Ros Labs Functional (CASE STUDY)

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    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

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    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

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    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

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    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.