Upload
joy-jarin
View
215
Download
0
Embed Size (px)
Citation preview
7/29/2019 Ros Labs Functional (CASE STUDY)
1/4
A. Review of Systems
(+) Cough and colds
(-) Weight Loss (-) Weakness
(-) Fatigue (-) Difficulty of breathing
(-) Chest pain (-) Diarrhea
1. Regional ExaminationAugust (?) , 2013System Actual Findings
General Concious, coherent, and not in cardiorespiratory distress
Vital signs:BP: 120/80 mmHgPR: 82 bpm
RR: 20 cpmT: 36.4 Wt: 46 kg.
HEENT Slightly icteric sclerae, pink palpebral cojunctivae, moist oralmucosa, no nasoaural discharge, no CLAD, no TPC
Chest and Lungs Symmetric chest expansion, clear breath sounds, (-) crackles,wheezes, or rales
Heart Adynamic precordium, normal rate, regular rhythm, no murmurs,heaves or thrills
Abdomen Hypoactive bowel sounds, (+) guarding, (+) tenderness, nopalpables masses, no organomegaly, (-) direct tenderness on theRUQ, (-) Murphys
Extremities Full and equal pulses, (-) bilateral knees non-tender, no swelling,no erythema at the time of examination, no cyanosis, CRT
7/29/2019 Ros Labs Functional (CASE STUDY)
2/4
2. Laboratory Studies / Diagnostics
Procedure
DateIndication
NormalFindings /
Values (
Actual
Findings
Significance /
Interpretation
Explanations of
the Findings
(as too High or
Low)
HematologyTo aid in diagnosing anemia and to
monitor blood loss and infection
August (?),
2013
Hgb
The oxygen-carrying pigment of red blood
cells that gives them their red color andserves to convey oxygen to the tissues
12.0 - 16.0
(g/L)13.8
(g/dL)
Hct
A measure of the packed cell volume ofred cells, express as a percentage of the
total blood volume.
0.37
0.47%.38 %
WBCThis is used to determine if there is
infection present.
5.00
10.0012
Slightly increased
WBC may indicate
Infection.
Urinalysis
A urinalysis consists of a number of physical, chemical and microscopic tests of a urine
sample as part of a checkup to help diagnose a urinary tract or metabolic disease. Doctorsalso use urinalysis as a general health screen.
August 24,
2013
MACROSCOPIC MICROSCOPIC
Color Light Yellow White Blood Cells 5-10 WBC
Transparency Slightly turbid Red Blood Cells 0-1 RBC
Sugar Negative Epithelial Cells Many
Protein NegativeCrystals:
Eurates/PhosphatesFew
7/29/2019 Ros Labs Functional (CASE STUDY)
3/4
FUNCTIONAL ASSESSMENT
(Pre-hospitalization)
* Health Perception and Health ManagementThe client feel good about herself. She also finds it easy to socialize with the
people around her and interact naturally; she sleeps an average of eight to ten hours; has
allergy to chicken; has a healthy appetite, she claims that she consumes a lot of food,
mostly rice and meat, shows a preference of meats over some fish and vegetables; does
not have a hard time with urination or bowel movement, if ever she does have problems,she claims it is usually solved through increasing fluid intake and eating foods high in
fiber.
* Nutritional and Metabolic PatternThe patient is having her diet as diet as tolerated during her confinement in the
hospital except for dark-colored foods.
* Elimination patternPatient usually defecates once a day, brown in color with no other problems
during defecations. She urinates approximately 4-6 times a day, yellowish in color, alsowith no other problems in voiding process.
* Activities of daily living (ADL)The patient verbalized that she can eat independently and can dress herself
properly without a need of any assistance as well as in bathing. She usually sleeps around
9 oclock in the evening and awake at 11 oclock in the morning.
* ValuesBelief PatternThe client is a Roman Catholic. She verbalized that the family does not always
attend worship sessions. They dont actively participate in the activities in their church.
(While confined)
* Self-perception and self-concept patternThe patient had a fighting spirit that she will overcome all the trials that may
come to her life. She had an overviewed that she will get well soon.
* Activities Tolerance-Exercise patternPatient was able to ambulate around and able to make walking exercises, she was
able to dress and eat on her own and walk without any assistance on her side not until
after the surgery that somebody has to assist her.
* Sleep rest pattern
7/29/2019 Ros Labs Functional (CASE STUDY)
4/4
The client doesnt have a difficulty in sleeping. The patient also verbalized that
the environment is not soothing for her but after a day she was able to adjust and adapt
gradually in the environment.
* Cognitive-PerceptionThe patient can speak fluently and understand fully in Tagalog and English. She isoriented with the time, people that surround her and place. Her memory is good and
answers the question that was given to her.
* Role-Relationship Pattern (while confined)The client is nice and easy to get along with but sometimes gets easily annoyed to
her 2 siblings because she doesnt want to be bothered.