LAB SERUM AMYLASE HGB FEMALE HGB MALE

NORMAL VALUE 25 TO 151 SOMOGYI UNITS = 53 TO 123 12 TO 15 14 to 18

PURPOSE PANCREAS FXN O2 CARRYING

ABNORMAL HIGH

LOW INCRESAED are dehydration and polycythemia, DECREASED overhydration and anemia. INCRESAED are dehydration and polycythemia, DECREASED overhydration and anemia. VALUES DEPEND ON SOURCE

HEMATOCRIT FE 36 TO 48

HEMATOCRIT MA PLATELETS SODIUM POTASSIUM

42 TO 52 150,000 TO 400,000 135 TO 145 3.5 TO 5

Notify physician if level greater than 5.5 mEq/L, and prepare to treat hyperkalemia.

CALCIUM MAGNESIUM PHOSPHORUS CREATININE MALE CREATININE FEMALE

8.6 TO 10 1.6 TO 2.6 2.7 TO 4.5 0.6 TO 1.3 0.5 TO 1.0; 0.7 to 1.4

BUN

10 TO 20

RENAL FUNCTION, better determinant of kidney function because it does not vary with protein intake and metabolic state End product of metabolism of proteins from muscles and dietary intake

Serum creatinine increases with decreased kidney function.

BUN level varies with urine output. Increased BUN decreased renal function, GI bleeding, dehydration, increased protein intake, fever, sepsis

URINE SPECIFIC GRAVITY

1.016 TO 1.022

BUN/ CREATININE RATIO SERUM AMMONIA SERUM PROTEIN NOT ALBUMIN SERUM LIPASE NORMAL RANDOM FASTING GLUCOSE ORAL GLUCOSE TOLERANCE TEST

10/1 TO 15/1 10 TO 80 6 TO 8 10 TO 140 70 TO 110

KIDNEYS ABILITY TO REGULATE FLUID BALANCE INDIRECT MEASURE OF THE AMOUNT OF PROTEIN IN THE URINE RENAL < 10/1 LOW UREA DISEASE CONCENTRATION KIDNEY >15/1 KIDNEY DYSFUNCTION FUNCTION LIVER FUNCTION

Decreased BUN END stage liver failure, low protein diet, starvation, pregnancy ELEVEATED PROTEIN IN URINE

BLOOD PRESSURE

NORMAL VALUES 120 MIN <<140; 30, 60 & 90 MINUTES << 200 < 120/ < 80

Essential HTN: cause is unknown 2ndary HTN: Renal failure Endocrine disease Coarction of aorta Neurological

Prehypertension 120 to 139 / 80 to 89 Hypertension 1 140 to 159 / 90 to 99 Hypertension 2 More than or equal to 160 / More than or equal to 100 Stage 2 HTN elevated BUN, creatinine associated, treated immediately with meds vs Stage 1

BNP

< 100

Drugs Pregnancy Heart damage due to stretching of myocardium Determinant of CHF

or prehypertension 100 to 300 mild CHF 300 to 600 moderate CHF > 600 severe CHF

TOTAL CHOLESTEROL

<< 200

LDLs

<100

Your total blood cholesterol is a measure of LDL cholesterol, HDL cholesterol, and other lipid components. LDL cholesterol can build up on the walls of your arteries and increase your chances of getting heart disease. That is why LDL cholesterol is referred to as "bad" cholesterol. The lower your LDL cholesterol number, the lower your risk. The table below explains what the numbers mean.

LESS THAN 200 DESIRED 201 TO 239 MILDLY HIGH 240 >> HIGH CAD 10% decrease in total cholesterol results in 30% decrease for risk of CAD

LDLLDL Cholesterol Cholesterol Category Less than 100 100 - 129 130 - 159 160 - 189 190 and above Optimal Near optimal/above optimal Borderline high High Very high

GOAL for CAD pts is to have total cholesterol lower than 70; Patient should have high amounts of soluble fiber in diet medical interventon is NOT generally initiated for levels under 240 mg/dl. Clients with cholesterol levels between 200 to 240 mg/dl, should begin with lifestyle modifactions.

HDLS

> 40 MEN > 50 WOMEN

When it comes to HDL cholesterol good cholesterol the higher the number, the lower your risk.

60 and above High; Optimal cardioprotective + associated with lower risk Goal Men > 45; Women > 55 Less than 40 in men and less than 50 in women Low; considered a risk factor for heart disease Weight reduction and exercise can increase HDLs << 150 NORMAL 150 199 Mildly High 200 499 HIGH 500 OR GREATER EXTERMELY HIGH; High triglycerides leads to high LDL levels.

TRIGLYCERIDES

METABOLIC SYNDROME

Triglycerides are the chemical form in which most fat exists in food and the body. A high triglyceride level has been linked to higher risk of coronary artery disease. 3 OF 6 DX Triglycerides FEATURES >150; HDLs <40 male, <50 female; BP >130/85; CRP >3; high fasting blood glucose > 100
<< 150 << 115
A SINGLE FASTING BLOOD GLUCOSE OF 350 + ALL SIGNS AND SYMPTOMS OF DIABETES AT THIS STAGE PT IS DIAGNOSED WITH DIABETES

1. Abdominal obesity
Men 40 inches or more Women 35 inches or more

2. 3. 4. 5.

hypertriglyceridemia low HDLs High blood pressure high fasting blood glucose 6. elevated CRP
Fasting plasma glucose 110 to 125= PRE-DIABETES Greater than 126 on 2 occasions= diabetes Two-hour post load glucose test 140 to 199= PRE-DIABETES Greater than 200mg at 2 hours= diabetes Random plasma glucose

GLUCOSE FASTING

6 Greater than 200= HGB A1C < 5.0 6.5% Criteria for Diagnosis Symptomatic patient with one Diabetes Fasting plasma glucose >= 7.0 mmol/L Fasting plasma glucose >= 7.0 HEMOGLOBIN mmol/L A1C > 8 Random plasma glucose >= INDICATES 11.1 mmol/L VERY If there are no symptoms then POOR/NO you need two separate CONROL OVER readings on different days THEIR BLOOD GLUCOSE & DIABETES PREDIABETES = VALUES 5.7 TO 6.4 CRP WBCS NEUTROPHILS AST VANCOMYCIN TITERS 30 TO 40 MCG/ML <1 4500 TO 11,000 1800 TO 7800 > 3 high risk 1.0 to 3.0 moderate risk High CRP is associated with heart disease, systemic inflammation associated with atheriosclerosis CARBAMAZEPINE CAN DEPRESS WBC COUNTS

DILANTIN THERAPUETIC SERUM THEOPHYLLINE THERAPUETIC DIGOXIN THERAPUETIC BLOOD pH

10 TO 20 MCG/ML 10 TO 20 MCG/ML 0.5 TO 2.0 7.35 to 7.45

LIVER VIRAL HEPATITIS LOWERED FUNCTION PEAK SERUM NEPHROTOXICITY AND MEASURED 1.5 OTOTOXICITY HOURS TO 2.5 HOURS AFTER THE COMPLETED IV INFUSION < 10 RISK FOR SEIZURE > 20 TOXICITY < 10 EXCERBATE RESPIRATORY DISORDER

paCO2 HCO3

35 to 45 22 TO 26

FIBRINOGEN 190 TO 420 FEMALES FIBRINOGEN 180 TO 340 MALES SCHILLING TEST INCREASED RBC COUNT

ELEVATED CO2 LEVELS OCCURS WITH LOWER pH respiratory acidosis ELEVATED HCO3 OCCURS WITH HIGHER pH metabolic alkalosis LOW HCO3 Metabolic acidosis TENDENCY TO BLEED, DIC TENDENCY TO BLEED, DIC DETERMINE PERNICIOUS ANEMIA DECREASED CARDIAC OUTPUT IMPAIRED PULMONARY GAS EXCHANGE CORTICOSTER OID THERAPY POLYCYTHEMI A VERA, SEVERE DIARRHEA, DEHYDRATION INCREASED PLATELET AGGREGATION OCCURS AFTER SURGERY, ACUTE ILLNESS, VENOUS THROMBOSIS DVT, PULMONARY EMBOLISM AUTOIMMUNE DISEASE DEGREE OF INFLAMMATIO

INCREASED PLATELET AGGREGATION

NORMAL LESS THAN 5 MINUTES

ESR ERYTHROCYTE SEDIMENTATIO N RATE

< 30 NORMAL 30 TO 40 MILD

PT PROTHROMBIN TIME

DECREASED PT VALUE ARTERIAL OCCLUSION, DVT, EDEMA, MI, PERIPHERAL VASCULAR DISEASE, PULMONARY EMBOLISM COPD, Liver and kidney dependent edema Right Sided HF emphysema failure back up in SVC jugular distension and IVC englarged liver anorexia/nausea distended abdomen, ascites portal hypertension abdominal pulses measureable swollen arms,hands nocturia, polyuria weight gain high or low blood pressure elevated BUN and creatinine kidney failure ATRIAL FIBRILLATION Left Sided HF Increased Left heart failure hacking cough with or without afterload will progress to pink frothy sputum Ejection fraction include RHF left pulmonary congestion <40% ventricular dypsnea hypertrophy Complications inspiratory crackles = rales, Back up into compensati pulmonary wheezes = ronchi do not pulmonary on, then edema (resp clear with cough arteries and lungs dilation of acidosis) tachypnea myocardium S3 or S4 gallop The most causes Atelectisis Fatigue, weakness, or accurate increased dizziness indicator of fluid preload Weight gain of 3 Oliguria elevated BUN loss or gain in lbs in week or 1 and creatinine an acutely ill Increased to 2 lbs during Pallor, cyanosis patient is weight. afterload the day CHF Weak peripheral pulses An accurate due to HTN is worsening tachycardia daily weight must be Increased stroke Cool extremeties

INFLAMM 40 TO 70 MODERAT E INFLAMM 70 TO 150 SEVERE INFLAMM FEM 9.5 TO 11.3 MALE 9.6 TO 11.8

N, CONNECTIVE TISSUE INFLAMM; RHEUMATOID ARTHRITIS ASPIRIN THERAPY BLEED TIME

obtained and recorded. A 1-kg weight gain is equal to 1000 mL of retained fluid.

risk

2. 3. 4. 5. 6.

JC core measures for pneumonia

Droplet precautions Gown, mask, eye shield, gloves

Community acquired < 48 hours after admission Hospital acquired/ventilat or aquired > 48 hours after admission Bacterial more serious than viral

Orthnopia trifold position Paroxysmal nocturnal dyspnea (PND) ATRIAL FIBRILLATION Ventricular tachycardia Angina Decreased LOC Respiratory acidosis blood culture before antibiotic antibiotic within 4-6 hrs documentation of smoking cessation teaching to patient patient given pneumococcal vaccine + influenza vaccine arranged appointment for follow up

TB

Get ABGs in addition to O2 saturation more accurate Meds watch liver function tests elevated ALTs and ASTs Insoniazid, Rifampin, pyrazinamide, myambutol, Streptomycin 2 to 3 times a

Admission: Fever > 100.4 Altered LOC, esp 70 yrs or older New onset or worsening cough Prurulent sputum, change in sputum Dyspnea or tachypnea Rales or bronchial breath sounds 02 sat <92%

Nonproductive early morning cough, 1st symptom Copius frothy pink sputum Night sweats Low grade fever Anorexia, weight loss History of exposure Positive TB skin test exposure and infection Ghon tubercle in Xray Positive AFB sputum culture

day for at least 6 months, or 3 to 6 months after negative sputum

COPD Chronic Bronchitis If perfusion <80% needs meds

Presence of productive cough for > 3 months

COPD Emphysema If perfusion <80% needs meds

Eventual lung changes result in brochectasis and emphysema Teach LEADS to RHF Dyspnea, chronic dry cough, Pursed respiratory infection, tachypnea, lipped accessory muscles, barrel cheat, breathing purse lipped breather, NO Diaphragma CYANOSIS, increases CO2 tic retention, Orthnopea, Wheezes, breathing, neck veins distended during controlled expiration, percussion of lungs is cough, hyperresonant, diminished breath graded sounds with rhonchi plus exercise decreased tactile fremitis,LEADS program TO RHF PINK PUFFER

True diagnostic for TB QFT gold blood test results within 2 hrs airborne isolation n95 exposed ppl prophylaxis of INH for 6 months abnormal Xray or immunosuppressed/HIV prophylaxis of INH for 12 months Hypoxia, hypercapnia, respiratory acidosis, digital clubbing, cardiomeagly, cor pulmonale right sided heart failure LATE in disease , increased risk for respiratory infection BLUE BLOATER

Weight gain/loss DRUG Statins

Antihyperlipidemics reduce absorption of lipid soluable vitamins including Vitamin K, and therefore can affect prothrombin time. This increases the client's risk for bleeding, so the client should be instructed to report any signs of bleeding such as excessive bruising. SE nausea/gas/diarrhea take with meal Statins (lovastatin) are better

absorbed when taken with food. Other statins such as Prvachol and Zocor can be taken without regard to food intake. However, all the statin drugs can cause adverse GI effects such as cramps, diarrhea, constipation, flatus and heartburn, and generally taken with evening meal or bedtime. Liver damage check LFTs Muscle pain/damage Rhabdomyolysis can cause severe muscle pain, liver damage, kidney failure and death 24 HOUR URINE COLLECTION SPECIMEN PLACE IN THE REFRIDGERATOR OR THE BACTERIA AND WBCS IN THE URINE WILL DECOMPOSE AND UNABLE TO MEASURE, PRESERVES THE ELEMENTS OF THE URINE, IF LEFT UNREFRIDGERATED THE URINE BREAKS DOWN TO AMMONIA AND BECOMES MORE ALKALINE 24 HOUR URINE COLLECTION IS TIMED, QUANTITATIVE MEASURE ESSENTIOAL TO START TEST WITH AN EMPTY BLADDER AT START TIME ASK PATIENT TO VOID, DISCARD THE SPECIMEN = BLADDER NOW EMPTY, AND NOTE THE START TIME. COLLECTION STARTS AFTER THIS VOID AND TIME. IN BETWEEN COLLECTIONS PLACE THE URINE SPECIMEN ON ICE OR REFRIDGERATE IT, AND AT THE END OF COLLECTION (24 HOURS) HAVE PATIENT VOID ADDING THIS TO THE COLLECTION. FIFTEEM MINUTES BEFORE THE END OF COLLECTION TIME THE PATIENT SHOULD BE ASKED TO VOID AND ADD THIS SPECIMENT TO THE COLLECTION CLEAN CATCH SPECIMEN HAVE PATIENT CLEANSE LABIA/PENIS USING TOWELS THEN HAVE THEM VOID INTO THE STERILE SPECIMENT CONTAINER GROSS HEMATURIA AND PROTEINURIA CLASSIC SIGNS OF GLOMERULONEPHRITIS THROAT CULTURE MUST BE REFRIDGERATED IF CANNOT BE ANALYZED WITHIN 1 HOUR CHRONIC CARRIER STATE OF HEPATITIS POSITIVE FOR HEPATITIS B SURFACE ANTIGEN (HBsAG) CHRONIC CARRIERS

Anti-HBs ANTIBODY TO SURFACE ANTIGEN MARKER FOR RESPONSE TO THE VACCINE AND INDICATES IMMUNITY TO HEPATITIS B Labs for bleeding and clotting times Lets look at the three tests used to determine bleeding or clotting times: 1. Prothrombin Time (PT) this blood test measures how long it takes blood to clot and can be used to check for bleeding problems. An abnormal PT/INR can be caused by liver disease; injury; lack of vitamin K; or treatment with blood thinners. QUIZ YOURSELF: Which blood thinner are we talking about here? (answer below). 2. International Normalized Ratio (INR) is a standardized way to report results of bleeding time. It is used in place of PT; in fact, some labs will only report INR. 3. Activated Partial Thromboplastin Time (APTT)* this blood test also measure the time it takes your blood to clot and to help diagnose bleeding problems. An abnormal APTT can be caused by bleeding disorders (such as hemophila); liver or kidney disease; or treatment with blood thinners. QUIZ YOURSELF: Which blood thinner are we talking about here? (answer below) Therapeutic Lab Values Lets look at these same lab tests once again. PT & INR If you answered warfarin (Coumadin) to the first question above, you were correct! How much warfarin the person is prescribed depends on the prothrombin time (or INR). The therapeutic value of PT is about 1.5 to 2.5 times the normal value; the therapeutic value of INR is 2 to 3 times the normal value. Test Normal lab value Therapeutic lab value Prothrombin time (PT) 11 13 seconds 15.5 35 seconds International normalized ratio 0.8 1.1 23 (INR) APTT If you answered heparin for this test, you were correct! As with the PT/INR test, the heparin dose is changed so that the APTT result is about 1.5 to 2.5 times the normal value. How can you remember if APTT is used for heparin or warfarin? I always remember APTT has 2 sticks (the Ts), and there are 2 sticks in the H in HEPARIN its stuck with me all these years. Test Normal lab value Therapeutic lab value Activated Partial thromboplastin 30 40 seconds 45 100 seconds

time (aPTT) Applying this information So, lets say you are caring for a client taking warfarin (for example, following total hip replacement surgery). This means that when you look at the labs for this client, you want to see longer bleeding times or, essentially abnormal values. The idea here is to prevent blood clots from forming. For heparin therapy, you are caring for a client who is on IV heparin (admission diagnosis is deep vein thrombosis). When you look at the labs for this client, you also want to see longer bleeding times. Keep in mind that if the number is too high for either client, you should start watching for signs of spontaneous bleeding and the dosage should be decreased. Another key point to remember, these tests should be done at the same time of day every day while the client is hospitalized. QUIZ YOURSELF: What are the antidotes for reversing the effects of heparin? And for warfarin? (Watch for the answer below.)** Now its your turn Are there any other topics you would like me to discuss in an upcoming blog? *Are you wondering if it's PTT or APTT? PTT was first used in the early 1950s and was replaced by APTT in the 1970s. ** The antidote for reversing the effects of heparin is... protamine sulfate. The antidote for reversing the effects of warfarin is... vitamin K. Did you come up with the correct response without looking? The risk of bleeding increases significantly when the INR is 3 or greater. DASH diet Low saturated fats, low cholesterol, low total fat, LOW SODIUM Stage 1 HTN < 2400 mg of sodium Stage 2 HTN < 1500 mg sodium Can increase K+ in diet though