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1
Nursing 2
35
: Adult Health II
Laboratory Analysis Case Scenario
Patient Initials: KH
Age: >60
Height: 65 in
Weight: 67.13 kg
HPI
KH presented to the ED with c/o bug bite on L thigh that occurred about 10 days ago that has turned into an abscess “as big as a personal sized watermelon.” Patient also reported urinary burning, frequency, and urgency. The ED, WBC 37,000, glucose 317, bicarbonate 13, anion gap
25
, large amount of acetone, HgbA1C 10.3. Patient was admitted to the hospital for evaluation and management of DKA, DVT, abscess, and UTI.
Past Medical/Surgical History:
· Type 2 Diabetes Mellitus
· Previous tobacco use (1/2 pack per day)
· MVA 7/13/20: pain in pelvis and knees since accident
Significant Clinical Events:
8/23/20
· Wound culture: staph aureus, methicillin sensitive
· Blood culture: no growth after 5 days (determined on 8/28/10)
· Urine analysis indicates infection and DKA
· Insulin drip for DKA
· IV antibiotics for UTI, multiple abscesses
· IV antifungals for multiple abscesses & topical antifungal for yeast infection
8/
24
/20
· Deep muscle abscess extends to femur (visualized via CT)
· I&D done in OR discovered diffuse myositis & muscle necrosis
· S/p insulin drip for DKA treatment
· Wound nurse consult
· Infectious disease consult
8/26/20
· I&D done in OR on L thigh, R groin abscess
· Patient experience bleeding post-op
· SCD and TED hose prescribed for DVT
8/28/20
· d/c Coumadin due to post procedure bleeding, switched to Lovenox
8/29/20
· bleeding from wound, changed lovenox to heparin
· anemia due to blood loss s/p I&D, received 2 units packed RBC
· Constipation for 1 wk, senna, colace, lactulose
8/30/20
· blood glucose 340-360 mg/dL all day
· patient complains of recent onset visual disturbances (since hospitalization on 8/23/10)
· notify MD, increase levemir to 32 units daily
· MD d/c IV antibiotic and heparin, change to PO antibiotics and coumadin
|
Test/Result
|
Admit
8/23/20
|
Sun
8/29/20
|
Mon
8/30/20
|
|
Hemoglobin (g/dL)
|
13.8
|
7.4L
|
9.1L
|
|
Hematocrit (%)
|
42.2
|
21.1L
|
25.8L
|
|
RBC (M/uL)
|
4.35
|
2.28L
|
2.82L
|
|
WBC (K/Ul)
|
37.2H
|
11.4H
|
14.2H
|
|
MCV (FL)
|
97.1H
|
92.5
|
91.7
|
|
MCH (PG)
|
31.7
|
|
32.3
|
32.3
|
MCHC (g/dL)
|
32.7
|
35
|
35.2
|
|
RDW (%)
|
15
.1H
|
15.8H
|
1
5.5
H
|
|
PLT (K/uL)
|
461H
|
408
|
428H
|
|
MPV (FL)
|
7.5
|
6.6
|
6.3
|
|
PT (Sec.)
|
|
|
|
n/a
|
9.7
|
10.0
|
|
INR
|
n/a
0.93
|
|
0.96
|
|
PTT (Sec.)
|
n/a
29.4 @ 0600
30.3 @ 1400
|
24.6 @ 0600
48.1 @ 1400
|
|
guaiac
|
negative
|
|
BUN (mg/dL)
|
15
|
7L
|
6L
|
|
Creatinine–mg/dl
|
0.96
0.29L
|
0.36L
|
|
GFR AF
|
54
|
n/a
>60
|
|
BNP
|
277H
|
|
AGAP
|
25.0H
|
8.0
|
9.0
|
|
Chlroide (mmol/L)
|
92L
|
102
|
98
|
|
CO2 (mmol/L)
|
13L
|
24
|
25
|
|
Potassium (mmol/L)
|
4.8
|
4.1
|
4.0
|
|
Sodium (mmol/L)
|
130L
|
134L
|
132L
|
|
Glucose (U/L)
|
397H
|
266H
|
368H
|
|
HgbA1C
|
10.3H
|
|
Urinalysis
Color
Yellow
|
yellow
|
|
Appearance
Clear
|
Hazy
|
|
Spec. Gravity
1.002-1.030
|
1.025
|
|
PH
4.5-8.0
|
5.5
|
|
Protein
Negative
|
200mg/dL
|
|
GLU
Normal
|
1000mg/dL
|
|
Ketones
Negative
|
>150
|
|
Blood
Negative
|
300
|
|
Urobilinogen
Normal
|
2mg/dL
|
|
Leuk Ester
Negative
|
500
|
Dx. Tests Date and Client Results
|
Gram Stain
|
8/23/10 & 8/25/10 wound culture: gram positive cocci staph like
|
|
Cultures/
Sensitivities
|
8/23/10 blood culture: no growth after 5 days (8/28/10)
8/23/10 wound culture of groin abscess: staph aureus, sensitive to methicillin, clindamycin, erythromycin, oxacillin, naficillin, amoxicillin, clavulanic acid, ampicillin, sulbactam, SXT, most parenteral and oral cephalosporins
8/23/10 urine culture: >100,000 CFU/mL staph aureus sensitive methicillin, nitrofurantoin, oxacillin, SXT
8/25/10 culture abscess L bottom: staph aureus (see above wound culture for sensitivities)
|
|
Therapeutic
Drug Levels
|
PT (9-11.5 sec) and INR (2.0-3.0) evaluate therapeutic drug levels of coumadin, PTT (60-70 sec) evaluate therapeutic levels of heparin.
|
Dx. Tests Date and Client Results
|
CXR
|
8/23/10 CXR: cardiac mediastinal silhouettes normal, lungs are clear. No pleural effusion or indication of CHF.
|
|
CT/US/
Nuc Med/ Spec Proc
|
8/26/10 CT abdomen & pelvis without contrast: inflammatory mass-like density with subcutaneous of R groin containing central air bubbles presumably secondary to recent drainage/intervention. No well-organized fluid collection in region. Body wall and intra-abdominal edema. Few non-specific bubbles of air within lower anterior abdominal wall. Abscess in proximal L thigh and L buttock not imaged.
8/26/10 CT pelvis with IV contrast: superficial L medial buttock abscess 5-6cm diameter extending inferiorly and connected to large deep muscle abscess, extends to femur measures 8x10cm
|
|
Cardiac monitoring
|
Measure and compare with report:
PR interval:
QRS:
QT interval:
P-P interval regular:
R-R interval regular:
|
|
Medications
|
|
Cefazolin (Ancef)
2g/D5W 110mL IVPB q 8hrs infuse over 30 min
|
|
Clindamycin (Cleocin)
900mg IVPB infuse over 30 min
|
|
Fluconazole (Diflucan)
100mg PO Q 24hrs
|
|
Heparin
100 units/mL standard infusion
|
|
Warfarin (Coumadin)
|
|
Nystatin
Topical
|
|
Insulin Aspart
0-14 units SQ 4 times daily ac/hs
|
|
Insulin Detemir (Levemir)
32 units SQ daily
|
|
Polyethylene glycol (Golytely)
400mL PO one time
|
|
Acetaminophen (Tylenol)
650mg PO q 4 hrs prn
|
|
Oxycodone (Oxycontin)
5 mg PO Q 4 hrs prn
|
|
Morphine (Duramorph)
4mg IV Q 3hrs prn
|
|
Hydromorphone (Dilaudid)
1mg IV Q 3hrs prn
|
|
Calcium Carbonate (Tums) chewable
500mg PO 3x daily prn
|
|
Promethazine (Phenergan)
6.25mg IV q 4hrs prn
|
|
Sennosides/ docusate sodium
8.6mg/50mg 1 tablet PO BID prn
|
|
Trazadone (Desyrel)
25mg PO hs prn
|
PAGE
Lab Analysis: Grading Rubric
TOTAL 50 Points
|
Content
|
Points
|
|
Analysis of data
|
All of these criteria apply:
·
Explanation unclear
· Interpretation inaccurate
· Some labs not addressed = 0 points
|
2 of these criteria apply:
· Explanation partially clear
· Interpretation partially inaccurate
· Some labs not addressed = 7.5 points
|
Explanation clear as to how altered lab values fit or don’t fit with patient’s current clinical status; all labs addressed; interpretation accurate =
15 points
|
|
Diagnostic Statement
|
All of these criteria apply:
· PCs/NANDAs are not based on lab results.
· Diagnostic statements are not in correct format = 0 point
|
1 of these criteria apply:
· PCs/NANDAs are not based on lab results.
· Diagnostic statements are not in correct format = 5 points
·
|
Identification of PCs/ NANDAs
based on lab results. Diagnostic statements are in correct format. = 10 points
|
|
Desired Outcome
|
All of these criteria apply:
· Desired outcomes are not measurable and achievable.
· Outcomes are not relevant to PCs/ NANDAs = 0 point
|
1 of these criteria apply:
· Desired outcomes are not measurable and achievable.
· Outcomes are not relevant to PCs/ NANDAs = 2.5 points
·
|
Desired outcomes are measurable and achievable and are relevant to the PCs/ NANDAs = 5 points
|
|
Interventions
|
All of these criteria apply:
· No specific intervention identified
· Interventions not relevant to NANDAs or PCs
· Rrationale do not support selected interventions. = 0 points
|
2 of these criteria apply:
· Nursing/collaborative interventions are not consistent with NANDAs and PCs;
· Are not relevant to address/correct altered lab values
· Rationale do not support the selected interventions. = 7.5 points
·
|
Nursing/collaborative interventions are consistent with
NANDAs and PCs; relevant to address/
correct altered lab values. Rationale support selection of interventions. = 15 points
|
|
Evaluation
|
Inaccurate or no identification of effects of nursing interventions on patient’s status =
0 points
|
Partial identification of effects of nursing interventions on patient’s status = 2.5 points
|
Identification of effects of nursing interventions on patient’s status =
5 points
|
|
Format
|
Many spelling or grammar errors; or, no citing of references =
deduct
4 points
|
Some spelling or grammar errors; or, incorrect citing of references; or, references page not in APA format =
deduct 2 point
|
Free of spelling and grammar errors; correct citation of references; reference page contains references in APA format = 0 point
|
|
TOTAL POINTS
|
PAGE
1
LABORATORY ANALYSIS ASSIGNMENT GUIDELINES
PURPOSE OF ASSIGNMENT
Integration of health alterations (medical and nursing diagnoses), presenting signs and symptoms, treatments, medications, and their effects on diagnostic laboratory results for a specific client.
DATA COLLECTION
The case scenario used for this Laboratory Analysis Assignment is similar to clients that you would have been assigned to in clinical.
FORMAT
· Introduction
· Description of health alterations
· Define medical diagnoses
· Explain the pathophysiology for each diagnosis
· Discuss how diagnoses are interrelated
· Signs and Symptoms
· Provide rationale for the client’s S&S in relation to the pathophysiology of his/her health alterations
· Complete Laboratory Analysis Table
· Analyze lab data for abnormal, pertinent normal, and therapeutic results, in relation to health alterations, client’s presenting S&S, and treatments (including medications). Explain how the lab results are a reflection of the pathologic process, client responsive or unresponsive to treatment, sign of a side effect or complication of treatment, and what S&S the client might exhibit from the lab results.
· Identify client problem—nursing diagnosis (NANDA) and/or collaborative problem based on the lab data.
· Identify NOC and write desired outcome for the client problem. Must be achievable and measurable.
· List NIC and nursing/collaborative interventions that address/correct the altered lab results. Include rationale for the interventions, with citations for the reference used (use APA format).
· Evaluate the expected effects of the interventions on the client’s status. Include evaluation of the effectiveness of the interventions, degree that desired outcomes have been achieved, and if the client problem was resolved.
· Use a separate Diagnostic Analysis table for each client problem. Related laboratory data can be included on the same table. For example:
· Health alteration: Glomerulonephritis
· Nursing diagnosis: Excess fluid volume related to inflammation of the glomeruli, decreasing filtration, as evidenced by weight gain, edema, I>O, hypertension, decreased total protein/ablumin, increased BUN/Cr, proteinuria.
· Lab Data: BUN, Creatinine, albumin, total protein, urinalysis
· Conclusion
· References (Use APA format)
