Fluid Volume
 The human body is constantly trying to
keep a balance of homeostasis with fluid
and electrolytes.
Fluid volume states
 Euvolemia
 Kidneys excrete 1 mL/kg/hr
 Skin


Sensible- sweating
Insensible- fever, exercise, and burns
 Lungs lose 300 mL/day

Increased with higher respiratory rate
Fluid Volume Deficit
 The loss of extracellular fluids exceeds the intake
ration to water
 Causes Whole fluid loss- Vomiting, diarrhea, sweating, GI
suctioning, hemorrhage
 Third spacing (burns, ascites)
 Excess diuresis- DI and adrenal insufficiency
 Not Dehydration
Nursing Management
 Assess
 Skin turgor, oral mucosa, urine output, mental status
 Measure everything
 Treat
 Administer oral fluids
 Administer IV fluids
Fluid Volume Excess
 Isotonic expansion of ECF caused by water and sodium
retention
 Causes Excess salt consumption
 Excessive administration of sodium containing IV fluids
 Failure (heart, kidneys or liver)
Nursing Managment
 Assess
 Daily weight, lung sounds, edema, I&Os, response to
medications
 Treat
 Restrict fluid and sodium intake
 Promote rest
Electrolytes
 Electrolytes are chemical compounds that break down
into ions, carrying a positive or negative charge. When
these are not in balance, pathological changes occur in
the human body
Sodium (Na+)
 Sodium (Na+) is the major component of extracellular
fluid (ECF). The normal values are 135-145 mmol/L
 Na+ takes part in the regulation of acid-base balance,
tissue osmolality and enzyme activity. Na+ is also
essential for the retention of body water by
maintaining osmotic pressure
Electrolyte Imbalances:
Hypernatremia
 Serum sodium > 145 mEq/L
 Causes include:
• Dehydration
• Decreased water intake
• Over-administration of Na+ supplementation
• Diuresis, or DI
• Impaired renal function
• Congestive heart failure
• Cushing’s syndrome
• Heat stroke
Hypernatremia: Clinical Picture
Nursing Management
 Treatment
 Hypotonic IV fluids
 Diuretics
 Monitor
 CNS changes
 Seizures
Electrolyte Imbalances: Hyponatremia
Hyponatremia: Clinical Picture
Nursing Management
 Treatment
 Underlying condition
 Sodium replacement
 Water restriction
 Encourage dietary sodium
 Medication
 Monitor
 Patients taking Lithium or diuretics that could be the
cause
Chloride (Cl-)
 Chloride (Cl-) is another component of ECF, with
normal values between 97-107 mmol/L.
 Cl- participates in tissue and cell osmolality, and
passively follows sodium and water. Cl- is necessary for
K+ retention, transport of carbon dioxide (CO2), and
formation of hydrochloric acid (HCL) in the
gastrointestinal tract.
 Cl- is usually provided in the form of NaCl or KCl
Hyperchloremia
 Causes
 Excess NS infusion
 Head injury
 Dehydration
 Diarrhea
 Respiratory alkalosis
 Metabolic acidosis
 Hyperparathyroidism
Hyperchloremia: Clinical Picture
 Tachypnea
 Lethargy, weakness
 Rapid, deep respirations
 HTN, edema
 Cognitive changes
Nursing Management
 Treatment
 Restore fluid and electrolyte balance first
 Infuse Lactated Ringers
 Sodium Bicarbonate (IV)
 Diuretics
 Patient teaching about diet and hydration
Hypochloremia
 Causes
 Reduced intake, GI loss (vomiting, diarrhea)
 Addison’s disease
 Ketoacidosis
 Excessive sweating, fever
 Burns
 Metabolic alkalosis
Hypochloremia: Clinical picture
 Agitation and irritability
 Weakness
 Muscular hyperexcitability
 Dysrhythmias
 Seizures
 Coma
Nursing Management
 Treat
 Normal Saline (IV)
 Avoid free water
 Encourage high chloride foods
Potassium (K+)
 Potassium (K+) is the major component of
intracellular fluid (ICF). The normal value range is 3.45.3 mmol/L.
 K+ participates in enzyme activity, regulation of tissue
osmolality and glycogen use. K+ is also essential for
cardiac function and central nervous system function
by regulating muscle and nerve excitability
Electrolyte Imbalances:
Hyperkalemia
 Causes
• Over-administration of potassium supplements
• Metabolic acidosis
• Renal failure
• Potassium-sparing diuretics
• ACE inhibitors, beta-blockers
• Trauma/bruising/bleeding
• Addison’s disease
Hyperkalemia: Clinical Picture
Nursing Management
 Treatment
• Kayexalate
• Calcium
• Sodium Bicarbonate
• Insulin and D50
• Dialysis
• Limit dietary intake
 Monitor
 ECG, apical pulse
 I&Os
Electrolyte Imbalances:
Hypokalemia
 Serum potassium < 3.5 mEq/L
 Causes
• Malnutrition, anorexia
• Decreased K+ intake
• Alcoholism
• Vomiting, diarrhea, or gastric suctioning
• Diuretics (except potassium sparing)
• Acute renal failure
• Steroids
• Tumor of the intestines
• Insulin overuse
• Epinephrine, bronchodilators
• Metabolic alkalosis (temporary)
• Cushing’s syndrome
Hypokalemia: Clinical Picture
Nursing Management
 Treatment
 Potassium replacement (Dietary or po)
 IV potassium (only if adequate UO)
 Monitor
 ECG changes
 ABG changes
 Patients receiving Digitalis
 Patients receiving diuretics
Magnesium (Mg2+)
 Magnesium (Mg2+) is found in the bone (50%), the
ICF (45%), and the ECF (5%). The normal range is 1.33.0 mg/dL.
 Mg2+ affects enzyme activity, cardiac and
neuromuscular function. Deficits with Mg2+ are
usually seen with deficits in Ca2+ and/or K+
Electrolyte Imbalances:
Hypermagnesia
 Causes
• Over-administration of magnesium products (including
antacids)
• Renal insufficiency or injury
• Renal failure
• Extensive soft tissue injury
• Severe dehydration (r/t hemoconcentration)
• Ketoacidosis
Hypermagnesia: Clinical Picture
Nursing Management
 Treatment
 Calcium gluconate (IV)
 Loop diuretics
 IV fluids (NS or LR)
 Monitor
 Deep Tendon Reflexes
 Changes in LOC
 ECG
Electrolyte Imbalances:
Hypomagnesia
 Causes
• Malnutrition or inadequate Mg2+ intake
• Alcoholism
• Chronic diarrhea
• Diuretics
• Rapid admin of citrated blood
• Ketoacidosis
• Acute myocardial failure
• Metabolic acidosis
• Aminoglycosides, digoxin
Hypomagnesia: Clinical Picture
Nursing Management
 Treatment
 Magnesium replacement (po or IV)
 Seizure precautions
 Monitor
 Dysphagia
 I&Os
Calcium (Ca2+)
 Calcium (Ca2+) is another component of the ECF, but
the majority is found in the bone. The normal values
are 8.0-10.2 mg/dL.
 Ca2+ is essential in blood coagulation, endocrine
functions, and neuromuscular function such as
muscular contraction and nerve excitability.
 Ca2+ serum values may vary, depending on total serum
albumin, as a relationship exists between the two.
Electrolyte Imbalances:
Hypercalcemia
 Causes
• Over-administration of calcium supplements
• Renal impairment
• Thiazide diuretics
• Bone fractures or prolonged immobility
• Malignancy
• Hyperparathyroidism
• Steroids
• Hypophosphatemia
Hypercalcemia: Clinical Picture
Nursing Management
 Treatment
 Increase fluid intake (po and IV)
 Loop diuretics
 Phosphorous supplements
 Increase fiber intake
 Monitor
 Safety
 I&Os
Electrolyte Imbalances:
Hypocalcemia
 Causes
• Dietary deficiencies of calcium, protein, and/or
vitamin D
• Malabsorption
• Osteoporosis
• Transfusion of citrated blood
• Low albumin
• Renal failure
• Hypoparathyroid
• Alkalosis
Hypocalcemia: Clinical Picture
Nursing Management
 Treatment
 Calcium replacement (po) with Vitamin D
 Calcium gluconate (IV)
 Exercise to decrease bone calcium loss
 Seizure precautions
Phosphorus (P+)
 Phosphorus (P+) is found in the bone and the ICF. The
normal range of values is 2.5-4.5 mg/dL.
 P+ plays a role in neuromuscular function, formation
of bones and teeth, body metabolism of nutrients, and
forming and storing of energy such as ATP.
Electrolyte Imbalances:
Hyperphosphatemia
 Causes
• Over-administration of phosphorus or Vitamin D
supplements
• Hypoparathyroidism
• Renal insufficiency
• Chemotherapy
• Acidosis
Hyperphosphatemia: Clinical Picture
Nursing Management
 Treatment
 Vitamin D supplementation (po)
 Phosphate binding antacids
 Loop diuretics
 IV fluids
 Dialysis
 Monitor
 Dietary (phosphate high foods)
 Signs of hypocalcemia
Electrolyte Imbalances:
Hypophosphatemia
Hypophosphatemia may be caused by:
• Ketoacidosis
• Burns, heat stroke
• Respiratory alkalosis
• Hyperventilation
• Antacids containing aluminum
• Malnutrition, anorexia
• Alcoholism
• Total parenteral nutrition (TPN)
• Vomiting, diarrhea
• Malabsorption
• Hyperparathyroidism
• Refeeding after starvation
• Hepatic encephalopathy
Hypophosphatemia: Clinical
Picture
Nursing Management
 Treatment
 Phosphorous replacement (po or IV)
 Encourage increased dietary intake
 Monitor
 Safety
In addition to electrolytes, there are other laboratory
tests that are included in a complete metabolic panel.
This combination of analyses can assist in providing
additional information about renal and hepatic
function.
Creatinine & BUN
 Creatinine is a non-protein
waste product of creatine
phosphate metabolism by
skeletal muscle tissue
 Dependent on the
Glomerular Filtration Rate
(GFR).
 Adult males: 0.8 - 1.4 mg/dl
 Adult females: 0.6 - 1.1
mg/dl
 Children: 0.2 - 1.0 mg/dl
• BUN is affected by hydration, hepatic metabolism of protein and
reduced GFR. The mean ratio of serum creatinine to the BUN should
be approximately 1:10
Elevated Creatinine
 Causes
 Impaired renal function
 Chronic nephritis
 Urinary tract obstruction
 Muscle diseases such as gigantism, acromegaly, and
myasthenia gravis
 Congestive heart failure
 Shock
 Medications
Elevated Creatinine: Clinical picture













Fatigue
Confusion, weakness, thirst
Shortness of breath
Nausea
Vomiting
Dry skin
Edema
Headaches
Loss of appetite
Weight loss
Itchy skin
Dark colored urine
Oliguria or anuria
Nursing Management
 Treatment
 BP management
 Glucose management
 IV fluids or Diuretics depending on cause
 Dietary teaching
 Dialysis if severe
 Monitor
 I&Os
 Daily weights
 Electrolyte values
Decreased Creatinine
 Causes
 Age
 Decreased muscle mass
 Inadequate dietary protein
 Muscle atrophy
Liver Function Tests
 ALT- an enzyme found mostly in the cells of the liver
and kidney.
 AST- In most types of liver disease, the ALT level is
higher than AST and the AST/ALT ratio will be low
(less than 1).
 Bilirubin- a waste product primarily produced by the
normal breakdown of heme.
 Alk Phos- This test is often used to detect blocked bile
ducts because ALP is especially high in the edges of
cells that join to form bile ducts.
Pancreatic Enzymes
 Amylase- the pancreatic and salivary gland enzyme
responsible for digesting carbohydrates
 Lipase- the pancreatic enzyme that, along with bile
from the liver, digests fats
Pancreatitis
Pancreatitis occurs when digestive enzymes become activated while still in the
pancreas, irritating the cells of your pancreas and causing inflammation.
Causes can include:
 Alcoholism
 Gallstones
 Abdominal surgery
 Certain medications
 Cigarette smoking
 Cystic fibrosis
 Family history of pancreatitis
 Hypercalcemia, which may be caused by hyperparathyroidism
 Hypertriglyceridemia
 Infection
 Injury to the abdomen
 Pancreatic cancer
 Endoscopic retrograde cholangiopancreatography (ERCP)
Pancreatitis: Clinical Picture
 Upper abdominal pain
 Abdominal pain that radiates to your back
 Abdominal pain that feels worse after eating
 Fever
 Rapid pulse
 Nausea
 Vomiting
 Tenderness when touching the abdomen
Nursing Management
 Treatments
 Gut Rest
 Pain meds
 Fluids, TPN
 ERCP
 Pancreatic enzymes
 Jejunal feeding
Thyroid Panel
 T4- high free T4 results may indicate an overactive thyroid gland,
and low free T4 results may indicate an underactive thyroid
gland
 TSH- produced by the pituitary gland. It is part of the feedback
system to maintain stable amounts of T4 & T3 in the blood and
to help control the rate at which the body uses energy.
Hypothyroidism
 Causes
 autoimmune disease
 treatment for hyperthyroidism
 radiation therapy
 thyroid surgery
 certain medications (i.e. Lithium)
 Pregnancy
 Iodine deficiency
Hypothyroidism: Clinical Picture
Myxedema: Clinical Picture
Nursing Management
 Treatments
 Medication (Levothyroid, Synthroid)
 Dietary modifications
 Supportive measures
Hyperthyroidism
Hyperthyroidism can accelerate your body's metabolism
significantly by producing too much thyroxine.
 Causes
 Graves' disease
 toxic adenoma
 Plummer's disease (toxic multinodular goiter)
 thyroiditis
Hyperthyroidism: Clinical Picture
Nursing Management
 Treatments
• Radioactive Iodine
• Medications (propylthiouracil and methimazole
(Tapazole))
• Surgery (Thyroidectomy)
• Symptom control (Beta Blockers)
• Eye Surgery (only for those who develop Graves’
Opthamopathy)
Glucose
 Glucose is a monosaccharide, or a simple sugar, which
is a product of cellulose, starch and glycogen. Free
glucose occurs in the blood and is the primary source
of energy for use in tissues of the body.
 The normal range is 60-200 mg/dL (non-fasting).
 Excess glucose is stored as glycogen in the liver or
muscle tissue.
Hyperglycemia
 Hyperglycemia occurs with a blood glucose greater than
200 mg/dL non-fasting, or a fasting blood glucose >100
mg/dL.
 Causes
• Diabetes mellitus
• Hyperosmolar nonketotic syndrome (HNKS)
• Cushing's syndrome
• Increased epinephrine levels from extreme stress (illness,
trauma, surgery
• Excess growth hormone secretion
• Over-administration of glucose
• Pregnancy (gestational diabetes)
• Medications- particularly steroids
Hyperglycemia: Clinical Picture
Nursing Management
 Treatment
 increased fluids
 insulin administration
 Dietary modification
Hypoglycemia
Hypoglycemia: Clinical Picture
Nursing Management
 Treatment
 Provide glucose and carbohydrates (po)
 Dextrose (IV)
 Symptom management
Serum Albumin
 Albumin is a large protein found in the blood plasma
that maintains the osmotic pressure between the
blood vessels and tissue (preventing a leak of the
blood from the blood vessels). It is also used to
determine liver function, kidney function, and
nutrition.
 The normal range for serum albumin is 3.5-4.8 g/dL.
Hypoalbuminemia
 Hypoalbuminemia occurs with a serum albumin <3.5 g/dL.
 Causes
• Poor nutrition
• Liver disease
• Impaired renal function
• Burns
• Lymphatic disease or cancer
• Congestive heart failure
• Inflammatory process
 Treatment
 Solve underlying problem
 Protein supplementation and nutrition support
Hypoalbuminemia: Clinical
Picture
Hyperalbuminemia
 Hyperalbuminemia occurs with a serum albumin >4.8
g/dL. Causes may include:
• Dehydration (abrupt)
• Liver disease
• Impaired renal function
• Tuberculosis
• An overdose of cortisone drugs

The clinical picture will depending on the cause of the
condition (liver ailment, kidney disease, etc.)
 Treatment is aimed at solving the underlying problem.
Cardiac Biomarkers
 Troponin I- most specific of the
cardiac markers. It is elevated
(positive) within a few hours of
heart damage and remains
elevated for up to two weeks.
 CK-MB- bound combination of
two variants (isoenzymes CKM
and CKB) of the enzyme
phosphocreatine kinase
 BNP- It is primarily used to help
detect, diagnose, and evaluate the
severity of heart failure.
Chemistry Panel: Case Study #1
 A 22 year old male patient is brought in via ambulance
after being found unresponsive at home.
 He is difficult to arouse and unable to answer
questions.
 He appears thin, and has poor skin turgor.
 BP is 100/60, HR 100, RR 16, T 99.2F.
 The EMS unit started an IV with normal saline, and
was unable to obtain a blood glucose reading.
 The first attempt at arterial blood gas is unsuccessful.
• Sodium (Na+)
• Potassium (K+)
• Chloride (Cl-)
• Magnesium (Mg2+)
• Calcium (Ca2+)
• Phosphorus (P+)
• Glucose
• Creatinine
150 mmol/L
5.1 mmol/L
108 mmol/L
2.6 mg/dL
9.2 mg/dL
4.2 mg/dL
987 mg/dL
1.7 mg/dL
Chemistry Panel: Case Study #2
 A 45 year old female patient, complaining of steady
right upper quadrant pain.
 BP is 138/98, HR 102, RR 14, T 98.9F.
 She has been experiencing nausea and vomiting x 24
hours.
 She has poor skin turgor, and you note scleral icterus.
 Her abdomen is non-distended but very painful to
touch.
 She rates her pain as a 10/10.
• Sodium (Na+)
• Potassium (K+)
• Chloride (Cl-)
• Magnesium (Mg2+)
• Calcium (Ca2+)
• Phosphorus (P+)
• Glucose
• Serum albumin
• Amylase
• Serum Creatinine
• BUN
• Alkaline Phos
• Protein
• Bilirubin
147 mmol/L
2.9 mmol/L
100 mmol/L
1.4 mg/dL
9.2 mg/dL
2.3 mg/dL
188 mg/dL
3.0 g/dL
185 unit/L
0.5 mg/dL
15 mg/dL
155 unit/L
8.6 g/dL
3.5 mg/dL
ABGs
 pH- the acidity or alkalinity of a substance
 paO2- the amount of circulating oxygenated blood
 paCO2- the amount of retained CO2 in the blood. In a healthy
adult, the paCO2 should remain in an inverse relationship with
the pH
 HCO3- Used by the kidneys to eliminate acids in the urine and
blood. Acid-base changes due to increases or decreases in HCO3concentration occur more slowly than changes in CO2, taking
hours or days
 Base Excess/Deficit- A calculated number that represents a sum
total of the metabolic buffering agents (anions) in the blood.
Anions are regulated to compensate for imbalances in blood pH.
Metabolic Acidosis
 Low pH, low bicarbonate
 Most commonly due to kidney injury
 Clinical picture
 Headache, confusion, drowsiness
 Increased RR
 hypotension, decreased CO, dysrhythmias, shock
 Treatment
 Correct underlying problem
Metabolic Alkalosis
 High pH, High bicarbonate
 Most commonly due to vomiting, GI suctioning, or
diuretic overuse
 Clinical picture
 Decreased calcium and potassium symptoms
 Respiratory depression
 Tachycardia
 Treatment
 Correct underlying disorder
 IV fluids with chloride
Respiratory Acidosis
 Low pH, High pCO2
 Always due to respiratory issues with inadequate excretion
of CO2
 Clinical picture
 Suddenly increased pulse, RR, and BP
 Mental status changes
 A feeling of fullness in the pts head
 Treatment
 Address the underlying problem first
 Improve ventilation
 Monitor
 Signs of increased ICP
Respiratory Alkalosis
 High pH, Low pCO2
 Always due to hyperventilation
 Clinical picture
 Lightheadedness, inability to concentrate
 Numbness and tingling
 Can lead to loss of consciousness if severe
 Treatment
 Correct cause of hyperventilation (anxiety, asthma
attack, etc.)
ABG
Interpretation
ABG Imbalances
ABG Interpretation
CBC Overview
 A typical adult circulates about 5 L of blood, which is
comprised of 3 L plasma and 2 L of blood cells.
 White blood cells (leukocytes), red blood cells
(erythrocytes), and platelets (thrombocytes) are all
created in the bone marrow.
 CBC results can be affected by the time of day,
hydration, medications, and other blood values.
Complete Blood Count
Tests included in a CBC include:
• Red blood cell count (RBC)
• Hematocrit (Hct)
• Hemoglobin (Hb or Hgb)
• Red blood cell components, such as mean corpuscular
volume (MCV), mean corpuscular hemoglobin (MCH), and
mean corpuscular hemoglobin concentration (MCHC)
• White blood count (WBC)
• A differential white blood cell count (diff)
• Platelets
Red Blood Cells
The primary purpose of RBCs, or erythrocytes, is to carry
oxygen from the lungs to body tissues and to transfer
carbon dioxide from the tissues to the lungs. Oxygen
transfer occurs via the hemoglobin contained in the
RBCs, which combines with oxygen and carbon dioxide.
Normal red blood cells values are:
• Adults: (males): 4.6-6.0 million/uL
• (Females): 4.2-5.0 million/uL
• Pregnancy: slightly lower than normal adult values
The average range of values for RBC is 4-5.9 million/uL.
Hemoglobin
Hemoglobin (Hgb) is a molecule comprised of an iron-containing
pigment (heme) and a protein (globulin). The ability of blood to
carry oxygen is directly proportional to its hemoglobin
concentration. The number of RBCs may not accurately reveal the
blood's oxygen content because some cells may contain more
hemoglobin than others.
• Normal hemoglobin values are:
• Adult: (males): 13.5 - 17 g/dl
• (Females): 12 - 15 g/dl
• Pregnancy: 11 - 12 g/dl
The average range of values for hemoglobin is 12-17.5 g/dL.
Critical values include:
• A hemoglobin < 5 g/dl can cause heart failure
• A hemoglobin > 20 g/dl can cause hemoconcentration and clotting
Hematocrit
The hematocrit (Hct) determines the percentage of red blood
cells in the plasma. It is calculated when a blood sample is
spun down, and the red blood cells sink to the bottom of the
sample.
• Normal hematocrit values are:
• Adults: (males): 40- 54%
• (Females): 37 – 46%
• Pregnancy: decreased hematocrit, especially in the last
trimester as plasma volume
increases
The average range of values for hematocrit is 37-54%
Critical values include:
• A hematocrit <15% can cause cardiac failure
• A hematocrit >60% can cause spontaneous blood clotting
MCV, MCH, and MCHC
 Mean corpuscular volume (MCV)- the average size of
individual red blood cells, calculated by dividing the
hematocrit by the total RBCs.
 Mean corpuscular hemoglobin (MCH)- the mass of
the hemoglobinin an RBC, calculated by dividing the
hemoglobin by the total RBCs.
 Mean corpuscular hemoglobin concentration
(MCHC)- how much of each cell is taken up by
hemoglobin. The calculation is the hemoglobin
divided by the hematocrit and multiplied by 100.
 The MCV, MCH, and MCHC can assist in
identification and diagnoses of disease processes.
Polycythemia
 An increase in the number of red blood cells is known as
polycythemia.
 Causes
• High altitudes
• Strenuous physical activity
• Medications, such as gentamicin and methyldopa
• Smoking
• Hydration
• Polycythemia vera
• COPD
• Chronic hypoxia
Polycythemia: Clinical Picture
Nursing Management
 Treatment
 Address the underlying cause
 Therapeutic Phlebotomy
Anemia
Anemia Panel
 Includes
 CBC
 Ferritin
 Folates
 Total Iron Binding Capacity with Iron (TIBC)
 Reticulocyte Count
 Vitamin B12
 Folic Acid
Anemia: Clinical Picture

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






Fatigue
Low energy
Weakness
Shortness of breath
Dizziness
Palpitations
Pallor
Chest pain
Tachycardia
Hypotension
Fainting
Nursing Management
 Treatment
 Address the underlying cause, and is dependent
on severity.
 Iron and B12 supplementation is used.
 PRBC transfusions


Healthy, symptomatic adult, not actively bleeding
 Hgb <7
Actively bleeding and symptomatic may transfuse
earlier
Transfusion Reactions
 Hemolytic
 Blood type or Rh incompatibility
 Reaction related to antibodies against patient’s blood
 Destroys transfused cells
 Mild to life threatening
 Immediate or after several units infused
 Allergic
 Sensitive to antibodies in donor blood
 During or up to 24 hrs post transfusion
 Febrile
 Non specific and most common
 Development of Anti -WBCs after several tx
 Bacterial
 Contaminated Blood products
Transfusion Reaction: Clinical
Pictures
 Hemolytic
 Apprehension/ Impending Doom
 HA, CP, Low back pain, N/V
 Increased HR and RR
 Hypotension
 Hematuria and decreased UO
 Allergic
 Fever, urticaria, bronchospasm
 Occasional anaphylaxis
 Febrile
 Sensations of cold, tachycardia, tachypnea, Fever, and
Hypotension
 Bacterial
 Tachycardia, hypotension, fever
 Chills and Shock
Nursing Management
 General Treatment
 Stop the transfusion
 Benadryl
 airway management
 Buffy coat
 Leukocyte filters
 Bacterial Treatment Only
 Blood culture, Antibiotic Therapy, Fluid resuscitation
 Vasopressors, Corticosteroids
White Blood Cells
White blood cells (WBC), or leukocytes, are classified into
granulocytes (which include neutrophils, eosinophils, and
basophils) and agranulocytes (which include lymphocytes and
monocytes). WBC are released from the bone marrow and
destroyed in the lymphatic system after 14-21 days.
Leukocytes fight infection through phagocytosis, where the cells
surround and destroy foreign organisms. White blood cells also
supply antibodies as part of the body's immune response.
The average range of values for WBC is 4-10 thousand/uL.
WBC critical lab values include:
• A WBC <500 places the patient at risk for a fatal infection.
• A WBC >30,000 indicates massive infection or serious disease (e.g.
leukemia)
WBC Differential
Leukocytosis
 WBC > 10,000.
 Causes
• Trauma
• Inflammation
• Acute infection
• Dehydration
• Hemoconcentration
• Cancer, such as leukemia
• Medications, such as corticosteroids
Leukocytosis: Clinical Picture &
Treatment
• Fatigue
• Hepatomegaly
• Splenomegaly
• Bleeding
• Bruising or petechiae
 Treatment is focused on the underlying cause, and is
dependent on severity.
Leukopenia
 WBC < 4,000.
 Causes
 Bone marrow disorders
 Viral infections
 Severe bacterial infections
 Cancer
 Medications, include chemotherapy, antibiotics,
anticonvulsants, and some cardiac medications
Leukopenia: Clinical Picture &
Treatment
• Headache
• Fatigue
• Fever
• Bleeding
 Treatment is focused on the underlying cause, and
dependent on severity. Steroids, vitamins, and
cytokines can be used
Leukopenic/
Neutropenic
Precautions
Platelets
Platelets are fragments of cells that are formed in the
bone marrow, and are vital to blood clotting.
Platelets live for approximately 9 to 12 days in the
bloodstream.
The average range of values for platelets is 150,000 and
399,000/mm³.
Vitamin K
 Serves as an essential cofactor for clotting
 Proteins dependent on Vitamin K levels
 factors II (prothrombin), VII, IX and X
 proteins C, S and Z
 osteocalcin and matrix-Gla protein, and certain
ribosomal proteins
 Deficiency of Vitamin K can result in hemorrhagic
disease
 Also used as a reversal agent
Coagulation Studies
 PT/INR- helps evaluate a person's ability to appropriately form
blood clots
 PT Range 11 – 12.5 seconds
 INR Range 0.7 - 1.8. (Coumadin Range 2 – 3)
 PTT- measures the number of seconds it takes for a clot to form
in a person's sample of blood after substances (reagents) are
added
 PTT range 30 – 40 seconds.
 If on anticoagulation, 1.5 to 2.5 times control
 Fibrinogen- a protein, a coagulation factor (factor I) that is
essential for blood clot formation.
 D-Dimer- one of the protein fragments produced when a blood
clot dissolves in the body. It is normally undetectable unless the
body is forming and breaking down blood clots.
Medication changes
 Unfractionated heparin therapy
 Thrombosis prevention
 Maintain therapeutic aPTT
 Heparin-induced thrombocytopenia
 Low-molecular-weight heparin therapy-Lovenox
 Warfarin (Coumadin) therapy
 Impact of vitamin K
 INR
 Dabigatran (Pradaxa) therapy
Bleeding disorders
 Secondary thrombocytosis
 Essential Thrombocytopenia
 Immune thrombocytopenic purpura (ITP)
 Platelet defects
 Hemophilia
 von Willebrand disease
Secondary Thrombocytosis
Thrombocytosis: Clinical Picture
• Dizziness
• Headache
• Chest pain
• Weakness
• Neuropathy
• Vision changes
• Fainting
 Treatment is focused on the underlying cause
 Limit injury, and place on bleeding precautions
Thrombocytopenia
Thrombocytopenia occurs when the platelet count is
<150,000, placing the patient at a high risk for bleeding
due to injury or disease. A platelet count <20,000 can
cause spontaneous bleeding that may result in patient
death.
Some causes of thrombocytopenia include:
 Decreased platelet production-chemo
 Increased platelet destruction-infection
 Increased platelet consumption-DIC
Thrombocytopenia: Clinical
Picture
• Easy bruising, petechiae or bleeding
• Hematuria
• Black, tar-like stools or frank bleeding with bowel
movements
• Hematemesis
• Syncope
• Visual disturbances
 Treatment is focused on the underlying cause, and
dependent on severity.
 Platelet transfusions may be used with severe
thrombocytopenia.
Immune Thrombocytopenic
Purpura
 Autoimmune disorder characterized by destruction of
normal platelets by an unknown stimulus.
 Causes
 Viral illness like hepatitis and HIV may lead to ITP
 sulfa drugs, lupus, pregnancy
 ASA, NSAID’s alter platelet function
 Clinical picture
 Easy bruising, heavy menses, petechiae
Nursing Management
 Treatment
 Only if less than 30,000 or extensive bleeding occurs
 Immunosupressive agents like Imuran (chronic) or
Prednisone (acute)
 IVIG
 splenectomy
 Transfusions don’t help because the antibodies just kill
the platelets
Platelet Defects
 Quantitative platelet defects (i.e., thrombocytopenia,
throm-bocytosis) are relatively common; however,
qualitative defects can also occur.
 With qualitative defects, the number of platelets may
be normal but the platelets do not function normally.
Hemophilia
 Group of hereditary clotting factor disorders
characterized by prolonged coagulation time that
results in prolonged and sometimes excessive
bleeding
 Hemophilia A and B are X-linked recessive traits
 Manifestations for both types
 Persistent and prolonged bleeding, hemarthrosis,
ecchymosis, GI bleeding, UTI
 aPTT increased
Hemophilia A





Classic Hemophilia
Lacks Factor VIII: Stabilizes fibrin clots
Most common form (80%)
Severity varies from mild to severe
Transmitted as X linked recessive disorder from mothers to
sons
 Treatment
 Cryoprecipitate containing 8 to 100 units of Factor VIII per
bag
 12 hour intervals until bleeding stops
 Freeze dried concentrate of Factor VIII may also be given
Hemophilia B
 Christmas Disease
 Lacks Factor IX: Influences amount of thromboplastin
available
 Also X-linked recessive trait
 Treatment
 Plasma or Factor IX concentrate given q 24 hours until
bleeding ceases
Von Willebrand’s Disease
 Lack of protein (vWF) that mediates platelet adhesion
 Necessary for Factor VIII activity
 Bleeding time is prolonged
 Often diagnosed after surgery or dental extraction
when prolonged bleeding is indicated
 Treatment
 DDAVP
 Concentrate of vWF and Factor VIII
Hemophilia: What is the
difference?
 In clients with Hemophilia A and B, platelet plugs are
formed at the site of bleeding, but clotting factor
impairs coagulation response and capacity to form
STABLE clot
 With Von Willebrands platelet plugs are difficult to
form
Nursing Management
 Treatment
 Teach avoidance of all aspirin products
 Application of cold, immobilization for 24 to 48
hours if hemarthrosis occurs
 Avoidance of injury
 Wearing MedicAlert bracelet
 Control bleeding through direct pressure,
application of hemostatic agents, and ice
 Bleeding precautions
 Genetic counseling
Acquired Coagulation Disorders
 Liver disease
 Antithrombin deficiency
 Vitamin K deficiency
 Protein C & S deficiency
 Complications of anticoagulant
 Activated protein C resistance
therapy (HIT)
 Disseminated intravascular
coagulation (DIC)
 Thrombotic disorders
 Hyperhomocysteinemia
and factor V Leiden mutation
 Acquired thrombophilia
 Malignancy
Disseminated Intravascular
Coagulation (DIC)
Causes
 DIC does not occur in isolation.
A number of underlying
conditions are responsible for
initiating and propagating the
process
 Sepsis
 Malignancy
 Trauma, especially to the central
nervous system
 Obstetrical complications,
including preeclampsia,
retained dead fetus, acute fatty
liver of pregnancy
 Intravascular hemolysis, often
due to transfusion reaction
DIC: Clinical Picture
Nursing Management
 Treatments
 Treat underlying cause
 Aggressive Hydration
 Transfusion only for bleeding patients
 Supportive measures
 Monitor
 bleeding and tissue oxygenation
 Monitor I & O hourly
 Monitor for renal failure, PE, CVA, and ARDS
CBC Values: Case Study #1
 A 62 year old male patient, complaining of fatigue,
dizziness, and bleeding from his gums.
 On assessment, you notice multiple bruises on upper
and lower extremities, back and trunk.
 BP is 138/98, HR 88, RR 12, T 100.9F.
• RBC
• Hct
• Hgb
• WBC
• Platelets
4.5 million/uL
40%
13.2 g/dL
2.9 thousand/uL
99 x 10³/mm³
CBC Values: Case Study #2
 A 24 year old female, with a history of drug abuse.
 She is complaining of shortness of breath, dizziness,
chest pain and palpitations.
 She appears pale and malnourished.
 BP 90/56, HR 106, RR 18, T 98.2F, O2 sat 89%.
• RBC
• Hct
• Hgb
• WBC
• Platelets
3.3 million/uL
23%
9 g/dL
4.9 thousand/uL
199 x 10³/mm³
Urinalysis
 Direct visual observation
 Normal: clear and pale to amber
 Abnormal

Cloudy



Excess cellular material or protein
Crystallization from standing at room temperature or
refrigerator
Red to reddish brown color

Food dye, consumption of beets, a drug, the presence of
hemoglobin (from the breakdown of blood), or myoglobin
(from the breakdown of muscle)
UA (cont.)
 Acid/Base (pH): 7.4-6 (acidic)
 Specific gravity: measures urine density 1.002-1.035
 Below 1.007-1.010=hydration
 Above 1.007-1.010=dehydration
 Protein 150mg/24 hrs or 10mg/100ml
 Greater than 3.5gm/24 hrs indicates nephrotic syndrome
 Glucose
 Ketones-diabetic ketosis or starvation
 Nitrate-positive may indicate bacteria are present-typically
gram negative rods (E.coli)
 Leukocyte Esterase-positive results from the presence of
white blood cells (Infection)
Microscopic
 RBC-hematuria
 Glomerular damage, tumors, kidney trauma, stones, ATN,
infection, nephrotoxins, physical stress
 WBC-Pyuria
 Infection
 Epithelial cells
 High levels=nephrotic syndrome
 Lipiduria
 Bacteria
 Casts-Urinary casts may be made up of white blood cells, red
blood cells, kidney cells, or substances such as protein or fat.
 Bacteria
 Yeast
 Crystals-can indicate liver impairment
Hemodynamic Monitoring
Nursing Care
Hemodynamic Monitoring
Complications
 Infection/Sepsis
 Infection at insertion site can occur if aseptic technique is
not used.
 Treatment







Change dressings per facility protocol and as needed.
Use surgical aseptic technique with dressing changes (mask,
sterile gloves, maintain sterile field).
Perform thorough hand hygiene.
Collect specimens (blood cultures, catheter tip cultures) and
deliver to the laboratory.
Administer antibiotic therapy as prescribed.
Administer IV fluids for intravascular support.
Administer vasopressors to correct vasodilation secondary to
sepsis.
Hemodynamic Monitoring
Complications
 Embolism
 Plaque or a clot can become dislodged during the
procedure.
 Risk of pneumothorax with insertion of the line.
 Risk of dysrhythmias with insertion/movement of the
line.
Hemodynamic Monitoring
 CVP
 Pulmonary artery pressure
 Swan-Ganz
 Intra-arterial BP monitoring
 Cardiac Output/Index
 Vigileo/EV1000
Central Venous Pressure
Monitoring
 Measure of blood volume and venous return and
reflects right heart filling pressures (preload)
 Catheter in the jugular or subclavian vein and distal
end in superior vena cava – above right atrium.
 Monitors fluid volume status
 Normal CVP: 2 to 6 mmHg (ATI 1 to 8)
 Decreased CVP – hypovolemia, shock
 Increased CVP – fluid overload, vasoconstriction,
cardiac tamponade
Pulmonary Artery Pressure
Monitoring
 Used to assess left ventricular function, diagnose the
etiology of shock, and evaluate the patient’s response
to medical interventions (e.g., fluid administration,
vasoactive medications).
 Inserted into large vein (preferably subclavian)
 Serious complications include pulmonary artery
rupture, pulmonary thromboembolism, pulmonary
infarction, catheter kinking, dysrhythmias, and air
embolism.
Pulmonary Artery Catheter and
Pressure Monitoring System
Intra-arterial pressure
monitoring
 Indwelling arterial line
 Allows direct and continuous monitoring of systolic,
diastolic, and mean arterial blood pressure
 Easy access for arterial blood sampling
 Allen’s Test / Doppler
 Monitor for complications by frequently assessing
pulse strength, perfusion and sensation distal to
insertion site
Allen’s Test
Intra-arterial monitor set up
EV1000/Vigileo
References
American Association for Clinical Chemistry. (2016). LabTestsOnline.Org.
LeFever, J., Paulanka, B., & Polek, C. (2010). Handbook of fluid,
electrolyte, and acid-base imbalances (3rd ed). Clifton Park, NY: Delmar
Cengage Learning.
Rush Medical University Center. (2012). Rush Medical Laboratory:
Normal ranges for common laboratory tests. In Martindale’s: The
Reference Desk. Retrieved January 2012 from
http://www.martindalecenter.com/Reference_3_LabP.html
Van Leeuwen, A.M., Poelhuis-Leth, D., & Bladh, M.L. (2011). Davis's
comprehensive handbook of laboratory & diagnostic tests with nursing
implications (4th ed). Philadelphia, PA: F.A. Davis Company.
Warrell, D.A., Firth, J.D., & Cox, T.M. (eds). (2010). Oxford textbook of
medicine (5th ed). Oxford, NY: Oxford University Press.