1. Caring for Older Adults Holistically, 4th Edition Chapter Twenty Laboratory Values and the Older Adult

2. Caring for Older Adults Holistically, 4th Edition Meaning of Laboratory Values  Many normal ranges are different for older adults  Greater deviation from normal when under stress  Return to normal is slower  Relationship to clinical status  Lab values should be evaluated in relationship to individual’s entire clinical situation  Abnormal lab value may indicate a clinical stressor or medication side effect rather than illness

3. Caring for Older Adults Holistically, 4th Edition Meaning of Laboratory Values  Routine laboratory evaluations  Complete blood cell count  Serum glucose  Serum creatinine level  Serum electrolytes  Thyroid function tests  Urinalysis  Stool guaiac test

4. Caring for Older Adults Holistically, 4th Edition Common Screening Tests  Tuberculin skin test  Negative result <10 mm of induration  Screening method for tuberculosis  May need to be repeated 1 week later  Urinalysis  Appearance—clear yellow/straw  Specific gravity—1.005–1.020  pH—4.5–8.0  Negative for glucose, ketones, blood, bilirubin

5. Caring for Older Adults Holistically, 4th Edition Common Screening Tests  Urinalysis (cont.)  Types of specimens  Mid-stream clean catch  Fasting  24-hour  Send specimen to lab within 10 minutes or keep refrigerated

6. Caring for Older Adults Holistically, 4th Edition Common Screening Tests  Stool for occult blood  Negative result—absence of test color  Test three specimens and two different sections of each stool  Avoid red meat, vitamin C intake, iron supplements, and aspirin 2 to 3 days before and during stool collection

7. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count  Values do not change with age  Red blood cell count  Men—5.4 ± 0.9 × 1012/L  Women—4.8 ± 0.6 × 1012/L  Diagnose anemia, polycythemia, other bone marrow abnormalities

8. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  Hemoglobin  Men—14–18 g/dL  Women—12–16 g/dL  Increase—polycythemia, dehydration  Decrease—anemia, recent hemorrhage, fluid retention, kidney disease

9. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  Hematocrit  Men—47.0 ≠ 5.0%  Women—42.0 ≠ 5.0%  Measures percentage by volume or packed RBC in whole blood  Increased—polycythemia  Decreased—anemia, hemodilution, bone marrow disease

10. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  RBC indices  MCV 90 ± 7 fl  MCH 29 ± 2 pg  MCHC 34 ± 2%  Aid in diagnosis and classification of anemias

11. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  White blood cell count  4.5–11.0 ×109/L  Used to identify infectious or inflammatory processes, monitor response to chemotherapy and radiation therapy  Increased—infection, leukemia, inflammation  Decreased—bone marrow depression, viral infection

12. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  White blood cell differential  Neutrophils 1.8–7.7 ×109/L or 30%–60%  Eosinophils 0–0.45 ×109/L or 1%–4%  Basophils 0–0.20 ×109/L or 0%–0.5%  Lymphocytes 1.0–4.8 ×109/L or 25%–35%  Monocytes 0–0.8×109/L or 1%–4.0%

13. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  White blood cell differential (cont.)  Used to determine severity of infection, detect allergic reactions, identify various leukemias

14. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  Platelet count  130,000–400,000/mL  Required for clot formation and hemostasis  Increased—iron-deficiency anemia, hemorrhage, malignancies, splenectomy  Decreased—bone marrow disease, folic acid or vitamin B12 deficiency, drug side effects

15. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  Coagulation  Prothombin time  Normal: 9.5–11.8 s (control ±1 s)  Therapeutic: 1.5–2.0 times normal control  Determined before anticoagulation therapy and monitored throughout therapy

16. Caring for Older Adults Holistically, 4th Edition Hematological Indicators  Complete blood count (cont.)  Coagulation  Activated partial thromboplastin time (APTT)  Normal: 25–36 s  Therapeutic: 1.5–2.5 times normal control  Evaluated clotting factors of the intrinsic pathway

17. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Blood glucose  Fasting:  Normal: 75–115 mg/dL  Diabetes mellitus: 140 mg/dL on at least two occasions  Two hours after eating:  Normal: 140 mg/dL  Impaired glucose tolerance: 140–200 mg/dL  Diabetes mellitus: >200 mg/dl on at least two occasions

18. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Blood glucose (cont.)  Decreased—side effects of various medications, strenuous exercise  Increased—medication side effects, recent illness or infection  Electrolytes  Sodium  136–145 mEq/L

19. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Electrolytes (cont.)  Sodium (cont.)  Hyponatremia  Caused by vomiting, diarrhea, renal disorders, diuretics, congestive heart failure  Hypernatremia  Caused by inadequate fluid intake, diarrhea, diuretics

20. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Electrolytes (cont.)  Potassium  3.5–5.0 mEq/L  Hypokalemia  Caused by diuretics, malnutrition, vomiting, diarrhea  Hyperkalemia  Caused by renal failure, injuries, acidosis, diabetes mellitus, several medications

21. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Electrolytes (cont.)  Calcium 9–10.5 mg/dL  Hypocalcemia  Caused by hypoparathyroid, laxative, chemotherapy, corticosteroids  Hypercalcemia  Caused by hyperparathyroid, thiazide antidiuretics, immobilization, excessive vitamin D, calcium-containing antacids

22. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Electrolytes (cont.)  Phosphate 3–4.5 mg/dL  Chloride 98–106 mEq/L  End products of metabolism  Blood urea nitrogen (BUN) 10–20 mg/dL  Increased caused by renal disease, urinary tract obstruction, drugs

23. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  End products of metabolism (cont.)  Blood urea nitrogen (cont.)  Decrease caused by severe liver failure, malnutrition, overhydration  Creatinine <1.5 mg/dL  Increase caused by renal disease, diabetic acidosis, starvation, diuretics  High levels indication of renal failure

24. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  End products of metabolism (cont.)  Bilirubin  Total: 0.3–1.0 mg/dL  Direct: 0.1–0.3 mg/dL  Indirect: 0.2–0.7 mg/dL  Uric acid Men: 2.5–8.0 mg/dL Women: 1.5–6.0 mg/dL  Increase caused by loop diuretics, thiazides, starvation, alcohol abuse, chemotherapy

25. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Liver function tests  ALT 0–35 U/L  Increase caused by liver disease, medications, cholecystitis, trauma, lead ingestion  AST or SGOT 0–35 U/L  Increase caused by myocardial infarction, liver disease, hemolytic anemia, pulmonary emboli

26. Caring for Older Adults Holistically, 4th Edition Blood Chemistry Indicators  Liver function tests  LDH 60–100 U/mL

27. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Protein indicators  Total serum protein 5.5–8.0 g/dL  Increase caused by dehydration, infection, diabetic acidosis, chronic alcoholism  Decreased caused by malnutrition, hepatic disease, renal disease, congestive heart failure  Albumin 3.5–5.5 g/dL  Increased caused by multiple myeloma  Decreased caused by malnutrition, liver and renal disease, collagen diseases, rheumatoid arthritis

28. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Globulins 2.0–3.0 g/dL  Increase caused by tuberculosis, chronic syphilis, subacute bacterial endocarditis, myocardial infarction, diabetes mellitus  Iron indicators  Iron: Men 80–180 mg/dL Women 60–160 mg/dL  Essential in production and function of hemoglobin

29. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Iron indicators (cont.)  Ferritin 15–200 ng/mL  Increased in hepatic disease, iron overload, leukemia, chronic renal disease  Decreased in chronic iron deficiency  Total iron-binding capacity  250–460 mg/dL

30. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Lipoproteins  Total plasma cholesterol  Desired <200 mg/dL  Borderline 200–239 mg/dL  High 240 mg/dL  High-density lipoprotein HDL  Desired >35

31. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Lipoproteins  Low-density lipoprotein (LDL)  Desired 130 mg/dL  Borderline 130–159 mg/dL  High 160 mg/dL  Triglycerides  160 mg/dL

32. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Lipoproteins  Lipid abnormalities are often familial  Secondary causes  Diets high in saturated fat or cholesterol  Excessive alcohol intake  Estrogen supplements  Smoking  Sedentary lifestyle

33. Caring for Older Adults Holistically, 4th Edition Nutritional Indicators  Lipoproteins  Cholesterol is decreased in malnutrition, hyperthyroidism and chronic obstructive pulmonary disease

34. Caring for Older Adults Holistically, 4th Edition Drug Monitoring and Toxicology  Drug monitoring is important when toxic and therapeutic range is narrow  Commonly monitored drugs  Digoxin  Therapeutic: 0.5–20 ng/mL  Toxic: 2.5 ng/mL  Signs of toxicity  Visual changes, headache, nausea and vomiting, weakness and fatigue

35. Caring for Older Adults Holistically, 4th Edition Drug Monitoring and Toxicology  Commonly monitored drugs (cont.)  Theophylline  Therapeutic: 10–20 µg/mL  Toxic: 20 µg/mL  Signs of toxicity  Anorexia, abdominal discomfort, dizziness, shakiness, restlessness, palpitation, tachycardia, hypotension

36. Caring for Older Adults Holistically, 4th Edition Drug Monitoring and Toxicology  Commonly monitored drugs (cont.)  Phenytoin  Therapeutic: 10–20 µg/mL  Toxic: 30 µg/mL  Signs of toxicity  Drowsiness, mental confusion, tremors, photophobia, blurred vision