mentPHYSICAL ASSESSMENT Last September 16, 2011 at exactly 9 o’clock in the morning, we conducted a physical assessment to Patient X who is 12 years old. He was admitted last September 15, 2011 at 12:30 am due to edema on the right ankle. He is under Dr. Uy. Patient X was admitted per wheelchair with watcher. General Survey Patient X was lying on bed. He was awake and coherent and responsive to any kind of stimulus. He had an IVF of PNSS 1 liter at KVO rate infusing well at his left metacarpal vein.
Elastic bandage was well attached at his right ankle. Vital Signs| 12:00 nn| Normal Range|
Blood Pressure | 90/60 mmHg| 110/70- 130/90 mmHg| Cardiac Rate| 95 bpm| 70-80 bpm| Pulse Rate| 93 bpm| 70-80 bpm| Respiration| 23 cpm| 13-20 cpm| Temperature| 36. 6 degree celcius| 36. 5- 37. 5 degree celcuis| Appearance and Mental Status As we observed the patient’s body built, it appears to be ectomorph. Patient X has height of 4 feet and 6 inches and weight of 30 kilograms. His body mass index is 16 kg/ m2 which result as underweight.
He was well-groomed. No body and breath odor noted. He was attentive and oriented upon assessment and respond appropriately in conversation with good eye contact.
Skin and Fingernails Upon inspection, the patient’s skin was uniform in color. Good skin turgor was noted, Smooth skin texture was noted upon palpation. He has an ideal skin temperature when touched using the back of the palm and compared to other parts of the body. Bruises were noted on his right elbow and in some portion in his both lower extremities which is the sign of hemophilia. No birthmarks and tenderness noted. His nails were clean and well-trimmed and have a convex curve. When his nails were pressed, it immediately returns to its usual color which is pink with a capillary refill time of 2 seconds.
Head Upon assessment, the patient’s skull appears to be normocephalic. No masses were noted. Hair is equally distributed. Eyes Upon inspection, eyebrows are symmetrical with equal movement and hair distribution. Eyelashes are long, evenly distributed and turned outwards. Palpebral fissures are equal in size when yes were open. Lacrimal ducts had no signs of swelling and tenderness noted. Bulbar conjunctiva was transparent in color. Sclera appeared white in color. When cornea was observed, it was smooth and shiny. Both of her nares were patent and symmetrical.
Pupils were black in color with 3 mm in diameter and it was equally round and briskly reactive to light accommodation. When extraocular muscles were assessed, converging eye follows the object within 5-8 centimeter of the nose. Ears Ears are symmetrical with color consistent with facial skin. Superior aspects of auricles are aligned with the outer canthus of the eyes. It was mobile upon palpation with no tenderness noted. External canals were clean without cerumen present. Gross hearing acuity was good. Nose Upon inspection of the nose, it has uniform in color.
There were no discharges and nasal flaring noted. When it palpate, there was absence of tenderness noted. Both of his nares were patent and symmetrical. Nasal septum was intact and in midline found in between the nasal chambers. Upon palpation of facial sinuses (frontal and maxillary), there was absence of tenderness noted. Mouth His buccal mucosa was pinkish, moist and smooth. The entire oral cavity was pinkish without ulcers. Teeth were not complete. One molar was missing which was located in left lower portion. Some teeth have caries specifically both lower left and right molars.
Tongue was able to move freely without tenderness noted. Uvula was position at the midline of soft palate. Hard palate has a lighter pink color compared to the soft palate. Tonsils were pink and there were no discharges. Neck Neck muscles are equal in size. When it assessed, equal strength was noted. Trachea is position at the midline of the neck. Thyroid glands ascend during swallowing and it was not visible. Thorax Chest wall was intact and has a full symmetric expansion. Skin was intact and uniform in temperature. There was absence of lesions. No tenderness or masses felt during palpation.
During inhalation and exhalation, full and symmetric chest expansion was seen. Heart Heart beat was normal, with a cardiac rate of _bpm. He has good cardiac rhythm. Point of maximal impulse is located at left mid clavicular 5th intercostal space. Palpitation and murmur was not noted upon auscultation. No palpable masses. No abnormal beat was noted. Abdomen Upon inspection, there was absence of rashes or other lesions on her abdomen. Skin was uniform in color. It was symmetric in terms of contour. During respiration, movement of the abdomen appears to be symmetric.
Genitourinary Genitourinary system was not assessed because the patient refused to have his genitourinary system assessed. Neuro-Vital Signs: Pupil Size:left – 2mm right –2mm Reaction: left – brisk right – brisk Motor Handgrip Leg Movement left – moderate left – strong right – moderate right – strong Level of consciousness: Reactive Level Scale: 1 Alert (awake, oriented, and responds too stimuli) Legend: Score| Reaction| 1| Alert with no delay in response (responds to the stimulus)| 2| Drowsy or confused but responds to light stimulation| | Very drowsy and confused but responds to strong stimulation| 4| Unconscious- localizes (moves a head towards) a painful stimulus but does not ward it off| 5| Unconscious- makes withdrawing movements following a painful stimulus| 6| Unconscious- stereotypic flexion movements following a painful stimulus| 7| Unconscious- stereotypic extension movements following a painful stimulus| 8| No response to painful stimuli| Glasgow Coma Scale Faculty| Response| Score| Eye opening| To speech| 4| Verbal response| Obeying| 5| Motor response| oriented| 6| Total| 15| Neurological Vital Sign: 1/15 Cranial Nerves
Cranial Nerve| Name| Results| I| Olfactory| We asked the patient to close his eyes and identify different aromas. He was able to guess the smell of soup and meal served. | II| Optic| He was able to read the readings from the students jot down notebook. | III| Oculomotor| In this test, we ask the patient to look straight and follow the direction of the finger were it was heading. Patient X was able to move his eyes in six ocular directions. | IV| Trochlear| In this test, we ask him to look straight and follow the direction of the finger were it was heading. Patient X was able to move his eyes in six ocular directions. V| Trigeminal a. Opthalmic b. Maxillary c. Mandibular| When we lightly touched the lateral sclera of the eye, the patient blinked. As the he closed his eyes, we wiped a wisp of cotton over his forehead and paranasal sinuses and when asked, he was able to feel it. We used the blunt and sharp ends of a pin to test for deep sensation over the same area and the patient was still able to feel it, as verbalized. | VI| Abducens| In this test, we ask patient X to look straight and follow the direction of the finger were it was heading. He was able to move his eyes in six ocular directions. VII| Facial| The patient was able to smile, raise both of his eyebrows, frown, puff out his cheeks, and close his eyes tightly even with against attempt to open them. | VIII| Auditory a. Vestibular b. Cochlear| As one of the student whispered, he immediately repeats the word. Thus, he has no problem in hearing. | IX| Glossopharyngeal| As we depressed the tongue with a depressor, the patient elicited gag reflex. He was able to move his tongue up, down and side to side. | X| Vagus| We asked the client to repeat the words we stated in order to assess the quality of her voice.
When words were repeated, it was delivered clearly and not in a grating manner. | XI| Accesory| He was able to shrug his shoulders and turn his head to side against resistance from a hand. | XII| Hypoglossal| He was able to protrude his tongue at midline and move it side to side. | INTRODUCTION Long before modern medicine, blood was viewed as magical—an elixir that held the mystical force of life—because when it drained from the body, life departed as well. Blood is the river of life that surges within us, transporting nearly everything that must be carried from one place to another.
Patients with hematopoietic disorders have problems related to their blood. Some problems are caused by too many cells, others by too few or defective cells. In this case, the students will study the nature of hemophilia, the factors that predispose it, and its relation to the lifestyle of their patient. Haemophilia A is an X-linked recessive disorder that primarily affects males. Although it is a hereditary disorder, there is no family history of this disorder in approximately 30% of newly diagnosed cases, suggesting that it has risen as a new mutation in the factor VIII gene.
The percentage of normal factor VIII activity in the circulation depends on the genetic defect and determines the severity of haemophilia (Porth 2004). According to National Institute of Health (NIH), haemophilia is occurring at about 1 in 5,000–10,000 male births. About 18,000 people in the U. S. have hemophilia. Each year, about 400 babies are born with the disorder. In Philippines there are about 1,000 people registered with hemophilia, but in a country 96 million there should be thousands more identified. The subject of this case has been diagnosed with hemophilia and was confined at San Pedro Hospital last September 15, 2011.
Our group had chosen Patient X as a subject of this case study. He is a 12 year old male who recently had hemophilia. We had chosen him for the reason that he’s suffering from concrete and obvious manifestation of hemophilia, it would obligate us to dig deeper onto the course of the disorder and therefore it would give us a deep understanding of the said condition. Another is that his mother is willing to participate completely and is earnestly sharing vital information that is needed for the completion of this study.
In relation to nursing education, it is important for us to know and understand the precipitating and predisposing factors, treatment, and for us to deliver the best quality nursing care to our client. Studying this can give us vital information to the disease itself. The implication of this study towards the nursing practice is to enable us to acquire knowledge and better understanding to execute the appropriate practices that should be done to our patient. It is our responsibility to understand the disease and the appropriate management in order for us to give the correct nursing interventions.
In nursing research, this will enable us to gain important information that will be used in the future studies. As learning individuals, we are very much encouraged to develop our researching capabilities to improve not only our knowledge itself but also to gain experience and skill to deliver appropriate nursing care. The things we learn from our research is important to our roles as health practitioners for it will assist us in efficiently imparting knowledge to our patients and other concerned individuals A. Biographical Data Name: AbuSayr Gender: Male
Age: 12 year old and 5 months Place of Birth: Compostella Valley Nationality: Filipino Address: Mabini, Comval Province Religion: Islam Number of Siblings: 3 Father’s Name: Reynaldo Educational attainment: College Graduate Occupation: Mother’s Name: Acrima Educational attainment: High school Graduate Occupation: Housewife B. Clinical Data Chief Complaint:Edema at Right Ankle Date of Admission:September 15, 2011 @ 12:30 am
Ward:Holy Child Ward Room #: 208-5 Admitting Diagnosis: Attending Physician: Dr. Lilia M. Yu Date of Discharge: March 5, 2011 Final Diagnosis: Hemophilia Health History Past Health History During the pregnancy of Mrs. A, she had her pre-natal check- up at health center in their hometown. She had never experience any complications. She was fully immunized of Tetanus Toxoid vaccine. The medications that she took were vitamins and food supplement. Patient X was born via normal spontaneous vaginal delivery on cephalic presentation and without any complication.
His birth weight was 3. 51 pounds. He delivered at their home. He was breastfed exclusive for about 1 year and 9 months. After that year his mother used bottle fed her child. They used formula milk which is Bonna for two years and with supplemental of cerelac. During school days, he usually wakes up at 6:30 in the morning and sleeps at 10 pm. But during Saturday and Sunday he wakes up at 8-9 am and sleeps at 10 -11 pm. He usually plays with his siblings, classmates and his peers. According to her mother he had his previous hospitalization during his 5 years old.
Last June 2011 he had administered a factor VIII injury of 2 vials. He has never experienced allergies, chicken pox, and mumps as reported. No accidents or serious injuries had been experienced and he was fully immunized. Immunization | 1 BCG| 3 DPT| 3OPV| 3 HEPA B| 1 measles| Present Health History Patient was diagnosed case of Hemophilia A, severe type times 7 years ago. Morning prior to admission, noted onset of swelling of the right ankle, dorsal surface of the right foot and right knee painful, with no associated of fever, bleeding and difficulty of breath.
Patient is warranted for factor VIII injury, thus prompting this admission. Narrative M was a product A and D’s love. Mr. A died at the age of 53 because of haemophilia and he has a hypertension. Mrs. D 56 years old, has a hypertension. M has eight siblings. She was an eldest among them. Second child was Mishba who is 36 years old, Najar was 34 years of age, Anwar was 33 years of age and he has asthma. Jonaidale was 32 years of age, Seguira was 29 years of age, Norjads was 28 years of age and the youngest child was Tihana was 19 years of age.
On the paternal side, Mr. Reynaldo was a product of Pepe and Gloria’s love. Pepe was 76 years old and he has a hypertension. Gloria was 65 years old when she died. The cause of her death was cancer. Reynaldo has nine siblings. The eldest child was Nida 54 years old, Reynaldo was 49 years of age and he has a hypertension. Armando was 47 years old he also has a hypertension. Violeta was 46 years of age, Judith was 45 years old, Lita was 40 years of age, Rico was 39 years old, Berta was 38 years of age, Aden was 36 years old and the youngest was Aden 33 years of age.
Reynaldo and M was fall in love and they blessed by 3 children who are: Alkhayer 14 years old, Abuseyr 12 years of age and is our patient who is suffering from Hemophilia and Ammulhyr 10 years old. Developmental Task Psychosocial Development (Early Adolescence 12- 20 years old) Erik Erikson adapted and expanded Freud’s theory of development to include the entire life span, believing that people continue to develop throughout life. According to Erikson’s theory, personality development goes through a series of eight, hierarchically ordered stages.
Associated with each stage is a psychosocial crisis that the individual either successfully resolves or fails to resolve. Erikson believes that the more success an individual has at each developmental stage, the healthier the personality of the individual. Failure to complete any developmental stage influences the person’s ability to progress to the next level. He described eight stages of development. Erikson’s eight stages reflect both positive and negative aspects of the critical life periods. The resolution of the conflicts at each stage enables the person to function effectively in society.
Patient X was belongs to school age. Central Task: Identity versus role confusion Indicator of Positive Resolution: Coherent sense of self Plans to actualize one’s abilities Indicator of Negative Resolution: Feelings of confusion, indecisiveness, and possible antisocial behavior Patient X is definitely achieved identity in a sense that he have establish a sense of oneself by expressing his self onto others showing that he can do things with self-esteem and discovering his capabilities as a pupil. He also can identify of what are the task as adolescence.
He actively participated in classroom activities. And he have also established close bond with his childhood friends and some of his opposite sex and siblings. Psychosocial Development (Adolescence) Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. He described growth and development as occurring during six stages, each associated with six to ten tasks to be learned. Havighurst’s developmental tasks provide a framework that the nurse can use to evaluate a person’s general accomplishments.
However, some nurses find that the broad categories limit its usefulness as a tool in assessing specific accomplishments, particularly those of infancy and childhood. In a multi-cultural society, the definition of success as well, making these task less relevant for some. Patient X is now 12 years old and 5 months which categorized him in adolescence. The tasks in adolescence which he needs to accomplish are as follows: Task | Achieved or not achieved| Justification | 1.
Achieving a new and more mature relations with age-mates of both sexes| Achieved| Upon our interview, we discovered that he is now more mature in his relationship to his friends and peers. He plays with her classmates at school and he had also a circle of friends. | 2. Achieving a masculine or feminine social role| Achieved| At his age he is already knew of what is the task of being a brother. He is now responsible to do all the house hold chores such as to fetch water and cooked a meal. | 3. Accepting one’s physique and using the body effectively | Achieved| | 4.
Achieving emotional independence from parents and other adults | Achieved| Patient X can now solved simple problems arose in his life such as resolved the things he had done wrong to his classmates and solved conflicts between his elder and younger brother without the help of significant others. | 5. Achieving assurance of economic independence| Achieved| Our patient achieved this task. He said that if there is excess money given by his parents he saves it for him to buy things that he wants. | 6. Selecting and preparing for an occupation| Achieved| Patient X said that he wants to be a police man someday.
He also said that his parents motivate him to study well and do well in school in order to achieve his dreams. Definitely he achieved this task. | 7. Preparing for a mirage and family life| Not Achieved| At this age he cannot achieved this task because he is only 12 years old he is more focus on his adolescence stage and as of now his not thinking this things. | 8. Developing intellectual skills and concepts necessary for civic competence| Not Achieved| At this age, this task in not applicable to our client because as of now he cannot do this things. | 9.
Desiring and achieving socially responsible behavior | Not Achieved| This task is not also applicable to his age. | 10. Acquiring a set of values and an ethical system as a guide to behavior | Not Achieved| | Medical Management A. Actual Date| Component| Definition and Normal Range| Rationale| Result| Interpretation and Significance| Nursing Responsibility| Sep. 15, 2011| Urine Flow CytometryWBCRBCEpithelial CellsCastBacteriaPhysical ExamColorClarityReactionSpecific GravityChemical AnalysisGlucoseProtein| Classifies urinary particles on the basis of their light scattering, fluorescence, and impedance properties.
The instrument counts erythrocytes, leukocytes, bacteria, epithelial cells, and casts and flags the presence of pathological casts, small round cells (SRCs), yeast-like cells, crystals, and spermatozoa. Cells of the immune system involved in defending the body against both infectious disease and foreign materialsNormal Range: 0-11/ULThe most common type of blood cell and the vertebrate organism’s principal means of delivering oxygen (O2) to the body tissues via the blood flow through the circulatory system. Normal Range: 0-11/ UL.
These cells are detected in the urine during microscopic urinalysis. However, the exact quantity of the cells is identified during the microscopic analysis of the urine sediment, which is often done as the last step of the urinalysis. Normal Range: 0-11/ ULTiny tube-shaped particles made up of white blood cells, red blood cells, or kidney cells. They form in kidney structures called tubules. Casts are held together by a protein released by the kidney. Normal Range: 0-1/ ULBacteria are living things that have only one cell. Under a microscope, they look like balls, rods or spirals.
Normal Range: 0-111/ UL Most changes in urine color are temporary and caused by foods you eat or medications you take. However, sometimes an abnormal urine color can indicate a serious disease. Normal: YellowUrine is normally clear. Bacteria, blood, sperm, crystals, or mucus can make urine look cloudy. The pH is a measure of how acidic or alkaline (basic) the urine is. A urine pH of 4 is strongly acidic, 7 is neutral (neither acidic nor alkaline), and 9 is strongly alkaline. Normal Range: 4. 6-8This checks the amount of substances in the urine. It also shows how well the kidneys balance the amount of water in urine.
Normal Range: 1. 020-1. 028It is used to detect both hyperglycemia and hypoglycemia, to help diagnose diabetes, and to monitor glucose levels in persons with diabetes. Normal: NegativeIt is used to detect protein in the urine, to help evaluate and monitor kidney function, and to help detect and diagnose early kidney damage and disease. Normal: Negative| The instrument is intended to replace, to an extent, routine urine microscopy. The number of WBCs in the blood is often an indicator of disease. This test also evaluates the shape and the size of the red blood cells.
This blood test is considered a very important indicator of a patient’s health. May suggest inflammation within the bladder, but they also may originate from the skin and could be contamination. The content of a cast can tell your health care provider whether your urine is healthy or abnormal. Small amounts of bacteria in a urine sample may be from contamination during sample collection. Large amounts of bacteria usually indicate a bladder infection, especially if an uncontaminated sample was obtained via cystocentesis. How dark or light the color is tells you how much water is in it.
This test detects ion concentration of the urine. Glucose can also be found in urine when the kidneys are damaged or diseased. | 3/ UL1/ UL1/ UL08/ ULYellowClear6. 01. 010(-)(-)| NormalNormalNormalNormalNormalNormalNormalNormalLow specific gravity; may be indicative of Diabetes Insipidus, certain renal diseases, Excess fluid intake and Diabetes MellitusNormalNormal| Pre-Test * Instruct the patient to obtain a urine specimen first thing in the morning. Midstream catch specimen if possible. * Obtain a list of medications the patient is taking, including herbs, nutritional supplements and nutraceuticals.
The requesting health practitioner and laboratory should be advised if the patient is regularly using these products so that their effects can take into consideration when reviewing its results. * There are no food, fluid, or medication unless by medical restriction. * Label the specimen, indicate whether the specimen is clean catch or catheter, and promptly transport it to the laboratory. Indicate on the label, the date, and the time of collections and any medications that may interfere with test results. Intra-Test * Remind the patient to catch urine midstream to have a clean catch. Instruct patient to collect at least 15cc of urine per procedure. Post-Test * Instruct the patient to practice proper hygiene practices, especially when procedure is done again to deter the spread of microorganisms. | Date| Component| Definition and Normal Range| Rationale| Result| Interpretation and Significance| Nursing Responsibility| Sep. 15, 2011| HematologyHemoglobinErythrocyteMCHMCVMCHCLeukocytesNeutrophi lLymphocyteMonocyteEosinophilsBasophilsHematocritThrombocyte | Concerned with the study of blood, the blood-forming organs, and blood diseases.
The iron-containing oxygen-transportmetalloprotein in the red blood cells of all vertebrates. Normal Range: 140-180 g/LThis test is used to evaluate any type of decrease or increase in the number of red blood cells as measured per liter of blood. Normal Range: Male: 4. 5-5. 0 10^12/LFemale: 4. 0-5. 0 10^12/LAverage mass of hemoglobin per red blood cell in a sample of blood. It is reported as part of a standard complete blood count. Normal Range: 27-33 pgIt is a measure of the average red blood cell volume that is reported as part of a standard complete blood count.
Normal Range: 80-96 flIt is a measure of the concentration of hemoglobin in a given volume of packed red blood cells. Normal Range: 32-36 g/dLThis test is used to test conditions or medications that weaken the immune system, such as HIV infection, chemotherapy, or radiation therapy cause a decrease in white blood cells. The WBC count detects dangerously low numbers of these cells. The WBC count is used to determine the presence of an infection or leukemia. It is also used to help monitor the body’s response to various treatments and to monitor bone marrow function. Normal Range: 5. -10 10^9/LA type of white blood cell, specifically a form of granulocyte, filled with neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis. Normal Range: 0. 55-0. 65 %A lymphocyte is a type of white blood cell in the vertebrate immune system. Normal Range: 0. 25-0. 40 %They replenish resident macrophages and dendritic cells under normal states, response to inflammation signals. Monocytes can move quickly (approx. 8-12hrs) to sites of infection in the tissues divide into macrophages and dendritic cells to elicit an immune response.
Half of them are stored in spleen. Normal Range: 0. 02-0. 06 %Type of WBC that is one of the immune system components responsible for combating multicellular parasites and certain infections in vertebrates. They also control mechanisms associated with allergy and asthma. Normal Range: 0. 01-0. 05%Basophils contain anticoagulant heparin, which prevents blood from clotting too quickly. They also contain the vasodilator histamine, which promotes blood flow to tissues. Normal Range: 0. 000-0. 005%The percentage of blood volume that is occupied by red blood cells. Normal Range: Male- 0. 40-o. 48 Female: 0. 37-0. 5 %Thromboyctes, also called platelets, are found in the blood. In general, its main purpose is to help blood clot when necessary, such as when a cut in the skin occurs. Normal Range: 150-300 10^g/L| To evaluate anemia, polycythemia, hydration status, and monitor therapy such as transfusion. Used in determining the likely etiology of anemias and other abnormalities of the erythron. In patients with anemia, it is the MCV measurement that allows classification as either a microcytic anemia (MCV below normal range), normocytic anemia (MCV within normal range) or macrocytic anemia (MCV above normal range).
This count is used to give a rough guide to what shade of red, RBC will be. | 125 g/L5. 17 10^12/L24 pg79. 3 fl30. 4 g/dL9. 9 10^9/L0. 71%0. 22%0. 06%0. 01%0. 00%0. 41%250 10^g/L| Decreased hemoglobin count;hemorrhageElevated erythrocyte countDecreased MCH;iron deficiencyDecreased MCV;Iron deficiencyDecreased MCHC; maybe decreased when MVV decreasesNormalElevated Neutrophil count;HemorrhageLow Lymphocyte count;A low normal to low absolute lymphocyte concentration is associated with increased rates of infection after surgery or trauma.
NormalNormalNormalNormalNormal| Pre- test * Explain to the patient the importance of this test. * Inform that it not needed to restrict fluids or food. But then, he should not eat 4 hours prior to the procedure. * Inform the patient that there will be extraction of blood sample. * Make sure that the patient is calm and rested. Intra – test * Hold the patient in the place for the procedure to be well administered. Post – test * Apply pressure to the venipuncture site until bleeding stops. * If hematoma develops, apply warm compress. * Ensure that patient is comfortable. After the test or series of tests is completed (and with the approval of the doctor), the person should eat, drink, and take any medications that were stopped for the test. | Date| Component| Definition| Rationale| Result| Interpretation and Significance| Nursing Responsibility| Sep. 15, 2011| aPTTProtime TestINR| APTT (Activated Partial Thromboplastin Time) is the time in seconds for a specific clotting process to occur, in the laboratory test. Normal Value: 22 to 34 secondsA blood test that measures the time it takes for the liquid portion (plasma) of your blood to clot.
Normal Value: 11 to 13. 5 secondsA test for blood clottingNormal Value: 1. 0-1. 5| Evaluate the function of all coagulation factorsTo check how well blood-thinning medications (anti-coagulants) are working to prevent blood clotsUsed to help diagnose bleeding| 71. 0 sec13. 7 sec1. 0| Increased aPTT;Indicates hemophiliaIncreased PT; Indicates Factor VII, X, II, V, I deficiencyNormal| Pre- test * Explain to the patient the importance of this test. * Inform that it not needed to restrict fluids or food. But then, he should not eat 4 hours prior to the procedure. Inform the patient that there will be extraction of blood sample. * Make sure that the patient is calm and rested. Intra – test * Hold the patient in the place for the procedure to be well administered. Post – test * Apply pressure to the venipuncture site until bleeding stops. * If hematoma develops, apply warm compress. * Ensure that patient is comfortable. After the test or series of tests is completed (and with the approval of the doctor), the person should eat, drink, and take any medications that were stopped for the test. B. Possible Diagnosis 1. DNA testing for hemophilia A will detect carriers of the disease. 2. Fibrinogen Test – This test also helps doctors assess a patient’s ability to form a blood clot. This test is ordered either along with other blood clotting tests or when a patient has an abnormal PT or APTT test result, or both. Fibrinogen is another name for clotting factor I (1). Date | Order| Rationale| 9/15/2011| DAT except hard, hot foodsVS q4 hoursLabs:CBCUA- MSCCaPTTBlood TypingVenoclysis with PNSS 500mg regulate at KVO rate microset)Medications:Paracetamol 500mg, 1tab q4 hours RTCSecure cryoprecipitate 4 “u” Blood typeO+ transfuse after proper retyping as Fast Drip 1 “u” after anotherGive Benadryl 50 mg 1 tab 30 mins prior blood transfusionVS monitoring to q30 mins while ongoing BTRefer for any transfusion reactionStrictly no ambulationApply elastic bandage @ right ankle and kneeElevate right leg at all timesAvoid traumatic extractionMonitor intake and output q shiftTransfuse 3 units cryoprecipitate of patient’s blood type(O+) as fast drip (one after the other) after proper retypingHold blood typing, retrieve old typing result formRefer to Dr.
Rachelle Chua-Descalles for dental cleaningGive Factor 8 concentrate 500 IV/vial1 vial dissolve in 5 mL diluents as close IVTT x 15 – 20 mins @ 3pm today then q12 hours thereafterFor dental cleaningStill for dental cleaning @ 11 amProphylaxis done at clinic| To obtain baseline data and to be able to provide correct and proper intervention. This is a basic screening test in all patients and is one of the most frequently ordered laboratory procedures. Since, its findings give valuable information about the patient’s diagnosis, prognosis, response to treatment, and recovery.
Urinalysis is an essential procedure for hospital admissions and physical examination. It is one of the most useful indicators of health and disease, and it is especially helpful in the detection of renal or metabolic disorders. It is an aid in diagnosing and following the course of treatment in diseases of the kidney and urinary system and in detecting disorders in other parts of the body such as metabolic or endocrinic abnormalities in which the kidneys function normally.
The aPTT test is used when someone has unexplained bleeding or clotting. Along with the PT test (which evaluates the extrinsic and common pathways of the coagulation cascade), the aPTT is often used as a starting place when investigating the cause of a bleeding or thrombotic (blood clot) episode. Blood typing is used to determine an individual’s blood group and what type of blood or blood components the person can safely receive.
To replace fluids, go with blood transfusions,hyponatremia, and burn victims, it is isotonic,( same osmolarity as our body fluids). Paracetamol is a widely used over-the-counter analgesic (pain reliever) and antipyretic (fever reducer). It is commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remediesContains high level of Factor VIII and fibrinogenTransfusions are used in a variety of medical conditions to replace lost components of the blood.
Used for the temporary relief of seasonal and perennial allergy symptoms. For immediate recognition and clinical management of complications during transfusionThey are at risk for injury and can result in serious bleeding problem; Avoids injury to the affected extremity or jointMost often prevents muscle bleedingControls bleedingTo prevent bleedingTo monitor the amount of fluids a client takes in and comparing this to the amount of fluid a client puts out.
To gain valuable insights into the client’s general health as well as monitor specific disease conditions. Contains high level of Factor VIIITransfusions are used in a variety of medical conditions to replace lost components of the blood. Effective in accelerating the coagulation of hemophilic bloodChildren with hemophilia and other bleeding disorders need an aggressive, prevention-oriented program to maintain optimal oral health and minimize the risk of complications if dental problems arise. |
Cite this Physical Assessment
Physical Assessment. (2019, May 01). Retrieved from https://graduateway.com/physical-assessment/