Mitral = Mild Mitral = Normal The patient has Mild Grade Mitral Regurgitation,
meaning the valve between the left heart chambers
doesn't close completely, allowing blood to leak
backward across the valve. This is the most common
type of heart valve disease (valvular heart disease). If
the leakage is severe, not enough blood will move
through the heart or to the rest of the body. As a result,
mitral valve regurgitation can make you feel very tired
(fatigued) or short of breath.

Tricuspid = Mild Tricuspid = Normal The patient has Mild Grade Tricuspid Regurgitation,
meaning the valve between the two right heart chambers
(right ventricle and right atrium) doesn't close properly.
As a result, blood leaks backward into the upper right
chamber (right atrium). The possible complication are
Atrial fibrillation or heart failure

Pulmonic = Mild Pulmonic = Normal The patient has Mild Grade Pulmonic Regurgitation,
meaning the pulmonic valve causing blood flow from the
pulmonary artery into the right ventricle during diastole.
 The most common cause is pulmonary hypertension. PR
is usually asymptomatic.

Isovolumic relaxation IVRT = 60 - 90 The patient has high/abnormal IVRT, it indicates that the
time (IVRT) = 113 msec patient has poor myocardial relaxation. Impaired/poor
msec myocardial relaxation is an important determinant of
cardiac output only during rapid heart rate and especially
when combined with prolonged systolic intervals. These
findings clarify the role of myocardial relaxation in the
pathogenesis of elevated filling pressures characteristic
of heart failure.
 LABORATORY EXAMINATIONS

Examination Date of Results Normal Values

Done Examination Relevance/Significance to Patient Condition

(Why was it done to the client? what is the significance of

the result to the client’s condition?)

Chemistry - IH: March 4, (ALT/SGPT) Alanine (ALT/SGPT) The patient has high level Alanine Aminotransferase,
Non Panel Items 2022 Aminotransferase = Alanine meaning the High levels of ALT in your blood can be due
Test 58.1 u/l Aminotransferase = to damage or injury to the cells in your liver. Elevated
0 - 55 u/l ALT levels can also indicate injury to cells in other parts
of your body, since ALT isn’t solely found in your liver.

(AST/SGOT) (AST/SGOT) The patient has a high level of Aspartate

Aspartate Aspartate Aminotransferase, meaning the in the blood may be a
Aminotransferase = Aminotransferase = sign of hepatitis, cirrhosis, mononucleosis, or other liver
47 u/l 5 - 34 u/l diseases. High AST levels may also be a sign of heart
Bilirubin, problems or pancreatitis.
Fractionated -
Adult Test (TBIL) Bilirubin, total (TBIL) Bilirubin, The patient has a high level of total Bilirubin, meaning
= 33.6 umol/l total = 3.4 - 20.5 the liver is not functioning correctly. Bilirubin is also a
umol/l product of breakdown of red blood cells, and an elevated
reading may be related to disorders of red blood cells
and not liver disease.

(IBIL) Indirect (IBIL) Indirect The patient has a high level of Indirect Bilirubin, meaning
Bilirubin = 23.1 Bilirubin = 0 - 19 the patient’s body is getting rid of too many red blood
umol/l umol/l cells

(DBIL) Direct (DBIL) Direct

Bilirubin = 10.49 Bilirubin = 0 - 8.60 The patient has a high level of Direct Bilirubin, it
umol/l umol/l indicates that the liver isn’t clearing bilirubin properly.
 LABORATORY EXAMINATIONS

Examination Date of Results Normal Values

Done Examination Relevance/Significance to Patient Condition

(Why was it done to the client? what is the significance of

the result to the client’s condition?)

Abdominal March 4, Mild Hepatic No Fats in Liver The patient has Mild Hepatic steatosis, meaning the
Ultrasonography 2022 steatosis patient has fatty liver disease

Distended The patient has Distended Gallbladder with cystic duct

Gallbladder with 1 stone, meaning the gallbladder is inflamed (cholecystitis)
cystic duct stone (0.7 pain. There is then a much greater risk of a perforation,
cm) or tear, in the gallbladder, as well as infection and tissue
death. The patient also has cystic duct stone which is
found in her gallbladder.

Atherosclerotic Aorta The patient has Atherosclerotic Aorta, meaning a

material called plaque (fat and calcium) has built up in
the inside wall of a large blood vessel called the aorta.
This plaque buildup is sometimes called "hardening of
the arteries."

Atrophic uterus with The patient has an Atrophic uterus with thin
thin endometrium endometrium, meaning the patient has a lack of
adequate estrogen.
 DRUG STUDY

Classificati Dosa Route of Mechanism Contraindication Nursing Responsibilities

Name of on ge Administra of Action Indication
Drug tion
(general
(Generic & indication, then
Brand) specific
indication to
patient)

Brand name: Class of 500 Oral Inhibits Ciprofloxacin is Contraindicated in Monitor signs of hypersensitivity
Cipro antibiotics mg bacterial used to treat hypersensitivity, reactions and anaphylaxis,
called DNA infections of the cross- including pulmonary symptoms
Generic fluoroquin synthesis by skin, lungs, sensitivity among
name: olones inhibiting airways, agents Watch for signs of
Ciprofloxaci DNA bones, and may occur. pseudomembranous colitis,
n Gyrase. joints Use cautiously in including diarrhea, abdominal
caused by underlying CNS pain, fever, pus or mucus in
Therapeutic susceptible pathology, renal stools, or other severe or
Effects: bacteria. impairment, prolonged GI problems (nausea,
Death of cirrhosis cramps, vomiting).
susceptible It is also
Bacteria. frequently Assess signs of peripheral
used to treat neuropathy such as numbness,
Spectrum: urinary tingling, and decreased muscle
Broad infections strength.
activity caused by
includes bacteria such Assess dizziness and
many as E. coli. drowsiness that might affect
gram-positiv gait, balance, and other
e It is effective in functional activities
pathogens treating
infectious
diarrheas
caused
by
E. coli,
Campylobacter
jejuni
, and
Shigella
bacteria
 DRUG STUDY

Classificati Dosa Route of Mechanism Contraindication Nursing Responsibilities

Name of on ge Administra of Action Indication
Drug tion
(general
(Generic & indication, then
Brand) specific
indication to
patient)

Brand name: Opiate 50 IV Binds to Tramadol Contraindicated Be alert for excessive sedation or
Deverol (narcotic) mg mu-opioid hydrochloride in patients who somnolence.
analgesic Q6 receptors. extended-releas have had a
Generic s Inhibits e capsules are hypersensitivity Monitor other changes in mood
name: reuptake of indicated for reaction to any and behavior, including euphoria,
Tramadol serotonin the opioid. Patients confusion, malaise, nervousness,
and management under the age of and anxiety.
norepinephr of moderate to twelve should not
ine in the moderately use the Use appropriate pain scales
CNS. severe chronic medication. (visual analogue scales, others)
pain in adults Patients under the to document whether this drug is
Therapeuti who require age of eighteen successful in helping manage the
c Effects: ↓ around-the should not be patient's pain.
pain. clock given the
treatment of medication if they Assess dizziness that might affect
their pain for have had a history gait, balance, and other
an extended of tonsillectomy or functional activities
period of time. adenoidectomy
Implement fall-prevention
strategies especially if the patient
exhibits sedation, dizziness, or
blurred vision.
 DRUG STUDY

Classificati Dosa Route of Mechanism Contraindication Nursing Responsibilities

Name of on ge Administra of Action Indication
Drug tion
(general
(Generic & indication, then
Brand) specific
indication to
patient)

Brand name: Analgesic 500 Oral Binds to Like other OTC Contraindication Be alert for signs of hepatotoxicity
Tylenol s (pain mg mu-opioid pain relievers, s to the use of and liver failure, including anorexia,
relievers) receptors. acetaminophen acetaminophen abdominal pain, severe nausea and
Generic and Inhibits temporarily include vomiting, yellow skin or eyes, fever,
name: antipyreti reuptake of relieves minor hypersensitivit sore throat, malaise, weakness,
Paracetamol cs (fever serotonin aches and y to facial edema, lethargy, and unusual
reducers). and pains due to acetaminophen bleeding or bruising.
norepinephr headache, , severe
ine in the backache, the hepatic Advise patients that analgesics are
CNS. common cold, impairment, or usually more effective if given
minor pain of severe active before pain becomes severe;
Therapeuti arthritis, hepatic emphasize that adequate pain
c Effects: ↓ toothache, disease control will allow better participation
pain. premenstrual in physical therapy.
and menstrual
cramps, and Caution patients about the use of
muscular over-the-counter products that
aches, and contain aspirin, other NSAIDs, or
temporarily acetaminophen while taking high
reduces fever. doses of acetaminophen.
 DRUG STUDY

Classificati Dosa Route of Mechanism Contraindication Nursing Responsibilities

Name of on ge Administra of Action Indication
Drug tion
(general
(Generic & indication, then
Brand) specific
indication to
patient)

Brand name: NSAID, 10 Spinal It inhibits used for the Hypersensitivity Patients who have asthma,
Toradol ANALGES mg Anesthesi synthesis of short-term to aspirin-induced allergy, and nasal
IC; a Block prostaglandi treatment of ketorolac; polyps are at increased risk for
Generic ANTIPYR ns moderate to individuals developing hypersensitivity
name: ETIC. and is a severe pain. It with complete or reactions
Ketorolac peripherally is usually used partial
acting before or after syndrome of Monitor BP during initiation and
analgesic. medical nasal periodically during therapy. May
Ketorolac procedures or polyps, cause fluid retention and edema
does after surgery. angioedema, leading to new onset or worsening
not have and hypertension.
any bronchospastic
known reaction to Assess signs of paresthesia,
effects aspirin or including numbness and tingling.
on opiate other NSAIDs;
receptors. during Assess symptoms of bronchospasm
labor and and asthma, including wheezing,
delivery; coughing, dyspnea, and tightness in
Therapeutic patients with chest.
Effects: severe
 Decreased renal Monitor signs of kidney toxicity,
pain. impairment or at including blood or pus in urine,
risk for renal increased urinary frequency,
failure due decreased urine output, weight gain
to volume from fluid retention, and fatigue.
depletion;
patients with risk Assess dizziness and drowsiness
of that might affect gait, balance, and
bleeding; active other functional activities
peptic
ulcer disease; Monitor injection site for pain,
pre- or swelling, and irritation.
intraoperatively;
intrathecal or
epidural
administration;
in
combination
with other
NSAIDs;
lactation

References:
❖ https://www.rxlist.com/consumer_ketorolac_acular/drugs-condition.htm
❖ https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139028867#:~:text=Be%20alert%20for%20excessive
%20sedation,malaise%2C%20nervousness%2C%20and%20anxiety.
❖ https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139000208
❖ https://reference.medscape.com/drug/ketorolac-343292
❖ https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139015291