Lab Data

Front 1

Labs Drs will commonly ask for: schematic included - 7

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top row: Na+, Cl-, Bun,
Second row: K+, CO2, Cr (creatinine), and Glucose on the right end.

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4 blood labs a doc will want to see

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WBC, Hgb, Platelets, Hct.

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Makes up a Comprehensive Metabolic Panel

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Serum glucose, Bun(Blood urea nitrogen, Creatinine, GFR(glomular filtration rate), Bilirubin, AST (Aspartate aminotransferase), ALT (alanine aminotranferase), ALP (alkaline phosphatase), Serum protein(comprised mainly of:): Albumin, Globulins, CO2 content, Anion Gap, Electrolyte review including: Sodium (Na+), Potassium (K+), Chloride (Cl-), calcium (Ca2+)

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Comprehensive Metabolic Panel helps a Dr. learn about:

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Kidney and liver function, electrolyte balance, acid-base balance, blood glucose levels, blood protein levels.

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A CMP helps monitor these conditions:

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Hypertension, dx diabetes, kidney or liver disease or functioning abilities. It also helps doctors monitor how a person's body is doing while on certain medications....is theIR body able to process these meds or are they causing tissue damage?

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Pertinent lab tests in addition to the CMP

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Lactic Acid,
Urinalysis, WBC Differential review, RBC differential review.

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Serum Glucose

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This measures the amount of freely circulating glucose in the blood. Fasting vs. Non-fasting values are important to note as there could be a large difference if a person has eaten within 2 hours or fasted for 8-12 hours. Know what the situation is.

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Increased Serum glucose levels may indicate: (if done fasting)

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1. Diabetes Mellitus
2. stress
3. TPN, Tube feedings,
d. Steroid and diuretic use: prednisone will raise: may need some sliding scale insulin.
e. insulin resistance : this leads to post prandial (after meals) elevations.

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Decreased glucose levels can signify:

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1. excessive insulin administration
2. postprandial hypoglycemia- usually BG <50mg/dl 2-5 hrs pc (after meal)

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FASTING Blood glucose level indicators:

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Hypoglycemic: <50
Normal: 70-100 mg/dl
Prediabetes:101-126
Diabetes:>126 mg/dl

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Post prandial up to 2 hours after meal BG levels

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Normal: <140
prediabetes:140-200
Diabetes: >200

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Nursing implications

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Hgb A1C & eAG

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HgbA1C

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Levels:
Normal: 4%-5.6
Risk for Diabetes:5.7%-6.4%
Diabetes: 6.5% and above
This test gives a back dated view of how a person's blood sugar is being controlled over a 6-12 week period.

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eAG

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estimated Average Glucose: this is figured out based on the A1C results

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BUN: Blood Urea Nitrogen

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tells how much nitrogenous waste is formed during protein catabolism by the liver and excreted primarily by the kidneys.
Liver breaks proteins down into ammonia (Nitrogenous waste) -ammonia is toxic, so the liver then converts the ammonia into urea which is then released into the blood stream, and processed out by the kidneys. If there is more ammonia in the blood the the BUN is LOW. if you are dehydrated, your bun will be higher, so this isn't super accurate... lack of volume d/t burns, shock, diarrhea also shows elevated BUN. ...as does GI bleeding...

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Increased Bun may indicate:

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1. Dehydration or reduced blood volume (d/t i.e. shock or burns)-lack of volume to excrete waste.
2. excessive protein intake-seen w/tube feedings.
3. impaired renal function or venous congestion in kidneys-seen in heart failure.
3. GI bleeding: digested blood acts as excessive protein
4. medications: HCTZ, Gentamycin, ASA, Lasix.

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Decreased Bun may indicate:

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Overhydration
severe liver disease
malnutrition
early pregnancy

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Nursing implications in r/t increased BUN

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look at I & O's, BUN, GFR, Cr...if we are losing protein we have a sick kidney. If there is a high bun: uremic syndrom...cranky to lethargic is how a pt. will present with ESRD... Assessments: I/O, UA results, Cr, fluid status, mental status if bun is >70. If a kidney can't convert protein, then a low protein diet may need to be adopted.

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Creatinine

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Nitrogenous end-product of skeletal muscle breakdown. Excreted by the kidneys. Its levels are unaffected by diet, hydration or tissue catabolism. It is on-going, and is a by-product the kidney excretes at a constant rate. It is all about muscle turnover, and is a better indicator of kidney function than BUN.
Normals vary with gender. RANGE: 0.5-1.1 is normal.

Front 20

Increased Creatinine indicates:

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1. impaired renal function or poor blood flow in kidneys. Elevates with 50% of nephrons are destroyed, prerenal issue. Diabetes can affect this.
Acute or Chronic? look at H&P: something above normal but less than 2 for creatinine baseline, and then if itis elevated above this baseline 0.5 above would indicate an acute on chronic...Someone on dialysis will have creatinine be about 8. It goes up after 50% of nephron function is lost.
2. large muscle mass, extreme exercise
3. rhabdomylosis (Found down for long period of time. CPK & Cr will both be elevated d/t muscle trauma.)
4. Nephrotoxic agents. Anesthesia is very toxic. Look at difference between B4 & after surgery. Increased CR is not good, it can cause renal failure.

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Decreased Creatinine

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old people, young children, paralysis...lacking muscle mass will cause a decrease. Recheck pre/post anesthesia.

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Nursing implications with creatinine

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recheck after dye or surgery as some meds may need to be held.
Compare to BUN, GFR.
CR>8, GFR <15:think about dialysis. Metformin and glucophage are held while a pts is in hospital if Cr is not 1.4 or less.

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glomular filtration rate

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# of ml of filtrate made by the kidneys/min. Dependent on amount of blood filtered and ability of glomeruli to act as a filter. This is estimated using the serum creatinine, age, sex and race.

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increased GFR

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Pregnancy, exercise, increased cardiac output state: anything that increases cardiac output will increase the GFR.

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Decreased GFR

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renal artery stenosis, dehydration, shock, age, decreased blood flow, glomerular damage.

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Nursing implicastions surrounding GFR

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Assess UA for protein, check creatinine, health teaching to reduce risk factors for chronic kidney disease.
Look at BUN, CR , GFR, and UZ: is there a sick kidney? nurse can order a dietician consult or diabetic diet based on nursing judgement.

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Chronic kidney disease stages

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1-5 dependent on GFR.

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CKD stage 1

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Kidney damage w/normal or increased GFR.
>or = to 90

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CKD stage 2

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Kidney damage with miild decrease in GFR. 60-89

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CKD stage 3

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moderate decline in GFR.
30-59

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CKD stage 4

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severe decline in GFR 15-29

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CKD stage 5

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Kidney failure. &lt;15, usually seen on dialysis.

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Bilirubin-Total (Tbil)

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this is unconjugated + congugated.
If you have a liver problem, you will have lots of unconjugated bilirubin that has not been converted. Conjugated bili is excreted via bile/stool. If you have high conjugated bili, then you probably have a blockage after the liver.

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indirect or unconjugated bilirubin

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a breakdown product of RBC's. they are fat soluble, bind to albumin for liver transport... Increases with more rbc turnover (these old/broken rbc usually are in the spleen)

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increased indirect bilirubin

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hemolysis, transfusion reactions, large hematoma resolution, some anemias: hemolytic anemia, micoplama pneumonia, autoimmune hemolytic anemia.... also hepatitis, cirrhosis, sepsis, neonatal hyperbilirubinemia (Liver is unable to convert or conjugate bilirubin: not enough enzymes d/t immature liver with baby. Can cause mental retardation in babies-put by window, light breaks bilirubin down. Bilirubin will try to get out: rootbeer dark urine-foamy, jaundice : 24-36 hours after bilirubin is elevated: seen in musous membranes, eyes, palms of hands, change ofmental status, whitish stool. Steroids can also cause elevated bilirubin, but not common.

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direct or conjugated bilirubin

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Water soluble, excreted in stool. Normal is negligible amount.

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Increased DIRECT or CONJUGATED bilirubin

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cholelithiasis, hepatic duct obstruction.

Front 38

bilirubin Assessments:

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check for jaundice, change in mental status, amber/rootbeer urine, clay-colored stools.

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AST: Aspartate aminotransferase

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an enzyme found in large amounts in heart and liver cells, lesser amounts in kidney & skeletal muscle. Less specific indicator than a liver injury as it is found in other tissues.

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Elevated AST may be d/t

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Elevated AST with liver injusry is likely alcohol related.
statin injury to liver: toxicity from drugs.
MI, post-CABG, Hepatic injury from ETOH or drugs(Tylenol), muscle trauma, bile duct stone.

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Decreased AST

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acute renal disease, renal dialysis, PG, DKA, Vit. B6 deficiency:not clinically significant-don't make decisions based on low AST.

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Nursing implications of AST

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Hepatitis will cause more AST elevations than other liver injuries.

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ALT: Alanine aminotransferase

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enzyme essential for energy production. Large quantities in hepatocytes, smaller amounts kidneys, other major organs and skeletal muclse. Think of this as ACUTE LIVER TROUBLE or Acute liver/Tylenol or Tylenol/aspirin Trouble.

Front 44

Increased ALT

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acute toxic injury, viral hepatitis, fatty liver, liver ischemia/inflammation, bile duct stone, strenuous exercise.

Wait 4-6 wks. after beginning a med. to see if there has been liver damaged.... ALT will be high if damage has occurred.

Front 45

ALP: Alkaline Phosphatase

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enzyme produced by osteoblasts (Bone) the liver and biliary tract epithelium. Liberates phosphate in alkaline conditions. It is also released from the placenta.

Front 46

Increased Alkaline Phosphatase

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2/3 is found in bone, so this would signal high bone turn over rate....
a. cancer of the bone, healing fractures, normal childhood growth.
b. normal pregnancy-placenta in 3rd trimester (increases).
c. bile flow obstruction: if ALP is normally excrreted in BILE and there is an obstruction/gal stone or sludge, teh ALP will go up. A fasting state would lead one to think a biliary problem.
d. trauma to intestines or kidneys.

Front 47

decreased ALK P...ALP

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malnutrition, hyphosphatemia, Vit. B12 deficiency, pernicious anemia, decreases ability to make phosphate.

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If ALP is increased and ALT is normal

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check for cause: bone trauma most likely.

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If the ALP is up and the ALT is UP

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it is a biliary problem

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Serum Proteins

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Major components: Albumin, Globulins,

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Increased Total protein mg/dl

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a. dehydration-this will make serum protein seem increased
b. excessive protein intake (0.8gr/kg of body wt. is the formula for normal need unless big exercises.)
norm: 6.2-8.4

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Decreased total protein

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a. malnutrition (huge bellied children have asceites d/t low albumin...not enough oncotic pressure so fluids 3rd spaced.)
b. Kidney disease; protein goes out through urine...look at u/a, is there protein in the urine? Kidney disease likely.

c. blood loss

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Nursing implications for low Total proteins

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cell building, medication binding, tissue healing, overall healing...

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Albumin

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small plasma proteins. Synthesized almost totally by the liver transport molecule, assists in maintaining serum oncotic pressure. Half-life is (12-20) 21 days, controls oncotic pressure. Transports lots of drugs, thyroid hormone, bilirubin, etc. fatty acids....
norm: 3.5-5

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increased albumin

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dehydration

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decreased albumin d/t

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can lead to edema, asceites or anasarca (total body edema: 2nd spacing)
a. impaired liver function
b. severe malnutrition, pregnancy
c. nephrosis
d. inflammation, sepsis (Albumin is lost out of capillaries.)
e. third spacing, burns-albumin hanging out everywhere.

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Nursing implications for low ALBUMIN

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a. monitor for hypotension.
b. protein intake
d. monitor serum calcium
e. actions to decrease edema.
a better lab is the PREALMUBMIN (3-7 half life) because it gives more recent news for actual albumin present in serum fluids.
Coul have precursor to postural hypotension. Liver and kidney function needs to be okay, and serum calcium may be affected. If serum albumin is low, serum calcium will also be low. check if ionized Ca.

Look at edema as well.

Front 58

How do you know if you will give a diuretic or albumin to correct edema?

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Look at electrolyte levels, look at cause, albumin is given to rescue BP , and get plasma back into blood vessels... long term diuretics given at home, short term albumin given at hospital.

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Globulins

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1. alpha and beta globulins:thrombins.
2. gamma globulins: immunoglobulin(IgG, M, A, D,E)-produced by plasma cells which are mature b-lymphocytes: hummoral immunity.

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Increased gamma globulins means

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acute/chronic infections, malignancies, chronic inflammation, cirrhosis, multiple myeloma.

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Decreased gamma globulins

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some genetic immune dsorders, immunosuppressants, steroids (at risk for infection)
norms 2.2-3.6

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CO2 content

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indirect measurement of bicarbonate (Metabolic base). It only tells you what is available. KNOW THAT IT IS AN INDICATOR OF METABOLIC BASE.. if up, may be alkalosis, if it is down it may mean acidosis, but needs other parameters. Not useful by itself.

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Anion Gap.

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measures difference between anions and cations. clinical indicator of metabolic ACIDOSIS.
Normal is 8-16mEq/L.
Na- (Cl + hco3)

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Increased Anion gap

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indicates metabolic acidosis (Lactic or ketoacidosis) or severe dehydration.

If anion gap is closing, it is getting closer: we need more bicarb, so acidosis is being corrected. We don't give IV bicarb to correct the ketoacidosis. f Lactiacidosis, treat BP, ketoacidosis. The gap will get bigger as bicarb is decreased.

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decreased anion gap:

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metabolic alkalosis is caused by excessive vomiting, NG suction or hyponatremia. A lot of bicarb present, so an acid loss.

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Sodium (Na+)

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normal level: 135-145 mEq/L. predominant extracellular ion, accounts for 92% of serum osmolality.
It is a stimulant at normal levels.

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Increased Na+ Levels:

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Water loss (most common) or salt gain.
1. water loss: diarrhea, excessive sweating, decreased H2O intake.
2. Sodium gain: excessive tube feedings, hyperaldosteronism.

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Decreased Na+ levels

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Water gain (Most common) or salt loss.
1. water gain: heart failure, SIADH
2. Sodium loss: GI losses, renal losses, burns hypoaldosteronism.

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Potassium K+

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A stimulant at normal levels.

Normal: 3.5-5.2 mEq/L
Predominant intracellular ion.

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Increased K+

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renal failure, acidosis, tissue trauma, hemolysis, spironolactone.

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decreased K+

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loop diurectics, GI losses, decreased oral intake, alkalosis.

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Chloride Cl-

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Stimulant in normal levels.
normal 95-107 mEq/L
Most abundant extracellular ANION. used to maintain acid base balance.
levels increase/decrease proportionally to sodium levels, and inversely proportionally to bicarbonate levels.

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increased Cl-

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renal failure, dehydration, metabolic acidosis, respiratory acidosis.

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decreased Cl-

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heart failure, GI losses, metabolic acidosis, chronic respiratory acidosis.

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Lactic Acid

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formed during anaerobic metabolism. used to assess tissue oxygenation and metabolic acidosis. 0.3-2.6.
predictor of severe septic shock.

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Increased Lactate/lactic acid

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sign of ischemia, sepsis, shock, hepatic/heart/respiratory failure, strenuous exercise.

If formation is more than liver can convert into glucose, blood levels rise.
>4 means put them in ICE-septic shock possible.

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Urinalysis U/A

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microscopic analysis following centrifuge to develop sediment. looks at color, clarity, specific gravity and pH. Culture indicated if any of these three things present in urine: WBC >5, positive leukocyte esterase, nitrates.

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Suspect UTI if these three things are present

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WBC (>5)
Leukocyte esterase
nitrites

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Suspect UTI if these three things are present

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WBC (>5)
Leukocyte esterase
nitrites

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RBC in Urine

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(0-4) if elevated, ? contamination, destruction of blood-urine barrier

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protein

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should be negative. If positive, indicates kidney disease, CHF or nephrotoxicity.

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Glucose

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Should be negative. renal threshold is 180 mg/dl, if CBG reads >180, there will be glucose in urine.

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Ketones

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Should be negative. if positive, diabetic ketoacidosis, starvation, high protein diet, alcoholism, febrile illness in infants and children.

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Bacteria

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should be negative. If positive, ? UTI or contamination.

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Bilirubin

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should be negative. If elevated, suspect obstructed bile duct or liver metastasis.

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Urobilinogen

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if elevated, suspect hemolysis, or large hemotoma

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Crystals in Urine

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Should be negative: if positive, suspect kidney stones, proteus UTI or gout if they are uric acid crystals.

Front 88

Casts in Urine

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should be negative.
formed in distal tubule and ocllecting duct when urine is acidic and concentrated. Indicate kidney disease.

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Hyaline casts

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protein based, seen with proteinuria and strenuous exercise.

Front 90

cellular casts

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maybe granular, fatty, waxy, epithelial, wbc, rbc, and usually indicates renal disease.

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MIC on a sensitivity report means:

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Mean inhibitory concentration.
R= resistant
S=sensitive
you want to choose drugs with an S with small concentration.

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CFU

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colony froming units. should be <100, 000 or there is an active infection forming. check source...catheter?

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WBC differential review includes

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neutrophils, lmphocytes, monocytes, eosinophils, and basophils.

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neutrophils

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increased: acute bacterial infection, trauma.

decreased:Overwhelming bacterial infection, immunosuppresion, autoimmune disorders, drug therapy, radiation.

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Lymphocytes

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Increased: chronic bacterial infection, acute VIRAL infection, lupus, RA.

Decreased: immunodeficiency diseases, drug therapy, radiation tx.

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monocyte

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increased: chronic inflammatory disorders, fungal infections, parasites
decreased: bone marrow failure.

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eosinophil

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increased: parasites, allergies
autoimmune diseases (IBS)
Decreased: not clinically significant

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basophil

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increased: acute allergic reaction, stress
decreased: not clinically significant

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RBC differential

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done to look for different types of anemia and heme concentration.

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Hemoglobin

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measures O2 carrying capacity of RBC.
Increased: polycythemia, Fluid vol. deficit.
Decreased: anemia, hemorrhage, GI losses, fluid volume excess
NORM: 11-17

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Hematocrit

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measures RBC as % of total blood volume. Usually 3x the Hgb.
Increased: Polcythemia, fluid volume deficit.
Decreased: anemia, hemorrhage, GI losses, fluid volume exess
NORM: 35-50

Front 102

Total RBC count

Back 102

# of circulating RBC
Increased: COPD, dehydration, stress, polycythemia vera;
Decreased: Chemotherapy, chronic inflammation, blood cancers, overhydration, hemolyitic anemia, renal disease, PG.

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MCV: Mean Corpuscular Volume

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relative size of RBC
Increased: Microcytosis
Decreased: Macrocytosis

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MCH: Mean Corpuscular Hemoglobin

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average wt. of Hgb/RBC.
Increased: microcytosis or Hypochromia
Decreased: macrocytosis

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MCHC:Mean corpuscular hemoglobin concentratoin

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evaluated RBC saturatoin with Hgb.
Increased: hypochromia
decreased: shpereocytosis

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RDW- red blood cell distribution width

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examines the size/shape of RBC
Increased: low variation of RBC size/shape
Decreased: iron deficient anemia

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Platelet count

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# of platelets available to maintain clotting function.
Increased: acute infection, chronic heart and liver disease, malignant lymphomas, heparin use.
Decreased: ETOH toxicity, metastatic cancer, severe hemorrhage, ITP, splenomegally.

Platelet counts determine if meds need to be held or not. ...coumadin...aspirin...
Normal range: 150,000-450,000

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Lab drawing times
Routine

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every 2 hours on odd hours

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Stat

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w/in 30 mins.

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timed

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+ or - 15 mins for time needed.

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asap

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w/in one hour

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critical

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w/in 15 mins.

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A.M.

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morning draw starting at 4am. labs will be available for morning physician rounds.