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Case Studies in Analyzing Lab Values
Julie Miller, RN, BSN, CCRN
Introduction
Correlate lab values to clinical patient assessment
Clues to assessment and interventions
ABG’S
pH
Acidosis 7.40 Alkalosis
7.35 - 7.45
PaCO2
Alkalosis 40 Acidosis 35 - 45 HCO3¯
Acidosis 22 - 26 Alkalosis
2
Uncompensated pH Uncompensated
Acidosis < < 7.35 -7.40 - 7.45 > > Alkalosis
Compensated Compensated
Acidosis AlkalosisAcidosis Alkalosis
7.40
pH First Name: Compensated or
Uncompensated
Last Name: Acidosis or Alkalosis
Identify PaCO2 & HCO3¯ Acidosis or Alkalosis
Middle NameMatch PaCO2 to pH for respiratory
Match HCO3¯ to pH for metabolic
Use the ph to obtain first and last names
pH: 7.20, PaCO2: 74, HCO3¯: 26
Fi t N L t NFirst Name Last Name
Uncompensated Acidosis
Use PaCO2 and HCO3¯ to obtain middle name
Middle Name
Respiratory
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First Name Middle Name Last Name
pH: 7 20 PaCO : 74 HCO ¯: 26 pH: 7.20, PaCO2: 74, HCO3 : 26
What conditions?Anything that causes Hypoventilation
First Name Middle Name Last Name
¯ pH: 7.52, PaCO2: 32, HCO3¯: 24
What conditions?Anything that causes hyperventilation
pH: 7.18, PaCO2: 35, HCO3¯: 12
What conditions?What conditions?Renal Failure, DKA, Diarrhea, Lactic Renal Failure, DKA, Diarrhea, Lactic acidosis, Ethylene Glycol, Drugs such as acidosis, Ethylene Glycol, Drugs such as Epinephrine, ASAEpinephrine, ASA
4
pH: 7.56, PaCO2: 45, HCO3¯: 34
What conditions?What conditions?NGT Suction, Hyperemesis, Antacid NGT Suction, Hyperemesis, Antacid abuse, Bicarb Drips, THAMabuse, Bicarb Drips, THAM
Base Excess or Deficit Calculated using pH, PaCO2 & HCT
Normal: -2 - +2 mEq/L
Negative = Metabolic Acidosis
Positive = Metabolic Alkalosis
Bicarb = One half the buffers in blood
Lactic Acid Normal Values
mEq/L
Venous: 0.5 – 2.2
Keys to Collection Avoid hand clench
Avoid tourniquet
Arterial: 0.5 – 1.6
Indicates? Shock state
Anaerobic metabolism
Place on ice
Discard if more than 15 minutes old
Predictor of mortality
5
Anion Gap
Normal 12 + or – 4 mEq/L 5 – 11 mEq/L or 8 – 16 mEq/L Check your Labs Normals
Calculated (Na + K) (Cl + HCO ) (Na + K) – (Cl + HCO3)
Reflects Amount of Other Anions NOT Routinely Measured Phosphates Sulfates Ketone Bodies Proteins Lactic Acid
Anion Gap High Anion Gap Acidosis
Increased Production of the Anions DKA
Non –Anion Gap Acidosis Loss of Bicarbonate
Retention of Chloride ions Diarrhea DKA
Lactic Acidosis
Rhabdomyolysis
Poisonings Methanol
Salicylate
Ethylene Glycol
Use of Acetazolamide Therapy
Total Carbon Dioxide
Normal: 22 -30 mEq/L
What other lab has similar normals?
6
Total CO2 SMA-7Na: 142
K+: 3.9
ABGpH: 7.33
PaCO2: 35K : 3.9
CL: 102
CO2: 22
Bun: 21
Cr: 0.5
PaCO2: 35
PaO2: 74
HCO3: 21
SaO2: 92%
CBC HGB, HCT, & PLT
WBC Differential
Left and Right shift
ANC
7
CBC HGB:
Females: 12 - 16 g/dl
Males: 14 - 18 g/dl
Newborns: 15.5 – 24.5 g/dl
Infants: 9.0 – 15.5 g/dl
HCT: Females: 37 - 47 %
Males: 40 - 54 %
Children: Varies by age
CBC Increased H/HAltitudeDehydration
Decreased H/HHemorrhageHypervolemiaDehydration
Chronic hypoxiaSmoking, COPD
CHFDrugs:
Gentamycin
HypervolemiaPregnancyHemolysis
IABPDrugs: Indocin
and antibiotics
Renal Failure
CBC Platelet count
Adults: 150 000 -
Heparin effect?
Adults: 150, 000 -400,000 μ l or mm³
Newborns: 100,000 –300,000
Infants @ 3months
Increased levels?
8
Case Study
64 y.o. M. FUO, s/p IMI on IABP & Epi
HGB 11.4, HCT 34, PLTHGB 11.4, HCT 34, PLT 84,000, WBC 18,000
CRP 18 mcg/ml
pH: 7.32, PaO2: 92, PaCO2: 35, HCO3¯: 20
What’s going on?
CBC & Differential
WBC = LeukocytesMales and Females: 4500 - 11,000/μl
Children: Newborns: 9,000 - 30,000/μl
Gradually decreases to adult level by 10 y.o.
Differential Granulocytes Neutrophils:
Bands 3 - 6 % (infants 5 – 11%)
Segs 50 – 62 % (infants 15 – 35 %)
Eosinophils 0 – 3 % Allergic Disorders and Parasitic Infections
Basophils 0 – 1 % Chronic Inflammation and allergic disorders
9
Differential Monocytes 3 – 7 %
Phagocytosis: Cellular debrisProduce interferon (antiviral)
Lymphocytes 25 – 40%T and B Cells
B Cells = Antigen/Antibody T Cells = Master Immune Cells
Differential
Neutrophils: Illustrated from left to right
Young cells on left more mature to right Young cells on left more mature to right
Bands Segs
ANC Absolute Neutrophil Count
(%Segs + %Bands) X WBC
{Percentage expressed as decimal}
Indicates? Neutropenic Less than 1500 – 2000/mm3
10
ANC - Nursing Implications
Neutropenic Precautions
Universal Precautions
No Rectal Temps meds or exams No Rectal Temps, meds or exams
Minimize Invasive Lines and Tests
Prevent Tissue Breakdown
Meticulous Oral Care
Limit Visitors to HEALTHY
Case Study 42 y.o. F metastatic breast CAWBC: 1500
B d 40 %Bands: 40 %
Segs: 25%
What is her ANC?
Case Study 42 y.o. F metastatic breast CAWBC: 3200
B d 20 %Bands: 20 %
Segs: 10%
What is her ANC?
11
Potassium
Normal:
3.5 - 5.3 mEq/L
K+ K+
K+ K+
K+ K+
Hyperkalemia Serum level > 5.3
Causes: K+ K+K+ K+
H+ H+ H+ H+
Causes:Crush injury
Acidosis
Renal failure
K+ K+ K+ K+
K+ K+ K+ K+
K+ K+ K+ K+
12
HyperkalemiaCardiac changes> 5.5 Peaked T waves
Hyperkalemia> 6.5 Prolonged PR and small P
waves
>7.0 Widened QRS Tall T wave
Hyperkalemia> 8.0 Widened QRS, Sine waves
Varies by patient progresses to asystole
13
Hyperkalemia Treatment
K+ K+
Serum level > 5.3
Protect the heart
Hide the K+
K+ K+ K+ K+
Hyperkalemia Protect the Heart
Calcium Chloride or gluconate
Excrete the Potassium
Hide the Potassium Insulin and glucose
Na Bicarbonate
Sodium polystyrene sulfonate
Diuretics
Dialysis
Case Study 63 y.o. F. Diabetic, Chronic renal failure, HX of
cardiac disease
Found semi-conscious and bradycardic
Transferred to ICU, Labs pending
14
Case Progression
Case Progression History obtained:Patient kept bottle of Salt Substitute at
bedsideN i I li tiNursing Implications
Case Conclusion
Hypokalemia Serum levels < 3.5
Causes:
Treatment Protect the Heart!
Causes:Diuresis
Gastric loss
Insulin
NaHCO3¯Replace losses
15
Hypokalemia
Case Study
54 y.o. M c/o 3 day history of diarrhea and vomiting.
Has continued lasix tablets but stopped KCL because it upset his stomach
Case Study
Guess the potassium?Guess the potassium?
16
Case Study
Potassium: 1.8 mEq/Liter
Treatment? Treatment?
What other dysrhythmias?
What acid/base disturbance?
Case Study Hypokalemia
If you wait to treat!
Magnesium
Normal: Normal:1.2 - 2.9 mEq/L
K+ K+
Mg++ K+
K+ Mg++
17
HypomagnesemiaSerum level < 1.2 mEq/L
Symptoms: Muscle tremors
Nausea
Cardiac dysrhythmias?
Case Study 44 y.o. M
Hx. Of gallstones
Pre op for gall
4 day hx of diarrhea and vomiting
Pre-op for gall bladder removal
diabetic
C/O C.P.
Case Study
18
Hypermagnesemia Serum level > 2.9 mEq/L
Symptoms: Respiratory depression
ECG is similar to hyperkalemia
Sodium
Normal Serum Levels:Levels:
135 -145 mEq/L
19
Hypernatremia Causes:DI, Dehydration – Water loss
Drugs: ie Na BicarbonateDrugs: ie Na Bicarbonate
S & Sx: Confusion to coma
Febrile, Tachycardic
Hypernatremia
Serum Labs HypernatremiaOsmolality elevated
•Dehydration•Almost Always
Osmolality elevated Hypokalemia
Urine Labs Hyponatremia Low osmolality
Hypernatremia
Sodium stays in body with massive fluid loss
Clues Urine Sodium Low with
Volume losses – DI
Urine Sodium HIGH with renal Na loss with osmotic diuresis ie with DKA
20
Hypernatremia
General Treatment Isotonic Fluids for
Vascular Space –Maintain
Monitor for Volume Overload Lung and Heart
SoundsMaintain Hemodynamic Stability
Hypotonic Fluids for Interstitial and Intracellular Replacement May Match UOP
Sounds Peripheral Edema
Check Albumin Levels
Monitor Sodium Correct Slowly!!!
Case Study 52 y.o, s/p subarachnoid
hemorrhage
800 ml of urine over last hour -Clear Pale YellowClear Pale Yellow
Serum Sodium 148
Urine Osmolality 200 mOsm/kg
What is this?
Diabetes Insipidus
Hyponatremia Causes:Dilutional
SIADH, CRF, DM, Water intoxicationintoxication
Salt Wasting Syndromes DKA, Water Intoxication
Atrial Natriuretic Peptide
ACE Inhibition
21
Hyponatremia
SIADH –Syndrome of Inappropriate ADH
S A“Swimming In” ADH Excess Secretion from Post. Pituitary
Excess ADH Decreased UOP
Water Retention – Volume Overload
Dilutional Hyponatremia
Hyponatremia Salt wastingAtrial Natriuretic Factor
Hormone produces sodium excretion Associated with Neurologic damage
Results in: High urine output Low serum sodium Water loss = Dehydration
Decreased CVP & PAOP
Hyponatremia Treat Underlying
CauseSIADH
S & SxHeadache, muscle
cramps, confusion, SIADH
Fluid Restrict, Diuretics, Hypertonic Saline
Salt Wasting Isotonic Fluid
Replacement
Hypertonic Saline
Tachycardia, Seizures
Dilutional Increased CVP & PAOP
Saline Loss Volume Loss
Decreased CVP & PAOP
22
Case Study 56 y.o. F Bronchogenic
Oat Cell Carcinoma, Ventilator Dependent –Trach, Confused.
Decreased urine output Urine Osmolality HIGH
Serum Na: 132 What is this?
SIADH due to Positive Pressure Ventilation
Differentiating
SIADH Salt Wasting
DI
Too Much ADH ANP related to HHH
Too Little ADHHHH
Low Serum Na Low Serum Na High Serum Na
Low UOP High UOP High UOP
23
Integrate 58 y.o. Male, diabetic
Pre-op for Thoracotomy
New onset Atrial New onset Atrial Fibrillation
On Enoxaparin for DVT prophylaxis
Integrate
ABG’s:pH: 7.28
PaO2: 88
PaCO2: 35
HCO3¯: 16
24
Integrate CBCWBC: 18,000
Hgb: 18.5
ChemistryGlucose: 225
Hgb: 18.5
HCT: 52
Platelets: 76,000
TSH: 0.3 μU/ml
Potassium: 3.2
Magnesium: 1.9
10 y.o. F. Grade II Splenic Laceration, MVC
CVP line and hemothorax with chest tubes
ABG: pH: 7.29, PaO2: 78, PaCO2: 49,
HCO3¯: 27
WBC: 14, 500, Hgb: 8.5, HCT: 30%, PLT: 96,000
25
Na: 138
K+: 3 5
BUN: 20
Cr: 0 7 K+: 3.5
CL¯: 107
CO2: 27
Cr: 0.7
Glucose: 120
26 y.o. M s/p crush injury to upper and lower extremities, CHI
Ventilator hemodynamic pressure Ventilator, hemodynamic pressure lines, chest tubes bilaterally
ABG’s: pH: 7.48, PaO2: 90, PaCO2: 32, HCO3¯: 21
Na: 148, K: 3.1
Cl 98 CO2 20 Cl: 98, CO2: 20
BUN: 44, Cr: 1.8
glucose: 187
26
WBC: 15,000 Bands: 40%, Segs:
20%
Fibrinogen: 400
FDP: 35 HGB: 9.6
HCT: 31%
Platelets: 420,000
PT: 16
PTT: 38
Amylase: 280
Urine Myoglobin: Positivey g
Ionized Calcium: 1.08
Lactic Acid: 8.4
Conclusion
Evaluation of laboratory data can assist in interventions for the patient
Speaker Contact: [email protected]
27
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2005;Aug;91(8):1013-1018. The Merck Manual, Endocrine and Metabolism Disorders: fluid and electrolytes: hyponatremia. Found at:
http://www.merck.com/mmpe/sec12/ch156/ch156d.html Last accessed 11/8/09 The Merck Manual, Endocrine and Metabolism Disorders: fluid and electrolytes: hypernatremia. Found at http://www.merck.com/mmpe/sec12/ch156/ch156e.html last accessed 11/8/09 The Merck Manual, Endocrine and Metabolism Disorders: fluid and electrolytes: water and sodium balance. Found at: http://www.merck.com/mmpe/sec12/ch156/ch156b.html last accessed 11/08/09 Urden LD, Stacy KM, Lough ME. (eds.) Critical Care Nursing: Diagnosis and Management. 6th edition. Mosby: St. Louis. 2010.
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