17/03/2020

Dry skin to her scalps

No neck complications

Pupils are 5mm and react to light 3mm

Conjunctiva is red complains of getting winded sometimes

Ears without drainage but have to repeat some words because she cannot hear well

Nose stuffy at times

Dry skin to her scalp

Mouth without any sores and still has teeth. The patient was seeing a dentist twice a year.

Hand grasp very weak on the left than the right one

Capillary refill fast to the hands and slow to the feet

Radial pulse strong on both hands

Heart sounds not regular and fast

Lungs sound with a wheezing sound when she breaths out to upper lungs from the backside only

Other lung diminished

Occasional congested morning cough and never spits anything

Abdomen soft with tenderness

4inch scar to her right abdomen

The last BM was 3days formed stool. Large amounts of urine yellow no odor

Achy pain to the lower back

She has a small healed scar to her lower back 2inch long

5inch long scar to her right knee

Pedal pulse is strong in the right foot but weak on the left foot

Left push /pull is absent, right foot push/pull pulses are strong

She is cooperative; speech is clear slight hesitations when asked questions

She knows who she is, where she is, and what day it is.

Cholesterol levels

225mg/dl

Some medication, medical conditions, and lifestyle factors, a blood disorder, affect a specific part of the blood or more parts, making an individual function abnormally.

Reason To Be Assessing This Lab

Cases of high cholesterol levels within the family

Cases of heart attacks in the family.

To complete blood count and check ten levels of blood components of every significant cell in the body, such as white blood cells, red blood cells, and platelets (Serraino & Murphy, 2017). The significance of blood count helps a doctor determine any disorders in the patient’s blood; however, the patient has to wait for the doctor’s advice before fasting before the test.

To conduct a metabolic test to determine why the patient has yellow, odorless urine. It also helps determine various components in blood plasma (Serraino & Murphy, 2017). A metabolic blood test also essential information about a person’s bones, organs, and muscles. We let the patient whether she must fast before the test.

High-density lipoprotein, a good level or low-density lipoprotein, is bad to check cholesterol levels. High-density lipoprotein levels are important because they help eliminate harmful substances for the blood and enable the liver to reduce them into waste (Serraino & Murphy, 2017). It is necessary for the patient to first at least eight hours before this test. Test enzyme makers because the patient has poor eating habits; these enzymes are CPK-2(CK-MB). These enzymes are in the heart and increase a person’s blood levels after having a heart attack.CPK-3 is found in the heart, resulting from muscle inflammation caused by intense exercise or injuries. CPK-1 exists in the brain, and their high levels indicate brain or lung injury.

Furthermore, when tropin links into the blood can cause heart injury. Enzyme tests help doctors identify particular conditions such as heart attacks. In case they suspect a heart attack condition, they quickly check the cardiac tropin enzyme.

We can also conduct coagulation tests to determine the blood’s clotting rate and how well it clots.  The importance of clotting helps stop bleeding in would or cuts (Serraino & Murphy, 2017). However, clots in arteries or veins can be dangerous because they block blood flow to the heart, brain, or lungs, causing strokes or heart attacks. These tests get determined by personal health conditions or any other health condition that may affect clotting. The coagulation test results can help determine whether the patient has thrombosis, liver conditions, acute leukemia, and vitamin K deficiency.

The main purpose of conducting a cholesterol test is to determine whether the levels are high and the underlying risks of developing a heart attack (Serraino & Murphy, 2017). A complete calculation of different types of fats is what gets referred to as a total cholesterol test. Since the initial cholesterol tests of the patient were abnormal, conducting a cholesterol test is important. Additionally, her family has a history of having high cholesterol levels. Hence a regular cholesterol test is important to monitor whether the medications are effective.

17/03/2021

Some of the reasons why a person may develop abnormal pulmonary function are asthma, foreign bodies obstructing the airway, emphysema, lungs’ inflammation, loss of lung tissues, challenges from arterial blood flow.

Reasons for assessing this lab

The main reason for conducting a pulmonary function test is to determine how well the lungs are working. These tests measure gas exchange rates and flow capacity, and lung volumes (Sapey, Patel, Greenwood, Walton, Hazeldine, Sadhra & Thickett, 2017).  Information obtaining after conducting these tests helps decide the best treatment for a specific lung disorder. However, there are two main causes of challenges of air moving in and out of the lungs. The first challenge is obstructive that happens when it becomes difficult for air to freely flow out of the lungs due to resistance in the airway. Reduced airflow is the primary cause of this challenge.

Restrictive challenges take place when the lungs are unable to expand. Due to this, airflow becomes a challenge due to low lungs (Sapey et al., 2017). Pulmonary function tests help diagnose allergies troubles in breathing due to lung injuries, respiratory infections, lung conditions, lung diseases, scleroderma, and sarcoidosis.

Additionally, there are risks associated with pulmonary tests depending on the age of an individual. These include dizziness, asthma, feeling short of breath, and coughing (Sapey et al., 2017). At the same time, there are reasons why an individual should not undergo pulmonary tests. First, if the person had belly surgery recently, recent eye surgery resulted from increased pressure in the eye. Notably, before the pulmonary test, the patient should avoid taking some medicines, stop smoking, avoid taking heavy meals, and adhere to any other doctor’s instructions.

Reasons For Abnormality

Abnormal tenderness can result from gallstones, endometriosis, celiac disease, gastritis, inguinal hernia, and hiatal hernia.

Reason to be Assessing this Lab

Abdomen tenderness indicates inflammation as an acute process in one or many organs in the body. Blocked or twisted organs can cause inflammation. Some common causes of abdomen tenderness are swelling of the appendix, which is a small pouch attached to the large intestines. Swelling on the appendix happens when it gets blocked by substances such as feaces passing through it. An abdominal abscess can also cause abdominal inflammation, a pocket filled with pus, and infected fluid inside the belly. The fluids come from a busted appendix, ovary, or intestine. The common cause of this inflammation in women is an inguinal hernia. It is a condition that occurs when there is a burst in the membrane lining the abdominal cavity or when the intestines burst. A twisted fallopian tube which in most cases it is a rare issue or a ruptured ovarian cyst.

Furthermore, ectopic pregnancy can cause abdominal tenderness. It is a life-threatening condition where the fetus starts to form outside the uterus, bursting the suck of fluid holding the fetus. Pelvic pulmonary infection is also another challenge. It is an inflammation of the female reproductive system that could result from infections from different STIs. All these infections get linked to some inflammation that causes tenderness on the abdomen.

·         Give Data to support that the need has been met

·         Give data that indicates that there is a possible problem

Heart:

Lungs:

Peripheral:

Asthmatic attacks

Arthritis on the lower spine

Ineffective breathing patterns

The patient cannot move the left leg

Mild swelling on both ankles

Bowel

Bladder

Urinal incontinent

a large amount of brown stool

involuntary leakage of urine

ACTIVITY/EXERCISE:

Mobility

Self –care

Arthritis on the lower spine

The patient is dirty

The patient is in a wheelchair, can turn a little in bed but cannot get out by herself.

The patient cannot bath

MAINTENANCE :

(physical & emotional)

Comfort

Safety

Health Management

she depends on the husband to make decisions

depression

taking naps while in a wheelchair

cholesterol level high

The patient has suicidal thoughts

The Patients does not sleep

High blood pressure

Stress/Coping

Apical 108 and irregular

Respiration 20 regular and unlabored at rest

Temperature 97.8

Oxygen saturation 90% F orally

Pulmonary infection

Pneumonia

Cardiovascular disease

High blood pressure

pneumonia

Prevent coronary events.

Primary and secondary prevention o atherosclerotic cardiovascular disease.

pneumonia

Increase oxygen saturation

Prevent pneumonia

Breathing rate normal

To improve breathing rate

High blood pressure

Control blood sugar

Blood pressure above the normal

Reduce blood pressure to normal

Pulmonary infection

Give inhaler

Treat the chronic obstructive pulmonary disease

Prevent damaging the lungs

Help in breathing

Repair damaged lungs