Indication Normal Values Tests I. Complete Blood WBC measures Count (CBC) inflammation and/or infection. White Blood Cells (WBC) Causes for abnormality Signs & Symptoms ↑ due to inflammation, infection, trauma, stress, pregnancy, and drugs (steroids) Assess for ↓ BP and ↑ HR Treatment depends on with known infection because the cause: it can indicate sepsis. -Allergy: antihistamines, Assess closely for any change corticosteroids, etc. -Inflammation: antiin temperature trend, inflammatory drugs especially in the elderly. -Infection: Antibiotics ↓ due to bone marrow failure, 5,000-10,000/mm3 elderly, chronic illnesses, drugs (antibiotics, antithyroid, chemotherapy) Hemoglobin is the ↑ due to COPD and HF oxygen-carrying ability of blood. This ↓ due to blood loss, bone marrow suppression, iron-deficiency Hemoglobin (Hgb) test is a GOLD STANDARD for evaluating severity and treatment of anemia. Treatment Nursing Responsibilities THINK INFECTION -Monitor WBC level -Monitor temperature -Monitor SxS of infection -Administer antibiotics Signs of hypoxia such as cyanosis, ↑ HR, ↑ RR, ↓ O2 sat, and delayed capillary refill. Treatment depends on THINK PERFUSION the cause of anemia such as iron -Monitor RR and O2 sat supplement, -Monitor SxS of hypoxia erythropoietin, or blood (cyanosis and delayed transfusion capillary refill) -Administer iron supplement, erythropoietin, or blood if ordered See above See above See above 12-17 Male: 13-17 g/dL Female: 12-16 g/dL % RBC in proportion to total plasma volume. Related to patient's hydration Hematocrit (Hct) status. ↑ due to dehydration (hemoconcentration) ↓ due to overhydration (hemodilution), hemorrhage, renal disease 35-50 Male: 39-49 % Female: 35-45 % Tests Indication Normal Values Causes for abnormality Signs & Symptoms Treatment Nursing Responsibilities Platelets are needed for coagulation. ↑ (thrombocytosis) due to pregnancy, cancer, infection Patients with low platelet count are at high risk for bleeding or may exhibit SxS of bleeding such as ↓ BP, ↑ HR, ↑ RR, ↓ O2 sat, confusion, bruising, and delayed capillary refill. Fresh frozen plasma to correct low platelet count to prevent bleeding or in anticipation of medical procedures that can cause bleeding. THINK RISK FOR BLEEDING -Administer fresh frozen plasma if ordered -Do not administer any anticoagulant if platelet count < 100,000 Hyponatremia: confusion, irritable, restlessness, lethargy, muscle cramps & weakness, seizures, urine specific gravity < 1.005 Hyponatremia: ↑ salt intake, avoid giving large amount of water, administer 0.9% NaCl or 3% NaCl THINK VOLUME Heparin => to Prevent clot => Antidote : Protamine sulfate Platelet (Plt) II. Basic Metabolic Panel (BMP) 100-400,000/mm3 ↓ (thrombocytopenia) due to the use of heparin (heparin-induced thrombocytopenia), cancer, and severe infection Sodium controls fluid ↑ due to intake of sodium, balance. dehydration, sweating, diabetes insipidus -Monitor other electrolytes as they can be affected ↓ due to sodium intake, ↑ fluid -Monitor urine specific intake (oral or hypotonic IV fluid), gravity, I&O, weight Sodium 135-145 mEq/L diarrhea, vomiting, nasogastric Hypernatremia: confusion, Hypernatremia: ↓ salt -Monitor SxS (Na) suction, diuretic, and HF irritable, lethargy, intake, ↑ fluid intake, hyponatremia and restlessness, dry mucous administer 0.45% NaCl hypernatremia membranes, ↑ body or D5W to dilute -Seizure precaution temperature, thirst, seizures, sodium, administer USG > 1.030 diuretic to excrete sodium Essential to cardiac ↑ due to dietary intake, impaired Hypokalemia: arrhythmias, Hypokalemia: THINK ELECTRICITY and skeletal muscle kidney function, potassium-sparing flattened T wave on EKG, ↑potassium intake (oral electrical conduction. diuretics, ACE inhibitors muscle weakness and or IV), assess SxS -Monitor other electrolytes cramping, ↓ peristalsis, ↑ risk digoxin toxicity if as they can also be affected Check BP and K+ value for digoxin toxicity indicated, teach proper ↓ due to dietary intake, diarrhea, -Monitor SxS hypokalemia use of laxatives and vomiting, gastric suction, and hyperkalemia 3.5-5.0 mEq/L Potassium potassium-wasting diuretics, Hyperkalemia: arrhythmias, diuretics -Monitor cardiac rhythm (K+) Antidote: Kayexalat e Tests laxatives Priority Tx for High K+ 1.IV Calcium Gluconate( Dysrhythmias) 2.IV50% Destrose + Regular insulin 3. Kayexalte (Polystrene sulfonate) 4.Dialysis Indication Normal Values Causes for abnormality peaked T wave on EKG, muscle weakness and paralysis, paresthesia of face/tongue/feet/hands Signs & Symptoms Hyperkalemia: restrict potassium intake, give Kayexalate, give potassium-wasting diuretics Treatment -Monitor BUN and creatinine levels Nursing Responsibilities Required for ↑ due to magnesium intake, transmission of nerve impaired kidney function impulses and muscle relaxation. ↓ due to magnesium intake, malabsorption, diarrhea, vomiting, gastric suction, and thiazide Magnesium (Mg) diuretics 1.6-2.0 mEq/L Mellow down the muscles Calcium (Ca) calcium contracts the muscles Phosphorus (Phos) Tests Waste from protein Creatinine Hypomagnesemia: ↑ deep Hypomagnesemia: ↑ THINK CARDIAC & tendon reflexes, ↑ BP, ↑ HR, magnesium intake (oral DEEP TENDON arrhythmias, confusion, mood or IV) REFLEXES changes V-Fib -Monitor other electrolytes as they can also be affected Hypermagnesemia: -Monitor SxS Hypermagnesemia: ↓ or restrict intake of hypomagnesemia and absent deep tendon reflexes, ↓ magnesium hypermagnesemia RR, ↓ BP, ↓ HR, arrhythmias, -Monitor airway, cardiac facial flushing rhythm, BP and HR, deep tendon reflexes Transmission of nerve ↑ due to calcium intake, ↑ vitamin Hypocalcemia: Trousseau and Hypocalcemia: ↑ THINK MUSCLE impulses, heart & D intake, bone cancer, prolonged Chvostek signs, numbness & calcium intake (oral or RESPONSE muscle contractions & immobilization, thiazide diuretics tingling of fingers and toes, IV), ↑ intake of vitamin -Monitor other electrolytes relaxation, blood spasm of laryngeal muscles, D as they can also be affected clotting, formation of ↓ due to calcium intake, vitamin D bone fractures, arrhythmias, -Monitor cardiac rhythm teeth and bone. and seizures, Diarrhea deficiency, malabsorption, loop Hypercalcemia: restrict -Monitor SxS diuretics calcium intake, ↑ fluid hypocalcemia and 8.4-10.6 mg/dL Hypercalcemia: arrhythmias, intake (oral or IV such hypercalcemia -Monitor respiratory status constipation, kidney stones, as 0.45% NaCl or muscle weakness D5W), loop diuretics, and implement seizure precautions for increase mobilization hypocalcemia 2.5-4.5 mg/dL Indication Normal Values ↑ due to impaired kidney function, Hypophosphatemia: ↑ intake of vitamin D, ↑milk intake, respiratory failure and hypocalcemia, excessive use of arrhythmias laxatives containing phosphates Hyperphosphatemia: SxS of ↓ due to ↓ phosphorous intake, hypocalcemia, arrhythmias malabsorption, hyperparathyroidism, alcoholism Hypophosphatemia: THINK CARDIAC administer intravenous phosphorous -Monitor other electrolytes -Monitor airway Hyperphosphatemia: -Monitor cardiac rhythm restrict phosphorous intake, teach proper use of laxatives Causes for abnormality Signs & Symptoms Treatments Nursing Responsibilities High creatinine level: - ↓ urinary output - ↓ GFR Correct underlying problem(s) THINK KIDNEY FUNCTION Waste product of ↑ due to kidney disease, skeletal muscle tissue. dehydration, and HF A GOAL STANDARD test to ↓ due to decreased muscle mass, evaluate kidney overhydration function. 0.6-1.2 mg/dL Blood Urea Nitrogen (BUN) Waste product of protein metabolism. Used with creatinine to evaluate kidney function. ↓ due to poor protein intake, overhydration 7-26 mg/dL Evaluate kidney function. Glomerular Filtration Rate (GFR) ↑ due to kidney disease, HF, dehydration, increased protein intake > 60 mL/min ↑ due to pregnancy or high cardiac ↓ urine output output Amber to dark urine color May have ↓ BUN/creatinine ↓ due to kidney disease, HF, or dehydration End-stage kidney < 15mL/min If high: increase fluid, dialysis if indicated -Monitor GFR level -Monitor I&O -Assess for SxS of If low: increase protein dehydration and fluid volume overload intake If high: increase fluid, dialysis if indicated THINK KIDNEY FUNCTION -Monitor GFR level If low: increase protein -Monitor protein level -Monitor I&O intake -Assess for SxS of dehydration and fluid volume overload Treat underlying cause THINK KIDNEY FUNCTION -Monitor I&O -Monitor urine characteristics Hyperglycemia due to stress, Corticosteroid-induced diabetes diabetes, IV fluids containing dextrose, corticosteroids Glucose 70-110 mg/dL Hypoglycemia due to poor food intake, antidiabetic medications Hypoglycemia: ↑ HR, skin cold and clammy, tremor, diaphoresis, lethargy, restlessness, blurred vision, seizures If high: oral or insulin antidiabetic agents If low: glucose, glucagon injection, or dextrose IV solution THINK SUGAR -Monitor FSBG -Assess SxS of hypoglycemia and hyperglycemia Hyperglycemia: -thirst/polydipsia -hunger/polyphagia -frequent urination/polyuria Tests Indication Normal Values III. Coagulation Studies Measures how long blood takes to clot. Refers to patients Prothrombin Time receiving warfarin. (PT) 10-13 seconds Causes for abnormality Signs & Symptoms Treatments ↑ due to warfarin, liver disease, clotting factor deficiency, vitamin K deficiency If level is high, may exhibit See INR test below SxS of bleeding such as ↓ BP, ↑ HR, ↑ RR, ↓ O2 sat, confusion, bruising, and ↓ due to high intake of green leafy delayed capillary refill. vegetables, vitamin K supplement Therapeutic level: Warfarin 1.5 - 2 times > normal PT value (Vitamin K antagonist) Measures therapeutic ↑ due to warfarin, liver disease, level for warfarin. 0.8-1.1 nmol/L International Normalized Ratio Therapeutic level: 2-3 nmol/L (INR) IV. Other Glycosylated Hemoglobin (HgbA1C) If level is high, may exhibit -If INR < 2, warfarin SxS of bleeding such as ↓ BP, dose may need to be ↑ HR, ↑ RR, ↓ O2 sat, increased. confusion, bruising, and -If INR > 3, warfarin dose may need to be ↓ due to high intake of green leafy delayed capillary refill. decreased. May give vegetables, vitamin K supplement vitamin K supplement Don’t hold warfarin 2~3 (antidote for warfarin) nmol/L clotting factor deficiency, vitamin K deficiency GOLD STANDARD ↑ due to diabetes or corticosteroid to diagnosed diabetes therapy and monitor for effectiveness of diabetic treatment. Pt has diabetes? Normal < 5.6 % Prediabetes 5.7-6.4% Nursing Responsibilities THINK RISK FOR BLEEDING -Monitor SxS bleeding -Monitor platelet count, Hgb and Hct -Monitor PT/INR levels -Adjust warfarin dose 46-70 THINK RISK FOR BLEEDING -Monitor for SxS bleeding -Monitor platelet count, Hgb and Hct -Monitor PT/INR levels -Adjust warfarin dose If high, SxS may be silent or If high: administer THINK SUGAR consistent with hyperglycemia antidiabetic agents (oral -Educate patient about or insulin), ↓ frequency of lab (every 3 carbohydrate intake months) -Teach patient how to selfmonitor blood sugar levels -Teach patient healthy lifestyle choices Diabetes ≥ 6.5% Controlled diabetes ≤ 7 Albumin Tests Monitor patient’s nutritional status during the past 3 months. 3.5-5.5 g/dL ↑ due to dehydration, high protein intake ↓ due to low protein intake, liver disease, overhydration If low, assess for edema and SxS of malnutrition Indication Normal Values Causes for abnormality Signs & Symptoms Treatments Nursing Responsibilities Assess patient’s nutritional status. Low: ↑ protein intake THINK NUTRITION Monitor patient’s ↑ due to high protein intake nutritional status ↓ due to malnutrition or liver during the past 3 days. disease Pre-albumin Measures urine concentration. Urine Specific Gravity Low: ↑ protein intake, administer IV albumin 1.005 – 1.030 THINK NUTRITION -Monitor I&O & nutritional status -Assess for edema if low protein level If patient is NPO for > 5 -Monitor I&O days, advocate for IV -Monitor nutritional status nutritional supplement. 23-43 mg/dL Used to monitor ↑ due to inflammation, tissue C-reactive protein inflammatory illness. damage/injury, infection (CRP) < 1.0 mg/dL High: ↓ protein intake Inflammation, tissue injury, or Treat underlying cause THINK INFLAMMATION infection -Monitor for SxS inflammation and/or infection ↑ due to dehydration If high: dark colored urine, ↓ due to overhydration, diabetes concentrated odor insipidus, impaired kidney function If low: light colored urine If high: ↑ oral or IV fluids THINK FLUID BALANCE If low: administer diuretics -Monitor I&O -Monitor urine characteristics Urine Analysis (UA) Brain natriuretic peptide (BNP) Tests Digoxin level Color: pale yellow Clarity: clear USG: 1.005 – 1.030 pH: 4.6-8 Protein: none Glucose: none Ketones: none Blood: none Nitrite: none WBC: 0-5 Leukocyte esterase: none Identify urinary infection. -Leukocyte esterase = presence of WBC -WBC = infection likely Treat with antibiotics. THINK UTI Infection is often caused by E.coli, -Nitrite = byproduct of bacteria a fecal bacterium that is introduced -Bacteria = infection likely into the urinary tract due to poor -SxS of UTI: dysuria, hygiene. urgency, frequency, malodor, cloudy urine, or blood in urine. -Monitor urinalysis test -Monitor SxS of UTI -Administer antibiotics -Teach proper hygiene techniques Identify patients who have heart failure ↑ due to heart failure -SxS of HF: dry cough, Treat with sodium and crackle lung sounds, S3 heart fluid restriction and diuretics. sound, dyspnea, fatigue, jugular venous distention, peripheral edema, hepatomegaly, weight gain, fatigue THINK FLUID VOLUME OVERLOAD -Assess VS, respiratory and cardiac assessments -Daily weight, I&O -Administer oxygen PRN -Restrict sodium & fluid -Administer diuretics Indication Normal Values Causes for abnormality Signs & Symptoms Nursing Responsibilities Monitor therapeutic level of digoxin ↑ due to taking digoxin Confusion, nausea, vomiting, Digoxin immune Fab anorexia, bradycardia, visual (Digibind) changes (halos), and arrhythmias. THINK CARDIAC Skin and eyes that appear Depends on the cause yellowish (jaundice), abdominal pain and swelling, dark urine color, pale stool color. THINK LIVER Skin and eyes that appear Depends on the cause yellowish (jaundice), abdominal pain and swelling, dark urine color, pale stool color. THINK LIVER < 100 pg/mL 0.8-2.0 ng/mL Toxic level >2.4 ng/mL Patients with hypokalemia, hypomagnesemia, hypoxia, heart disease, renal disease, and hypercalcemia are at risk for digoxin toxicity Injury or disease ↑ due to hepatitis, cirrhosis, affecting the liver will cholestasis, hepatotoxic drugs cause the release of Alanine Aminotransferase this enzyme into the bloodstream. (ALT) Treatments -Monitor BP & apical pulse -Cardiac assessment -Monitor digoxin level -Skin/eye assessment -Abdominal assessment 4-36 units/L Tylenol Injury or disease affecting the heart muscle, liver cells, and skeletal muscle Aspartate Aminotransferase cells will release this enzyme into the (AST) bloodstream. ↑ due to myocardial infarction, hepatitis, cirrhosis, liver cancer, hepatotoxic drugs, and skeletal muscle trauma -Skin/eye assessment -Abdominal assessment -Cardiac assessment -Musculoskeletal assessment 0-35 units/L Used to determine the ↑ due to genetics, hypothyroidism, No signs or symptoms. risk for coronary heart uncontrolled diabetes, high disease. cholesterol diet Total Cholesterol Tests < 200 mg/dL Indication Normal Values Lipid-lowering medications THINK CARDIAC - Monitor lipid panel (TC, TG, HDL, LDL) ↓ due to malabsorption, malnutrition, hyperthyroidism, cholesterol-lowering medications, liver disease Causes for abnormality Signs & Symptoms Treatments Nursing Responsibilities Lipid-lowering medications THINK CARDIAC Triglycerides Used to determine the ↑ due to genetics, hypothyroidism, No signs or symptoms. risk for coronary heart high-carbohydrate diet, disease. uncontrolled diabetes ↓ due to malabsorption, malnutrition, hyperthyroidism < 150 mg/dL Lipid-lowering medications and exercise High-density Lipoprotein (HDL) Used to determine the ↑ due to genetics and excessive risk for coronary heart exercise disease and to monitor medication therapy. ↓ due to metabolic syndrome, genetics, liver disease > 60 mg/dL No signs or symptoms. - Monitor lipid panel (TC, TG, HDL, LDL) THINK CARDIAC - Monitor lipid panel (TC, TG, HDL, LDL) Low-density Lipoprotein (LDL) Used to determine the ↑ due to genetics, liver disease, risk for coronary heart hypothyroidism disease and to monitor medication therapy. ↓ due to genetics, malabsorption, malnutrition, hyperthyroidism < 100 mg/dL Revised 8/30/2024 No signs or symptoms. Lipid-lowering medications THINK CARDIAC - Monitor lipid panel (TC, TG, HDL, LDL) Fluid & Electrolyte Basics III Fundamentals of Nursing TEST TIP The MOST deadly conditions are typically the MOST tested conditions, since the main goal of nursing school is to create safe nurses. Electrolytes Function HYPER ‘’HIGH’’ Hypo ‘’low’’ P HYPERkalemia (over 5.0) HYPOkalemia (below 3.0) Potassium K+ 3.5 - 5.0 Priority P Potassium K+ P RITY PRIO Potassium Pumps the heart Manifestations (S/S) Heart = HIGH pumps 1 - Peaked T Waves & ST Elevation 2 - Severe: V Fib & Cardiac Arrest 3 - Hypotension & Bradycardia Neuromuscular = HIGH Potassium 1 - Increased DTR 2 - Paralysis & paresthesia (tingling) 3 - Muscle weakness (general feeling of heaviness) K+ Causes: - Renal failure - Low aldosterone Memory Trick for AL A - Adds Sodium L - Loses Potassium 1 - Diarrhea 2 - Hyperactive bowel sounds S 135 - 145 Sodium Na+ Sodium Na+ Swells the body with FLUID Chloride ClMagnesium Mg+ 1.3 - 2.1 Magnesium Mg+ LOW Related to sodium Maintains: • Blood pressure • Blood Volume • pH balance 1 - Edema (swollen body) 2 - Flushed “red & rosey” skin 3 - Increased muscle tone 4 - Swollen dry tongue 5 - Nausea & Vomiting Causes: - Low ADH (antidiuretic hormone) DI: Diabetes Insipidus Think Dry Inside - Rapid respirations - Watery diarrhea - Loss of thirst 9.0 - 10.5 Calcium Causes: Fluid loss/electrolyte loss “Where fluids flow, electrolytes goooo!” Diarrhea, Diuretics, Diet, DKA, Aldosterone Manifestations (S/S) Brain = Low & slow 1 - Headache = Cerebral edema 2 - Mental status changes 3 - Seizures & Coma Muscular = Low & slow - Fatigue & muscle cramps Respiratory = Low & slow Causes: - Sweating - Excess water intake (running in the extreme heat) TEST TIP - SIADH (Excess ADH - Vomiting & diarrhea, - Diuretics & Diuresis - Diet low in salt - Low aldosterone HYPOchloremia (below 97) Chloride NEARLY SAME AS HIGH SODIUM 1 - Swollen dry tongue 2 - Nausea & vomiting pH Chloride Cl- Cl- NEARLY SAME AS low SODIUM 1 - Fatigue & muscle cramps 2 - Fever (only difference) Metabolic Alkalosis - vomiting HYPERmagnesemia (over 2.1) M M Magnesium Mellows the muscles Manifestations (S/S) Heart = High Mellow Magnesium 1 - Heart block 2 - Hypotension, bradycardia Mg+ DTR = High Mellow - Hyporeflexia (decreased DTR) Causes: - Renal failure - Alcoholism - Malnourishment Lungs & GI = High Mellow Keeps the 3 Bs Strong B - Bone B - Blood (clotting) B - Beats (heart) Ca Inverse relationship with Phosphate Phosphate - Ca HIGH = Phosphate Low - Ca Low = Phosphate HIGH 3.0 - 4.5 GI = Low & slow - Respiratory Arrest C HYPERcalcemia (over 10.5) Calcium Calcium Ca Manifestations (S/S) HIGH Calm C Contracts the muscles Inverse relationship with Calcium 1 - Kidney stones, moans & groans (Renal Calculi) 2 - Constipation 3 - Bone pain 4 - Severe muscle weakness & lethargy Ca Calcium Ca Causes: - Hyperparathyroidism High PTH = High Calcium - Cancer - Immobility HYPERphosphatemia (over 4.5) Manifestations (S/S) Think Low Calcium signs Calcium 1 - Trousseau’s & Tetany 2 - Chvostek's 3 - Weak B’s (bones, blood, beats) HYPOmagnesemia (below 1.3) Manifestations (S/S) Heart = Low Mellow - Excited! 1 - Torsades de Pointes TOP TESTED & V Fib (ventricular fibrillation) DTR = Low Mellow - Excited! - HYPERreflexia (increased DTR) GI = Low Mellow - Excited! Causes: - Crohn's disease - Celiac disease - Diarrhea - Hyperactive bowel sounds - Depressed respirations - Hypoactive bowel sounds Calcium Ca 1 - Shallow Respirations! Most DEADLY 2 - Decreased DTR 3 - Muscle cramping & flaccid paralysis (paralyzed limbs) HYPOnatremia (below 135) HYPERchloremia (over 107) NORMAL HIGH 97 - 107 Manifestations (S/S) Body = Big & Bloated S Chloride Cl- Neuromuscular = Low & slow HYPERnatremia (over 145) Sodium Maintains: • Blood Pressure • Blood volume • pH balance 1 - Flat T waves, ST depression & Uwave 1 - Constipation 2 - HypOactive bowel sounds 3 - Paralytic ileus (paralyzed intestine) Priority* risk for SBO GI = HIGH pumps Sodium Na+ Manifestations (S/S) Heart = Low & slow pump Causes: - Renal failure TEST TIP Chronic kidney disease (CKD) HYPOcalcemia (below 9.0) Manifestations (S/S) Low Calm = Excited! 1 - T - Trousseau’s Sign Twerking arm when BP cuff on Tetany: muscle spasms all over 2 - C - Chvostek’s Sign Cheeky smile when stroking face 3 - Diarrhea 4 - Weak B’s Weak Bones = Fractures Weak Blood clotting = r/f bleeding Weak Beats = Cardiac dysrhythmias Causes: -Hypoparathyroidism Low PTH = Low Calcium - Renal failure TEST TIP Chronic kidney disease (CKD) HYPOphosphatemia (below 3.0) Manifestations (S/S) Think High Calcium signs 1 - Kidney stones, moans & groans (Renal Calculi) 2 - Constipation 3 - Bone Pain 4 - Severe muscle weakness & lethargy Causes: - Hyperparathyroidism High PTH = High Calcium - Genetics - Cancer How to interpret lab values Critical Concepts • Understand lab results to formulate the plan of care • Practice “Thinking like a nurse”: 1. Understand the context 2. Know when to intervene and when to monitor 3. Always look at the “bigger picture” Understand the context • Questions to ask patient: oWhat are the patient’s demographics? oWhat is their current condition? oWhat is normal (historically) for the patient? oWhat chronic conditions do they have? oWhat medications they are on? oWhat was the source of the specimen and how was it collected? Know when to intervene and when to monitor • Not every abnormal lab value requires intervention • Degree of risk for the intervention should be weighed against potential harm of the condition • An intervention does not have to be treatment, it can simply be to follow up on the result • Always trend lab values and consider the context Always look at the “bigger picture” • Treat the patient, not the number • Lab value alone is rarely used to guide treatment • Medical history, physical assessment, imaging, and patient preferences are used to guide treatment • Even “normal” lab values can be abnormal in some patients • “High normal” or “low normal” may need further investigation Scenarios 1. White Blood Cells (WBC) A patient on post-op day 1 for abdominal surgery has WBC 13,500 and temperature 98.6 F (37 C) - Normal range 5,000-10,000/mm3 - Measures inflammation or infection - Does this patient have an infection? No. This is a post-op inflammatory response related to stress. In 1 day, bacteria can’t reproduce enough to achieve the threshold needed to cause infection. 2. White Blood Cells (WBC) A patient on post-op day 5 for abdominal surgery has WBC 19,000 and temperature 101.3 F (38.5 C) - Does this patient have an infection? Yes, patient has elevated WBC, fever, and 5 days after surgery - What SxS might the patient have? Fever, chills, diaphoretic, ↑ abdominal pain, and/or incisional pain. Wound site with ↑ redness, ↑ swelling, ↑ heat, and purulent drainage (pus). 3. Hemoglobin (Hgb) & Hematocrit (Hct) A 35-year-old female patient has Hgb 10 g/dL & Hct 30% - Normal values for female: Hgb 12-16 g/dL & Hct 35-45% - Hgb measures the amount of hemoglobin in your blood, which is needed to carry oxygen to tissues - For this patient, her low Hgb can be caused by chronic blood loss, low RBC production, or heavy menses - SxS Patient may have mild symptoms of hypoxia such as pale skin, mild fatigue, weakness, shortness of breath, and activity intolerance. 4. Hemoglobin (Hgb) & Hematocrit (Hct) An adult male patient has baseline Hgb 15 g/dL & Hct 45% Post-op day 1: Hgb 8 g/dL & Hct 24% - Patient has a sudden drop of Hgb & Hct, most likely due to bleeding secondary to surgery - How is this scenario different from the previous scenario? Acute blood loss versus chronic/slow blood loss - What SxS might the patient have? More severe symptoms since the body is not used to these low blood levels. Patient may have signs and symptoms of hypoxia (low BP, tachycardia, tachypnea, cyanosis, dyspnea) 5. Platelets A patient has a prescription for heparin 5000 units SQ Q8 hours. Patient’s platelet count is 93,000 - Normal value 100,000-400,000/mm3 - Heparin is an anticoagulant given to prevent blood clots. - Would you administer heparin? No. Low platelets can cause bleeding. Heparin can also cause bleeding. 6. Sodium (Na) A patient has a sodium level of 150. - Normal range 135-145 mEq/L - Causes of high sodium level? Increased salt intake or dehydration. Dehydration causes serum Na+ more concentrated (hemoconcentration) 7. Sodium (Na) A patient has a sodium level of 123. - Normal range 135-145 mEq/L - Causes of low sodium level? Decreased salt intake, vomiting, diarrhea, and overhydration. Overhydration causes serum Na+ more diluted (hemodilution) 8. Potassium (K) A patient takes furosemide 40 mg QD. Patient’s potassium level is 2.8 and he reports skipped heart beats. - Normal range 3.5 – 5.0 mEq/L - Furosemide is a loop diuretic given to remove excess fluid and to lower BP. - What causes this patient to have low potassium level? Furosemide causes increased potassium (K+) excretion in the urine - Would you administer furosemide? No, furosemide will lower K+ to dangerous levels. Notify the provider and request an order for potassium supplement before administering furosemide. 9. Magnesium (Mg) A patient has renal dysfunction. - Would magnesium level be low or high? Renal dysfunction causes the kidneys to not excrete magnesium sufficiently leading to higher level in the blood. 10. Calcium (Ca) A patient takes over-the-counter Tums 2 tablets every hour for 8 hours. - Tums is an antacid and it is used to treat heartburn or acid reflux. - Would calcium level be low or high? Tums is calcium carbonate. Consumption of calcium products in great quantity leads to higher level in the blood. 11. Blood Urea Nitrogen (BUN) & Creatinine (Cre) A patient has renal dysfunction. - BUN: a waste product of protein metabolism, measure kidney function, normal value is 7-26 mg/dL - Creatinine: a waste product that comes from the normal wear and tear of muscles, measure kidney function, normal values 0.6-1.2 mg/dL - This patient’s BUN and creatinine will be high. Renal dysfunction impairs the kidneys’ ability to filter and excrete waste products such as BUN & Creatinine. 12. Glomerular Filtration Rate (GFR) A patient has end-stage renal disease. - Normal value > 60 mL/minute - GFR measures how well the kidneys are working to remove waste and excess fluid from the blood. - Will the patient’s GFR be low or high? Low because the kidneys are not excreting the waste products properly. 13. Glucose A patient with diabetes ran out of insulin. - Insulin is a hormone produced in the pancreas. Insulin regulates the amount of glucose in the blood. - Normal value 70-110 mg/dL - Will this patient’s glucose level be low or high? High, due to the patient not taking insulin. 14. Glucose A patient is taking prednisone for the treatment of an inflammatory disease. Prednisone belongs to the corticosteroid drug class. It is a potent antiinflammatory drug. Corticosteroids -blocks insulin and cause the liver to release more glucose into the bloodstream -stimulate cortisol. Cortisol causes sympathetic nervous response “fight or flight” leading to more glucose being released from the liver. 15. Prothrombin Time (PT) & International Normalized Ratio (INR) A patient is receiving warfarin 5 mg PO daily. - PT is used to evaluate blood clotting, normal value 10-13 seconds - INR measures the time the blood takes to clot for patients who take warfarin, normal value 0.8-1.1 - Warfarin is an anticoagulation, used to prevent blood clots from forming or growing larger in the blood and blood vessels 15. Prothrombin Time (PT) & International Normalized Ratio (INR) INR Goal Would you administer warfarin in these situations? • Patient’s INR level is 0.6 Yes, to ↑ warfarin to therapeutic level. • Patient’s INR level is 1.8 Yes, to ↑ warfarin to therapeutic level. • Patient’s INR level is 2.5 Yes, to maintain therapeutic level of warfarin. • Patient’s INR level is 3.7 No, the patient is at risk for dangerous bleeding. 16. Glycosylated Hemoglobin (HgbA1C) A patient with diabetes has HgbA1C 12 - HgbA1c measures average blood glucose value over the past 3 months. Shows how well patients with diabetes are controlling their blood sugar over time. - Patients with diabetes should have HgbA1c level < 7% - HgbA1c 12 indicates patient’s diabetes is not well controlled. 17. Urine Specific Gravity A patient has nausea, vomiting, and diarrhea for 3 days. - Normal value 1.005 – 1.030 - USG measures the concentration of urine - Would this patient’s USG be high or low? High due to the dehydration. In the setting of dehydration, the kidneys will concentrate urine to conserve water. 18. Urinalysis Patient reports urinary urgency, frequency, and dysuria. Interpret the results of the urinalysis below. -color: amber -clarity: cloudy -WBC: 10 -leukocyte esterase: positive -nitrite: positive -blood: negative -protein: negative 18. Urinalysis Patient reports urinary urgency, frequency, and dysuria. Interpret the results of the urinalysis below. -color: amber. Should be light yellow. Urine gets darker with dehydration as the kidneys conserve water. -clarity: should be clear. Cloudy is due to WBC’s response to bacteria creates pus > visibly cloudy. -WBC: 10. Normal 0-5. This is abnormally high, possible infection. -leukocyte esterase: positive. Should be negative. Enzyme produces by WBCs. -nitrite: positive. Should be negative. Produce by certain types of bacteria. -blood: negative. Normal. Presence of blood may indicate kidney or bladder damage or menstruation. -protein: negative. Normal. Presence of protein may indicate kidney damage. Urine Culture & Sensitivity 19. Total Cholesterol A patient is taking atorvastatin 20 mg QHS. - Normal value < 200 mg/dL - Atorvastatin belongs to a drug class known as HMG-CoA Reductase Inhibitors (statins) and it is used to lower bad cholesterol (LDL) and increase good cholesterol (HDL) to lower the risk for coronary heart disease. - What time of the day is best to take atorvastatin? Explain your answer. At night when the liver makes the most cholesterol.
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