Lecture 8 Lab Values

LECTURE 8 LAB VALUES • you have to know the main ones but also know which ones are more dangerous than others! -> need to know how to prioritize PT’s according to ! lab values (not good enough to just know basics) • scheme (priority levels):! -> the value is abnormal BUT what priority is it?! A = not a priority/low priority; don’t do anything ! about, not a big deal (don’t really need to report it)! B = need to be concerned but nothing you need to do; ! just needs closer monitoring! C = crossed a line from low to high priority; it is ! critical, you have to do something about it ! i. always hold (if there’s something to hold)! ii. assess (focused)! iii. prepare to give! iv. call whomever is appropriate! D = highest priority that you can possibly have w/ a ! lab value; do something STAT!! -> you cannot leave their bedside (you can leave ! the bedside of a “C” level if needed); get other ! people to help! Name and Info pH Normal Range 7.35 7.45 BUN (blood urea nitrogen) 8 - 25 nitrogen waste products in the blood HgB 12 - 18! Bicarb 22 - 26 CO2! 35 - 45 * not for ! COPD ! PT’s, reg. ! PT’s from arterial blood gas Name and Info Serum Creatinine! Normal Range 0.6 - 1.2 (same as Lithium) best indicator of kidney function INR (international normalized ratio) 2 - 3’s (variation of PT) Hematocrit A! - never make a PT w/ high creatinine as ! highest priority! - probably have kidney disease BUT they ! are not going to die in the next 4 hours! - only time you might call MD is if they’re going for a test that has a dye in it (but still ! wait to call in the morning, not right away) C = anything that is 4 & above is! i. hold Coumadin ii. assess bleeding! iii. prepare to give Vit. K! iv. call MD 36 - 54! ! * 3X the HgB (so memorize the HgB & multiply by 3) Priority Level if Abnormal PO2 78 - 100 from arterial blood gas (not from pulse oximetry) monitors Coumadin K+ not a good indicator of something specific, just that something is wrong 3.5 - 5.3 C = if lower than 3.5! i. nothing to hold! ii. assess the heart! iii. prepare to give K+! iv. call MD! ! C = between 5.4 - 5.9 i. hold all K+! ii. assess the heart! iii. prepare to give D5W + reg. insulin + ! Kayexelate! ! iv. call MD! ! D = if > 6 (this PT could die soon; do all the ! same as C but do it stat! & need more ! than 1 person) O2 Sat D = in the 6’s (ex. 6.58) i. nothing to hold! ii. assess vitals (body goes down w/ the ! pH) to make sure they’re alive! iii. nothing to prepare BUT treat the ! underlying cause (which only the MD ! can do)! iv. call MD faster than in any other case A = if elevated it’s not a big deal ! -> assess PT for dehydration! ! Hint: if they give an elevated blood value & you have no clue what’s going on & they ask “for what would you assess them” ! -> dehydration is a great guess (because all ! blood values go up from concentration) B = 8 - 11! ** boards - assess for low HgB (bleeding, malnutrition) tend to not go into C = below 8 genders i. nothing to hold (this is the ii. assess for bleeding normal iii. prepare to give blood adult iv. call MD HgB) • Hint: Assess before you do unless delaying doing puts your PT at higher risk! (ex. blood transfusion reaction)! - ex. you should put the HOB up first before doing resp. ! assessment because keeping a dyspneic PT flat on bed ! longer puts them at higher risk! - DON’T FORGET TO SEE IF IT’S A FIRST vs. BEST question Priority Level if Abnormal 93 - 100 A C = high but in the 50’s! -> PT will be dyspneic! i. nothing to hold ii. assess resp. status! iii. prepare to get PT to do pursed-lipped ! breathing (prolongs exhalation to get ! rid of CO2)! iv. breathing usually fixes it so you don’t ! have to call! D = in the 60’s -> one of the criteria for ! resp. failure (MEDICAL EMERGENCY) i. nothing to hold! ii. assess resp. status! iii. prepare to intubate & ventilate! iv. call resp. therapy first then MD B = elevated! -> assess for dehydration C = low but still in 70’s! i. nothing to hold! ii. assess resp. status! iii. prepare to give O2! iv. most times the O2 administration ! works and you don’t have to call the ! MD because the dyspnea goes away! * hypoxic -> heart rate speeds up first and ! when the heart can’t work hard anymore, ! the resp. rate goes up! ! D = if in the 60’s -> the other criteria for resp. failure (MEDICAL EMERGENCY) i. nothing to hold! ii. assess resp. status! iii. prepare to intubate & ventilate! iv. call resp. therapy first then MD ! * you can still put O2 during this time ! -> won’t solve the problem but will help ! keep them calm C = anything less than 93 i. nothing to hold ii. assess them iii. prepare to give O2 if really low iv. don’t need to call MD if O2 goes up! * you better freak out though if in paeds it ! goes below 95! * anemia falsely elevates it (you should look ! for other indicators); dye procedures in ! the last few hours also invalidates it w/ ! false elevation Name and Info BNP (brain natriuretic peptide) Normal Range should be under 100 best indicator of congestive heart failure Priority Level if Abnormal B = elevated BNP! - you know they have CHF/watch them for ! CHF! - it’s not high priority because it indicates a ! chronic condition Sodium 135 - 145 B = if abnormal then assess! - if high -> assess for dehydration! - if low -> assess for overload! ! C = if Na is abnormal and there is a change in LOC (because it becomes a safety issue) WBC’s! Total C = all of them -> if they go below their * 3 counts ! WBC! thresholds that you ! 5,000 i. nothing to hold must ! 11,000! ii. assess for signs of infection ! know iii. instead of preparing, place them on ANC neutropenic precautions ! (absolute Neutrophil count)! needs to be above 500! ! CD4! needs to above 200 Platelets RBC’s -> if it falls below you go from HIV to AIDS C = below 90,000! -> bleeding precautions 4-6 million D = below 40,000 B • memorize the 5 D’s => highest priorities!! - pH in the 6’s! - K+ in the 6’s! - CO2 in the 60’s! - O2 in the 60’s! - platelet below 40,000! —> boards doesn’t really put these kind of PT’s ! against each other because it’s not fair • learn the C’s