ideal & actual dx tests - meningitis

8/7/2019 ideal & actual dx tests - meningitis

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DIAGNOSTIC PROCEDURES

This section refers to the diagnostic procedures that should be done to the patient (IDEAL) and the diagnostic procedures that

were made to the patient (ACTUAL) to rule out the problem or to diagnose the condition of the patient. The diagnostic procedures

are very important to confirm diagnosis of the Physicians; to determine the extent of the disease; to know the significant values that

need to be monitored; and to know necessary managements and therapy that should be done for the patients recovery or help in

planning treatment. The purpose, normal values, significant values, implications and nursing responsibilities are included in this part

of the case study. The description and purpose of the procedure is included or stated in the ideal procedures.

I. IDEAL Procedures

NAME of thePROCEDURE

DESCRIPTION PURPOSE

1. PHYSICALEXAMINATION

Meningitis or meningeal irritation results in anumber of well recognized signs common to alltypes of meningitis:

Nuchal rigidity (stiff neck): This is an earlysign. Any attempts at flexion of the headare difficult because of spasms in themuscles of the neck. Forceful flexion causes

severe pain. Positive Kernigs sign: when the patient is

lying with the thigh flexed on the abdomen,the leg cannot be completely extended.

Positive Brudzinskis sign: when the

To assess and determine patients clinicalmanifestations.


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patients neck is flexed (after ruling outcervical trauma or injury), flexion of theknees and hips is produced; when the lowerextremity of one side is passively flexed, asimilar movement is seen in the oppositeextremity. Brudzinskis sign is a moresensitive indicator of meningeal irritationthan Kernigs sign.

2. CEREBROSPINALFLUID ANALYSIS viaLUMBAR PUNCTURE

CSF analysis is commonly obtained by lumbarpuncture (usually between the third and fourthlumbar vertebrae); rarely, by cisternal orventricular puncture (for qualitative analysis).

May also be obtained during other neurologictests such as myelography.

Lumbar puncture is also known as spinal tap.

Considered as key diagnostic test formeningitis.

The presence of polysaccharide antigen in CSFfurther supports the diagnosis of bacterialmeningitis.

To help diagnose viral or bacterialmeningitis, subarachnoid or intracranialhemorrhage, tumors, brain abscesses, andchronic central nervous system infections.


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3. BLOOD CULTURE Involves inoculating a culture medium with ablood sample, incubating it for isolation, andidentifying the causative pathogens inbacteremia and septicemia.

Identifies about 67% of pathogens within 24hours, and up to 90% with in 72 hours.

Timing of the specimen collection dependent

on type of suspected bacteremia and whetherdrug therapy needs to restart regardless of testresults.

The test requires blood samples.

No dietary restrictions are required.

To confirm a diagnosis of bacteremia.

To identify the causative organism inbacteremia and septicemia.

To determine the cause of fever with anunknown origin.


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ACTUAL procedures

NAME andPURPOSE of the

PROCEDURE

ACTUALRESULT

NORMALVALUES

IMPLICATIONS orSIGNIFICANCE

NURSINGRESPONSIBILITIES

1. BLOODCHEMISTRY

(February 16, 2011) FBS: To measure

serum glucose levelsafter 8-12-hour fast.

BUN: To evaluatekidney function andaid in the diagnosis ofrenal disease; to aid inthe assessment ofhydration.

CREA: To assess

glomerular filtrationand to screen for renaldamage.

CHOLESTEROL: To

FBS: 113.6mg/dL

BUN: 34.5 mg/dL

CREA: 2.4 mg/dL

TotalCholesterol:

256.3

FBS: 70-110 mg/dL

BUN: 8-26 mg/dL

CREA: 0.5-1.7mg/dL

Total Cholesterol: 120-310

Increased levels mayindicate pancreatitis,recent acute illness (MI),

brain tumor, sepsis, andseizure disorders.

Levels of 126 mg/dL ormore, obtained on twoor more occasions,confirm diabetes.

Elevated BUN levels mayindicate renal disease,reduced renal blood flow(caused by dehydration),or urinary tractobstruction.

Increased level usuallyindicates renal diseasethat has seriouslydamaged 50% or moreof the nephrons.

Inc serum cholesterollevels may indicate a

Instruct patient to fast for 8-12hours before the test.

Inform client regardingrationale of this test.

Tell the patient that the testrequires a blood sample.

Explain that he may experienceslight discomfort from thetourniquet and needlepuncture.

Inform the patient that the testshould take less than 5minutes.

Apply direct pressure to thevenipuncture site until bleedingstops.

Provide a balanced meal or asnack.

After the procedure, informpatient to resume his usual dietand medications, as ordered.


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assess the risk of CAD;to evaluate fatmetabolism; and tohelp diagnosenephrotic syndrome,pancreatitis, hepaticdisease, hypo- andhyperthyroidism.

SODIUM: To evaluatefluid-electrolyte and

acid-base and relatedneuromuscular, renal,and adrenal functions.

POTASSIUM: Toevaluate clinical signsof potassium excess orpotassium depletion;to monitor renalfunction, acid-basebalance, and glucosemetabolism; toevaluateneuromuscular andendocrine disorders;and to detect the

origin of arrhythmias.

CHLORIDE: To detectacid-base imbalance(acidosis or alkalosis)and to help evaluate

Sodium: 147.4

Potassium: 4.08

Chloride: 115.0

Sodium: 135-145mEq/L

Potassium: 3.5-5.0 mEq/L

Chloride: 100-108mEq/L

risk of CAD, incipienthepatitis, lipid disorders,obstructive jaundice,nephrotic syndrome,pancreatitis, andhyperthyroidism.

Increased or decreasedsodium level or alteredstate of hydration may

be found. May be due towater loss in excess ofsodium (such asprolongedhyperventilation, severevomiting or diarrhea).

The test implied anormal result.

An increase in chloridelevels may be evident insevere dehydration, andcomplete renalshutdown.

May anticipate hematoma atthe venipuncture site.

Inform the AP of abnormalresults.


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fluid status andextracellular cation-anion balance.

2. URINALSIS

(February 16,2011)

To screen patientsurine for renal orurinary tract disease

To help detectmetabolic or systemicdisease unrelated torenal disorders.

Test result:

Color: Yellow

Character:Turbid

Reaction:Acidic

Specificgravity: 1.030

Sugar:Negative

Albumin:+3

WBC: 15-20Hpf

RBC: TMTC

Bacteria: Few

Normal Results:

Color: Straw todark yellow

Character: Clear

Reaction: 4.5 to8

Specific gravity:1.010-1.030

Sugar: Negative

Albumin:Negative

WBC: 0-5 hpf

RBC: 0-2 hpf

Bacteria:

Mucus threads:Few

Abnormal results mayreveal that:

An acid pH- typical of ahigh-protein diet

produces turbidity andthe formation of oxalate,cystine, leucine, tyrosine,amorphous urate, anduric acid crystals.

Turbid urine may containRBCs or WBCs, andbacteria may reflectrenal infection.

Proteinuria suggestsrenal failure or disease.

Hematuria indicatesbleeding within thegenitourinary tract and

may result frominfection, obstruction,inflammation, trauma,tumors, and hemorrhagicdisorders.

Check Physicians order.

Explain that this analysishelps to diagnose renal orurinary tract disease and toevaluate overall body function.

Inform the patient that hedoesnt need to restrict foodand fluids.

Collect a random urinespecimen of at least 15 ml.Obtain a first-voided morningspecimen if possible.

Refrigerate the specimen ifanalysis will be delayed by 1hour or greater.

Inform the practitioner of

abnormal results.


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Mucusthreads: Few

Epithelial: Few

Crystals: Few

Epithelial: Few

Crystals: Few

WBC in urine suggestsrenal infection or non-infective inflammatorydisease.

3. HEMATOLOGY

(February 16,2011)

Helps the Physician todiagnose conditions,such as anemia,infection, and otherdisorders.

Hematologyreport:

Hemoglobin:129 g/L

Hematocrit:0.39%

WBC Count:14.1 x 10 9/L

WBCDifferential:Neutrophils:88.5

Lymphocytes:7.6Monocytes: 3.9

Platelet count:

Normal Result:

Hemoglobin:120-160 g/L

Hematocrit:0.36-0.48%

WBC Count:4-10 x 10 9/L

WBC Differential:Neutrophils: 54-75Lymphocytes:

25-40Monocytes: 2-8

Platelet count:140-400 x 10 9/L

An increased WBC countsignals infection, such asmeningitis.

Inform client regarding purposeof this test.

Tell the patient that the testrequires a blood sample.

Tell patient that there are nodietary restrictions.

Tell the patient who willperform the test and where itwill be done

Explain that he may experienceslight discomfort from thetourniquet and needlepuncture.

Inform the patient that the test

should take less than 5minutes.

Apply direct pressure to thevenipuncture site until bleedingstops.


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156 x 10 9/L If a large hematoma develops

at the venipuncture site,monitor pulses distal to thesite.

Inform the AP of abnormalresults.

4. CHEST AP(Supine)

(February 16,2011)

To establish abaseline for futurecomparison.

To detectpulmonary disorderssuch as pneumonia.

To detectmediastinalabnormalities such astumors.

Findings:

Pneumonitis,left

Cardiomegaly

Artheromatousaorta

Dextroscoliosis, thoracic spine

Normal Results:

The trachea isvisible midline inthe anteriormediastinalcavity.

Heart is visible inthe anterior leftmediastinalcavity, appearingsolid.

The aortic knob isvisible as waterdensity.

The mediastinum

is visible as thespace betweenthe lungs.

Ribs are visible asa thoracic cavity

Make sure the patient hassigned an appropriate consentform.

No dietary restrictions arerequired.

Move IV tubing and otherequipment out of theradiographic field.

Explain the purpose of thetest.

Tell the patient who willperform the test and where it

will be done.

Explain that the patient will beasked to take a deep breathand hold it momentarily during


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encasement.

Spine has avisible midline inthe posteriorchest thats mostvisible on alateral view.

Lung roots arevisible above theheart and exist

where pulmonaryvessels, bronchiand lymph nodesjoin the lungs.

The bronchi andlung fields arentusually visible,except for bloodvessels.

Thehemidiaphragmis rounded andvisible.

the x-ray.

Inform the patient that the testtakes less than 5 minutes.

Postprocedure care: Checkthat no tubes have beendislodged during positioning.

If possible, place a lead apronover the patients abdomen toprotect the gonads.

5. CT SCAN

(February 17,

2011)

To diagnoseintracranial lesionsand abnormalities.

Findings:

Sign of Acute

Meningitis

Age-relatedbrain atrophy

Normal Results:

Brain matter

appears inshades of gray.

Ventricular andsubarachnoid

Make sure thepatient has signed anappropriate consent form.

Note and reportallergies.

There aredietary restrictions if a


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To assess focalneurologicabnormalities.

Bilateral basalganglioncalcification

cerebrospinalfluid appearsblack.

contrast medium is to be used.

Explain thepurpose of the test and howits done.

Tell the patientwho will perform the test andwhere it will be done.

If the patient

wont receive a contrastmedium, tell him that he neednot restrict food and fluidintake before the test.

If the patientwill receive a contrast medium,instruct him to fast for 4 hoursbefore the test.

Advise thepatient that he mayexperience transientdiscomfort from the needlepuncture and a warm orflushed feeling if an IV contrastmedium is used.

Stress the needto remain still during the test

because movement can limitaccuracy of the test.

Warn the


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patient that he mayexperience minimal discomfortbecause of lying still andimmobilizing his head.

Caution that thepatient will hear clackingsounds as the head of thetable moves into the scanner,which rotates around his head.

Inform thepatient that the test takesabout 30 minutes.

Assist thepatient into a supine positionon a radiographic table.

If the patientreceived a contrast medium,watch for delayed adversereactions.

Instruct thepatient to resume his usualdiet and medications unlessordered otherwise.

6. CSF ANALYSIS(February 18,

2011)

To help diagnose

Test Result:

Color:Colorless, crystalclear

Normal Results:

The fluidobtained is clearand colorless.

Results revealed anincrease in protein; thissuggests tumors, trauma,hemorrhage, DM, and/orpolyneuritis.

Tell the patient thatno dietary restrictions arerequired.

Make sure that thepatient or a responsible family


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viral or bacterialmeningitis, tumors,and brain abscesses.

Volume:Approx. 3.0 ml

Cell Count(Tube 1):WBC:2 lymphocytes

RBC: Rare

ChemistryTube 2:Sugar:3.64 mmol/L

Total CHON:59.32 mg/dL

Microbiology(Tube 3):Gram Staining:Nomicroorganism

AFB Staining:No

microorganism

The cell countreveals no redblood cells; 0-5WBCs.

Gram stainreveals absenceof any organisms.

CSF pressure isbetween 50-180mm H2O

member has signed aninformed consent form.

If the patient isunusually anxious, assess andreport his vital signs.

Explain that this testanalyzes the fluid around thespinal cord.

Tell the patient whowill perform the test and

where it will be done.

Instruct the patient toremain still and breathenormally; movement andhyperventilation can alterpressure readings or causeinjury.

Advise the patientthat a headache is the mostcommon adverse effect of alumbar puncture, but reassurehim that his cooperationduring the test helps minimizethis effect.

Tell the patient thatwhen the spinal needle isinserted, he may feel slightlocal pain as the needletransverses the dura mater.


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Instruct the patient toreport pain or sensations thatdiffer from or continue afterthis expected discomfortbecause such sensations mayindicate irritation or punctureof a nerve root, requiringneedle repositioning.

Inform the patient

that the test should take lessthan 30 minutes.

Confirm the patientsidentity.

Help in thepositioning of the patient.

After the specimen iscollected, label the containersin the order in which they werefilled.

Postprocedure care:In most cases, instruct thepatient to keep lying flat for 8hours after the procedure.

Encourage the patientto drink fluids. Provide aflexible straw.

Check the puncture


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site for redness, swelling, anddrainage every hour for thefirst 4 hours, and then every 4hours for the first 24 hours.

Inform AP of theabnormal results.


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ideal & actual dx tests - meningitis

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