Chap. 34 Berman

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Chap. 34 Berman
2012-12-06 22:45:10
Diagnostic Lab tests

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  1. RBC count (# of RBCs per cubic mL)
    • Normal:
    • Men - 4.6-6.0 million/mm3
    • Women - 4.0-5.0 million/mm3

    Increased: Primary polycythemia (ex. polycythemia vera); Secondary polycythemia or erythrocytosis--usually caused by O2 need (ex. chronic lung disease, congenital heart defects)

    Decreased: Abnormal loss of RBCs; abnormal destruction of RBCs; lack of needed elements or hormones for RBC production; bone marrow suppression; lead poisoning; thalassememia

    Low RBCs indicative of anemia; pts. w/ chronic hypoxia may develop higher than normal counts known as polycythemia
  2. 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
    • Normal:
    • Men - 13.5-18 g/dL
    • Women - 12-15 g/dL
    • Anemia classified as hgb <10.5 g/dL

    • Increased: polycythemia
    • Decreased: blood loss, hemolytic anemia, bone marrow suppression, sickle cell anemia
  3. 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
    • Normal:
    • Men - 40-54%
    • Women - 36-46%

    • Increased: dehydration; burns; hypovolemia
    • Decreased: blood loss; overhydration; dietary deficiency; anemia
  4. H&H
    Hgb, Hct
  5. 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
    • MCV normal: 
    • Men - 80-98 micrometers cubed; Women - 78-102 micrometers cubed

    • Increased: liver disease; alcoholism; pernicious anemia
    • Decreased: microcytic iron deficiency anemia; lead poisoning

    • MCH normal: 25-35 pg
    • Increased: rarely seen
    • Decreased: Iron deficiency anemia

    • MCHC normal: 31-37%
    • Increased: rarely seen
    • Decreased: iron deficiency anemia
  6. 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 normal:
    • 4,500-11,000/mm3

    • Increased: leukocytosis, infection
    • Decreased: leukopenia, autoimmune disease
  7. WBC differential - the proportion of each of the five types of WBCs in a sample of 100 WBCs

    Normal Neutrophils- 50-70%

    • Increased: stress, acute infection
    • Decreased: viral diseases, some drugs (chemotherapy, antibiotics such as nafcillin, penicillin, and cephalosporins) radiation therapy

    Normal Lymphocytes- 25-45%

    • Increased: viral infection, mononucleosis, tuberculosis, chronic bacterial infections, lymphocytic leukemia
    • Decreased: adrenal corticosteriods and other immunosuppressive drugs; autoimmune diseases (e.g. lupus erythematosus)

    • Normal Monocytes- 4-6%
    • Increased: chronic inflammatory disorders, tuberculosis, protozoan infections (e.g. malaria, rocky mountain spotted fever)
    • Decreased: drug therapy- prednisone

    • Normal Eosinophils- 1-3%
    • Increased: allergic reaction (e.g. asthma, hay fever, or hypersensitivity to a drug), parasitic infestations (e.g. round worms)
    • Decreased: corticosteriod therapy

    Normal Basophils- 0.4-1.0%

    • Increased: leukemia
    • Decreased: acute allergic reaction, corticosteroids, acute infections
  8. Platelet count - platelets are fragments of cytoplasm that function in blood coagulation
    Normal platelets: 150,000-350,000/mm3

    • Increased: malignant tumors, polycythemia vera
    • Decreased: idiopathic, thrombocytopenic purpura, viral infections, aids, systemic lupus erythematosus, chemotherapy drugs, some types of anemias
  9. 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)
  10. Plasma makes up ? % of blood
    Formed elements make up? % of blood
    • 55% plasma
    • 45% formed elements (RBCs, WBCs, platelets)
  11. 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
    Urea measured in BUN (blood urea nitrogen)
  12. Normal electrolyte values for adults:
    Sodium -?
    Potassium -?
    Chloride -?
    Calcium (total ionized) -?
    Magnesium -?
    Phosphate -?
    Serum osmolality -?
    Sodium - 135-145 mEq/L

    Potassium - 3.5-5.3 mEq/L 

    Chloride - 95-105 mEq/L

    Calcium (total ionized) - 4.5-5.5 mEq/L or 8.5-10.5 mg/dL; 56% of total calcium (2.5 mEg/L or 4.0-5.0 mg/dL)

    Magnesium - 1.5-2.5 mEq/L or 1.6-2.5 mg/dL

    Phosphate - 1.8-2.6 mEq/L (phosphorus)

    Serum osmolality - 280-300 mOsm/kg water
  13. 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
  14. Drug monitoring-
    peak level-
    trough level-
    Conducted to determine if client is in therapeutic range (e.g. digoxin, theophylline, aminoglycosides)

    Indicates the highest concentration of the drug in the blood serum

    Indicates the lowest concentration of the drug in the blood serum
  15. Arterial blood gases-
    Blood withdrawn from artery (radial, brachial, femoral- commonly) done by specially trained person, after draw pressure is held on site for 5-10 minutes to prevent hemorrhaging
  16. 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
    Normal HbA1c - 4.0-5.5%; an elevated one reflects hyperglycemia in diabetics

    Brain natriuretic peptide or B-type natriuretic peptide (BNP) test; levels increase as heart failure becomes more severe
  17. 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 
  18. 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.
  19. 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
    ALT (alanine aminotransferase, formerly known as serum pyretic transaminase or SGPT)

    • Normal adult: men: 10-55 unit/L; women: 7-30 unit/L
    • Increased: hepatitis, infectious monocleosis, acute pancreatitis, acute MI, heart failure
    • Decreased: not clinically significant

    AST (aspartate aminotransferase, formerly known as serum glutamic-oxaloacetic trasaminase or SGOT)

    • Normal adult: men: 10-40 unit/L; women: 9-25 unit/L
    • Increased: liver diseases (e.g. hepatitis, alcoholism, drug toxicity), acute MI, anemias, skeletal muscle diseases
    • Decreased: chronic renal dialysis, vit. b6 deficiency


    • Normal adults: 3.5-4.8 g/dL or 35-48 g/L; Panic value <1.5 g/dL
    • Increased: no pathology causes the liver to produce more albumin; increased level caused by dehydration
    • Decreased: chronic liver dysfunction, aids, severe burns, malnutrition, renal disease, acute and chronic infections

    Alkaline phosphatase

    • Normal adults: 25-100 unit/L
    • Increased: liver disease, bone disease, hyperparathyroidism, MI, chronic renal failure, heart failure
    • Decreased: malnutrition, pernicious anemia, and severe anemias, hypothyroidism, magnesium and zinc deficiency


    • Normal adults: 15-45 mcg/dL
    • Increased: liver disease, cirrhosis, reye's syndrome, GI hemorrhage
    • Decreased: renal failure


    • Normal adults: Total - 0.3-1.0 mg/dL; direct - 0.0-0.2 mg/dL; indirect - 0.1-1.0 mg/dL; panic value - >12mg/dL
    • Increased: total - hepatitis, obstruction of the common bile or hepatic ducts, pernicious anema, sickle cell anemia; direct - cancer of the head of the pancreas, choledocholithiasis; indirect - hemolytic anemias, drug toxicity, transfusion reaction
    • Decreased: not clinically significant

    GGT (gamma-glutamyl transferase)

    • Normal adults: men: 1-94 unit/L; women: 1-70 unit/L
    • Increased: liver disease, alcohol abuse
    • Decreased: not clinically significant


    • Normal adult: 11-13 seconds; critical value - >20 seconds for non-anticoagulated persons
    • Increased: liver disease, damage, vit. K deficiency, obstruction of common bile duct, deficiency of factors II, V, VII, or X
    • Decreased: thrombophlebitis, malignant tumor
  20. 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
    CK (creaine kinase)

    • Normal adult total: men: 38-174 unit/L; women: 26-140 unit/L; normal adult isoenzymes: mm(ck3): 96-100%; mb(ck2): 0-6%; bb(ck1): 0%
    • Increased: total - acute MI, myocarditis, after open heart surgery, acute cerebrovascular disease, muscular dystrophy, chronic alcoholism; CK isoenzymes - mb(ck2): MI, myocardial ischemia, angina pectoris
    • Decreased: not clinically significant


    • Normal adult: 5-70 ng/mL
    • Increased: MI, angina, other muscle injury (e.g. trauma), renal failure, rhagdomyolysis
    • Decreased: rheumatoid arthritis, myasthenia gravis

    Troponin I/Tropinin T

    • Normal adult: Troponin I - <0.35 ng/mL; Critical value - >1.5 ng/mL; Troponin T - <0.2ng/mL
    • Increased: troponin I - small infarct, myocardial injury; troponin T - acute MI, unstable angina, myocarditis
    • Decreased: not clinically significant
  21. 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
    BNP (brain natriuretic peptide, or B-type natriuretic peptide)

    • Normal adult: <100 pg/mL or <100 ng/L
    • Increased: heart failure, symptomatic cardiac volume overload, paroxysmal atrial tachycardia
    • Decreased: not clinically significant
  22. 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)

    • Normal adults: <200mg/dL
    • Increased: type II familial hypercholesterolemia, biliary cirrhosis, chronic renal failure, poorly controlled diabetes mellitus, alcoholism, diet high in cholesterol and fats
    • Decreased: severe hepatocellular disease, hyperthyroidism, malnutrition, chronic anemias, severe burns

    HDL-C (high density lipoprotein cholesterol) 

    • Normal adult: men: 35-65 mg/dL; women: 35-80 mg/dL
    • Increased: HDL excess, chronic liver disease, long-term aerobic or vigorous exercise
    • Decreased: familial hypoliproteinemia, hypertriglyceridemia (familial), poorly controlled diabetes mellitus, chronic renal failure

    LDL (low density lipoprotein)

    • Normal adult: desirable <130mg/dL
    • Increased: type II familial hyperlipidemia; secondary causes can include diet high in cholesterol and sat. fat, nephritic syndrome, multiple myeloma, diabetes mellitus, chronic renal failure
    • Decreased: hypolipoproteinemia, hyperthyroidism, chronic anemias, severe hepatocellular disease


    • Normal adults: desirable <150mg/dL
    • Increased: hyperlipoproteinemia, liver disease, renal disease, hypothyroidism, pancreatitis, MI
    • Decreased: malnutrition, hyperthyroidism, brain infarction, COPD
  23. Stool specimen - often done to determine presence of occult (hidden) blood which can occur from GI ulcers, tumors, inflammatory disease; 

    Test to find blood ?


    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.
    Guaiac test

    Steatorrhea - excessive amount of fat in stool can indicate faulty absorption in small intestine; for tests of dietary products/digestive secretions, nurse needs to collect entire stool instead of just small specimen

    Presence of ova/parasites - specimen be transported immediately while still warm and 3 stool specimens over period of days are taken

    Presence of bacteria/virus - small amount of stool collected so culture can be done, needs to be transported immediately; must be collected sterile
  24. 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
  25. 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; 
  26. 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?
    Normal range - 1.010-1.025
  27. pH urine testing - can be done less accurately w/ litmus paper on nursing unit;

    Normal urine pH?
    Normal urine pH - slightly acidic ( avg. of 6)
  28. 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
  29. 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
  30. 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
  31. Urine osmolality - measure of solute concentration of urine; more accurate than SG; also used to monitor fluid/electrolyte balance

    Normal range -?
    Normal range - 50-1200 mOsm/kg; avg. urine osmolality is 200-800 mOsm/kg
  32. 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
  33. 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
  34. Anoscopy - 
    Proctoscopy - 
    Proctosigmoidoscopy -
    Colonoscopy -
    • Anoscopy - viewing the anal canal
    • Proctoscopy - viewing the rectum
    • Proctosigmoidoscopy - viewing rectum and sigmoid colon 
    • Colonoscopy - viewing large intestine
  35. 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
  36. 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.
  37. 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
  38. 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
  39. 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
  40. 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
  41. 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.
  42. 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
  43. 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
  44. BUN value -
    8-25 mg/dL
  45. CO2 value-