Mr. Nichols PHHS

 Introduce vital signs and their use in clinical practice  Introduce basic laboratory tests and their use in clinical practice  Discuss normal values and test interpretation

 Temperature  Pulse rate  Respiration rate (RR)  Blood pressure (BP)

 Measure of body’s core temp (temp of internal organs)  in ° F (or °C, 1C=1.8F)  Locations: oral, rectum, ear  Rectal = 0.5 – 0.7° F higher than oral temp  Axilla = 0.3 – 0.4° F lower than oral temp  Normal: 97.8 – 99° F (36.5 – 37.2° C)  Critical: > 98.6° F orally or 99.8° F rectally (pyrexia [fever]); < 95° F (hypothermia)

 Heart rate (HR) or number of heart beats/min  Normal: 60 – 100/min  ↑ (tachycardia): ↑ Na + intake, ↓ Na + loss, Excessive free body H 2 O loss  ↓ (bradycardia): ↓ Na + intake, ↑ Na + loss, ↑ free body H 2 O

 Number of breaths/min  At rest  Also note breathing effort or difficulty  Normal: 15 – 20/min  Critical: 25  ↑ (hyperventilation): ↑ Na + intake, ↓ Na + loss, Excessive free body H 2 O loss  ↓ (hypoventilation): ↓ Na + intake, ↑ Na + loss, ↑ free body H 2 O

 Measures the force of blood against the arterial vessel walls  Measured while seated, after resting for 5 mins, arm heart level (if possible)  Reported as a fraction (systolic/diastolic) & consists of 2 separate measurements:  Systolic – pressure within artery during cardiac contraction  Diastolic – pressure within artery during cardiac relaxation and filling  Normal: < 120 mm Hg systolic and < 80 mm Hg diastolic  Critical: > 220 mm Hg systolic or > 125 mm Hg diastolic  ↑ (hypertension [htn]): ↑ Na + intake, ↓ Na + loss, Excessive free body H 2 O loss  ↓ (hypotention): ↓ Na + intake, ↑ Na + loss, ↑ free body H 2 O

 Provides information on cellular components of blood  Includes RBC count, Hemoglobin (Hgb), Hematocrit (Hct), RBC indices, White blood cell (WBC) count and differential, Platelet count

 Measurement of total WBC count  Consists of total # of WBCs/mm 3 of peripheral venous blood  Part of “routine” testing  Useful for evaluation of infection, neoplasm, allergy & immunosuppression  Normal: 4,000 – 10,000/mm 3  Critical: 30,000/mm 3  ↑ (leukocytosis): infection, malignancy, trauma, stress, hemorrhage, tissue necrosis, inflammation, dehydration, thyroid storm  ↓ (leukopenia): drug toxicity, bone marrow failure, overwhelming infections, dietary deficiency, congenital marrow aplasia, bone marrow infiltration, autoimmune disease, hypersplenism

 Measures # of circulating RBCs/mm 3 of peripheral venous blood  Direct measure of RBC count  Part of “routine” testing and anemia evaluation  Normal: 3.5 – 5.5 x 10 6 /μL  ↑: erythrocytosis, congenital heart disease, severe COPD, polycythemia vera, severe dehydration, hemoglobinopathies  ↓: anemia, hemoglobinopathy, hemorrhage, bone marrow failure, renal disease, leukemia, prosthetic valves, normal pregnancy, multiple myeloma, Hodgkin disease, lymphoma, dietary deficiency

 Measures total amount of Hgb in blood  Indirect measure of RBC count  Part of “routine” testing and anemia evaluation  Normal: 12 – 15 g/dL  Critical: 20 g/dL  ↑: erythrocytosis, congenital heart disease, severe COPD, polycythemia vera, severe dehydration ↓: anemia, hemoglobinopathy, hemorrhage, bone marrow failure, renal disease, leukemia, prosthetic valves, normal pregnancy, multiple myeloma, Hodgkin disease, lymphoma, dietary deficiency

 Measure of RBC percent of total blood vol  Indirect measure of RBC # & volume  Part of “routine” testing and anemia evaluation  Normal: 36 – 48%  Critical: 60%  ↑: erythrocytosis, congenital heart disease, severe COPD, polycythemia vera, severe dehydration  ↓: anemia, hemoglobinopathy, hemorrhage, bone marrow failure, renal disease, leukemia, prosthetic valves, normal pregnancy, multiple myeloma, Hodgkin disease, lymphoma, dietary deficiency

 Measure of average volume/size of single RBC  MCV = Hct (%) x 10/RBC (million/mm 3 )  Useful in anemia classification  Normal: 80 – 100 mm 3  ↑ (macrocytic): pernicious anemia (vit B 12 deficiency), folic acid deficiency, antimetabolic therapy, alcoholism, chronic liver disease, hypothyroidism  Normocytic: bone marrow failure/replacement, acute blood loss, chronic diseases, hemolytic anemias  ↓ (microcytic): Fe deficiency anemia, thalassemia, anemia of chronic illness

 Measure of average amount of hgb within a single RBC  MCH = Hgb (g/dL) x 10/RBC (million/mm 3 )  Provides little additional info to other indices  Normal: 24 – 32 pg  ↑: macrocytic anemias  ↓: microcytic anemia, hypochromic anemia

 Measure of average [hgb] within a single RBC  MCHC = Hgb (g/dL) x 100/Hct (%)  37 g/dL = maximum Hgb able to fit into an RBC (cannot be hyperchromic)  Normal (normochromic): 32 – 36 g/dL  ↑: spherocytosis, intravascular hemolysis, cold agglutinins  ↓ (hypochromic): Fe deficiency anemia, thalassemia

 Measure of variation of RBC size (indicator of degree of anisocytosis)  Useful in anemia classification  Normal: variation of 11.5 – 16.9%  ↑: Fe deficiency anemia, vit B 12 or folate deficiency anemia, hemoglobinopathies, hemolytic anemias, posthemorrhagic anemias

 Measurement of platelets (thrombocytes)  Consists of actual # of platelets/mm 3 of peripheral venous blood  Part of “routine” testing  Useful for evaluation of petechiae, spontaneous bleeding, increasingly heavy menses or thrombocytopenia  Useful for monitoring discourse/therapy of thrombocytopenia/bone marrow failure  Normal: 150,000 – 400,000/mm 3  Critical: 1,000,000/mm 3  ↑ (thrombocytosis): malignant disorders, polycythemia vera, postsplenectomy syndrome, rheumatoid arthritis, Fe deficiency anemia  ↓ (thrombocytopenia): Hypersplenism, hemorrhage, immune thrombocytopenia, leukemia & other myelofibrosis disorders, TTP, DIC, SLE, chemotherapy, pernicious anemia

 Leukocytosis – abnormally large number of leukocytes; generally indicated by WBC count of ≥ 10,000 cells/mm3  Lymphocytosis – form of actual or relative leukocytosis due to increase in numbers of lymphocytes  Left shift – increase in the number of immature neutrophils (bands/stabs) found in the blood

 Measurement of percentage of each WBC type in specimen  Useful for infection, neoplasm, allergy & immunosuppression evaluations  Normal: Neutrophils (50 – 70%), Lymphocytes (20 – 40%), Monocytes (2 – 8%), Eosinophils (0 – 5%), Basophils (0 – 2%)  ↑: refer to individual cell types on chart  ↓: refer to individual cell types on chart

 Measures electrolytes, chemicals, metabolic end products & substrates  Consists of Glucose, Blood Urea Nitrogen (BUN), Creatinine, Na +, K +, Cl -, Bicarbonate (HCO 3 - ), Ca 2+

 Direct measure of blood glucose  Commonly used to evaluate diabetic pts  Part of “routine” testing  Normal: mg/dL  Critical: 400 mg/dL ( ♂ ) or 400 mg/dL ( ♀ )  ↑ (hyperglycemia): DM, acute stress response, Cushing syndrome, pheochromocytoma, chronic renal failure, acute pancreatitis, acromegaly, corticosteroid therapy  ↓ (hypoglycemia): insulinoma, hypothyroidism, hypopituitarism, Addison disease, extensive liver disease, insulin overdose, starvation

 Measures urea nitrogen in blood  End product of protein metabolism (produced in liver)  Indirect measure of renal function & glomerular function (excretion)  Measure of liver metabolic function  Part of routine labs  Usually interpreted along with Cr (less accurate than Cr for renal disease)  Normal: mg/dL  Critical: > 100 mg/dL  ↑: prerenal causes, renal causes, postrenal azotemia  ↓: liver failure, overhydration because of SIADH, neg nitrogen balance, pregnancy, nephrotic syndrome

 Measures serum sodium level  Major cation in EC space  Balance between dietary intake and renal excretion  Normal: 136 – 146 mEq/L  Critical: 160 mEq/L  ↑ (hypernatremia): ↑ Na + intake, ↓ Na + loss, Excessive free body H 2 O loss  ↓ (hyponatremia): ↓ Na + intake, ↑ Na + loss, ↑ free body H 2 O

 Measures serum potassium level  Major cation within cell  Normal: 3.4 – 5.2 mEq/L  Critical: 6.5 mEq/L  ↑ (hyperkalemia): excessive intake, acidosis, acute/chronic renal failure, Addison disease, hypoaldosteronism, infection, dehydration  ↓ (hypokalemia): deficient intake, burns, hyperaldosteronism, Cushing syndrome, RTA, licorice ingestion, alkalosis, renal artery stenosis

 Measures CO 2 content of blood  Major role in acid-base balance  Regulated by kidneys  Used to evaluate pt pH status & electrolytes  Normal: 22 – 32 mEq/L  Critical: < 6 mEq/L  ↑: severe vomiting, high- volume gastric suction, aldosteronism, mercurial diuretic use, COPD, metabolic alkalosis  ↓: chronic diarrhea, chronic loop diuretic use, renal failure, DKA, starvation, metabolic acidosis, shock

 Measures serum calcium level  Direct measurement  Used to evaluate parathyroid function & Ca metabolism  Used to monitor renal failure, renal transplantation, hyperparathyroidism, various malignancies, & Ca level when giving large-volume blood transfusions  Normal: Total = 8.3 – 10.3 mg/dL, Ionized = 4.5 – 5.6 mg/dL  Critical: Total 13 mg/dL, Ionized 7 mg/dL  ↑ (hypercalcemia): hyperparathyroidism, bone mets, Paget disease of bone, prolonged immobilization, milk-alkali syndrome, vit D intoxication, hyperthyroidism  ↓ (hypocalcemia): hypoparathyroidism, renal failure, rickets, vit D deficiency, osteomalacia, pancreatitis, alkalosis, malabsorption, fat embolism

 Measures total protein in blood  Combination of prealbumin, albumin & globulins  Normal: 6.4 – 8.3 g/dL

 Provides information about kidneys & other metabolic processes  Used for diagnosis, screening & monitoring  Frequently used to test for urinary tract infections (UTIs)

 Appearance: clear  Color: amber yellow  Odor: aromatic  pH: 4.6 – 8  Protein: 0 – 8 mg/dL  Nitrites: none  Ketones: none

 Crystals: none  Glucose: negative  White Blood Cells: 0 – 4/low-power field  WBC casts: none  Red Blood Cells (RBCs): ≤ 2  RBC casts: none

 Examples: β- hydroxybutyric acid, acetoacetic acid, acetone  Associated with poorly controlled diabetes  Used to evaluate ketoacidosis associated w/ alcoholism, fasting, starvation, high-protein diets, isopropanol ingestion

 Screen for UTI (dipstick method)  Test based on chemical rxn by bacterial reductase (reduces nitrate to nitrite)  50% accurate

 Collected via lumbar puncture (LP)  Useful for the diagnosis metastatic brain/spinal cord neoplasm, cerebral hemorrhage, meningitis, encephalitis, degenerative brain disease, autoimmune diseases w/ CNS involvement, neurosyphilis, demyelinating diseases

 Opening pressure: <20 cm H 2 O  Color: clear & colorless  Blood: none  RBCs: 0  WBCs: 0 – 5 cells/μL  Neutrophils: 0 – 6%  Lymphocytes: 40 – 80%  Monocytes: 15 – 45%

 Protein: 15 – 45 mg/dL  Glucose: 50 – 75 mg/dL or 60 – 70% of blood glucose level

 Causes of ↑ lymphs/plasma cells: viral, tubercular, fungal or syphilitic meningitis; multiple sclerosis (MS), Guillain-Barré syndrome