Chap. 34 Berman

RBC count (# of RBCs per cubic mL)

Hemoglobin (Hgb); composed of pigment (heme), which contains iron, and a protein (globin)

Anemia classified as?

Main intracellular protein of RBCs, carries O2 through body
Hgb in african americans typically 0.5-0.73 g/dL lower than caucasians

Hematocrit (Hct); hematocrit or packed cell volume (Hct, pcv, or crit) is a fast way to determine the % of RBCs in the plasma; Hct is reported as % b/c it is the proportion of RBCs to the plasma

H&H

RBC indices:

Mean corpuscular volume (MCV) - the mean of avg. sice of the individual RBC

Mean corpuscular hgb (MCH) - Amount of hgb present in one cell

Mean corpuscular hgb concentration (MCHC) - the proportion of each cell occupied by hgb

White blood cell (WBC) count - count of the total number of WBCs in a cubic mL of blood

High counts seen in bacterial infections; low counts often seen if viral infection present

WBC differential - the proportion of each of the five types of WBCs in a sample of 100 WBCs

Neutrophils-
Lymphocytes-
Monocytes-
Eosinophils-
Basophils-

Platelet count - platelets are fragments of cytoplasm that function in blood coagulation

Serum electrolytes:
Routinely checked for pts. in hosp. screening for electrolyte and acid-base imbalances, or commonly for pts. being treated with diurectics for htn or heart failure

Most commonly checked are sodium, potassium, chloride, bicarbonate; may be ordered as Chem 7
or BMP (basic metabolic panel)

Plasma makes up ? % of blood
Formed elements make up? % of blood

Blood levels of two metabolically produced substances urea and creatinine routinely checked to determine renal function; normally both are eliminated by kidneys through filtration and tubular secretion

Urea, the end product of protein metabolism is measured in ?
Creatinine is produced in relatively constant quantities by the muscles and is excreted by the kidneys; therefore the amount of creatinine in the blood relates to renal excretory function

Normal electrolyte values for adults:
Sodium -?
Potassium -?
Chloride -?
Calcium (total ionized) -?
Magnesium -?
Phosphate -?
Serum osmolality -?

Serum osmolality- measure of solute concentration of the blood; particles included are sodium (major determinant), glucose, and urea (BUN)

Used primarily to evalutate fluid balance; increase in serum osmolality indicates fluid volume deficit and decrease indicates fluid volume excess

Drug monitoring-
peak level-
trough level-

Arterial blood gases-

Blood chemistry - performed on blood serum; include serum electrolytes, certain enzymes, serum glucose, hormones, and other substances such as cholesterol and triglycerides

Elevated cardiac markers (CK, myoglobin, troponin I, troponin T) can help differentiate and MI from chest pain or angina, or pleuritic pain

Common lab test is glycosylated hemoglobin or hemoglobin A1C (HbA1c) which measures blood glucose bound to hemoglobin; checks control of glucose levels over last 3-4 mo.

Normal HbA1c ?


Specific blood test to detect and guide treatment for heart failure is ?; and is secreted by the left ventricle in response to increased ventricular volume and pressure

Metabolic screening - newborns routinely screened for congenital metabolic conditions

Tests for PKU and congenital hypothyroidism are required in all states in US; other conds. commonly tested for include sickle cell disease, galactosemia

Venous blood collected through heel stick 

Capillary blood glucose-

Forearm testing may not be as accurate as fingerstick blood glucose and can only be used before or after a meal, physical exercise, or admin. of insulin dose

Lateral aspects of fingers used b/c less calleous or nerve endings; earlobe may be used if client in shock or has edematous fingertips; some newer monitors allow for specimens to be obtained from less sensitive areas in arms, legs, abdomen

Before test, wrap finger in warm cloth or hold in hand to warm; hold hand in position under heart being a dependent posi. to increase blood flow and make puncture one time deal; gently squeeze around puncture site to get drop of blood

Outer aspect of heel is most common site for neonates/infants; use side of finger for clients older than 2 yrs.; older adults often have poor circulation, wrap hand in warm cloth 3-5min. and put in dependent posi.

Common Liver Function Blood chemistry tests

ALT (alanine aminotransferase, formerly known as serum pyretic transaminase or SGPT) - marker of hepatic injury; more specific of liver damage than AST

AST (aspartate aminotransferase, formerly known as serum glutamic-oxaloacetic trasaminase or SGOT) - found in heart, liver, and skeletal muscle; can also be used to indicate liver injury

Albumin - is protein produced by the liver

Alkaline phosphatase - found in the tissues of the liver, bone, intestine, kidney, and placenta; used as an index of liver and bone disease when correlated with other clinical findings

Ammonia - liver converts ammonia, a by-product of protein metabolism, into urea which is excreted by the kidneys

Bilirubin - results from the breakdown of hemoglobin in the RBCs; removed from body by the liver, which excretes it into the bile

GGT (gamma-glutamyl transferase) - found primarily in the liver, kidney, prostate, and spleen; is more specific for the hepatobiliary system

Prothrombin - protein produced by the liver for clotting of blood

Blood chemistry cardiac markers

CK (creatine kinase) - an enzyme found in the heart and skeletal muscles; has three isoenzymes: MM or CK3, MB or CK2, and BB or CK1

Myoglobin - after an MI, serum levels of myoglobin rise in 2-4 h, making it an early marker for muscle damage in MI

Troponin I; Troponin T - cardiac troponin is highly concentrated in teh heart muscle; this test is used in early diagnosis of MI; after an MI, troponin I begins to increase in 4-6h and remains elevated for 5-7 days; troponin T begins to increase in 3-4h and remains elevated for 10-14 days

Blood chemistry cardiac marker

BNP (brain natriuretic peptide, or B-type natriuretic peptide) - a hormone produced by the L ventricle of the heart; is a marker of ventricular systolic and diastolic dysfunction; this test is useful in diagnosing and guiding tx of heart failure

Blood chemistry lipoprotein profile

Cholesterol (this test is an important screening test for heart disease)

HDL-C (high density lipoprotein cholesterol); a class of lipoproteins produced by the liver and intestines; the "good cholesterol

LDL (low density lipoprotein); up to 70% of the total serum cholesterol is present in LDL; the "bad" cholesterol

Triglycerides (this test evaluates suspected atherosclerosis and measures the body's ability to metabolize fat)

Stool specimen - often done to determine presence of occult (hidden) blood which can occur from GI ulcers, tumors, inflammatory disease; 

Test to find blood ?

Steatorrhea?

Presence of ova/parasites?

Presence of bacteria/virus?

Sterile stool specimen done by nurse; occult can be done by UAP; in some instances, may need to refrige stool b/c bateriologic changes take place if left @ room temp.

Fecal occult blood testing (FOBT); take tongue blade and smear stool onto hemoccult test card spaces, turn over and apply 2 drops of reagent which assesses for presence of enzyme perioxidase in hemoglobin molecule if present in stool; if positive guaiac then test area will turn blue; any other color or no change is negative



False positive results can occur if----Certain foods: red meat, raw vegetables or fruits (radishes, turnips, horseradish, melons); certain meds that irritate GI mucosa and cause bleeding (aspirin, NSAIDS, steriods, Fe preps, anticoagulants);

False negative results -----250 mg vit. C or more can cause false negative up to 3 days before test even if bleeding present

Usually 3 specimens are collected from consecutive and diff. BMs

Take specimen from 2 diff. areas on stool if two diff. test areas are present

Urine specimens: 

CVUA - done for routine urinalysis; done on 1st urination in morning b/c more uniform concentrated and higher acidity

Clean-catch or midstream urine specimen done for urine culture; must be transported to lab immediately before any contaminating organisms can grow, multipoly, and produce false results

Alert!: kidney function directly relates to cardiac output therefore any health prob. that changes cardiac output may affect urine output

Timed urine specimen - either refrigerated or contain a component to prevent bacterial growth and degradation of urine components; 

Specific gravity - an indicator of urine concentration, or the amount of solutes (metabolic wastes and electrolytes) presence in the urine; SG of distilled water is 1.00; excess fluid intake or diseases affecting kidneys ability to concentrate urine can lead to low SG; dehydration or fluid deficit can show high SG

Normal range?

pH urine testing - can be done less accurately w/ litmus paper on nursing unit;

Normal urine pH?

Urine glucose - tested for pts. w/ DM or for pregnant and doing GTT; usually amount negligible, although if ingested large amount of glucose, some small amount may be present in urine; considered inadequate measurement of BG; used only for pts. that cannot or wont do fingerstick

Urine ketones - normally not present in urine; are a product of fatty acid metabolism; may be in urine of pts. w/ poorly controlled DM
 
-recommended for type I DM who are at home not feeling well, running a fever, or have BG consistently >300mg/dL

Urine protein - usually too large to escape glomerular capillaries into filtrate; if glomerular membrane damaged by inflammatory process (e.g. glomerulonephritis), proteins can leak into urine

Urine osmolality - measure of solute concentration of urine; more accurate than SG; also used to monitor fluid/electrolyte balance

Normal range -?

Sputum specimens - usually collected in the morning when client can cough up much sputum that has settled

Offer mouth care prior to collection, ask client to deep breathe and cough up 1-2 tsp. of sputum; offer mouth care /p as well; transport immediately before bacteria can multiply if doing bacterial culture

Hemoptysis - presence of blood in sputum

Throat culture - done to assess presence of microorganisms in oropharynx; have client sit up, stick tongue out and say ah; sitting posi. and extension of tongue help expose pharynx, saying ah relaxes throat muscles and helps minimize contraction of the constrictor muscle of pharynx (gag reflex); quickly wipe swab on tonsillar pillars and remove

Anoscopy - 
Proctoscopy - 
Proctosigmoidoscopy -
Colonoscopy -

Pts. w/ urinary alterations - 

kidneys/ureters/bladder (KUB) 

intravenous pyelography (IVP) - contrast medium is injected IV

retrograde pyelography - contrast medium is instilled directly into the kidney pelvis via urethra, bladder, and ureters then xrays are taken to evaluate urinary tract structures 

renal ultrasonography - noninvasive test uses reflected sound waves to visualize the kidneys

cystoscopy - the bladder, ureteral orifices, and urethra can be directly visualized using cystoscope (lighted instrument inserted through urethra

MRI (magnetic resonance imaging) - noninvasive diagnostic scanning technique in which client placed in magnetic field; pts. w/ implanted metal devices (pacemaker, metal hip prothesis) cannot undergo these b/c of metal and magnet of field; no radiation exposure; if contrast is needed it is not iodine contrast; shows better contrast between normal/abnorm. tissue than CT scan but more costly

Have clients remove metallic objects, titanium, niobium, or surgical stainless steel okay b/c aren't attracted by magnet; have client inform practitioner if have tattoo b/c may experience some edema or stinging @ site; transdermal patches should also be removed b/c may contain foil

Commonly used for visualization of brain, spine, limbs, joints, heart, blood vessels, ab., pelvis

Narrow closed high magnet scanner or open, low magnet scanner used

very loud and lasts between 60-90 min.

Nuclear imaging studies - admin. of radioactive isotopes for diagnostic purposes; radiopharmaceutical (targeted to specific organ) given through various route; the distribution of the isotope is diff. in norm. vs diseased tissue; in norm. tissue the distribution of the isotope is equal, uniform, and gray; hyperfunction of an organ shows darker images referred to as hot spots and hypofunctioning of an organ appears as lighter images or cold spots

Positron emission tomography (PET) - noninvasive radiologic study involving inj. or radioisotope; images are then created and allow the study of various aspects of organ function adn may include eval. of blood flow and tumor growth; sometimes used w/ detecting alzheimer's disease

LP (lumbar puncture) CSF is drawn from subarachnoid space of the spinal canal between the 3rd and 4th lumbar vertebrae or between 4th adn 5th LV

Pt. is positioned on laterally w/ head bent towards chest and knees flexed onto ab., and back @ edge of table; CSF pressure is frequently read during procedure w/ manometer

Will need to lay in dorsal recumbent posi. for 1-12 h with 1 head pillow

Ab. paracentesis - 

ascites- a large amount of fluid accumulates in ab. cavity; normal ascitic fluid is serous, clear, and light yellow in color; done by primary care provider to get fluid specimen or relieve pressure from fluid buildup; done midway between umbillicus and symphysis pubis @ midline

small incision made, trocar w/ cannula inserted then trocar removed and tubing attached to cannula to drain fluid; if specimen needed generally a long aspirating needle used to collect instead of incision normally about 1500 mL is the max. amount of fluid drained @ one time to avoid hypovolemic shock and fluid drained slow to avoid it also

Thoracentesis - remove excess fluid or air to ease breathing or to introduce chemothrerapeutic drugs intrapleurally; pt. will be positioned sitting and w/ arm held to front and up or sitting and leaning forward over pillow; to get fluid needle is usually inserted on the lower post. chest and to remove air needle inserted on upper ant. chest

Don't remove more than 1000 mL in first 30 min.

Bone marrow biopsy - used to detect pernicious anemia or leukemia; bones commonly used are sternum, iliac crests, ant. or post. iliac spines, proximal tibia in children; post. superior iliac crests is posi preferred for prone or side lying client; 1-2 mL of marrow obtained from red marrow of spongy bone;

May need to hold pressure on site /p aspiration for 5-10 mins. to prevent bleeding

Liver biopsy - client will have liver aspiration done on R side in lower ribs or through ab. below right rib cage; client is posi. on side to create pressure and keep from bleeding; PTT and platelet count are normally taken well in advance of the procedure b/c pts. w/ liver disease usually have blood clotting defects

Client may take vit. k for several days before procedure to prevent hemorrhage; may also need to fast for 2 h prior to procedure

BUN value -

CO2 value-