phlebotomy principles preferably anticubital; definitely avoid underside of wrist. largest vein...

Phlebotomy PrinciplesPhlebotomy Principles

Preferably anticubital; definitely avoid underside of wrist.Preferably anticubital; definitely avoid underside of wrist.Largest vein smallest needle for what you need to drawLargest vein smallest needle for what you need to drawDo not draw labs from the same arm as an IV infusion Do not draw labs from the same arm as an IV infusion If you must, stop IV, flush line and wait about 5 minutes to draw.If you must, stop IV, flush line and wait about 5 minutes to draw.Monitor site for hemostasis prior to applying bandaid and leaving.Monitor site for hemostasis prior to applying bandaid and leaving.Drawing labs from a central line, waste 5 cc of blood (may reinstill)Drawing labs from a central line, waste 5 cc of blood (may reinstill)All specimens labeled at bedside by the person who drew the blood. All specimens labeled at bedside by the person who drew the blood. Label with:Label with:– Pt namePt name– Pt ID numberPt ID number– DateDate– TimeTime– Initials of person who drew bloodInitials of person who drew blood

HematologyHematology

CBCCBC– RBCRBC– HemglobinHemglobin– HematocritHematocrit

WBC with Differential:WBC with Differential:– BandsBands– Segmented NeutrophilsSegmented Neutrophils– BasophilsBasophils– EosinophilsEosinophils– MonocytesMonocytes– LymphocytesLymphocytes

Erythrocyte Sedimentation RateErythrocyte Sedimentation Rate

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo Low

HematocritHematocrit

(Hct)(Hct)

Prep: nonePrep: none

Percentage of Percentage of RBCs in the RBCs in the plasmaplasma

Men: 42-49%Men: 42-49%

Women 35-47%Women 35-47%

Effected by hydration.Effected by hydration. Lose of plasma Lose of plasma relative to RBCs relative to RBCs elevated Hct (i.e. burn elevated Hct (i.e. burn pts). In euvolemic pt, pts). In euvolemic pt, increased Hct increased Hct indicates true increase indicates true increase in RBCsin RBCs

Decreased Hct can Decreased Hct can be caused by be caused by overhydration overhydration or a or a true decrease in true decrease in RBCs. Hct RBCs. Hct immediately after immediately after blood lose will be blood lose will be normal (equal loss normal (equal loss of RBCs and of RBCs and Plasma). Within a Plasma). Within a few hours plasma few hours plasma vol normal but vol normal but RBCs causes RBCs causes HctHct

HemoglobinHemoglobin

(Hgb)(Hgb)


Amount of “heme” Amount of “heme” pigment in the pigment in the RBCs. Normally RBCs. Normally Hct is 3 times Hct is 3 times Hgb. Hgb. Vital in Vital in assessing types assessing types of anemiaof anemia. Hgb is . Hgb is vehicle for vehicle for transporting transporting oxygen.oxygen.

Men:Men:

14-16.5 g/100 ml14-16.5 g/100 ml

Women: Women:

12-15 g/100 ml12-15 g/100 ml

Hyperchromic (too Hyperchromic (too much Hgb pigment)much Hgb pigment)

Hypochromic (too Hypochromic (too little hgb pigment) little hgb pigment) is seen in diseases is seen in diseases with abnormal with abnormal types of Hgb that types of Hgb that are fragile (sickle are fragile (sickle cell. Hypochromic, cell. Hypochromic, microcytic cells are microcytic cells are seen in iron seen in iron deficiency anemiadeficiency anemia


Red Blood Red Blood Cell Count Cell Count (RBC)(RBC)


Number of Red Number of Red Blood Cells per Blood Cells per cubic millimeter of cubic millimeter of blood. The blood. The hormone, hormone, erythropoietin,erythropoietin, secreted from the secreted from the kidneys stimulates kidneys stimulates RBC production RBC production by red bone by red bone marrow. Tissue marrow. Tissue hypoxia causes hypoxia causes increased release increased release of erythropoietin. of erythropoietin. “Anemia” is a “Anemia” is a nonspecific term nonspecific term for decreased for decreased RBCs. Dx RBCs. Dx AnemaisAnemais

Men: 4.5-5.3 Men: 4.5-5.3 million/mmmillion/mm33

Women: 4.1-5.1 Women: 4.1-5.1 million/mmmillion/mm33

Pregnancy: 5-5 – 6 million/mm3

In congenital heart In congenital heart disease, and chronic disease, and chronic lung disease the body lung disease the body increases RBCs to increases RBCs to attempt to compensate attempt to compensate for hypoxia. Also for hypoxia. Also occurs in persons who occurs in persons who live at high altitudes. live at high altitudes. Increased RBCs called Increased RBCs called Polycythemia or Polycythemia or ErythrocytosisErythrocytosis

Decreased RBC Decreased RBC count can be due to count can be due to 1) abnormal loss of 1) abnormal loss of erythrocytes erythrocytes (bleeding) 2) (bleeding) 2) abnormal abnormal destruction of destruction of erythrocytes (look erythrocytes (look for increased for increased bilirubin) 3) lack of bilirubin) 3) lack of needed elements or needed elements or hormones for hormones for erythrocyte erythrocyte production (renal production (renal failure) 4) Bone failure) 4) Bone marrow marrow suppression.suppression.

White Blood White Blood Cell Count Cell Count (WBC)(WBC)


Total number of Total number of White Blood Cells White Blood Cells in a cubic in a cubic millimeter of millimeter of blood.blood.

4,800-11,000 /mm

If elevated - infection

Severe bacterial infections will cause an elevation in WBC count due to a rise in neutrophils.

LeukopeniaLeukopenia: : Chemotherapy, Chemotherapy, radiation therapy, radiation therapy, leukemia and leukemia and aplastic anemia. In aplastic anemia. In addition, many addition, many common common medications.medications.

Decreased RBCsDecreased RBCs

HemolysisHemolysis

Decreased RBCs related to AnemiaDecreased RBCs related to Anemia

Renal FailureRenal Failure

Bone Marrow SuppressionBone Marrow Suppression

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowBands (Stabs Bands (Stabs or Young or Young Neutrophils)Neutrophils)


Immature Immature neutrophilsneutrophils increase (shift to increase (shift to the left) with the left) with overwhelming overwhelming bacterial infection.bacterial infection.

0-5% Increase when body if Increase when body if fighting overwhelming fighting overwhelming bacterial infectionbacterial infection, , increases number of increases number of immature neutrophilsimmature neutrophils

Shift to right – excessively high segmented neutrophils sometimes seen in anemias, liver disease, or long-term infections.

Segmented Segmented Neutrophils Neutrophils (Segs or (Segs or Polys)Polys)


Body’s first Body’s first defense against defense against bacterial infection bacterial infection and severe stress. and severe stress. Mature neutrophils Mature neutrophils are segs.are segs.

45-75% Neutrophilia

Shift to right – excessively high segmented neutrophils sometimes seen in anemias, liver disease, or long-term infections.

NeutropeniaNeutropenia

Reduced when Reduced when there is a shift to the there is a shift to the left and more left and more immature immature neutrophils. neutrophils. Neutropenic Neutropenic precautionsprecautions..

EosinophilsEosinophils


Function not Function not clearly clearly understood, but understood, but are associated are associated with antigen-with antigen-antibody antibody response.response.

0-8% Eosinophilia

Most common cause for elevation is allergic reaction (asthma, hay fever) or hypersensitivity to medication. Also, parasitic infestation (round worms will cause it).

Incresed levels of Incresed levels of adrenal steroids will adrenal steroids will decrease eosinophil decrease eosinophil count (i.e. patients count (i.e. patients with COPD on with COPD on corticosteroids)corticosteroids)

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowBasophilsBasophils


Clinical Clinical significance not significance not knownknown

0-3% Do know that leukemia Do know that leukemia and other pathologic and other pathologic alterations in bone alterations in bone marrow production marrow production may increase may increase basophils.basophils.

Corticosteroids, Corticosteroids, allergic reacions and allergic reacions and acute infections may acute infections may decrease basophil decrease basophil count.count.

LymphocytesLymphocytes


Principle Principle component of component of body’s immune body’s immune system.system. Only Only small portion of small portion of these circulate in these circulate in the blood stream.the blood stream.

Most are T Most are T lymphocytes. 90% lymphocytes. 90% of leukemias of leukemias (acute or chronic) (acute or chronic) are lymphocytic. are lymphocytic.

25-35% LympocytosisLympocytosis

A common reason is A common reason is lymphocytic leukemia. lymphocytic leukemia. Lymphocytes also Lymphocytes also increase in many viral increase in many viral infections including infections including mumps, hepatitis, mumps, hepatitis, pertusis, infectious pertusis, infectious mononucleosis. Also mononucleosis. Also sometimes with some sometimes with some tumors and often with tumors and often with tuberculosis.tuberculosis.

LymphocytopeniaLymphocytopenia

HIV and AIDsHIV and AIDs are the are the most common cause most common cause of reduced of reduced lympocytes (T-lympocytes (T-lymphocytes in lymphocytes in particular). particular). Adrenocorti-Adrenocorti-costeroids and other costeroids and other immunosuppressive immunosuppressive medication. medication. Autoimmune disease Autoimmune disease such as systemic such as systemic lupus erythematosus.lupus erythematosus.

MonocytesMonocytes


Monocytes are Monocytes are present in tissue present in tissue as macrophages. as macrophages. Act as phagocytes Act as phagocytes in some chronic in some chronic inflammatory inflammatory diseasesdiseases

4-6% PAD. Some protozoan infections (i.e. malaria), and rickettsial infection (i.e. rocky mountain fever) increase monocytes. Chronic ulcerative colitis also.

Depleted in Depleted in overwhelming overwhelming bacterial infection.bacterial infection.

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowErythrocyte Erythrocyte Sedimentation Sedimentation Rate (Sed Rate (Sed Rate)Rate)

Prep: Fasting Prep: Fasting not necessary not necessary but a fatty but a fatty meal may meal may cause plasma cause plasma alteration.alteration.

Measures the Measures the speed at which speed at which RBCs settle in a RBCs settle in a tube of tube of anticoagulated anticoagulated blood. Increased blood. Increased plasma globulins plasma globulins or fibrinogen or fibrinogen increase sticking increase sticking together and together and settling. If they are settling. If they are macrocytic the macrocytic the settle faster; settle faster; microcytic slower. microcytic slower.

Non-specific for Non-specific for chronic chronic inflammation, or inflammation, or chronic infection.chronic infection.

Men: 0-17 mm/hrMen: 0-17 mm/hr

Women: 1-25 mm/hrWomen: 1-25 mm/hr

Pregnancy: 44-114 Pregnancy: 44-114 mm/hrmm/hr

May be normal as in May be normal as in pregnancy. However pregnancy. However an increase in sed rate an increase in sed rate typically reflect an typically reflect an inflammation or tissue inflammation or tissue injuryinjury. Sed rate > 100 . Sed rate > 100 mm/hr (in nonpregant mm/hr (in nonpregant persons) is most likely persons) is most likely caused by infection, caused by infection, malignant tumors, malignant tumors, collagen vascular collagen vascular disease. Also elevated disease. Also elevated in Rheumatoid in Rheumatoid Arthritis, Pelvic Arthritis, Pelvic Inflammatory Disease, Inflammatory Disease, AIDs and Temporal AIDs and Temporal Arteritis.Arteritis.

Low sed rate is not Low sed rate is not usually clinically usually clinically significant. May be significant. May be associated with associated with sickle cell anemia, sickle cell anemia, hypoalbuminemia or hypoalbuminemia or a deficiency in a deficiency in Factor V.Factor V.

Coagulation StudiesCoagulation Studies

Activated Partial Thromboplastin TimeActivated Partial Thromboplastin Time

Prothrombin TimeProthrombin Time

INRINR

Platlet CountPlatlet Count

Bleeding TimeBleeding Time

Fibrin Split ProductsFibrin Split Products

Coagulation StudiesCoagulation StudiesLab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo Low

Activated Partial Activated Partial Thromboplastin Thromboplastin Time (aPTT)Time (aPTT)

Prep: Draw Prep: Draw blood 1 hour blood 1 hour prior to prior to intermittent intermittent heparin dose. heparin dose. Transport to lab Transport to lab immediately.immediately.

Usually used to Usually used to monitor heparin monitor heparin therapy effects. therapy effects. Evaluates how well Evaluates how well the coagulation the coagulation cascade is cascade is functioning. functioning.

20-36 seconds20-36 seconds

Heparin Therapy Heparin Therapy desired value:desired value:

1.5 – 2.5 times 1.5 – 2.5 times normalnormal

Increased likelihood Increased likelihood of bleeding. Usually of bleeding. Usually due to due to too much too much heparinheparin, decrease , decrease dosage. dosage. Protamine Protamine sulfate is antidote if sulfate is antidote if patient too patient too anticoagulated from anticoagulated from heparin (risk of clots heparin (risk of clots though).though).

In persons not taking In persons not taking heparin signifies heparin signifies bleeding disorder bleeding disorder such as such as hemophilia A hemophilia A (facot VIII) or B (facot VIII) or B (Christmas disease(Christmas disease – – factor IX)factor IX)

Subtherapeutic Subtherapeutic heparin therapy, heparin therapy, increase dosage. increase dosage. Not clinically Not clinically significant except for significant except for reflectign reflectign hypercoagulability.hypercoagulability.

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowProthrombin Prothrombin TimeTime

(PT)(PT)

Prep: NonePrep: None

Obtain baseline Obtain baseline prior to coumadin prior to coumadin therapy. Diets high therapy. Diets high in green leafy in green leafy vegtables (vit K) vegtables (vit K) will decrease PTwill decrease PT

Male Adults:Male Adults:

9.6 -11.8 seconds9.6 -11.8 seconds

Female Adults:Female Adults:

9.5 – 11.3 seconds9.5 – 11.3 seconds

Coumadin Therapy:Coumadin Therapy:

1.5 – 2 times lab 1.5 – 2 times lab control.control.

> 30 seconds places client at significant risk of bleeding. Increased likelihood Increased likelihood of bleeding. Too high of bleeding. Too high may need to may need to administer IM administer IM injection of injection of vitamin Kvitamin K

Typically not Typically not significant unless on significant unless on coumadin. coumadin.

SubtherapueticSubtherapuetic coumadin dosing, coumadin dosing, increase dosage or increase dosage or pt at risk for clot.pt at risk for clot.

INRINR

Prep: NonePrep: None

A calculated A calculated adjustment to adjustment to standardize PT standardize PT results based on results based on the type of the type of thromboplastin thromboplastin reagent used reagent used (varying (varying sensitivities)sensitivities)

2.0 – 3.0 for 2.0 – 3.0 for standard coumadin standard coumadin therapytherapy

3.0 - 4.5 for high 3.0 - 4.5 for high dose coumadin dose coumadin therapytherapy

Increased likelihood Increased likelihood of bleeding. Too high of bleeding. Too high may need to may need to administer IM administer IM injection of vitamin Kinjection of vitamin K

Subtherapuetic Subtherapuetic coumadincoumadin dosing, dosing, increase dosage or increase dosage or pt at risk for clot.pt at risk for clot.

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowBleeding timeBleeding time

Prep: Do not Prep: Do not administer administer heparin for at heparin for at least 3 hours least 3 hours prior.prior.

The time required The time required for the interaction for the interaction of all steps in the of all steps in the clotting cascade to clotting cascade to clot blood. Use BP clot blood. Use BP cuff up to 40 mm cuff up to 40 mm Hg and filter paper.Hg and filter paper.

2– 9 minutes2– 9 minutes Evaluation of Evaluation of bleeding disorders bleeding disorders such as DIC, or such as DIC, or hemophilia.hemophilia.

Test will be falsely Test will be falsely prolonged by any prolonged by any anticoagulant anticoagulant therapy, agitation of therapy, agitation of vial or exposure of vial or exposure of blood tube to high blood tube to high temp.temp.

None.None.

Platlet CountPlatlet Count


Platlets are vitally Platlets are vitally important in important in hemostatic plug hemostatic plug formation, formation, coagulation factor coagulation factor activation. activation. Bleeding Bleeding precautions for precautions for thrombocytopenia thrombocytopenia patients.patients.

150,000-400,000 150,000-400,000 cells/mmcells/mm3

Living at high Living at high altitudes, chronic cold altitudes, chronic cold weather and exercise weather and exercise increase platlet increase platlet count. Increased risk count. Increased risk of clots.of clots.

Thrombocytopenia. Thrombocytopenia. Increased risk of Increased risk of bleeding. Seen in bleeding. Seen in DICDIC, various , various bleeding disorders. bleeding disorders. Some medications Some medications may cause may cause thrombocytopenia thrombocytopenia (i.e. heparin, (i.e. heparin, chemotherapy). chemotherapy).

Fibrin Fibrin Degredation Degredation (Split) Product (Split) Product (FDP or FSP)(FDP or FSP)

Resulst from Resulst from breakdown of fibrin breakdown of fibrin clots by the action clots by the action of the enzyme of the enzyme plasmin. Used to plasmin. Used to diagnose DICdiagnose DIC

< 2.5 mcg/ml< 2.5 mcg/ml Suggestive of DICSuggestive of DIC NoneNone

LFTsLFTs

AlbuminAlbumin

SGOTSGOT

SGPTSGPT

Alkaline phosphataseAlkaline phosphatase

AmmoniaAmmonia

BilirubinBilirubin

LFTsLFTsTestTest SignificancSignificanc

eeNormal Normal ValueValue

Too HighToo High Too LowToo Low

Serum Serum Alkaline Alkaline phosphatase phosphatase

(ALP)(ALP)

Prep: fasting Prep: fasting for 12 hours for 12 hours prior; avoid prior; avoid hepatotoxic hepatotoxic meds 12 meds 12 hours prior hours prior or the or the results may results may be elevated.be elevated.

Mostly in liver Mostly in liver and bone. Also and bone. Also intestines and intestines and placenta. placenta. Increased Increased during new during new bone bone formationformation – – therefore therefore children have children have higher levelshigher levels

100-115 U/L 100-115 U/L

Children 1-2 Children 1-2 times adult times adult levelslevels

Not specific testNot specific test. If . If the alkaline the alkaline phosphatase is phosphatase is elevated, biliary elevated, biliary tract damage and tract damage and inflammation inflammation should be should be considered. May be considered. May be renal or GI too. renal or GI too. May also elevate May also elevate during periods of during periods of bone growth bone growth ((pagets disease)pagets disease)

In child prior to In child prior to puberty indicates puberty indicates lack of normal lack of normal bone formation. bone formation.

Serum Serum Ammonia Ammonia levellevel

Prep: fast, Prep: fast, except for except for water, and water, and avoid avoid smoking for smoking for 8 to 10 8 to 10 hours prior. hours prior.

The liver The liver normally normally convert NH3 convert NH3 (ammonia), a (ammonia), a byproduct of byproduct of protein protein metabolism metabolism into urea to be into urea to be excreted by excreted by kidneys. kidneys.

35 - 65 m35 - 65 mg/dLg/dL In severe liver In severe liver failure BUN failure BUN decreases as decreases as ammonia levels ammonia levels increase. Elevated increase. Elevated ammonia levels ammonia levels will cause s/s of will cause s/s of hepatic hepatic encephalopathy.encephalopathy.

NoneNone

Hepatic EncephalopathyHepatic EncephalopathyHepatic encephalopathyHepatic encephalopathy is a potentially-reversible neuropsychiatric is a potentially-reversible neuropsychiatric abnormality in the setting of acute or chronic liver failure due to elevated abnormality in the setting of acute or chronic liver failure due to elevated ammonia levelsammonia levels– Dx by exclusion of other neurological, psychiatric, infectious, and metabolic Dx by exclusion of other neurological, psychiatric, infectious, and metabolic

etiologies etiologies ManifestationsManifestations– earliest manifestations: "day-night reversal” individuals tend to sleep during the earliest manifestations: "day-night reversal” individuals tend to sleep during the

day and stay awake at night. day and stay awake at night. – impairment in spatial perception: poor ability to copy or draw various simple impairment in spatial perception: poor ability to copy or draw various simple

images, e.g., cube, star, clock. images, e.g., cube, star, clock. – changed level of consciousnesschanged level of consciousness– asterixisasterixis is the hallmark of hepatic encephalopathy: Detected by having the is the hallmark of hepatic encephalopathy: Detected by having the

patient hold out his outstretched arms and hands while cocking his wrists back. In patient hold out his outstretched arms and hands while cocking his wrists back. In the presence of asterixis, there is a non-synchronized, intermittent flapping motion the presence of asterixis, there is a non-synchronized, intermittent flapping motion at the wristsat the wrists

TreatmentTreatment– Treat causeTreat cause– Antibiotics may be given to kill bacteria present in the bowel, thereby decreasing Antibiotics may be given to kill bacteria present in the bowel, thereby decreasing

bacterial conversion of protein to ammonia bacterial conversion of protein to ammonia – Lactulose: osmotic diarrhoeaLactulose: osmotic diarrhoea, thus lessening the time available for intestinal , thus lessening the time available for intestinal

bacteria to metabolise protein into ammonia within the bowel. bacteria to metabolise protein into ammonia within the bowel.

TestTest SignificancSignificancee

Normal ValueNormal Value Too HighToo High Too LowToo Low

Albumin Albumin

(Alb) (Alb) Major protein Major protein present within present within the blood. the blood. Synthesized Synthesized by the liver.by the liver.

3.4-5 g/dL3.4-5 g/dL HyperalbuminemiaIHyperalbuminemiaIncreased in ncreased in dehydration due to dehydration due to hemoconcetration.hemoconcetration. Also, may increase Also, may increase in in metastatic metastatic carcinomas or carcinomas or diarrheadiarrhea..

Liver failure, Liver failure, alcoholism, and alcoholism, and acute infections acute infections can cause low can cause low albumin albumin (hypoalbuminemi(hypoalbuminemia). a). Malnutrition,Malnutrition, in the absence of in the absence of liver failureliver failure, can , can also cause low also cause low albumin.albumin.

Aspartate Aspartate transaminase transaminase

(AST or SGOT) (AST or SGOT)

It is It is less less specific for specific for liver disease.liver disease. May be May be elevated in elevated in other other conditions conditions such as an MI.such as an MI.

0-45 U/L 0-45 U/L Enzyme Enzyme elevation elevation reflects damage reflects damage to the hepatic to the hepatic (i.e. hepatitis) or (i.e. hepatitis) or cardiac cells cardiac cells (myocardial (myocardial infarction), but infarction), but non-specific.non-specific.

No Clinical No Clinical Signficance.Signficance.

Alanine Alanine transaminase transaminase

(ALT or SGPT)(ALT or SGPT)

Found in Found in various various bodily tissuesbodily tissues, , but is most but is most commonly the commonly the

liverliver

0- 50 U/L 0- 50 U/L Usually liver or Usually liver or cardiac cause: viral cardiac cause: viral hepatitis, congestive hepatitis, congestive heart failure, liver heart failure, liver damage, biliary duct damage, biliary duct problems, infectious problems, infectious mononucleosis. mononucleosis.

No clinical No clinical significance.significance.

Lab Test Significance

Normal Value

Too Hi Too Low

Total Bilirubin

Prep: fast rro 4 hours prior; eat diet low in yellow foods (i.e. carrots, yams, yellow beans) for 3-4 days prior.

RBCs normal life span 120 days. RBC breakdown (normal or abnormal releases bilirubin). Removed from blood by liver, spleen and bone marrow.

0.3 to 1.5 mg/dL Increase with any type of jaundice. Discoloration of skin and the sclera of the eye occurs when bilirubin accumulates in the blood at a level greater than approximately 2.5 mg/dL.

No significance

Direct (conjugated) Bilirubin

Conjugated bilirubin excreted in GI tract. Tells you whether the problem is occuring before or after the liver.

0 - 0.3 mg/dL Elevated direct (or conjugated) bilirubin (post hepatic problem – i.e. obstruction – gall stone)

No significance

Indirect(unconjugated) Bilirubin

Unconjugated circulates in blood stream excreted by kidneys (urobilogen).Tells you whether the problem is occuring before or after the liver.

0.1 - 1.0 mg/dl Elevated indirect (or unconjugated) bilirubin (Intra or pre-hepatic problem – i.e. hemolysis, or hepatic failure)

No significance

BilirubinBilirubinIncreased by Increased by – Increased RBC distruction i.e. hemolytic Increased RBC distruction i.e. hemolytic

transfusion reactiontransfusion reaction– Liver dysfunction failure and inability to Liver dysfunction failure and inability to

conjugateconjugateHepatitisHepatitis

CirrhosisCirrhosis

Liver CancerLiver Cancer

– Inability to excrete conjugated bilirubin Inability to excrete conjugated bilirubin Common bile duct obstruction (i.e. gal stone)Common bile duct obstruction (i.e. gal stone)

Hepatitis TestingHepatitis Testing

Antibody test i.e.. Anti-HBs or Anti- HVCAntibody test i.e.. Anti-HBs or Anti- HVC

AntigenAntigen testtest i.e.. (HBsAg) i.e.. (HBsAg)

Pancreatic FunctionPancreatic Function

Serum AmylaseSerum Amylase

Serum LipaseSerum Lipase

Urine Amylase Urine Amylase

Pancreatic FunctionPancreatic FunctionLab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo Low

Serum Serum AmylaseAmylase

Prep: list meds Prep: list meds since since numerous numerous meds can meds can effect level. effect level. Results invalid Results invalid if pt had chole-if pt had chole-cystography cystography with contrast with contrast within 72 within 72 hourshours

This enzymes is This enzymes is produced by the produced by the pancreas and pancreas and salivary glands – salivary glands – digests digests carbohydrates. carbohydrates. Excreted by kidneys.Excreted by kidneys.

25-151 units/L25-151 units/L Greatly increased Greatly increased

along with lipasealong with lipase in in

acute pancreatitis. acute pancreatitis.

Rises 3 – 6 hours Rises 3 – 6 hours

after onset of pain. after onset of pain.

Isolated Isolated Causes: Causes:

Pancreatic neoplasm Pancreatic neoplasm

Perforated peptic ulcer Perforated peptic ulcer

Intestinal Obstruction Intestinal Obstruction

Intestinal infarction Intestinal infarction

Acute Cholecystitis Acute Cholecystitis

AppendicitisAppendicitis

Ruptured Ectopic Ruptured Ectopic Pregnancy Pregnancy

PeritonitisPeritonitis

No significance.No significance.

Serum LipaseSerum Lipase

Prep: ERCP Prep: ERCP may may

Pancreatic enzyme Pancreatic enzyme converts fats and converts fats and triglycerides into fatty triglycerides into fatty acids and glycerol.acids and glycerol.

10-140 units/L10-140 units/L Elevated in pancreatic Elevated in pancreatic disorders along with disorders along with amylase. amylase. More More diagnosticdiagnostic then then amylase which amylase which from from other causes.other causes.

No significance.No significance.

Pancreatic FunctionPancreatic FunctionLab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo Low

Urine AmylaseUrine Amylase

Prep: may be Prep: may be a 2 hour a 2 hour specimen, but specimen, but typically a 24 typically a 24 hour urine.hour urine.

If the serum amylase If the serum amylase is elevated the body is elevated the body tries to excrete it tries to excrete it renally.renally.

4-400 units/L4-400 units/L Acute pancreatitis. Acute pancreatitis. Levels will remain Levels will remain elevated for up to 2 elevated for up to 2 weeks after acute weeks after acute episode even after episode even after serum amylase has serum amylase has begun to return to begun to return to normal. Continued normal. Continued elevation suggests elevation suggests formation of formation of pancreatic pancreatic pseudocyst.pseudocyst.

No significanceNo significance

Renal FunctionRenal Function

Blood Urea Nitrogen (BUN)Blood Urea Nitrogen (BUN)

CreatinineCreatinine

Creatinine ClearanceCreatinine Clearance

Serum Uric AcidSerum Uric Acid

Urine Uric AcidUrine Uric Acid

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowBlood Urea Blood Urea NitrogenNitrogen

No special No special prep of pt.prep of pt.

Urea, a waste Urea, a waste product of protein product of protein metabolism, is metabolism, is formed by the formed by the liver and carried liver and carried in the blood to be in the blood to be excreted by the excreted by the kidneys.kidneys.

8-25 mg/dL8-25 mg/dL Diseased or damaged Diseased or damaged kidneys can result in kidneys can result in BUN for failure to BUN for failure to excrete. Also, excrete. Also, decreased perfusion decreased perfusion to kidneys or lack of to kidneys or lack of volume flow volume flow (dehydration). Also, (dehydration). Also, increased protein increased protein intact or GI bleed.intact or GI bleed.

Over hydration. Over hydration. Increase in ADH Increase in ADH will dilute plasma will dilute plasma and decrease BUN and decrease BUN artificially. Severe artificially. Severe liver failure can liver failure can reduce metabolism reduce metabolism of protein and urea of protein and urea formation, but formation, but other nitrogenous other nitrogenous waste (i.e. waste (i.e. ammonia will ammonia will increase)increase)

Serum Serum CreatinineCreatinine

Minimize Minimize intake of intake of ascorbic ascorbic acid, acid, barbiturates barbiturates or cephalo-or cephalo-sporins sporins antibiotics antibiotics which may which may elevate lab.elevate lab.

Waste product of Waste product of creatinine creatinine phosphate, a phosphate, a high-energy high-energy compound found compound found in skeletal in skeletal muscle.muscle.

Men: 0.6 – 1.5 Men: 0.6 – 1.5 mg/dLmg/dL

Women: 0.6-1.1 Women: 0.6-1.1 mg/dLmg/dL

Elevated creatinine is Elevated creatinine is caused by damaged caused by damaged nephrons. nephrons. More More diagnostic then BUNdiagnostic then BUN

Creatinine > 1.5 mg = Creatinine > 1.5 mg = > 50% nephron > 50% nephron function loss.function loss.

Creatinine > 4.8 = as Creatinine > 4.8 = as high as 75% nephron high as 75% nephron function loss.function loss.

Decreased level Decreased level may indicate may indicate atrophy of muscle atrophy of muscle tissue.tissue.

BUN :Creatinine BUN :Creatinine Ratio should be Ratio should be 10:110:1


Creatinine Creatinine Clearance TestClearance Test

Prep: 2, 12 or Prep: 2, 12 or 24 hour urine 24 hour urine collection; collection; discard first discard first void; sometime void; sometime during during collection a collection a serum serum creatinine is creatinine is collected.collected.

Creatinine Creatinine Clearance Test is Clearance Test is used as an used as an indicator of indicator of glomerular glomerular filtration rate. filtration rate. Compares serum Compares serum creatinine with creatinine with the amount of the amount of creatinine creatinine excreted in a excreted in a specified period specified period of time. of time. Better Better indicator of renal indicator of renal functionfunction than than BUN or creatinine BUN or creatinine alone.alone.

Men: 95-135 ml/minMen: 95-135 ml/min

Women: 85-125 ml/minWomen: 85-125 ml/min

No significanceNo significance Decreased Decreased creatinine clearance creatinine clearance indicates decreased indicates decreased glomerular function. glomerular function. Used to evaluation Used to evaluation progression progression (continued (continued deterioration) of deterioration) of renal disease. A renal disease. A creatinine clearance creatinine clearance of at of at least 10 ml/min least 10 ml/min is needed to sustain is needed to sustain life or dialysis is life or dialysis is necessary.necessary.


Serum Uric Serum Uric AcidAcid

Prep: Prep: overnight fast; overnight fast; dietary history dietary history regarding regarding foods high in foods high in purines.purines.

Uric acid is an Uric acid is an end product of end product of purine purine metabolism. metabolism. Purines are in the Purines are in the nucleoproteins of nucleoproteins of all cells are all cells are obtained from obtained from various dietary various dietary sources and the sources and the breakdown of breakdown of body proteins.body proteins.

Foods high in Foods high in purines:purines:

LiverLiver

SardinesSardines

AnchoviesAnchovies

SweetbreadsSweetbreads

KidneysKidneys

SpinachSpinach

MushroomsMushrooms

AsparagusAsparagus

LentilsLentils

Men <40: 3.6-8.5 Men <40: 3.6-8.5 mg/dLmg/dL

Women: 2.3-6.6 Women: 2.3-6.6 mg/dLmg/dL

HyperuricemiaHyperuricemia

Renal impairment Renal impairment most common cause most common cause (decreased (decreased excretion). Also excretion). Also preeclampsia, preeclampsia, neoplasms, neoplasms, chemotherapy or chemotherapy or radiation therapy, radiation therapy, chronic malnutrition or chronic malnutrition or diet high in purines.diet high in purines.

Hypervolemia – Hypervolemia – diluted (i.e.. Iv fluids diluted (i.e.. Iv fluids or SIADH)or SIADH)

NoneNone

Urine Uric AcidUrine Uric Acid

Prep: 24 hour Prep: 24 hour urine collectionurine collection

250-750 mg/24 250-750 mg/24 specimenspecimen

Cardiac BiomarkersCardiac Biomarkers

CKCKCK-MBCK-MBLDHLDHMyoglobinMyoglobinTroponin ITroponin ITroponin TTroponin TB-Type Natriuretic PeptideB-Type Natriuretic PeptideC-Reactive ProteinC-Reactive Protein

Cardiac BiomarkersCardiac BiomarkersLab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo Low

Creatinine Creatinine Kinase (CK or Kinase (CK or CPK)CPK)

Prep: If test is Prep: If test is being done to being done to evaluate evaluate skeletal muscle skeletal muscle avoid strenuous avoid strenuous exercise prior; exercise prior; avoid ETOH 24 avoid ETOH 24 hrs prior; no IM hrs prior; no IM injectionsinjections

Is an enzyme Is an enzyme found in cardiac, found in cardiac, and skeletal and skeletal muscle and the muscle and the brain. Elevation brain. Elevation reflects tissue reflects tissue catabolism from catabolism from cell trauma.cell trauma.

Serial testing q 10 Serial testing q 10 hours times 3 hours times 3 typicallytypically

26-174 units/L26-174 units/L

Isoenzymes:Isoenzymes:

CK-MB 0-5% CK-MB 0-5%

CK-MM 95-100%CK-MM 95-100%

CK-BB 0%CK-BB 0%

Elevation of total CK Elevation of total CK

must be fractioned must be fractioned

down into down into

Isoenzymes. Isoenzymes. Elevation Elevation

reflects brain, muscle reflects brain, muscle

or cardiac damage. IM or cardiac damage. IM

injections or injections or

strenuous exercise strenuous exercise

may increase MM.may increase MM.

NoneNone

Lactate Lactate DehydrogenaseDehydrogenase

(LDH1-5)(LDH1-5)

LDH1 and LDH 2 LDH1 and LDH 2 are the are the isoenzymes more isoenzymes more specific to cardiac specific to cardiac muscle.muscle.

Serial testing q 10 Serial testing q 10 hours times 3hours times 3

100-200 U/L 100-200 U/L LDH flip strongly LDH flip strongly suggestive of an MIsuggestive of an MI

When LDH1 is higher When LDH1 is higher than LDH2.than LDH2.

NoneNone

TestTest IndicationIndication Normal RangeNormal Range

MyoglobinMyoglobin Cardiac enzymes elevation Cardiac enzymes elevation reflects cardiac damagereflects cardiac damage

Normal < 85 ng/mlNormal < 85 ng/ml

Troponin Troponin

cTnTcTnT

Normal < 0.05 ng/ml Normal < 0.05 ng/ml

May be elevated by CRFMay be elevated by CRF

Troponin ITroponin I

cTnI cTnI

Normal < 0.05 ng/ml Normal < 0.05 ng/ml

Not elevated by CRFNot elevated by CRF

B-Type Natriuretic B-Type Natriuretic Peptide (BNP)Peptide (BNP)

Used to diagnosis CHF Used to diagnosis CHF and severityand severity

Normal cut off Normal cut off

<100 pg/ml<100 pg/ml

C-Reactive ProteinC-Reactive Protein A marker for A marker for inflammation and risk of inflammation and risk of atherosclerosis, MI, atherosclerosis, MI, CVA, PVD, diabetes. CVA, PVD, diabetes. Produced by the liver in Produced by the liver in response to response to inflammatory process.inflammatory process.

CRP <1 mg/L lowest riskCRP <1 mg/L lowest risk

CRP 1-3 mg/L intermediate CRP 1-3 mg/L intermediate riskrisk

CRP >3 mg/L highest riskCRP >3 mg/L highest risk

Biomarker TrendsBiomarker Trends

OnsetOnset PeakPeak ReturnReturn

CKCK 3-6 hr3-6 hr 10-30 min10-30 min 3-4 days3-4 days

CK MBCK MB 4-8 hr4-8 hr 10-30 hr10-30 hr 3 days3 days

MyoglobinMyoglobin 2-6 hr2-6 hr 8 hr8 hr 12-18 hrs12-18 hrs

TroponinTroponin 3-5 hr3-5 hr 14-21 hr14-21 hr 3 days3 days

ASTAST 6 hr6 hr 12-14 hr12-14 hr 4 days4 days

LDHLDH 24-48 hr24-48 hr 3-6 days3-6 days 14 days14 days

Lipid ProfilesLipid ProfilesLabLab Normal ValueNormal Value CommentsComments

Total CholesterolTotal Cholesterol < 200 mg/dl< 200 mg/dl Essential for the production of Essential for the production of bile salts and steroid hormones, bile salts and steroid hormones, but excess increase but excess increase atherosclerotic plaque. O.5-1.0% atherosclerotic plaque. O.5-1.0% of the population have of the population have hyperlipidemia that is familial. hyperlipidemia that is familial. The remainder is caused by The remainder is caused by DIET, liver disease with biliary DIET, liver disease with biliary obstruction, corticosteroids, obstruction, corticosteroids, hypothyroidism, and pancreatic hypothyroidism, and pancreatic dysfunction. HDLs are the dysfunction. HDLs are the “good” cholesterol (doesn’t stick “good” cholesterol (doesn’t stick in coronaries.in coronaries.

HDLs HDLs > 45 mg/dl> 45 mg/dl

LDLsLDLs < 100 mg/dl< 100 mg/dl

TriglyceridesTriglycerides <150 mg/dl<150 mg/dl Elevated due to diet, but also Elevated due to diet, but also can be elevated due to nephrotic can be elevated due to nephrotic syndrome, pancreatic syndrome, pancreatic dysfunction, diabetes and dysfunction, diabetes and hypothyroidism.hypothyroidism.

Glucose StudiesGlucose Studies

Fasting blood sugarFasting blood sugar

Glucose tolerance testGlucose tolerance test

Glycosylated hemoglobin (HbAGlycosylated hemoglobin (HbA1c1c))

Lab TestLab Test SignificanceSignificance Normal Normal ValueValue

Too HiToo Hi Too LowToo Low

Fasting Blood Fasting Blood SugarSugar

Prep: No food Prep: No food for at least 8 for at least 8 hours; water hours; water ok.ok.

Diagnosing Diagnosing diabetesdiabetes

80-100 mg/dL80-100 mg/dL Prediabetics have Prediabetics have FBS of 100-125 FBS of 100-125 mg/dLmg/dL

Stress, infection, Stress, infection, corticosteroids, TPN, corticosteroids, TPN, PPN will increase BSPPN will increase BS

Too much insulin Too much insulin injected. Too little injected. Too little food, too much food, too much exercise.exercise.

Glucose Glucose Tolerance TestTolerance Test

Prep: eat usual Prep: eat usual diet for several diet for several days prior. days prior. Then fasting Then fasting after 12 mn. after 12 mn. Given a Given a glucose drink glucose drink and BS and BS checked at 1-checked at 1-2-3 hour 2-3 hour intervalsintervals

Diagnosing Diagnosing diabetesdiabetes

FBS: 80-100 FBS: 80-100 mg/dlmg/dl

1Hour:1Hour:

120-160mg/dL120-160mg/dL

2 Hour:2 Hour:

80-140mg/dL80-140mg/dL

3 Hour:3 Hour:

80-100mg/dL80-100mg/dL

An inadequate return An inadequate return to normal indicative to normal indicative of diabetes.of diabetes.

Lab TestLab Test SignificanceSignificance Normal Normal ValueValue

Too HiToo Hi Too LowToo Low

GlycohemogloGlycohemoglobin bin (hemoglobin) (hemoglobin) A1CA1C


Evaluates long Evaluates long term compliance term compliance with diabetic with diabetic regimen and regimen and overall stability of overall stability of BS in normal BS in normal rangerange

4-6% nondiabetics4-6% nondiabetics

<7% ideal range <7% ideal range for diabetcisfor diabetcis

>9% poor diabetic >9% poor diabetic controlcontrol

Poor diabetic controlPoor diabetic control Too much insulin Too much insulin injected. Too little injected. Too little food, too much food, too much exercise.exercise.

Thyroid StudiesThyroid Studies

TSHTSH

T3T3

T4T4

Thyroid LabsThyroid LabsLabLab Normal Normal

ValueValueCommentsComments

TSHTSH 0.5-6 µU/ml0.5-6 µU/ml The thyroid gland is under the control The thyroid gland is under the control of the of the pituitary glandpituitary gland. When the level of . When the level of T3 & T4 drops too low, the pituitary T3 & T4 drops too low, the pituitary gland produces Thyroid Stimulating gland produces Thyroid Stimulating Hormone (TSH) which stimulates the Hormone (TSH) which stimulates the thyroid gland to produce more thyroid gland to produce more hormones.hormones.

T3 T3

(Serum (Serum Triiodothyronine)Triiodothyronine)

80-180 µg/dl80-180 µg/dl T3 & T 4 secreted from thyroid in T3 & T 4 secreted from thyroid in response to TSHresponse to TSH. Low T3 and T4 levels . Low T3 and T4 levels could mean a diseased thyroid gland ~ could mean a diseased thyroid gland ~ OR ~ a non-functioning pituitary gland OR ~ a non-functioning pituitary gland which is not stimulating the thyroid to which is not stimulating the thyroid to produce T4. If the T3 and T4 levels are produce T4. If the T3 and T4 levels are low and TSH is not elevated, the low and TSH is not elevated, the pituitary gland is more likely to be the pituitary gland is more likely to be the cause for the hypothyroidism.cause for the hypothyroidism. Hyperthyroidism: Graves' disease Hyperthyroidism: Graves' disease (antibody ass autoimmune response) is (antibody ass autoimmune response) is the most common etiology (70-80% of the most common etiology (70-80% of hyperthyroidism. Other causes include: hyperthyroidism. Other causes include: Toxic thyroid adenoma, Toxic Toxic thyroid adenoma, Toxic multinodular goitre.multinodular goitre.

T4 T4

(Serum Thyroxine)(Serum Thyroxine)4.6-12 µg/dl4.6-12 µg/dl

UrinalysisUrinalysis

Routine UrinalysisRoutine Urinalysis

Lab TestLab Test Normal ValueNormal Value SignificanceSignificance

ColorColor Clear light yellowClear light yellow Dark yellow, amber too concentrated. Abnormal color may Dark yellow, amber too concentrated. Abnormal color may be medication. Pseudomonas bladder infection – green be medication. Pseudomonas bladder infection – green color. Urobilogen causes dark orange – foams when color. Urobilogen causes dark orange – foams when shaken.shaken.

AppearanceAppearance ClearClear Hazy suggests infectionHazy suggests infection

pHpH 5-9 (mean of 6)5-9 (mean of 6) Acidic: Meat and eggs contribute to acidic metabolic waste. Acidic: Meat and eggs contribute to acidic metabolic waste. Fruits and vegetables contribute to alkaline urine.Fruits and vegetables contribute to alkaline urine.

Most infections (except E.Coli – most common) cause urine Most infections (except E.Coli – most common) cause urine to be alkaline. Cranberry juice makes it acidic.to be alkaline. Cranberry juice makes it acidic.

Specific Specific GravityGravity

1.001-1.0351.001-1.035 How dilute or concentrated (reflective of conditions like How dilute or concentrated (reflective of conditions like SIADH or Diabetes Mellitus or Diabetes Insipidus.SIADH or Diabetes Mellitus or Diabetes Insipidus.

ProteinProtein NegativeNegative ProteinuriaProteinuria

Persistent elevated levels (beyond trace) suggestive of Persistent elevated levels (beyond trace) suggestive of renal damage. Heavy exercise may cause transient.renal damage. Heavy exercise may cause transient.

SugarSugar NegativeNegative GlycosuriaGlycosuria

Trace in normal pregnancy. Elevates in later trimester. Trace in normal pregnancy. Elevates in later trimester. Otherwise suggest hyperglycemia as in Diabetes Type I or Otherwise suggest hyperglycemia as in Diabetes Type I or II, may occur with TPN patients.II, may occur with TPN patients.

KetoneKetone NegativeNegative Increased ketones occur from insufficient glucose available Increased ketones occur from insufficient glucose available for energy – breaks down fatty acidfor energy – breaks down fatty acid

DiabetesDiabetes

Lab TestLab Test Normal ValueNormal Value SignificanceSignificanceBilirubinBilirubin NegativeNegative Suggestive of obstructive jaundice. This bilirubin is conjugate Suggestive of obstructive jaundice. This bilirubin is conjugate

(liver functioning) just couldn’t get to GI tract(liver functioning) just couldn’t get to GI tract

Occult BloodOccult Blood NegativeNegative UTI or inflammation in Renal/Urinary system UTI or inflammation in Renal/Urinary system (glomerulornephritis, acute tubular necrosis, malignancy)(glomerulornephritis, acute tubular necrosis, malignancy)

LeukocytesLeukocytes NegativeNegative UTIUTI

NitriteNitrite NegativeNegative UTIUTI

UrobilogenUrobilogen 0.1-1.0 EU/dL0.1-1.0 EU/dL Urobilogen is formed in the intestines from conjugated bilirubin. Urobilogen is formed in the intestines from conjugated bilirubin. Some reabsorbed and excreted via kidneys. Will decrease in Some reabsorbed and excreted via kidneys. Will decrease in obstructive jaundice (not making it to intestines. Increased obstructive jaundice (not making it to intestines. Increased urobilogen occurs with hemolysis. Also, used to detect early urobilogen occurs with hemolysis. Also, used to detect early liver failure – liver can’t handle reabsorbed urobilogen fast liver failure – liver can’t handle reabsorbed urobilogen fast enough.enough.

WBCsWBCs 0-4/hpf0-4/hpf UTIUTI

RBCsRBCs Female 0-5/hpfFemale 0-5/hpf

Male 0-3/hpfMale 0-3/hpf

UTI or inflammation in Renal/Urinary system (ATN, UTI or inflammation in Renal/Urinary system (ATN, glomerulonephfritis)glomerulonephfritis)

CastsCasts 0-4/lpf0-4/lpf Describes a cylindrically shaped aggregation of some Describes a cylindrically shaped aggregation of some particulate that forms in the distal convoluted tubule or distal particulate that forms in the distal convoluted tubule or distal nephron via precipitation of a mucoprotein secreted by tubule nephron via precipitation of a mucoprotein secreted by tubule cells. Elevation indicates renal diseasecells. Elevation indicates renal disease

BacteriaBacteria NegativeNegative UTIUTI

TuberculosisTuberculosis

Tuberculin Skin Test Tuberculin Skin Test – Intradermally administered, read in 48-72 hoursIntradermally administered, read in 48-72 hours– Read results by looking for induration (raised Read results by looking for induration (raised

hardened area) across the forearm (perpendicular to hardened area) across the forearm (perpendicular to the long axis) in millimeters the long axis) in millimeters

– Positive = Positive = – > 5mm in immunocompromised person> 5mm in immunocompromised person

– 10 mm or more in high risk person10 mm or more in high risk person

– 15 mm or more in average person15 mm or more in average person

– Never repeat it on someone who has had a Never repeat it on someone who has had a previous positive (CXR)previous positive (CXR)

Interpreting the Mantoux Interpreting the Mantoux tuberculin skin test by the tuberculin skin test by the Sokol ballpoint pen method Sokol ballpoint pen method involves slowly approaching involves slowly approaching the site of induration using a the site of induration using a ballpoint or felt tip pen from ballpoint or felt tip pen from above or below the area until above or below the area until resistance is felt. The resistance is felt. The procedure is repeated on the procedure is repeated on the opposite side. As shown in opposite side. As shown in (B), the distance between (B), the distance between the lines where resistance the lines where resistance was noted is measured in was noted is measured in millimeters. This measures millimeters. This measures the degree of induration the degree of induration found 48 to 72 hours after found 48 to 72 hours after application of the application of the

Changes in Urine ColorChanges in Urine Color

FoodsFoodsEating beets can result in reddish-purple urine.Eating beets can result in reddish-purple urine.Acidic urine will turn red after eating blackberries. Acidic urine will turn red after eating blackberries. Alkaline urine will look reddish after eating rhubarb. Whether your Alkaline urine will look reddish after eating rhubarb. Whether your urine is acidic or alkaline is usually determined by other foods you urine is acidic or alkaline is usually determined by other foods you have eaten.have eaten.Candy or pills with a dye can temporarily turn the urine red.Candy or pills with a dye can temporarily turn the urine red.

PoisonPoisonLead or mercury poisoning can turn the urine reddish. If you suspect Lead or mercury poisoning can turn the urine reddish. If you suspect you have ingested and have been handling those toxic metals, and you have ingested and have been handling those toxic metals, and your urine is red, you should see your physician.your urine is red, you should see your physician.

Therapeutic Drug RangesTherapeutic Drug RangesMedicationMedication Therapeutic RangeTherapeutic Range

AmitriptylineAmitriptyline 120-150 ng/ml120-150 ng/ml

TegretolTegretol 5-12 mcg/ml5-12 mcg/ml

ChloramphenicolChloramphenicol 10-20 mgc/ml10-20 mgc/ml

Digoxin (Lanoxin)Digoxin (Lanoxin) 0.5-2 ng/ml0.5-2 ng/ml

Disopyramide (Norpace)Disopyramide (Norpace) 2-5 mcg/ml2-5 mcg/ml

GentamicinGentamicin 5-10 mcg/ml5-10 mcg/ml

Imiparmine (Tofranil)Imiparmine (Tofranil) 150-300 ng/ml150-300 ng/ml

Lidocaine (Xylocaine)Lidocaine (Xylocaine) 1.5-5 mcg/ml1.5-5 mcg/ml

Phenobarbital (Luminal)Phenobarbital (Luminal) 10-30 mcg/ml10-30 mcg/ml

Therapeutic Drug RangesTherapeutic Drug RangesMedicationMedication Therapeutic RangeTherapeutic Range

Phenytoin (Dilantin)Phenytoin (Dilantin) 10-20 mcg/ml10-20 mcg/ml

Propranolol (Inderal)Propranolol (Inderal) 50-100 ng/ml50-100 ng/ml

Salicylate Salicylate 100-250 mcg/ml100-250 mcg/ml

Theophylline (aminophylline, Theo-Dur)Theophylline (aminophylline, Theo-Dur) 10-20 mcg/ml10-20 mcg/ml

Tobramycin (Nebcin)Tobramycin (Nebcin) 5-10 mcg/ml5-10 mcg/ml

Valproic Acid (Depakene)Valproic Acid (Depakene) 50-100 mcg/ml50-100 mcg/ml

ElectrolytesElectrolytesElectrolyte Symbol Functions

Sodium Na+ Distribution of water between extracellular and intracellular fluid

Nerve impulses

Heart muscle contractibility

Potassium K+ Nerve conduction

Muscle activity

Cardiac muscle function

Calcium Ca+ Bones and teeth

Muscular contraction

Nerve impulses

Coagulation Factor IV

Magnesium Mg+ Muscular contraction

Carbohydrate metabolism

Coagulation process

Chloride Cl− Distribution of water between cells and plasma

Acid/base balance

Bicarbonate HCO3− Maintenance of normal pH

Transportation CO2 from tissue to lungs

Phosphorus P Glucose and fat metabolism

Energy transfer and storage


Serum Serum SodiumSodium


A major A major extracellular catio extracellular catio responsible for responsible for serum osmolalityserum osmolality

135-145 mEq/L135-145 mEq/L Hypernatremia- Hypernatremia- consider cause 1) consider cause 1) actual gain of sodium actual gain of sodium (saline IV infusions, (saline IV infusions, sea water ingestion, sea water ingestion, Cushing’s Syndrome, Cushing’s Syndrome, Hyperaldosteronism - Hyperaldosteronism - adrenal cortical adrenal cortical adenoma also known adenoma also known as Conn's syndrome ) as Conn's syndrome ) or 2) lose of fluid or 2) lose of fluid relative to sodium relative to sodium (dehydration, diabetes (dehydration, diabetes insipidous)insipidous)

Hyponatremia – Hyponatremia – consider cause 1) consider cause 1) actual lose of actual lose of sodium (K-sparing sodium (K-sparing diuretics) or 2) diuretics) or 2) excess of fluid excess of fluid relative to sodium relative to sodium (i.e. Hypotonic IV (i.e. Hypotonic IV infusions, SIADH infusions, SIADH and water and water intoxication)intoxication)

Serum Serum ChlorideChloride

Prep: do not Prep: do not allow pt to allow pt to clench or clench or unclench fist.unclench fist.

A component of A component of hydrochloric acid hydrochloric acid and aids in and aids in digestion, osmotic digestion, osmotic pressure and pressure and water balance.water balance.

98-107 Eq/L98-107 Eq/L Hyperchloremia - Hyperchloremia - hyperparathyroidism; hyperparathyroidism; drug (ammonium drug (ammonium chloride), dehydrationchloride), dehydration

Hypochloremia – Hypochloremia – occurs most occurs most commonly in commonly in prolonged GI prolonged GI suctioning, enteritis, suctioning, enteritis, acute intestinal acute intestinal obstruction and obstruction and continued vomiting continued vomiting (lose of HCl), (lose of HCl), diarrhea and diarrhea and impaction.impaction.

Lab TestLab Test SignificanceSignificance Normal ValueNormal Value Too HiToo Hi Too LowToo LowSerum Serum CalciumCalcium

Prep: fasting Prep: fasting sample sample desirable; desirable; excessive excessive milk milk ingestion, ingestion, defined as defined as three quarts three quarts of milk per of milk per day, can day, can cause an cause an increase in increase in plasma plasma calcium.calcium.

Used in bodily Used in bodily processes such processes such as muscular as muscular contraction, contraction, cardiac cardiac functioning, functioning, hormone hormone secretion, and secretion, and the transmission the transmission of nerve of nerve impulses. Ionized impulses. Ionized calcium is calcium is essential for essential for blood blood coagulation. coagulation. Since calcium is Since calcium is essential for essential for clotting, any clotting, any condition that condition that decreases the decreases the amount of ionized amount of ionized calcium can calcium can subsequently subsequently lead to lead to coagulation and coagulation and hemostasis hemostasis problems.problems.

9.0–10.5 mg/dl 9.0–10.5 mg/dl The most common The most common cause of increased cause of increased calcium in the blood calcium in the blood is metastatic bone is metastatic bone disease. Hodgkin’s disease. Hodgkin’s disease, multiple disease, multiple myeloma, and myeloma, and leukemia may also leukemia may also cause cause hypercalcemia. Other hypercalcemia. Other disorders or disorders or conditions associated conditions associated with increased with increased calcium levels are calcium levels are hyperparathyroidism, hyperparathyroidism, Paget’s disease of Paget’s disease of bone, prolonged bone, prolonged immobilization, and immobilization, and Addison’s disease. Addison’s disease. Drugs that increase Drugs that increase plasma calcium plasma calcium include lithium, include lithium, vitamin D, thiazide vitamin D, thiazide diuretics, thyroid diuretics, thyroid hormone, and hormone, and hydralazine, an hydralazine, an antihypertensive antihypertensive medication. medication.

Since much of the plasma Since much of the plasma calcium is bound to calcium is bound to albumin, decreased albumin, decreased plasma calcium levels, plasma calcium levels, hypocalcemia, can be hypocalcemia, can be related to a lowered related to a lowered plasma albumin level. plasma albumin level. Other causes Other causes hypoparathyroidism and hypoparathyroidism and renal failure, Vitamin D renal failure, Vitamin D deficiencies and deficiencies and malabsorption associated malabsorption associated with sprue, celiac disease, with sprue, celiac disease, and pancreatic and pancreatic dysfunctions. Heparin, dysfunctions. Heparin, magnesium salts, oral magnesium salts, oral contraceptives, aspirin, contraceptives, aspirin, and corticosteroids and and corticosteroids and excessive use of laxatives excessive use of laxatives may cause a decrease in may cause a decrease in plasma calcium plasma calcium


Serum Serum PotassiumPotassium

Prep: do not Prep: do not allow pt to allow pt to clench or clench or unclench fist. unclench fist. Very Very suseptible to suseptible to dietary intake.dietary intake.

A major A major intracellular intracellular

cation which cation which regulates regulates electrical electrical conduction in conduction in muscles, and muscles, and helps buffer H+ to helps buffer H+ to maintain maintain

acid-base acid-base balance.balance.

3.5-5.1 mEq/L3.5-5.1 mEq/L Hyperkalemia – seen Hyperkalemia – seen in acidosis (i.e. DKA), in acidosis (i.e. DKA), renal failure, renal failure, excessive dietary excessive dietary intake, massive intake, massive trauma, trauma, rhabdomylosis, rhabdomylosis, Addison’s disease, Addison’s disease, potassium potassium supplements, or supplements, or potassium sparing potassium sparing diuretics.diuretics.

Hypokalemia – seen in Hypokalemia – seen in patients on loop patients on loop diuretics (i.e. lasix and diuretics (i.e. lasix and bumex) with bumex) with inadequate dietary or inadequate dietary or pharmaceutical pharmaceutical supplementation, supplementation, severe diarrhea or severe diarrhea or vomiting. Hyper-vomiting. Hyper-aldosteronism – retain aldosteronism – retain Na in exchange for K. Na in exchange for K. Alkalosis and Alkalosis and Cushing’s.Cushing’s.

Serum Serum BicarbonateBicarbonate

Prep: Prep: ingestion of ingestion of acid or acid or alkaline alkaline susbstance susbstance may alter may alter results. results.

Part of the Part of the bicarbonate – bicarbonate – carbonic acid carbonic acid buffering system buffering system responsible for responsible for body pH. body pH. Produced by Produced by kidneys.kidneys.

22-26 mEq/L22-26 mEq/L

phlebotomy principles preferably anticubital; definitely avoid underside of wrist. largest vein...

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increased rbcs

rbcs elevated hct

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