Introduksi

Joel N. Kniep, M.D. Dept. of Pathology

Objectives
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

Clinical Vital Signs (Vitals)

Temperature Pulse rate Respiration rate (RR) Blood pressure (bp)

Temp
Measure of bodys core temp (temp of internal organs)
in F (or C) Locations: oral, rectum, axilla, 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)

Pulse rate
Heart rate (HR) or number of heart beats/min Normal: 60 100/min (tachycardia): Na+ intake, Na+ loss, Excessive free body H2O loss (bradycardia): Na+ intake, Na+ loss, free body H2O

RR
Number of breaths/min
At rest Also note breathing effort or difficulty

Normal: 15 20/min Critical: < 12 or > 25 (hyperventilation): Na+ intake, Na+ loss, Excessive free body H2O loss (hypoventilation): Na+ intake, Na+ loss, free body H2O

Bp
Measures the force of blood against the arterial vessel walls
Measured while seated, after resting for 5 mins, arm resting @ 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 H2O loss (hypotention): Na+ intake, Na+ loss, free body H2O

Complete Blood Count (CBC)

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

Total WBCs (leukocytes)

Measurement of total WBC count
Consists of total # of WBCs/mm3 of peripheral venous blood Part of routine testing Useful for evaluation of infection, neoplasm, allergy & immunosuppression

Normal: 4,000 10,000/mm3 Critical: < 2,500 or > 30,000/mm3 (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

Erythrocyte count (RBC)

Measures # of circulating RBCs/mm3 of peripheral venous blood
Direct measure of RBC count Part of routine testing and anemia evaluation

Normal: 3.5 5.5 x 106/L : 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

Hgb
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: < 5 or > 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

Hct
Measure of RBC percent of total blood vol
Indirect measure of RBC # & volume Part of routine testing and anemia evaluation

Normal: 36 48% Critical: < 15% or > 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

RBC indices
Measures size and hgb content of RBCs Used to classify anemias Includes Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red blood cell distribution width (RDW)

MCV
Measure of average volume/size of single RBC
MCV = Hct (%) x 10/RBC (million/mm3) Useful in anemia classification

Normal: 80 100 mm3 (macrocytic): pernicious anemia (vit B12 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

MCH
Measure of average amount of hgb within a single RBC
MCH = Hgb (g/dL) x 10/RBC (million/mm3) Provides little additional info to other indices

Normal: 24 32 pg : macrocytic anemias : microcytic anemia, hypochromic anemia

MCHC
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

RDW
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 B12 or folate deficiency anemia, hemoglobinopathies, hemolytic anemias, posthemorrhagic anemias

Platelet count
Measurement of platelets (thrombocytes)
Consists of actual # of platelets/mm3 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/mm3 Critical: < 50,000 or > 1,000,000/mm3 (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

WBC definitions
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

WBC differential
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

Basic Metabolic Panel (BMP)

Measures electrolytes, chemicals, metabolic end products & substrates Consists of Glucose, Blood Urea Nitrogen (BUN), Creatinine, Na+, K+, Cl-, Bicarbonate (HCO3-), Ca2+

Glucose
Direct measure of blood glucose
Commonly used to evaluate diabetic pts Part of routine testing

Normal: 70 - 100 mg/dL Critical: < 50 and > 400 mg/dL () or < 40 and > 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

BUN
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: 6 -21 mg/dL Critical: > 100 mg/dL : prerenal causes, renal causes, postrenal azotemia : liver failure, overhydration because of SIADH, neg nitrogen balance, pregnancy, nephrotic syndrome

Creatinine
Measures serum creatinine
Catabolic product of creatine phosphate (skeletal muscle contraction) Excreted entirely by kidneys direct measure of renal function Minimally affected by liver function Elevation occurs slower than BUN Doubling 50% reduction in GFR

Normal: 0.44 1.03 mg/dL Critical: > 4 mg/dL : diseases affecting renal function (glomerulonephritis, pyelonephritis, ATN, urinary tract obstruction, reduced renal blood flow, diabetic nephropathy, nephritis), rhabdomyolysis, acromegaly, gigantism : debilitation, decreased muscle mass

Na+
Measures serum sodium level
Major cation in EC space Balance between dietary intake and renal excretion

Normal: 136 146 mEq/L Critical: < 120 or > 160 mEq/L (hypernatremia): Na+ intake, Na+ loss, Excessive free body H2O loss (hyponatremia): Na+ intake, Na+ loss, free body H2O

K+
Measures serum potassium level
Major cation within cell

Normal: 3.4 5.2 mEq/L Critical: < 2.5 or > 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

Cl Measures serum chloride level

Major anion in EC space Helps maintain electrical neutrality; follows sodium

Normal: 98 108 mEq/L Critical: < 80 or > 115 mEq/L (hyperchloremia): dehydration, metabolic acidosis, RTA, Cushing syndrome, renal dysfunction, respiratory alkalosis, hyperparathyroidism (hypochloremia): overhydration, SIADH, CHF, chronic respiratory acidosis, metabolic alkalosis, Addison disease, Aldosteronism, vomiting/prolonged gastric suction, hypokalemia

HCO3 Measures CO2 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

Ca2+
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 < 6 or > 13 mg/dL, Ionized < 2.2 or > 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

Comprehensive Metabolic Panel (CMP)

Includes all components of BMP plus Albumin, Total protein, Alkaline phosphatase (ALP), Alanine aminotransferase (ALT), Aspartate aminotransferase (AST) and Bilirubin

Albumin
Measures amount of albumin in blood
Formed within liver & comprises 60% of total protein in blood Maintains colloidal osmotic pressure & transports blood constituents Measure of both hepatic function and nutritional state

Normal: 3.5 5 g/dL : dehydration : malnutrition, pregnancy, liver disease, protein-losing enteropathies, protein-losing nephropathies, 3rd space losses, overhydration, capillary permeability, inflammatory disease, familial idiopathic dysproteinemia

Total Protein
Measures total protein in blood
Combination of prealbumin, albumin & globulins

Normal: 6.4 8.3 g/dL

ALP
Measures serum ALP concentration
Detect & monitor liver and bone disease

Normal: 30 -120 units/L : 1 cirrhosis, intrahepatic/extrahepatic biliary obstruction, 1/metastic liver tumor, hyperparathyroidism, Paget disease, normal growing bones in children, bone mets, RA, MI, sarcoidosis, healing fracture, normal pregnancy, intestinal ischemia or infarction : hypophosphatemia, malnutrition, milk-alkali syndrome, pernicious anemia, scurvy

ALT
Found predominantly in liver
Injury/disease to parenchyma release into blood ID & monitor hepatocellular diseases of liver If jaundiced, implicates liver rather than RBC hemolysis

Normal: 4 36 international units/L @ 37C Sig : hepatitis, hepatic necrosis, hepatic ischemia Mod : cirrhosis, cholestasis, hepatic tumor, hepatotoxic drugs, obstructive jaundice, severe burns, trauma to striated muscle Mild : myositis, pancreatitis, MI, infectious mono, shock

AST
Found in highly metabolic tissue (cardiac & skeletal muscle, liver cells)
Disease/injury lysing of cells & release into blood Elevation proportional to # of cells injured Used for evaluation of suspected coronary artery disease or hepatocellular disease

Normal: 0 35 units/L : heart diseases, liver diseases, skeletal muscle diseases : acute renal disease, beriberi, DKA, pregnancy, chronic renal dialysis

Bilirubin
Measures level of total bilirubin in blood
End product of RBC metabolism (RBCs Hgb Heme (+ globin) Biliverdin Bilirubin (unconjugated/indirect) Bilirubin (conjugated/direct) Component of bile Consists of conjugated (direct) & unconjugated (indirect) bilirubin Used to evaluate liver function; hemolytic anemia workup in adults & jaundice in newborns Jaundice occurs when total bilirubin > 2.5 mg/dL

Normal: 0.3 1 mg/dL Critical: > 12 mg/dL

Unconjugated bilirubin
Measures level of indirect bilirubin in blood Normal: 0.2 0.8 mg/dL : erythroblastosis fetalis, transfusion rxn, sickle cell anemia, hemolytic jaundice, hemolytic anemia, pernicious anemia, large-volume blood transfusion, large hematoma resolution, hepatitis, cirrhosis, sepsis, neonatal hyperbilirubinemia, Crigler-Najjar syndrome, Gilbert syndrome

Conjugated bilirubin
Measures level of direct bilirubin in blood
Produced by conjugating glucuronide w/ unconjugated/indirect bilirubin in liver

Normal: 0.1 0.3 mg/dL : gallstones, extrahepatic duct obstruction, extensive liver mets, cholestasis from drugs, Dubin-Johnson syndrome, Rotor syndrome

Urinary Analysis (UA)

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

UA Normal Values
Appearance: clear Color: amber yellow Odor: aromatic pH: 4.6 8 Protein: 0 8 mg/dL Specific gravity: 1.005 1.030 Leukocyte esterase: negative Nitrites: none Ketones: none

UA Normal Values cont.

Bilirubin: none Urobilinogen: 0.01 1 Ehrlich unit/mL Crystals: none Casts: none Glucose: negative White Blood Cells: 0 4/low-power field WBC casts: none Red Blood Cells (RBCs): 2 RBC casts: none

Urinary Protein
Used to monitor kidney function Normally not present in normal kidney due to size barrier in glomerulous Normally tested by dipstick method, quantification requires 24-hour urine collection Presence (proteinuria) can indicate nephrotic syndrome, multiple myeloma or complications of DM, glomerulonephritis, amyloidosis

Urinary Glucose
Glucosuria presence of glucose in urine
Reflection of serum glucose levels Helpful in monitoring DM therapy Renal glucose reabsorption threshold = 180 mg/dL (in proximal renal tubules) Not always abnormal
Can occur after a high-carbohydrate meal or IV dextrose fluids Can occur in diseases affecting renal tubules; genetic defects of metabolism & glucose excretion

: DM & other causes of hyperglycemia, pregnancy, renal glycosuria, Fanconi syndrome, Hereditary defects in metabolism of other reducing substances, ICP, nephrotoxic chemicals

Urinary Leukocyte esterase

Screen to detect leukocytes in urine (dipstick method) Presence indicates UTI 90% accurate

Urinary Ketones
End products of fatty acid catabolism Examples: -hydroxybutyric acid, acetoacetic acid, acetone Associated with poorly controlled diabetes Used to evaluate ketoacidosis associated w/ alcoholism, fasting, starvation, highprotein diets, isopropanol ingestion

Urinary Nitrites
Screen for UTI (dipstick method) Test based on chemical rxn by bacterial reductase (reduces nitrate to nitrite) 50% accurate Enhances leukocyte esterase sensitivity

Urinary Casts
Hyaline conglomerations of protein; indicative of proteinuria; few = normal especially after exercise Cellular conglomerations of degenerated cells
Granular glomerular disease Fatty nephrotic syndrome Waxy chronic renal disease Epithelial cells & casts (renal tubular casts) WBCs & casts acute pyelonephritis RBCs & casts glomerular diseases

Cerebral Spinal Fluid (CSF) Analysis

Collected via lumbar puncture (LP) Useful for the diagnosis of 1 or metastatic brain/spinal cord neoplasm, cerebral hemorrhage, meningitis, encephalitis, degenerative brain disease, autoimmune diseases w/ CNS involvement, neurosyphilis, demyelinating diseases

CSF analysis Normal Values

Opening pressure: <20 cm H2O Color: clear & colorless Blood: none RBCs: 0 WBCs: 0 5 cells/L Neutrophils: 0 6% Lymphocytes: 40 80% Monocytes: 15 45%

CSF analysis Normal Values cont.

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

CSF WBC count

Pleocytosis turbidity of CSF due to increased #s of cells

CSF PMNs
Causes of PMNs: bacterial meningitis, tubercular meningitis, cerebral abscess, subarachnoid bleeding, tumor

CSF Lymphs
Causes of lymphs/plasma cells: viral, tubercular, fungal or syphilitic meningitis; multiple sclerosis (MS), Guillain-Barr syndrome

CSF Monos
Causes of monos: tubercular or fungal meningitis, hemorrhage, brain infarction

CSF Profile
RBCs/mm
3

WBCs/m m3 (> 1,000 PNMs) (lymphs/m onos)

Glucose (mg/dL) (< 45 mg/dL)

Protein (mg/dL) (> 250 mg/dL)

Opening pressure (cm H2O)

Appearan ce Cloudy

-globulin (% protein)

Bacterial meningitis Viral meningitis Aseptic meningitis SAH

GuillainBarr syndrome
MS Normal in 2/3 pts; > 15 in < 5% of pts

Pseudotu mor cerebri

References
Pagana, K.D. & Pagna, T.J. (2006). Mosbys Manual of Diagnostic and Laboratory Tests. St. Louis: Mosby Elsevier. 27th edition (2000). Stedmans Medical Dictionary. Baltimore: Lippincott Williams & Wilkins. UpToDate. Retrieved July 26, 2009, from http://www.uptodateonline.com Urinalysis. Retrieved July 17, 2009, from http://library.med.utah.edu/WebPath/TUTORIAL/URINE/ URINE.html Vital Signs. Retrieved July 17, 2009, from http://www.healthsystem.virginia.edu/uvahealth/adult_no ntrauma/vital.cfm

Additional Resources
Corbett, J.V. (2008). Laboratory Tests and Diagnostic Procedures with Nursing Diagnoses 7th Edition. Upper Saddle River: Prentice Hall. Fischbach, F.T. & Dunning, M.B. (2008). A Manual of Laboratory & Diagnostic Tests 8th Edition. Philadelphia: Lippincott Williams & Wilkins. Jacobs, D.S., De Mott, W.R. & Oxley, D.K. (2001). Jacobs & DeMott Laboratory Test Handbook with Key Word Index 5th Edition. Hudson: Lexi Comp, Inc. Wu, A. (2006). Tietz Clinical Guide to Laboratory Tests 4th Edition. St. Louis: Saunders Elsevier. Young, R.H. & Hicks, J. (2002). Directory of Rare Analyses 20002002. St. Louis: AACC Press. http://www.labtestsonline.org/

Special Thanks
Dr. Amira F. Gohara, M.D. Dr. Carol Bennett-Clarke, Ph.D. Dr. Constance Shriner, Ph.D. Cynthia R. OConnell, BSMT (ASCP)