Lab Values Podcast (Nursing Podcast, normal lab values for nurses for NCLEX®) by NRSNG

Normal

Normal 135-145 mEq/L Indications Monitor: Extracellular osmolality Electrolyte imbalance Description Sodium (Na+) is the most abundant cation in extracellular fluid. Sodium aids in osmotic pressure, renal retention and excretion of water, acid-base balance, regulation of other cations and anions in the body. Sodium plays a role in blood pressure regulation and stimulation of neuromuscular reactions. Sodium and water have a direct relationship; water follows salt. What would cause increased levels? Cushing Syndrome Hyperaldosteronism Dehydration Burn injury Azotemia (elevated nitrogen) Lactic acidosis (LA) Fever/excessive sweating Excessive IV fluids containing sodium Diabetes Insipidus Osmotic diuresis What would cause decreased levels? Congestive Heart Failure (CHF) Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Cystic Fibrosis Diuretic use Metabolic acidosis Addison's Disease Nephrotic Syndrome Vomiting Diarrhea Ascites Excessive Antidiuretic Hormone(ADH) Liver failure

Normal 3.5 - 5.0 mEq/L Indications Evaluate: Electrolyte imbalances Cardiac arrhythmias Monitor patients who are: Acidotic Receiving diuretic therapy Description Potassium (K+) is the most abundant intracellular cation and plays a vital role in the transmission of electrical impulses in cardiac and skeletal muscle. It plays a role in acid base equilibrium. In states of acidosis hydrogen will enter the cell which will force potassium out of the cell. A 0.1 decrease in pH will cause a 0.5 increase in K+. What would cause increased levels? Renal failure Hypoaldosteronism Addison's disease Injury to tissues Diabetes Mellitus (DM) Ketoacidosis Hyperventilation Acidosis Infection Dehydration Burns What would cause decreased levels? Hyperaldosteronism Excess insulin Alkalosis Diarrhea Vomiting Cystic Fibrosis Cushing Syndrome

Normal 25 - 35 seconds Indications Detection of coagulation disorders Evaluate response to Heparin (PT for Coumadin) Preoperative assessment Description Partial Thromboplastin Time (PTT)evaluates the function of factors I, II, V, VIII, IX, X, XI, and XII. PTT represents the amount of time required for a fibrin clot to form. Monitors therapeutic ranges for people taking Heparin. What would cause increased levels? Disseminated Intravascular Coagulation (DIC) Clotting Factor Deficiencies: Hypofibrinogenemia Von Willebrand Disease Hemophilia Liver disease: Cirrhosis Vitamin K deficiency Polycythemia Dialysis What would cause decreased levels? N/A

Normal 95 - 100% Indications Determine respiratory status Part of Arterial Blood Gas (ABG) testing Description Oxygen saturation (SaO2) is a measurement of the percentage of how much hemoglobin is saturated with oxygen. Oxygen is transported in the blood in two ways: oxygen dissolved in blood plasma (pO2) and oxygen bound to hemoglobin (SaO2). About 97% of oxygen is bound to hemoglobin while 3% is dissolved in plasma. SaO2 and pO2 have direct relationships, if one is decreased so is the other. The relationship between oxygen saturation (SaO2) and partial pressure O2 (PaO2) is referred to as the oxyhemoglobin (HbO2) dissociation curve. SaO2 of about 90% is associated with PaO2 of about 60 mmHg. What would cause increased levels? Polycythemia Increased inspired O2 Hyperventilation What would cause decreased levels? Anemia's Hypoventilation Bronchospasm Mucus plugs Atelectasis Pneumothorax Pulmonary edema Adult respiratory distress syndrome

Normal 261 – 280 mOsm/kg Indications Monitor: Electrolyte balance Acid-Base balance Hydration Evaluate function of antidiuretic hormone.   Description Osmolality is a measure of the particles in solution. The size, shape, and charge of the particles do not impact the osmolality   What would cause increased levels? Dehydration Azotemia Hypercalcemia Hyperglycemic Hyperosmolar Nonketotic State (HHNS) Hypernatremia Diabetes Insipidus Hyperglycemia Mannitol therapy Uremia Severe pyelonephritis Shock Ketosis   What would cause decreased levels? Hyponatremia Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Overhydration

Normal 1.6 – 2.6 mg/dL Indications Monitor: Renal failure Chronic alcoholism Cardiac arrhythmias Description Magnesium (Mg) is a cation necessary for protein synthesis, nucleic acid synthesis, muscle contraction, ATP (adenosine triphosphate) use, nerve impulse conduction, and blood clotting. Magnesium affects the absorption of sodium, calcium, phosphorus, potassium.   What would cause increased levels? Renal insufficiency Uncontrolled Diabetes Mellitus (DM) Addison Disease Dehydration Hypothyroidism Overuse of antacids Tissue trauma   What would cause decreased levels? Alcoholism Diabetic acidosis Renal failure: Glomerulonephritis Hypercalcemia Malnutrition Malabsorption Hypoparathyroidism Diarrhea

Normal

Normal 0.3 -2.6 mmol/L Indications Determine cause of acidosis Evaluate tissue oxygenation Description Lactate (Lactic Acid) is a byproduct of anaerobic metabolism. Normally, the tissues use aerobic metabolism to breakdown glucose for energy and the byproduct is CO2 and H2O which we excrete through our kidneys and exhalation. However, if the tissues are starved of oxygen (hypoxic), they use anaerobic metabolism. This can be compounded if the liver is also hypoxic causing the liver to be unable to clear the lactic acid. What would cause increased levels? Shock Sepsis Tissue ischemia Carbon monoxide poisoning Lactic acidosis Diabetes Mellitus (DM) Heart failure Pulmonary edema Strenuous exercise What would cause decreased levels? N/A

Normal 0.8 - 1.2 Therapeutic Levels of Warfarin 2.0 – 3.5 Indications Evaluate therapeutic doses of Warfarin Identify patients at higher risk for bleeding Identify cause of: Bleeding Deficiencies Description International normalized ratio(INR) takes results from a prothrombin time test and standardizes it regardless of collection method. What would cause increased levels? Disseminated Intravascular Coagulation (DIC) Liver disease Vitamin K deficiency Warfarin What would cause decreased levels? Too much vitamin K Estrogen containing medications such as birth control

Normal >60 optimal mg/dL Indications Monitor risks of heart disease Description Cholesterol is transported via lipoproteins. There are multiple types of lipoproteins and they each have slightly different functions: high-density lipoprotein (HDL), low-density lipoprotein (LDL) very low-density lipoprotein (VLDL). HDL cholesterol is considered the good cholesterol because it travels through the blood picking up extra cholesterol and taking it back to the liver. What would cause increased levels? Familial HDL Lipoproteinemia Exercise Unsaturated fats: Mono- Poly- Hypothyroid What would cause decreased levels? Metabolic Syndrome Hepatocellular disease: Hepatitis Cirrhosis Hypoproteinemia: Nephrotic Syndrome Malnutrition Smoking High saturated and trans fat diets Excess body weight Hyperthyroid

Normal 5.6-7.5 % of total Hgb Indications Assess control of blood sugars over a several month time frame Diagnose Diabetes Mellitus (DM) Description Glycosylated Hemoglobin (HbA1c) is the combination of glucose and hemoglobin. When glucose is elevated in the blood the amount of glycosylated hemoglobin increases proportionally. A red blood cells lifespan is about 4 months, so you can get an idea of blood sugar control over the last several months. What would cause increased levels? Poorly controlled Diabetes Mellitus(DM) Non-Diabetic Hyperglycemia: Stress Cushing Syndrome Pheochromocytoma Corticosteroid Therapy What would cause decreased levels? Renal failure Blood loss Hemolytic anemia Sickle cell anemia

Normal 2 - 20 ng/mL Indications Diagnose megaloblastic anemia Monitor effects of long-term Total Parenteral Nutrition (TPN) Identify Folate Deficiency Description Folic acid is an essential water soluble B vitamin. It is stored in the liver and is an important part of Red Blood Cell (RBC) and White Blood Cell (WBC) function, DNA replication, and cell division. What would cause increased levels? Excess folate intake What would cause decreased levels? Vitamin B12 deficiency Pernicious anemia Hemolytic anemia Celiac Disease or Crohn Disease Inflammatory Bowel Disease (IBS) Alcoholism Malnutrition

Normal 20-300 ng/mL Indications Diagnosing: Iron-deficiency anemiaH emochromatosis Monitor: Iron levels Description Ferritin is a protein that stores iron. It is formed in the liver spleen and bone marrow. Ferritin in the blood is usually proportional to stored ferritin. Ferritin is a more sensitive and specific test for identifying iron-deficiency anemia, however, it is usually measured in conjunction with total iron binding capacity and iron. What would cause increased levels? Inflammation Alcoholic liver disease Multiple blood transfusions Hemochromatosis What would cause decreased levels? Long term Gastrointestinal(GI) bleeding Iron-deficiency anemia Heavy menstrual bleeding

Normal 96-108 mEq/L Indications Identify Acid-Base Imbalance Description Chloride (Cl-), an anion found in the blood, works together with sodium to help maintain oncotic pressure and water balance in the body. Chloride is inversely related to bicarbonate levels in the blood. Chloride is also part of hydrochloric acid (HCL) which is utilized in the stomach to breakdown food. When red blood cells (RBCs) take up CO2 they take up chloride as well. The negative ion bicarbonate then leaves the red blood cell so that the electrical charge is maintained. Extra chloride is excreted into the urine by the kidneys. What would cause increased levels? Dehydration Acute Renal Failure Cushing Disease Metabolic Acidosis Respiratory Alkalosis. What would cause decreased levels? Congestive Heart Failure (CHF) Water intoxication Burns Metabolic Alkalosis Respiratory Acidosis Addison Disease Salt-losing Nephritis Excessive sweating Diarrhea Vomiting

Normal 8.4-10.2 mg/dL Indications Identify problems with: Parathyroid Neuromuscular functions Diseases that affect bone Effectiveness of treatments. Description Calcium (Ca+), a positive ion in the body, is necessary for neuromuscular processes, bone mineralization, and hormonal secretion. The parathyroid gland and vitamin D are responsible for calcium regulation in the body. In the blood, about half of calcium travels in ion form, the other half is bound to proteins like albumin. When albumin levels are low, calcium levels will appear lower. Calcium has an important relationship with phosphorus: they are inversely proportional. What would cause increased levels? Cancers: Breast, lung, and multiple myeloma are the most common Hyperparathyroidism Acidosis Renal transplant Sarcoidosis Vitamin D toxicity Dehydration What would cause decreased levels? Malnutrition Cirrhosis Chronic Renal Failure Hypoparathyroidism Alkalosis Hypomagnesemia Hypoalbuminemia Hyperphosphatemia Malabsorption Alcoholism Osteomalacia Vitamin D deficiency

Normal 12-37 U/L Indications Monitor progression of: Liver disease Response to treatments. Monitor liver toxic medications Description Aspartate Aminotransferase (AST) is an enzyme primarily found in liver and heart cells, and to a smaller extent, AST can also be found in the pancreas, kidneys, skeletal muscle, and brain. Levels of AST increase from cell death (necrosis) because the AST enzyme is released into the blood. What would cause increased levels? Liver disease Liver cancer Shock Congestive Heart Failure (CHF) Pericarditis Biliary tract obstruction Dermatomyositis Pancreatitis Muscular Dystrophy CVA Hemolytic anemia Delirium Tremens (DT) What would cause decreased levels? N/A

Normal 0-130 U/L Indications Diagnosing: Pancreatitis Pancreatic Duct Obstruction Macroamylasemia Trauma to Pancreas Description Amylase is made in the pancreas. It is an enzyme that breaks down carbohydrates to allow our body to absorb it. Monitoring amylase levels can help identify problems with the pancreas. What would cause increased levels? Pancreatitis Pancreatic Cancer Pancreatic Cyst DKA Peritonitis Abdominal Trauma Duodenal Obstruction Mumps Alcohol use What would cause decreased levels? Pancreatic Insufficiency Pancreatectomy Toxemia of Pregnancy Cystic Fibrosis Liver Disease

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Normal 30-40 seconds Indications Identifying congenital deficiencies in clotting Monitoring heparin therapeutic levels (PT for warfarin) Monitoring effects of: Liver Disease Protein Deficiency Fat malabsorption on clotting Description Activated Partial Thromboplastin Time (aPTT) is a test that measures the amount of time it takes for a fibrin clot to form after reagents have been added to the specimen. It is useful in diagnosing clotting disorders. In conjunction with PT it can be used to differentiate the specific factor that may be missing. What would cause increased (Prolonged) levels? Vitamin K Deficiency Disseminated Intravascular Coagulation (DIC) Hemodialysis Patients Afibrinogenemia Polycythemia Liver disease Von Willebrand Disease. What would cause decreased levels? N/A

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Overview Urinalysis Color & Clarity Protein RBC WBC Glucose Specific gravity Ketones pH Bilirubin/Urobilinogen Nursing Points General Normal value range Color & Clarity Normal – Yellow Other colors Drug interactions Propofol  – green Methylene blue – blue/green Trauma Red/Brown Liver failure Brown/tea colored Clear – Normal Cloudy Cell or contaminant related Turbid Severe presence of cells (WBC, RBC) pH ~6 Changes in body condition can change pH Metabolic acidosis/alkalosis Protein 0-trace Glomerular permeability/infection RBC 0-2 Bleeding Trauma/injury  below kidneys WBC Negative Sepsis/Infection/UTI Glucose Negative Diabetes Ketones Negative Presence of ketones can indicate endocrine disease like Diabetes Urine Specific Gravity 1.010-1.030 Facilities vary Ability to concentrate urine Hydration Overhydration Decreased USG Dehydration Increased USG Diabetes insipidus Causes increased diuresis SIADH (Syndrome of Inappropriate Antidiuretic Hormone) Causes decreased diuresis Bilirubin/Urobilinogen Negative Presence indicates potential liver problems Nursing Concepts Lab Values Elimination

Overview White Blood Cells Normal Value Range Pathophysiology Special considerations Abnormal values (high) Abnormal values (low) Nursing Points General Normal value range WBC 4500-10000/mcL Differential Neutrophils 40-60% Bands 3-5% >8% indicates signal to WBC for more production Infection or inflammation is severe Eosinophils 1-4% Basophils 0.5-1% Lymphocytes 20-40% Monocytes 2-8% Pathophysiology WBC Formed in the bone marrow Responsible for responding to foreign invaders Creating antibodies (immunity) Phagocytosis (eating bacteria or fungi) Multiple types with different purposes Neutrophils – inflammation and first response to invader Eosinophils – Inflammation Allergic response Parasites Basophils Inflammation Allergic response Lymphocytes Create antibodies Recognize antigens Destroy cells T Cells B Cells Natural Killer cells Monocytes Macrophages Engulf and destroy invaders Indicative of infection Special considerations Lavender top tube Will commonly be submitted for Complete Blood Count with differential Abnormal lab values Increased White Blood Cell count (leukocytosis) Infection Inflammation Trauma/Stress Pregnancy Asthma Allergic Reaction Decreased lab values (leukopenia) Systemic Lupus Erythematosus (SLE)/Rheumatoid arthritis Cancers Chemotherapy/Radiation Medications Neutropenic precautions Masks Gloves Wash hands Consider yourself infectious Prevent spread of infection to the patient Assessment Consider the overall WBC count plus abnormalities in differential Evaluate patient Signs or symptoms of: Trauma Inflammation Infection Therapeutic Management Antibiotic therapies where indicated by infection (followed by cultures to determine efficacy of antibiotics) Anti-inflammatories for inflammation Provide neutropenic precautions when necessary Nursing Concepts Lab Values Infection Control Patient Education Educate patient on the finishing any antibiotics completely. Do not stop prior, even if the patient says they are feeling better.

Overview Troponin I Normal value range Pathophysiology Special considerations Elevations in lab values Nursing Points General Normal value range Typically, less than 0.035 ng/mL or less Can vary among institutions Has to be greater than the 99th percentile Pathophysiology Troponin is released during myocardial cell damage Decreased perfusion causes myocardial cell damage Causes of myocardial cell damage Myocardial infarction Demand ischemia Cardiogenic ACS Noncardiogenic Sepsis Renal failure Extreme exercise Special considerations Submitted in green top tube Value peak Detection 6-12 hours after acute injury Peaks 24 hours after injury Can stay elevated for a week Knowing patient history is critical Increased values Any elevated value is typically considered critical Acute elevations warrant immediate investigation Typically PCI (percutaneous coronary intervention)/Angiography and EKG to rule out MI or ACS (acute coronary syndrome) Other elevations CABG Extreme exercise End Stage Renal Failure Assessment Assess for: Acute chest pain Symptoms of MI Nausea Vomiting Angina in any form Reflux (especially in women) Therapeutic Management EKG Angiography or PCI Management of non-cardiogenic etiology Nursing Concepts Lab Values Perfusion Patient Education Educate patient on keeping history of elevated levels or cardiac disease for future reference Educate patient on duration of elevated troponin levels, post injury

Objective: Determine the significance and clinical use of  Thyroid Stimulating Hormone in clinical practice   Lab Test Name: Thyroid Stimulating Hormone   Description: Thyroid Stimulating Hormone (TSH) is released from the anterior pituitary in response to low levels of thyroid hormone.  TSH stimulates the thyroid gland to release thyroid hormones Triiodothyronine (T3)  Thyroxine (T4) T3 and T4 have an inverse relationship with TSH   Indications: Aids to diagnose: Hyperthyroidism Hypothyroidism Anterior pituitary function Monitor:  Thyroid replacement therapy   Normal Therapeutic Values: Normal –  2-10 mU/L Collection:  Plasma separator tube   What would cause increased levels? TSH levels increase in the following conditions: Hypothyroidism Thyroidectomy Thyroid dysfunction Thyroiditis Thyroid Agenesis Large doses of iodine Pituitary TSH-secreting tumor   What would cause decreased levels? Recall the inverse relationship between TSH and T3/T4 labs, and how the negative feedback loop works with these hormones. TSH levels decrease in the following conditions: Anterior pituitary hypofunction- If the pituitary isn't secreting TSH, the level will be low. Hyperthyroidism- If there is a large amount of thyroid hormone circulating, the feedback system relays the info upstream and less TSH is released. 

Overview Red blood cells Normal Value Range Patho Special considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments Nursing Points General Normal range Measured in millions Normal values Males 4.5-5.5 x106/mcL Females 4-4.9×106/mcL Pathophysiology Red Blood Cell generation Formed in bone marrow Stimulated by kidneys by erythropoietin Function AKA Erythrocytes Reticulocytes Young RBC Indicate regeneration Carries oxygen Via Hemoglobin Allows for transfer of CO2 Bioconcave shape Increases surface area Allows for ability to “squeeze” into capillaries 2.4 M made every 1 second Special considerations Submitted via LAVENDER top tube (EDTA) Technique can destroy red blood cells Allow vacuum in vacutainers to draw blood, never force blood into tubes Consider angiocath/IV size when drawing blood Elevated RBC results Dehydration Result of decreased plasma Polycythemia Bone marrow cancer, causes increase in RBC COPD Pulmonary fibrosis Decreased RBC results Anemia Sickle-cell ↓ EPO due to kidney disease Hemorrhage Bone marrow failure Pregnancy Assessment Assess for signs of anemia Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor Therapeutic Management Blood transfusions as necessary Treat primary cause of anemia Nursing Concepts Lab Values Oxygenation

Objective: Determine the significance and clinical use of Prostate Specific Antigen in clinical practice   Lab Test Name: Prostate Specific Antigen – PSA   Description: Measurement of PSA in the bloodstream Used to diagnose and assess prostate health, size and function.   Indications: Evaluate: Enlarged prostate when prostate cancer is suspected Stage cancer Effectiveness of treatments   Normal Therapeutic Values: Normal –  Male: < 4 ng/mL  Female: < 0.5 ng/mL Collection:  Serum Separator Tube   What would cause increased levels? Increased: Benign Prostatic Hypertrophy (BPH) Prostate cancer Prostatitis Urinary retention   What would cause decreased levels? Decreased: Long-term use of NSAIDs- explained in part by the anti-inflammatory effect of these medications Thiazides- reduces bioavailable testosterone, associated with resulting in functional hypogonadism Statins- cholesterol plays a role in synthesis of androgen, which affects the size of the prostate 5-alpha-reductase inhibitors- due to the effect on prostate size.

Overview Platelets Normal Value Range Pathophysiology Special considerations Elevated platelet levels Decreased platelet levels Nursing Points General Normal value ranges 100,000 – 450,000/mcL Also known as – Thrombocytes Pathophysiology Formed from Megakaryocyte Formed from bone marrow Produces 1000-3000 platelets Injury occurs at site Collagen releases activators Thrombocytes activate “sticky fingers”, which allow them to bind together. Travel to site (along with other clotting factors) Adhere to site, increase stimulation for other PLT, until clot is formed with fibrin Special considerations Use a lavender top tube (EDTA) Often sent in CBC Abnormal lab values Elevated platelets (thrombocytosis) Cancers Absence of a spleen Breaks down platelets Birth control Polycythemia vera Overproduction of cells Treatment via bloodletting, medications or hydration Decreased platelets (thrombocytopenia) ITP (Idiopathic thrombocytopenic purpura) Autoimmune disease Medications Hemorrhage Treated with transfusion Leukemia Treated with chemotherapy/radiation Medications Some diuretics Nonsteroidal anti-inflammatory drugs (NSAIDs) Ranitidine Some antibiotics Assessment Assess for signs of petechia (small purplish blemishes, indicating bleeding) Therapeutic Management Control and stop hemorrhage Replace platelets via transfusion Consider stopping or changing medications that cause thrombocytopenia Nursing Concepts Lab Values Clotting Patient Education For patients who have bleeding disorders, instruct patients to be cautious of injury. If patient has thrombocytopenia, instruct patient to seek emergency treatment in the event of bleeding that does not stop. **DISCLAIMER – The video states that the normal value of platelets is 100,000 – 400,000 cells/mcL. The correct information is 100,000 – 450,000 cells/mcL.

Objective: Determine the significance and clinical use of  Lipase in clinical practice   Lab Test Name: Lipase   Description: Lipase Measurement of lipase in the blood Used to diagnose pancreatitis and pancreatic cancer An enzyme produced by the pancreas Aids in breakdown of fats Released into the bloodstream as a result of damage to the pancreas   Indications: Diagnose: Pancreatitis Severe upper abdominal pain Abdominal pain – radiates Fever N/V Tachycardia Pancreatic cancer Discoloration of urine and stool Weight loss Diabetes   Normal Therapeutic Values: Normal:  23-300 U/L Collection: Plasma separator tube Serum separator tube   What would cause increased levels? Pancreatitis Pancreatic cyst Pseudocyst Pancreatic duct obstruction Renal failure Cholecystitis Peptic ulcer disease   What would cause decreased levels? N/A

Objective: Determine the significance and clinical use of iron levels in clinical practice   Lab Test Name: Iron – Fe   Description: Measures the amount of Fe in the bloodstream.  Evaluates:  Sufficient Fe level  oxygen transport  proper hemoglobin & RBC production Iron (Fe) is an element that is an important component of hemoglobin in red blood cells. Iron aids hemoglobin's transport of oxygen from the lungs to all the cells of the body.  The storage form of iron is ferritin. Iron is transported in the blood by a protein called transferrin.   Indications: Identify: Blood loss Hemochromatosis Malabsorption of iron Iron overload Type of anemia: Thalassemia Sideroblastic anemia Iron deficient anemia   Normal Therapeutic Values: Normal –  50-175 μg/dL Collection: plasma separator tube   What would cause increased levels: What would cause Increased Levels of Iron? Hemochromatosis Lead toxicity Iron poisoning Acute liver disease Multiple blood transfusions Hemolytic anemia Sideroblastic anemia   What would cause decreased levels: What would cause Decreased Levels of Iron? Blood Loss: Gastrointestinal (GI) bleeding Heavy menstruation Chronic hematuria Hypothyroidism Iron-deficiency anemia Inadequate absorption of iron

Overview Hemoglobin Normal Value Range Pathophysiology Special considerations Elevated hemoglobin Decreased hemoglobin Nursing Points General Normal value range Males – 13.5-16.5 g/dL Females – 12.0 – 15.0 g/dL Pathophysiology Protein attached to red blood cell Iron based protein 4 groups 2 alpha 2 beta Has a high affinity (attraction) for oxygen Oxyhemoglobin Has oxygen attached Deoxyhemoglobin Oxygen has been released Oxyhemoglobin Dissociation Curve Oxygen saturation Shift to the right Partial pressure is higher HGB attraction to oxygen is lower Oxygen becomes less “sticky” and wants to be released Causes ↓pH ↑pCO2 ↑Temperature Shift to the left Partial pressure is lower HGB attraction is higher Oxygen wants to stay “stuck” to HGB Causes ↑pH ↓pCO2 ↓Temperature Special considerations Submit in lavender top tube Be cautious with phlebotomy technique Reduce hemolysis with proper tubing and syringes Elevated HGB values Polycythemia vera Treatments Blood letting Increased water intake Some medications Dehydration Lung disease Pulmonary fibrosis COPD Certain medical therapies EPO supplementation Decreased HGB values Thalassemia Blood loss Sickle Cell anemia Aplastic anemia Cancers Assessment Assess for signs of anemia Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor Therapeutic Management Blood transfusions as necessary Treat primary cause of anemia Nursing Concepts Lab Values Oxygenation

Overview Hematocrit Normal Value Range Pathophysiology Special considerations Elevations in lab results Decreased HCT levels Nursing Points General Normal value range HCT measured in percentage Males – 41-50% Females – 36-44% Pathophysiology Measurement of total pRBCs compared to rest of blood volume Helps to indicate anemia Often measured with HGB (hemoglobin) Special considerations Lavender top tube (EDTA) Be cautious with technique Do not force sample into tube Can cause hemolysis Alters results Causes of HCT elevation Dehydration Change in % compared to total blood volume Respiratory disease COPD Pulmonary fibrosis Increased need for oxygen -> increased need for RBC production Polycythemia vera RBC overproduction due to bone marrow cancer Treatment includes bloodletting and increasing water consumption (also some medications) Causes of decreased HCT Blood loss Trauma Hemorrhage Treatment Stop bleeding Transfuse blood Anemia Kidney disease Decrease in EPO production Treatment Supplement with EPO Pregnancy Relative to increase total blood volume Leukemia Decreased bone marrow production causes ↓ RBC Treat leukemia via oncology pathways Chemotherapy Radiation Bone marrow transplant Assessment Assess for signs of anemia Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor Therapeutic Management Blood transfusions as necessary Treat primary cause of anemia Use oncologic methods to treat leukemia Bloodletting (phlebotomy) for polycythemia patients Nursing Concepts Lab Values Oxygenation

Objective: Determine the significance and clinical use of Erythrocyte Sedimentation Rate in clinical practice   Lab Test Name: Erythrocyte Sedimentation Rate- ESR   Description: The Erythrocyte Sedimentation Rate (ESR) test measures sedimentation of Red Blood Cells (RBCs).  In normal conditions, RBCs settle or sediment very little.  Inflammation affects proteins in the blood causing RBCs to stick and settle together out of the liquid portion of the blood.   Indications: Identifies inflammation which assists in diagnosing: Cancer Infection Autoimmune diseases   Normal Therapeutic Values: Normal – 0-20 mm/hr   What would cause increased levels? Increased Conditions: Anemia Chronic Renal Failure Systemic Lupus Erythematosus (SLE) Infection Tuberculosis Pregnancy Polymyalgia Rheumatica Multiple myeloma Medications: Oral contraceptives Theophylline Vitamin A   What would cause decreased levels? Decreased Conditions: Sickle cell anemia Polycythemia Vera Leukocytosis Congestive Heart Failure (CHF) Medications: Aspirin Cortisone Quinine

Objective: Determine the significance and clinical use of  D-Dimer in clinical practice   Lab Test Name: D-Dimer- DDI   Description: Measurement of D-Dimer evaluates the amount of byproduct produced as part of fibrinolysis D-dimer (DDI) is a product of fibrinolysis D-dimer levels are elevated in the setting of clot breakdown, and will be significantly elevated in the setting of Disseminated Intravascular Coagulation (DIC).   Indications: Identify and monitor  Disseminated Intravascular Coagulation (DIC) Rule out a blood clot: Pulmonary Embolism (PE) Deep Vein Thrombosis (DVT) Stroke   Normal Therapeutic Values: Normal – ≤ 250 ng/mL Collection:  Light blue lab tube   What would cause increased levels? Increased Surgery Trauma Infection Cancer Heart attack Pregnancy Deep Vein Thrombosis (DVT) Disseminated Intravascular Coagulation (DIC)   What would cause decreased levels? Indicates a lack of the substance that is released during the breakdown of a blood clot (i.e. lack of blood clots, or lack of fibrinolysis)

Objective: Determine the significance and clinical use of C-Reactive Protein in clinical practice   Lab Test Name: C-Reactive Protein – CRP   Description: C-reactive protein (CRP) is made in the liver in response to inflammation Measures CRP in the blood Increases quickly Decreases quickly   Indications: Monitor or Identify: Inflammation in the body Appendicitis Pelvic Inflammatory Disease (PID) Crohn's Ulcerative Colitis Rheumatoid Arthritis (RA) Lupus (SLE – Systemic Lupus Erythematosus) Evaluate: Coronary Artery Disease (CAD) Cholesterol level – atherosclerosis   Normal Therapeutic Values: Normal –

Overview Creatinine Normal Value Range Pathophysiology Special considerations Elevations in creatinine Decreases in creatinine Nursing Points General Normal values 0.7 – 1.4 mg/dL Pathophysiology Muscle breakdown and use Creatine -> creatinine Released into bloodstream Filtered through kidneys Excreted in urine Creatinine more specific to kidney function Special considerations Green top Submitted with renal panels or chems Creatinine clearance Tests creatinine in urine Compare to serum creatinine 24 hour urine Toss first urine sample, then start On ice Increased creatinine values Renal disease Rhabdomyolysis Muscle breakdown Trauma Extreme workouts Congestive heart failure Dehydration Shock Decreased creatinine values Loss of muscle mass Muscular dystrophy Decreased protein intake Pregnancy Liver disease Assessment Assess patient's nutritional status Assess urine output Consider other causes for increase in creatinine Muscle Therapeutic Management Treat cause of renal insufficiency Dialysis vs medication Nursing Concepts Lab Values Elimination

Objective: Determine the significance and clinical use of measuring Creatinine Clearance in clinical practice   Lab Test Name: Creatinine Clearance – CrCl   Description: Healthy kidneys remove creatinine from the blood. It then passes out of your body through urine. Creatinine is created in the body as a byproduct from normal wear and tear on muscles and protein in your diet.   Creatinine Clearance is a test that compares the level of creatinine in the blood against the level in the urine and evaluates Glomerular Filtration Rate. Hydration, blood volume status, blood pressure, and the state of the glomeruli impact GFR.    Remember that GFR is the amount of blood cleaned each minute by tiny filters in your kidneys called glomeruli.   An increase in CrCl indicates an increase in GFR.   Indications: The creatinine clearance test is done when your healthcare provider thinks that the eGFR result given with your blood creatinine level may not be accurate. This would be in patients who have diabetes, those with HF, those with kidney disease, and is sometimes evaluated in those with hypertension. Kidney Function GFR Diabetes Heart Failure Hypertension   Normal Therapeutic Values: Normal – Creatinine clearance rates go down as you age Male: 97 to 137 mL/min  Female: 88 to 128 mL/min  For every decade after age 40, a normal test result is 6.5 mL/min less than the numbers above. Collection: Plasma separator tube for serum Urine is collected for 24 H in a plastic container First void is flushed Date and time recorded, and urine collected and stored at room temperature Processed once collection is complete   What would cause increased levels? Increased Creatinine Clearance→ Increased GFR Pregnancy- higher blood volume Large protein intake Exercise   What would cause decreased levels? The kidneys are solely responsible for removing Creatinine from the blood. If kidney function is declining, the creatinine level increases in the blood, but less creatinine is excreted into the urine. Decreased Creatinine Clearance→ Decreased GFR Abnormal kidney function Poor perfusion Dehydration Bladder obstruction Nephrotoxic medications

Overview Cholesterol Normal Value Range Pathophysiology Any special considerations when drawing the lab (i.e. on ice, etc.) Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments Nursing Points General Normal values 60 mg/dL Low Density Lipoprotein (LDL) Contributes to plaque buildup Goal

Overview BNP Normal Value Range Pathophysiology Special considerations Lab value elevations Nursing Points General Normal value range 100 pg/mL Pathophysiology Increased pressure overload due to increased SVR or volume Ventricular stretching causes release of BNP into bloodstream BNP released to aid in stress due to overload by: Increases excretion of sodium in urine = natriuresis Sodium follows water Decreased intravascular volume Decreased workload on the heart = improved cardiac function Special considerations Lavender tube (EDTA) NT-proBNP may be requested instead Submit in serum separator tube (tiger top) Elevated lab values >100 pg/mL – heart failure likely The higher the value, the more likely the diagnosis of heart failure Assessment Assess patient for acute exacerbation of heart failure Lung sounds Oxygen status Need for supplemental oxygen Radiographic evaluation May need diagnostics for evaluation Echocardiogram can determine contractility function Therapeutic Management Treatment Treat heart failure Diurese Improve contractility Nursing Concepts Lab Values Perfusion

Overview Blood Urea Nitrogen (BUN) Normal Value Range Pathophysiology Special Considerations Elevated Values Decreased Values Nursing Points General Normal value range 7-20 mg/dL Pathophysiology Protein broken into amino acids -> Ammonia Ammonia converted to urea Urea excreted via kidneys Special considerations Green top tube Submitted in multiple panels Chem 7/Chem 10 CMP Renal panel Elevated values Renal failure Congestive heart failure Myocardial infarction Dehydration Urinary obstruction Diabetes Decreased values Liver failure Overhydration Inadequate protein intake Malnutrition Pregnancy Assessment Assess patient's nutritional status Assess urine output Find primary cause for renal impairment (pre-/intra-/post-renal) Therapeutic Management Treat cause of renal insufficiency Dialysis vs medication Nursing Concepts Lab Values Elimination

Overview Total bilirubin Normal Value Range Pathophysiology Special considerations Elevations in Total bilirubin Nursing Points General Normal values 0.1-1.2 mg/dL Patho Breakdown product of RBCs Specifically heme (iron portion of hemoglobin) Transported to liver Bound with bile Excreted via GI tract and kidneys Conjugated Water soluble Unconjugated Not able to excrete it Carried to liver via albumin Conjugated in liver Special Considerations Submit in green top tube Usually submitted with liver function tests Elevated Total Bilirubin Newborn jaundice Treated with phototherapy Liver tumors Liver disease Cirrhosis Hepatitis Alcoholism Cholecystitis Biliary obstruction Assessment Assess patients for jaundice or icterus, or changes in color of stool (clay colored) Therapeutic Management Phototherapy for newborns, as they are unable to properly breakdown bilirubin Treat primary cause of liver/gallbladder disease Nursing Concepts Lab Values Gastrointestinal/Liver Metabolism

Overview Ammonia Normal Value Range Pathophysiology Special considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments Nursing Points General Normal value range 19-60 mcg/dL Pathophysiology Byproduct of protein metabolism Proteins → ammonia Ammonia → urea via the liver Urea excreted to the kidneys If ammonia is not converted to urea Ammonia ↑ in bloodstream Causes hepatic encephalopathy Neurotoxic ↓ Level of consciousness Confusion Altered mental status Refer to Neuro lesson 03.06 Encephalopathies Special considerations Sent in either green or lavender tube Typically sent on ice Discuss with facility lab or unit Elevations in ammonia Liver failure Treatment: Lactulose Ammonia binding agent Given PO or PR Ammonia excreted via stool Hepatic encephalopathy TPN GI hemorrhage Reye's syndrome Decreased ammonia levels Antibiotics Assessment Assess patient's cognition and level of consciousness Assess patient's ability to swallow and protect airway Therapeutic Management Lactulose via rectal tube or PO if patient can tolerate oral medications and follow directions Nursing Concepts Lab Values Gastrointestinal/Liver Metabolism

Objective: Determine the significance and clinical use of  alkaline phosphatase in clinical practice   Lab Test Name: Alkaline Phosphatase – ALP   Description: Measures amount of ALP in circulation Located in several places in the body: Liver Intestines Biliary tract Bones Placenta Different isoenzymes of ALP are used to determine: Liver, bone, intestine and other cancers Bone turnover in postmenopausal women   Indications: Evaluation of ALP: Hepatobiliary disease Malignancies Bone disease Bone damage in renal patients   Normal Therapeutic Values: Normal – 40-130 U/L Collection:  Plasma separator tube   What would cause increased levels? Increased levels assessed in: Liver disease Bone disease Pregnancy Amyloidosis Lung cancer Pancreatic cancer Congestive heart failure Ulcerative colitis Hodgkin's disease Chronic renal failure Sarcoidosis   What would cause decreased levels? Hypophosphatasia (spelling error on existing outline on NURSING.com) Anemia Kwashiorkor Cretinism Hypothyroidism Zinc or magnesium deficiency Scurvy

Overview Albumin Normal Value Range Pathophysiology Special Considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments Nursing Points General Normal value range 3.5 – 6.0 g/dL Pathophysiology Produced in the liver Main protein of plasma Responsible for maintaining oncotic pressure Draws fluid into blood vessel “Protein pulls” Refer to Fluid & Electrolytes lesson  01.02 Fluid Pressures Transport protein Serves as amino acid Nutrition Poor indicator of nutrition Due to long half-life Pre-Albumin Better indicator of nutrition Special considerations Green top typically Usually sent with several other labs Chemistries Liver function tests Nutritional labs Elevated Albumin levels Dehydration Excess infusion of albumin Decreased albumin levels Liver disease Fluid loss Fistula Hemorrhage Kidney Disease Burns Congestive heart failure Long term poor nutrition Inadequate intake Inflammation Assessment Assess patient's pre-albumin for nutritional status or indications of acute illness Nursing Concepts Lab Values Nutrition

Objective: Determine the significance and clinical use of Alanine Aminotransferase in clinical practice   Lab Test Name: Alanine Aminotransferase – ALT   Description: Measures amount of ALT, an enzyme produced by the liver, present in circulation Found in: Most abundantly in liver Heart Skeletal muscle kidney Increases in lab values indicate liver disease or liver damage   Indications: Evaluation of ALT: Progression of liver disease Monitoring response to treatment   Normal Therapeutic Values: Normal – 40-130 U/L Collection:  Plasma separator tube   What would cause increased levels? INCREASED:  Cirrhosis Muscle damage Preeclampsia Biliary tract obstruction Burns Pancreatitis Long-term alcohol abuse Liver Cancer Muscular dystrophy MI Myositis Shock Infection-mononucleosis   What would cause decreased levels? DECREASED: Pyridoxal phosphate deficiency A rare genetic metabolic disorder

Overview Glucose Normal Value Range Pathophysiology Special considerations Hyperglycemia Hypoglycemia Nursing Points General Normal value 70-115 mg/dL Pathophysiology Consumed via diet Carbohydrates Glycolysis Creates net positive energy sources Insulin Produced in pancreas Required to force glucose into cell Deficiency in insulin causes high glucose in blood Increase in insulin resistance causes high glucose in blood Special considerations Lab Green or gray tube Bedside CBG (Capillary blood glucose) Use glucometer Use gauze and alcohol Hyperglycemia (high levels of glucose) Diabetes Absent or inefficient insulin Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Stress Increases cortisol production Pancreatitis Disrupts insulin production Renal failure Cushing's syndrome Steroid use Increases insulin resistance Hypoglycemia (low levels of glucose) Insulinoma Hypothyroidism Hypopituitarism Addison's Disease Insulin overdose Malnutrition Nursing Concepts Lab Values Glucose Metabolism

Get a free nursing lab values cheat sheet at NURSING.com/63labs   What is the Lab Name for White Blood Cell (WBC) Lab Values? White Blood Cell   What is the Lab Abbreviation for White Blood Cell? WBC   What is White Blood Cell in terms of Nursing Labs? White blood cells (WBCs) are created in the bone marrow. Their primary function is to defend the body against infection. There are various types of WBCs which have different shapes and functions. Decreased WBC count is called Leukopenia and increased WBC count is called Leukocytosis.   What is the Normal Range for White Blood Cell? 4,500 – 10,000 cells/mcL   What are the Indications for White Blood Cell? Evaluate for infection   What would cause Increased Levels of White Blood Cell? Infection/inflammation Leukemic Neoplasia Trauma/stress Tissue necrosis Pregnancy Cushing Disease Asthma Allergic reaction   What would cause Decreased Levels of White Blood Cell? Systemic Lupus Erythematosus (SLE) Anemia Rheumatoid Arthritis (RA) Chemotherapy/radiation Overwhelming infections (WBCs are all used up)

Get a free nursing lab values cheat sheet at NURSING.com/63labs   Overview Urinalysis Color & Clarity Protein RBC WBC Glucose Specific gravity Ketones pH Bilirubin/Urobilinogen Nursing Points General Normal value range Color & Clarity Normal – Yellow Other colors Drug interactions Propofol  – green Methylene blue – blue/green Trauma Red/Brown Liver failure Brown/tea colored Clear – Normal Cloudy Cell or contaminant related Turbid Severe presence of cells (WBC, RBC) pH ~6 Changes in body condition can change pH Metabolic acidosis/alkalosis Protein 0-trace Glomerular permeability/infection RBC 0-2 Bleeding Trauma/injury  below kidneys WBC Negative Sepsis/Infection/UTI Glucose Negative Diabetes Ketones Negative Presence of ketones can indicate endocrine disease like Diabetes Urine Specific Gravity 1.010-1.030 Facilities vary Ability to concentrate urine Hydration Overhydration Decreased USG Dehydration Increased USG Diabetes insipidus Causes increased diuresis SIADH (Syndrome of Inappropriate Antidiuretic Hormone) Causes decreased diuresis Bilirubin/Urobilinogen Negative Presence indicates potential liver problems Nursing Concepts Lab Values Elimination

Get a free nursing lab values cheat sheet at NURSING.com/63labs   What is the Lab Name for Troponin I (cTNL) Lab Values? Troponin I   What is the Lab Abbreviation for Troponin I? cTNL   What is Troponin I in terms of Nursing Labs? Troponins are proteins that initiate contraction of muscle fibers. Troponin I (cTNL) is specific to heart muscle. Troponin levels stay elevated for a week after muscle damage before returning to normal.   What is the Normal Range for Troponin I? There is a wide range of normal values among varying institutions and texts with regard to Troponin I. It is essential to verify institutional norms. < 0.035 ng/mL   What are the Indications for Troponin I? Evaluating damage to heart muscle Diagnose a Myocardial Infarction (MI)   What would cause Increased Levels of Troponin I? Heart damage Myocardial Infarction (MI)   What would cause Decreased Levels of Troponin I? N/A

Get a free nursing lab values cheat sheet at NURSING.com/63labs   What is the Lab Name for Triglycerides (TG) Lab Values? Triglycerides   What is the Lab Abbreviation for Triglycerides? TG   What is Triglycerides in terms of Nursing Labs? Triglycerides (TG) are required to provide energy during the metabolic process, excess triglycerides are stored in adipose tissue.   What is the Normal Range for Triglycerides?

Get a free nursing lab values cheat sheet at NURSING.com/63labs   Objective: Determine the significance and clinical use of  Thyroid Stimulating Hormone in clinical practice   Lab Test Name: Thyroid Stimulating Hormone   Description: Thyroid Stimulating Hormone (TSH) is released from the anterior pituitary in response to low levels of thyroid hormone.  TSH stimulates the thyroid gland to release thyroid hormones Triiodothyronine (T3)  Thyroxine (T4) T3 and T4 have an inverse relationship with TSH   Indications: Aids to diagnose: Hyperthyroidism Hypothyroidism Anterior pituitary function Monitor:  Thyroid replacement therapy   Normal Therapeutic Values: Normal –  2-10 mU/L Collection:  Plasma separator tube   What would cause increased levels? TSH levels increase in the following conditions: Hypothyroidism Thyroidectomy Thyroid dysfunction Thyroiditis Thyroid Agenesis Large doses of iodine Pituitary TSH-secreting tumor   What would cause decreased levels? Recall the inverse relationship between TSH and T3/T4 labs, and how the negative feedback loop works with these hormones. TSH levels decrease in the following conditions: Anterior pituitary hypofunction- If the pituitary isn't secreting TSH, the level will be low. Hyperthyroidism- If there is a large amount of thyroid hormone circulating, the feedback system relays the info upstream and less TSH is released.