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Common Diagnostic Procedures

DiagnosticTesting

Phases of Diagnostic Testing

  • Pretest

  • Intratest

  • Post test

Pretest Phase

Preparing the client

Knowing about the test ordered

Pretest Phase Preparing the client – Knowing about the test ordered – Gathering equipment and supplies

Gathering equipment and supplies

Intratest Phase

  • Collecting the specimen
    Performing or assisting

  • Providing emotional and physical support

  • Monitoring

  • Correct labeling, storage, and transportation of specimen

Post Test Phase

Nursing care of client Performing follow-up activities and observations

Comparing the previous and current test results

Modifying nursing interventions as needed Reporting the results

Common Blood Tests

Common Blood Tests • Complete blood count • Serum electrolytes • Serum osmolality • Arterial blood

Complete blood count Serum electrolytes Serum osmolality Arterial blood gases Blood chemistry Metabolic screening Capillary blood glucose Drug monitoring (peak and tough levels)

Common Blood Tests • Complete blood count • Serum electrolytes • Serum osmolality • Arterial blood
Common Blood Tests • Complete blood count • Serum electrolytes • Serum osmolality • Arterial blood

Complete Blood Count

Hemoglobin

Hematocrit

RBC count

RBC count

RBC indices WBC count WBC differential

What is the complete blood

count test (CBC)?

What is the complete blood count test (CBC)? The complete blood count (CBC) is one of

The complete blood count (CBC) is one of

the most commonly ordered blood tests.

The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute.

A CBC helps your health professional check any symptoms, such as weakness,

fatigue, or bruising, you may have. A CBC

also helps him or her diagnose conditions, such as anemia, infection, and many other disorders.

White blood cell (WBC,

leukocyte) count.

White blood cell (WBC, leukocyte) count. • White blood cell count (WBC) is the number of

White blood

cell

count (WBC)

is

the

number of white blood cells in a volume of

blood.

White blood cell (WBC, leukocyte) count. • White blood cell count (WBC) is the number of

White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. When a person has a bacterial infection, the number of white cells rises very quickly.

White blood cell types (WBC

differential).

White blood cell types (WBC differential). • The major types of white blood cells are <aneutrophils , lymphocytes, monocytes, eosinophils, and basophils. Immature neutrophils, called band neutrophils, are also part of this test. Each type of cell plays a different role in protecting the body. " id="pdf-obj-10-6" src="pdf-obj-10-6.jpg">

The major types of white blood cells are neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Immature neutrophils, called band neutrophils, are also part of this test. Each type of cell plays a different role in protecting the body.

The numbers of each one of these types of white blood cells give important information about the immune system. Too many or too few of the different types of white blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and many conditions, such as leukemia.

• The numbers of each one of these types of white blood cells give important informationimmune system . Too many or too few of the different types of white blood cells can help find an infection, an allergic or toxic reaction to medicines or chemicals, and many conditions, such as leukemia . " id="pdf-obj-11-13" src="pdf-obj-11-13.jpg">

Red blood cell (RBC) count

Red cell count (RBC) signifies the

Red blood cell (RBC) count • Red cell count (RBC) signifies the number of red blood

number of red blood cells in a volume of

blood.

Red blood cells carry oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled.

Red blood cell (RBC) count • Red cell count (RBC) signifies the number of red blood

If the RBC count is low (anemia), the body may not be getting the oxygen it needs. If

• If the RBC count is low (anemia), the body may not be getting the oxygenpolycythemia ), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen. " id="pdf-obj-13-6" src="pdf-obj-13-6.jpg">

the count is too high (a condition called polycythemia), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen.

Hematocrit (HCT, packed cell

volume, PCV).

Hematocrit (HCT, packed cell volume, PCV). • This test measures the amount of space (volume) redhematocrit of 38 means that 38% of the blood's volume is made of red blood cells. " id="pdf-obj-14-6" src="pdf-obj-14-6.jpg">

This test measures the amount of space (volume) red blood cells take up in the

blood. The value is given as a percentage of red blood cells in a volume of blood. For

example, a hematocrit of 38 means that 38% of the blood's volume is made of red blood cells.

Hemoglobin (Hgb).

•

Hemoglobin is the protein molecule within

red blood cells that carries oxygen and

gives blood its red color.

Hemoglobin (Hgb). • Hemoglobin is the protein molecule within red blood cells that carries oxygen and

The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body.

Red blood cell indices.

Red blood cell indices. • There are three red blood cell indices: mean corpuscular volume (MCV),

There are three red blood cell indices:

mean corpuscular volume (MCV), mean

corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC). They are measured by a machine and their values come from other measurements in a CBC.

• The MCV is the average volume of a red blood cell. This is a calculated

The MCV is the average volume of a red blood cell. This is a calculated value derived from the hematocrit and red cell count. Normal range may fall between 80 to 100 femtoliters (a fraction of one millionth of a liter).

• The MCV is the average volume of a red blood cell. This is a calculated

The MCH value is the amount of hemoglobin in an average red blood cell. This is a calculated value derived from the

measurement of hemoglobin and the red

cell count. Normal range is 27 to 32

picograms.

• The MCHC measures the concentration of hemoglobin in an average red blood cell. These numbers

The MCHC measures the concentration of hemoglobin in an average red blood cell.

These numbers help in the diagnosis of different types of anemia. This is a

calculated volume derived from the hemoglobin measurement and the hematocrit. Normal range is 32% to 36%.

• Red Cell Distribution Width (RDW) is a measurement of the variability of red cell size

Red Cell Distribution Width (RDW) is a measurement of the variability of red cell

size and shape. Higher numbers indicate greater variation in size. Normal range is 11 to 15.

Platelet (thrombocyte) count.

  • Platelets (thrombocytes) are the smallest type of blood cell.

  • They

are

important

in

blood clotting.

When bleeding occurs, the platelets swell, clump together, and form a sticky plug that helps stop the bleeding.

If there are too few platelets thrombocytopenia) , uncontrolled bleeding may be a problem. If there are too many plateletsthrombocytosis) , there is a chance of a blood clot forming in a blood vessel. Also, platelets may be involved in hardening of the arteries (atherosclerosis).

NORMAL VALUES

White blood cell (WBC, leukocyte) count Men and nonpregnant women:

4,50011,000/mcL 3 or 4.511.0 x 10 9 /liter (SI units)

Pregnant women:

1st trimester: 6,60014,100/mcL or 6.6

  • 14.1 x 10 9 /L

2nd trimester: 6,90017,100/mcL or 6.9

  • 17.1 x 10 9 /L

3rd trimester: 5,90014,700/mcL or 5.9

  • 14.7 x 10 9 /L

Postpartum: 9,70025,700/mcL or 9.725.7 x 10 /L

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25

White blood cell types (WBC differential)

Neutrophils:

50%62% Band neutrophils:

3%6% Lymphocytes:

25%40%

Monocytes:

3%7% Eosinophils:

0%3% Basophils:

0%1%

Red blood cell (RBC) count

Men:

4.76.1 million RBCs per

or 4.76.1 x 10 12 /liter (SI units)

Women:

4.25.4 million RBCs per mcL or 4.25.4 x

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10

12 /L

Children:

4.05.5 million RBCs per mcL or 4.64.8 x

  • 10 12 /L

Newborn:

4.87.1 million RBCs per mcL or 4.87.1 x

  • 10 12 /L

27

Hematocrit (HCT)

Men:

42%52% or 0.42

  • 0.52 volume

fraction (SI units)

Pregnant women:

1st trimester:

35%46%

Women:

2nd trimester:

37%47% or 0.37

  • 0.47 volume

fraction Children:

32%44% Newborns:

30%42%

3rd trimester:

34%44%

Postpartum:

30%44%

44%64%

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28

Hemoglobin (Hgb)

Men:

(SI units)

Women:

1216 g/dL or 7.4

  • 9.9 mmol/L

Pregnant women:

1st trimester: 11.415.0 g/dL or 7.1

  • 9.3 mmol/L

2nd trimester:

10.014.3 g/dL or 6.28.9 mmol/L

3rd trimester: 10.2

14.4

g/dL or 6.3

8.9

mmol/L

Postpartum: 10.4

18.0

g/dL or 6.4

9.3

mmol/L

Children:

9.515.5 g/dL

Newborn:

1424 g/dL

Red blood cell indices

Mean corpuscular volume (MCV):

8298 femtoliters (fL) Mean corpuscular hemoglobin (MCH):

2634 picograms (pg) Mean corpuscular hemoglobin concentration (MCHC):

3138 grams per deciliter (g/dL) or 31%38%

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Red cell distribution width

Normal:

(RDW)

11.5%14.6%

Platelet (thrombocyte) count

Children: 150,000450,000 platelets per mm 3 or 150450 x 10 9 /liter (SI units)

Adults: 150,000400,000 platelets per mm 3 or 150400 x 10 9 /liter (SI units)

Serum Electrolytes/

Serum Osmolality

Serum electrolytes

Sodium Potassium Chloride Bicarbonate ions

  • Electrolytes are measured by a process known as potentiometry. This method measures the voltage that develops between the inner and outer surfaces of an ion selective electrode.

  • Electrolyte tests are performed on whole blood, plasma, or serum, usually collected from a vein or capillary.

Sodium

Sodium Sodium plays a major role in regulating the amount of water in the body. Also,

Sodium plays a major role in regulating the amount of water in the body. Also, the

passage of sodium in and out of cells is necessary for many body functions, like

transmitting electrical signals in the brain and in the muscles. The sodium levels are measured to detect whether there's the right balance of sodium and liquid in the blood to carry out those functions.

• If a child becomes dehydrated because of vomiting, diarrhea, or inadequate fluid intake, the sodium

If a child becomes dehydrated because of vomiting, diarrhea, or inadequate fluid

intake, the sodium levels can be abnormally high or low, which can cause a

child to feel confused, weak, and lethargic, and even to have seizures.

Potassium

Potassium Potassium is essential to regulate how the heart beats. Potassium levels that are too high

Potassium is essential to regulate how the heart beats. Potassium levels that are

too high or too low can increase the risk of an abnormal heartbeat. Low potassium

levels are also associated with muscle weakness.

Chloride

Chloride Chloride , like sodium, helps maintain a balance of fluids in the body. If there's

Chloride, like sodium, helps maintain a

balance of fluids in the body. If there's a

large loss of chloride, the blood may become more acidic and prevent certain chemical reactions from occurring in the body that are necessary it to keep working properly.

Bicarbonate

Bicarbonate Bicarbonate prevents the body's tissues from getting too much or too little acid. The kidney

Bicarbonate prevents the body's tissues

from getting too much or too little acid. The

kidney and lungs balance the levels of bicarbonate in the body. So if bicarbonate levels are too high or low, it might indicate a problem with those organs.

NORMAL VALUES

serum or plasma sodium: 135145 mmol/l; alert levels: less than 120 mmol/l and greater than 160 mmol/l

serum potassium: 3.65.4 mmol/l (plasma, 3.65.0 mmol/l); alert levels: less than 3.0 mmol/l and greater than 6.0 mmol/l

serum or plasma chloride: 98108 mmol/l

sweat chloride: 460 mmol/l

serum or plasma bicarbonate: 1824 mmol/l (as total carbon dioxide, 2226 mmol/l); alert levels: less than 10 mmol/l and greater than 40 mmol/l

serum calcium: 8.510.5 mg/dl (2.02.5 mmol/l); alert levels:

less than 6.0 mg/dl and greater than 13.0 mg/dl

ionized calcium: 1.01.3 mmol/l

serum inorganic phosphorus: 2.34.7 mg/dl (children, 4.07.0 mg/dl); alert level: less than 1.0 mg/dl

serum magnesium: 1.83.0 mg/dl (1.22.0 meq/l or 0.51.0 mmol/l)

ionized magnesium: 0.530.67 mmol/l

Arterial Blood Gases

Arterial Blood Gases • An arterial blood gas (ABG) test measures the acidity ( <a href=pH ) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood. " id="pdf-obj-41-4" src="pdf-obj-41-4.jpg">

An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.

• An ABG test uses blood drawn from an artery, where the oxygen and carbon dioxide

An ABG test uses blood drawn from an artery, where the oxygen and carbon

dioxide levels can be measured before they enter body tissues.

  • Usually taken by specialty nurses, Respiratory Therapists

  • Take specimens of blood from radial, brachial, femoral arteries

An ABG measures:

An ABG measures: • Partial pressure of oxygen (PaO2). This measures the pressure of oxygen dissolved

Partial pressure of oxygen (PaO2). This measures the pressure of oxygen

dissolved in the blood and how well oxygen is able to move from the airspace

of the lungs into the blood.

An ABG measures: • Partial pressure of oxygen (PaO2). This measures the pressure of oxygen dissolved

Partial pressure of carbon dioxide (PaCO2). This measures how much carbon dioxide is dissolved in the blood and how well carbon dioxide is able to move out of the body.

pH. The pH measures hydrogen ions (H+) in blood.

  • Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of

blood from becoming too acidic or too

basic.

  • Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content measures the amount of oxygen in the blood. Oxygen saturation measures how much of the hemoglobin in the red blood cells is carrying oxygen (O2).

Normal Values

pH 7.35 (7.4) to 7.45

PaCO 2 35 (40) to 45 mm Hg

HCO 3 ˉ 22 (24) to 26 mEq/L (assumed average values for ABG interpretation)

PaO 2 80 to 100 mm Hg

Oxygen saturation >94%

Nursing alert

Avoid suctioning prior to drawing of blood Place specimen on ice

Apply firm pressure to the puncture site for 5-10 minutes

Assess the puncture site for bleeding or hematoma

Coagulation Studies

  • Blood

coagulation

test

is

done

to

determine presence of illness.

  • Before you have surgery your doctor may order blood tests to determine how quickly your blood clots. This group of tests is known as a coagulation study, individually these tests are commonly referred to as a PT (Prothrombin Time), PTT(Partial Thromboplastin Time), and INR

(International Normalized Ratio).

During some surgeries it is important that the blood not clot as quickly as normal, and

During some surgeries it is important that

the blood not clot as quickly as normal,

and medications may be given to slow the clotting time. Drugs commonly used to slow clotting have a variety of names, but Heparin, Coumadin, Lovenox and Warfarin are among the most common. In other cases, the patient may not clot quickly enough, and steps may be taken to make the blood to clot more quickly.

Prothrombin Time Blood

Test-PT

  • This test is done to evaluate the blood for

its ability to clot. It is often done before

surgery to evaluate how likely the patient is to have a bleeding or clotting problem during or after surgery.

  • Normal PT Values: 10-12 seconds (this can vary slightly from lab to lab)

Common causes of a prolonged PT include vitamin K deficiency, hormones drugs including hormone replacements and

Common causes of a prolonged PT

include vitamin K deficiency, hormones drugs including hormone replacements

and oral contraceptives, disseminated

intravascular coagulation (a serious clotting problem that requires immediate

intervention), liver disease, and the use of

the anti-coagulant drug warfarin. Additionally, the PT result can be altered

by a diet high in vitamin K, liver, green tea,

dark green vegetables and soybeans.

Partial Thromboplastin Time

Blood Test-PTT

  • This test

is

performed

primarily

to

determine if heparin (blood thinning)

therapy is effective. It can also be used to

detect the presence of a clotting disorder. It does not show the effects of drugs called ―low molecular weight heparin‖ or most commonly by the brand name Lovenox.

  • Normal PTT Values: 30 to 45 seconds (this can value slightly from lab to lab)

Extended PTT times can be result of anticoagulation therapy, liver problems, lupus and other a diseases

Extended PTT times can be result of anticoagulation therapy, liver problems, lupus and other

a

diseases

clotting.

that

result

in

poor

International Normalized Ratio

Blood Test-INR

  • Normal INR Values: 1 to 2
    The INR is used to make sure the results

from a PT test is the same at one lab as it

is at another lab. In the 1980’s the World

Health Organization determined that patients may be at risk because the results of a PT test would vary from one lab to

another, based upon the way the test was done.

Sources:

The ―normal‖ range for one lab would be different than a ―normal‖ value from another lab,

The ―normal‖ range for one lab would be

different than a ―normal‖ value from

another lab, creating problems for patients who were being treated in several locations. In order to standardize the results between labs, the INR was created. The INR result should be the

same, regardless of the location where the tests are performed.

Nursing Alerts

PTT critical level 175 seconds PT critical level 24 seconds Clotting Time 12 minutes

If pt is taking anticoagulant, when the blood level value exceeds the critical value withold the next dose

For pt taking heparin monitor PTT For pt taking coumadin monitor PT

BLOOD CHEMISTRY

Renal function test

Kidney function

tests is

a collective

term for a variety of individual tests and procedures that can be done to

evaluate how well the kidneys are

functioning. A doctor who orders

kidney function tests and uses

the

results to assess the functioning of

the kidneys is called a nephrologist.

There are a number of urine tests that can be used to assess kidney

function.

A

simple, inexpensive

screening testa routine urinalysisis often the first test conducted if kidney problems are suspected.

If

results

indicate

a

possibility

of

disease or impaired kidney function,

one

or

more

of

the

following

additional tests is usually performed to pinpoint the cause and the level of

decline in kidney function.

Creatinine clearance test

This test evaluates how efficiently the kidneys clear a substance called creatinine from the blood.

Creatinine, a waste product of muscle energy metabolism, is produced at a

constant rate that is proportional to the

individual's muscle mass.

Because the body does not recycle it, all creatinine filtered by the kidneys in a given amount of time is excreted in the urine, making creatinine clearance a very specific measurement of kidney function.

The test is performed on a timed urine specimena cumulative sample collected

over

a

two

to

24-hour

period.

Determination of the blood creatinine level is also required to calculate the urine clearance.

Urea clearance test

Urea is a waste product that is created by protein metabolism and excreted in the urine. The urea clearance test requires a blood sample to measure the amount of urea in the bloodstream and two urine

specimens, collected one hour apart, to determine the amount of urea that is filtered, or cleared, by the kidneys into the urine.

Urine osmolality test

Urine osmolality is a measurement of the number of dissolved particles in urine. It is

a more precise measurement than specific

gravity for evaluating the ability of the

kidneys to concentrate or dilute the urine.

Kidneys that are functioning normally will

excrete more water into the urine as fluid

intake is increased, diluting the urine. If fluid intake is decreased, the kidneys

excrete less water and the urine becomes

more concentrated

The

test

may

be

done

on

a urine

sample collected first thing in the morning,

on multiple timed samples, or

on

a

cumulative sample collected over a 24- hour period. The patient will typically be prescribed a high-protein diet for several days before the test and be asked to drink

no fluids the night before the test.

Urine protein test

Healthy kidneys filter all proteins

from the

bloodstream and then reabsorb them,

allowing no protein, or only slight amounts of

protein, into the urine. The persistent presence of significant amounts of protein in

the urine, then, is an important indicator of

kidney disease. A positive screening test for protein (included in a routine urinalysis) on a random urine sample is usually followed up

with a test on a 24-hour urine sample that

more precisely measures the quantity of

protein.

Normal Value

Creatinine clearance. For a 24-hour urine collection, normal

results are 90 mL/min139 mL/min for adult males younger than 40, and 80125 mL/min for adult females younger than 40. For people over 40, values decrease by 6.5 mL/min for

each decade of life.

Urine osmolality. With restricted fluid intake (concentration testing), osmolality should be greater than 800 mOsm/kg of water. With increased fluid intake (dilution testing), osmolality should be less than 100 mOSm/kg in at least one of the specimens collected. A 24-hour urine osmolality should average 300900 mOsm/kg. A random urine osmolality should average 500800 mOsm/kg.

Urine protein. A 24-hour urine collection should contain no more than 150 mg of protein.

Urine sodium. A 24-hour urine sodium should be within 75200 mmol/day.

Normal Value

Normal urine is transparent. Turbid (cloudy) urine may be caused by either

normal or abnormal processes. Normal

conditions giving rise to turbid urine

include precipitation of crystals, mucus, or

vaginal discharge. Abnormal causes of

turbidity include the presence of blood

cells, yeast, and bacteria.

Glucose: negative (quantitative less than 130 mg/day or 30 mg/dL).

Bilirubin: negative (quantitative less than 0.02 mg/dL).

Ketones:

mg/dL).

negative (quantitative 0.53.0

pH: 5.08.0.

Protein:

negative

(quantitative

15150

mg/day, less than 10 mg/dL).

Blood: negative. Nitrite: negative.

Specific gravity: 1.0031.025.

Urobilinogen:

02

Ehrlich

units

(quantitative 0.31.0 Ehrlich units). Leukocyte esterase: negative. Red blood cells: 02 per high power field.

White blood cells: 05 per high power field

(010

per

high

power

field

standardized systems).

for

some

Nursing Alerts

First voided urine for urinalysis Use clean container Decreased sp. gr. Diabetes insipidus Increased sp. gr. Diabetes mellitus (+) Protein: nephrotic syndrome (+) Glucose: D.M. infection

Creatinine test

This

test

measures

blood

levels of

creatinine, a by-product of muscle energy

metabolism that, similar to urea, is filtered

from the blood by the kidneys and excreted into the urine.

Creatinine is affected very little by liver

function,

an

elevated

blood

creatinine

level is a more sensitive indicator of

impaired kidney function than the BUN.

N.V. 0.6 to 1.3 mg/dl

Nursing considerations: instruct the client to avoid excessive for 8 hours and excessive red meat intake for 24 hrs before the test.

Blood urea nitrogen test (BUN)

Urea is a byproduct of protein metabolism. Formed in the liver, this waste product is

then filtered from the blood and excreted in the urine by the kidneys. The BUN test

measures the amount of nitrogen

contained in the urea. High BUN levels can indicate kidney dysfunction, but

because BUN is also affected by protein

intake and liver function, the test is usually

done together with a blood creatinine, a

more specific indicator of kidney function.

N.V.: 8 25 mg/dl Nursing considerations: should be analyzed together with creatinine

Other blood tests.

Measurement of the blood levels of other elements regulated in part by the kidneys

can also be useful in evaluating kidney function. These include sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphorus, protein, uric acid, and glucose.

Cardiac markers

Cardiac marker tests identify blood chemicals associated with myocardial infarction (MI),

commonly known as a heart attack. The myocardium is the middle layer of the heart wall composed of heart muscle. Infarction is tissue

death caused by an interruption in the blood

supply to an area.

Cardiac markers help physicians to assess acute coronary syndromes and to identify

and manage high-risk patients.

Creatine kinase-MB (CK-MB), myoglobin, homocysteine, C-reactive protein (CRP), troponin T (cTnT), and troponin I (cTnI) are all used for assessment of the

suspected acute myocardial infarction. CK-MB, cTnT, and cTnI may also be used

to identify and manage high-risk patients.

Creatine Kinase

Creatine kinase

is

an

enzyme found in

muscle and brain tissue that reflects tissue

catabolism resulting from cell trauma.

The

test

for

CK

is

performed to detect

myocardial or skeletal muscle damage or central nervous system damage.

Isoenzymes includes:

CK MB found mainly in the cardiac muscle CK BB is found mainly in brain tissue CK MM found mainly in the skeletal muscles

Normal Value

Total

CK:

units/L for

Reference

value

men and 26140

is

38174

units/L for

women. The values begin to rise within four to six hours and peak at 24 hours.

Values return to normal within three to four days.

CK-MB: Reference value is 1013 units/L. The values

begin to rise within three to four hours and peak at 1024 hours. Values return to

normal within

days .

two

to

four

NURSING CONSIDERATIONS

Invasive injections

falsely.

procedures

may

elevate

and

IM

CK

levels

If

the

test

is

to evaluate

skeletal

muscle, instruct the client to avoid

strenuous activities for 24 hrs before

the test

is a protein found in both skeletal and myocardial muscle. It is released rapidly

after tissue injury and may be elevated

as early as one hour after myocardial

injury, though it may also be elevated

due to skeletal muscle trauma.

However, if myoglobin values do not rise within three to four hours after a person

shows acute symptoms, it is highly unlikely that he or she had an MI.

Normal Value

Myoglobin:

Reference

value

is

less than 110 nanograms/mL.

The values

begin

to rise

within

one to two hours and peak at four

to eight hours. Values return normal within 1224 hours.

to

Troponins

A regulatory protein found in the striated muscle (skeletal and myocardial)

Increased

amounts

of

troponins

are

released into the blood stream when an

infarction causes myocardium

damage

to

the

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are the newest additions

to the list of cardiac markers. Cardiac troponins are specific to heart muscle. They have enabled the development of assays (tests) that can detect heart muscle injury with great sensitivity and specificity

While these markers have been used mainly to aid in the diagnosis of chest-pain patients with nondiagnostic electrocardiograms, they are also used as prognostic indicators of a MI. According to the American Heart Association, "Several studies have identified a measurable relationship between cardiac troponin levels and long-term outcome after an episode of chest discomfort. They suggest that these tests may be particularly useful to evaluate levels of risk. In other words, it's possible that the results of a troponin test could be used to identify people at either low risk or high risk for later, serious heart problems."

Troponin I: value is usually less than 0.6 ng/ml; greater than 1.5 ng/ml is consistent

with MI Troponin T:

greater than

consistent with MI No need for fasting

0.2 ng/ml

is

Lactate Dehydrogenase (LDH)

Lactate

dehydrogenase

catalyses

the

conversion of pyruvate to lactate. LDH-1 isozyme is normally found in the heart muscle and LDH-2 is found predominately

in blood serum. A high LDH-1 level to

LDH-2 suggest MI. LDH

levels are also

high in tissue breakdown or hemolysis. It

can mean cancer, meningitis, encephalitis, or HIV.

LDH begins to rise about 24 hrs after MI and peak in 48 72 hours; returns to normsl within 7 14 days

Lactate dehydrogenase 140-280 units/L Isoenzymes

LDH 1 14 - 26% LDH-2 29 39%

Nursing Considerations

The LDH isoenzymes should

be interpreted in view clinical findings

of the

Testing should be repeated on 3 consecutive days.

C-reactive protein (CRP)

CRP is a protein found in serum or plasma at elevated levels during a inflammatory processes.

CRP binds to part of the capsule of Streptococcus pneumoniae. It is a sensitive marker of acute and chronic inflammation and infection, and in such cases is increased several hundred-fold.

Several recent studies have demonstrated that CRP levels are useful in predicting the risk for a thrombotic event (such as a blood clot causing MI). These studies suggest that a high-sensitivity assay for CRP be used that is capable of measuring the very low level normally found in serum (0.12.5 mg/L). Heart patients who have persistent CRP levels between 4 and 10 mg/L, with clinical evidence of low-grade inflammation, should be considered to be at increased risk for thrombosis.

Normal Value

C-reactive protein: According to the U.S. Food and Drug Administration, in healthy people, reference values are below 5 mg/dL; in various diseases, this threshold is often exceeded within four to eight hours after an acute inflammatory event, with CRP values reaching approximately 20500 mg/dL.

Homocysteine

Homocysteine is an amino acid. According to the American Heart Association, studies have shown that too much homocysteine in the blood is related to a higher risk of coronary heart disease, stroke, and peripheral vascular disease; and that it may also have an effect on atherosclerosis. High levels of homocysteine are the result of a

lack of certain B vitamins, inheritance, or

dietary excess and have been implicated in

vascular-wall injury.

It is believed that laboratory testing for

plasma homocysteine levels can improve

the assessment of risk, particularly in patients with a personal or family history of

cardiovascular disease, but in whom the well-established risk factors (smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity, and diabetes) do not exist.

Normal value

The normal fasting level for plasma is

515

micromol/L.

intermediate,

and

hyperhomocysteinemia

Moderate,

severe

refer

to

concentrations between 16 and 30,

between

31

and

100, and

less than

100 micromol/L, respectively.

Liver Function Test

Liver function tests help detect, evaluate and monitor liver disease or damage. Liver function

tests generally refer to a group of

blood tests that measure certain

enzymes or

blood.

proteins

in

your

Liver function

tests may

be

done

for

a

variety of reasons. Liver function tests can

help screen for liver viruses such as hepatitis. They can also help monitor the

progression of a disease

like

viral

or

alcoholic hepatitis and determine how well a treatment is working. Liver function tests

can even measure the severity of a disease, particularly if you have cirrhosis an irreversible scarring of the liver.

LFTs include measurements of albumin, various liver enzymes (ALT, AST, GGT

and ALP), bilirubin, prothrombin time, cholesterol and total protein. All of these tests can be performed at the same time.

Common liver function tests

Alanine amino transferase (ALT).

An enzyme found mainly in liver cells, ALT helps your body metabolize protein. Normally, ALT levels in the blood are low. When the

liver is damaged, ALT is released in the

bloodstream and levels increase.

Formerely known as SGPT serum glutamic pyruvate transaminase.

The normal range of ALT levels is between 5 IU/L to 60 IU/L (International

Units per Liter). ALT levels in people with HCV often rise and fall over time, so additional testing such as HCV RNA, HCV genotyping and a liver biopsy may be needed to help determine the cause and extent of liver damage.

Aspartate aminotransferase (AST). This enzyme, which plays a role in processing

proteins, is found in the liver, heart, muscles, and kidneys. When the liver is injured or inflamed, levels of AST in the blood usually rise.

Also known as serum glutamic oxaloacetic transaminase

The normal range for AST levels in

the bloodstream are 5 IU/L to 43 IU/L. Like ALT levels, AST levels in people

with HCV often vary over time and

can't be used to forecast disease progression or specifically measure

liver damage.

GGT and ALP are also called cholestatic liver enzymes.

Chloestasis is

a

term

used for

partial

or

full

blockage of the bile ducts. Bile ducts bring bile

from

the

liver

into the gallbladder and the

intestines. Bile is a green fluid produced in liver

cells. Bile helps the body to break down fat,

process cholesterol and get rid of toxins. If the bile duct is inflamed or damaged, GGT and ALP

can get backed up and spill out from the liver

into the bloodstream.

ALP metabolizes phosphorus and brings energy to the body. GGT brings oxygen to tissues.

Causes of elevated ALP and GGT levels

Scarring of the bile ducts (called primary biliary cirrhosis),

Fatty liver (steatosis), sAlcoholic liver disease, Liver inflammation from medications and certain herbs, Liver tumors, Gallstones or gall bladder problems.

ALP (also called alkaline phosphatase) is found in the bones, intestines, kidneys and

placenta as well as the liver. Abnormally high ALP can have many causes other than liver damage, including: bone disease, congestive heart failure, and hyperthyroidism. A rise in ALP levels can indicate liver trouble if GGT levels are also elevated. The normal range of ALP is from 30 IU/L to 115 IU/L.

GGT (gamma-glutamyltranspeptidase) is

found in

drinking,

the liver. Obesity, PBC,

fatty

liver,

and

heavy

certain

medications or herbs that are toxic to the

liver can cause GGT levels

to

rise

the

normal range of GGT is from 5 IU/L to 80 IU/L.

Bilirubin is a yellow fluid produced in the liver when worn-out red blood cells are

broken down. Bilirubin can leak out from the liver into the bloodstream if the liver is damaged. When bilirubin builds up, it can cause jaundice - a yellowing of the eyes and skin, dark urine and light colored feces

The

causes

include:

of

abnormal

bilirubin

levels

Viral hepatitis, Blocked bile ducts, Other liver diseases, Liver scarring (cirrhosis)

Total

bilirubin

testing

measures

the

amount of bilirubin in the bloodstream.

Normal total bilirubin levels

range from

.20mg/dl to 1.50 (milligrams per deciliter). Direct bilirubin testing measures bilirubin made in the liver. The normal level of direct bilirubin range from .00 to .03 mg/dl

Total protein testing

(also called TP

or

serum total protein) measures the amount

of proteins in the bloodstream. Many different things can cause abnormally high or low protein levels. A doctor may order total protein testing to help diagnose kidney or liver disease, blood cancer,

malnutrition or abnormal body swelling. Normal protein levels in the bloodstream range from 6.5 to 8.2 grams per deciliter

Albumin is a protein made in the liver. If

the

liver

is

badly

damaged, it

longer produce albumin.

can

no

Albumin

maintains the amount of blood in the veins

and arteries. When albumin levels become very low, fluid can leak out from the blood

vessels

into nearby tissues,

causing

swelling in the feet and ankles. Very low

levels of

albumin may be

a

sign of

liver

damage.

The normal albumin range

is

from

3.9

grams/

deciliter

to

5.0

grams/deciliter

Prothrombin (also called factor II)

is

a

protein that helps

to

clot

blood.

Prothrombin is

made

in

the

liver.

A

prothrombin time test measures how much time it takes for a person's blood to clot. The normal time needed for blood to clot is between 10 and 15 seconds.

Nursing considerations

Although the hepatic function panel can be done without any preparation, it's more

accurate when performed after fasting. Your child may be asked to stop eating and drinking for 10 to 12 hours before this blood test.

Draw from extremity that does not have IV infusion on it

Medications that are hepatotoxic should not be given within 12 hours prior to test

Instruct

patient to eat a diet low

in yellow

food for

3

to

4

days

before

the

blood

is

drawn

(bilirubin)

Transport

the

specimen

to

laboratory immediately

Lipoproteins Profile

Lipoproteins are the "packages" in which cholesterol and triglycerides

travel throughout the body. Measuring the amount of cholesterol carried by

each type of lipoprotein helps

determine a person's risk for cardiovascular disease (disease that affects the heart and blood vessels, also called CVD).

Cholesterol and triglycerides are fat-like substances called lipids. Cholesterol is

used to build cell membranes and hormones. The body makes cholesterol and gets it from food. Triglycerides provide a major source of energy to the body tissues. Both cholesterol and triglycerides are vital to body function, but an excess of either one, especially cholesterol, puts a person at risk of cardiovascular disease.

Because cholesterol and triglycerides can't

dissolve in watery liquid, they must be

transported by something that

can

dissolve in blood serum. Lipoproteins contain cholesterol and triglycerides at the core and an outer layer of protein, called apolipoprotein.

Major classes of lipoproteins

LDL, often called "bad" cholesterol, is formed primarily by the

breakdown of VLDL. LDL contains

little triglycerides

and

a

large

amount of cholesterol (60-70% of a

person's total cholesterol).

Serum

from a person with a large amount of LDL will be clear.

LDL carries cholesterol in the blood and

deposits it in body tissues and in the walls

of blood vessels, a condition known as atherosclerosis. The amount of LDL in a person's blood is directly related to his or her risk of cardiovascular disease. The higher the LDL level, the greater the risk. LDL is the lipoprotein class most used to trigger and monitor cholesterol lowering therapy.

HDL is often called "good" cholesterol. HDL removes excess cholesterol from tissues and vessel walls and carries it to the liver,

where it is removed from the blood and

discarded. The amount of HDL in a person's blood is inversely related to his or her risk of

cardiovascular disease. The lower the HDL

level, the greater the risk; the higher the

level, the lower the risk. The smallest

lipoprotein, it contains 20-30% of a person's

total cholesterol and can be separated into

two major subclasses.

WHAT YOUR CHOLESTEROL

LEVELS MEANS

Less than 200 mg/dL: Desirable

If your LDL, HDL and triglyceride levels are also at desirable levels and you have no other risk factors for heart disease, total blood cholesterol below 200 mg/dL puts you at relatively low risk of coronary heart disease. Even with a low risk, however, it’s still smart to eat a heart-healthy diet, get regular physical activity and avoid tobacco smoke. Have your cholesterol levels checked every five years or as your doctor recommends.

200239 mg/dL: Borderline-High Risk

If your total cholesterol falls between 200 and 239 mg/dL, your doctor will evaluate your levels of LDL (bad) cholesterol, HDL (good) cholesterol and triglycerides. It's possible to have borderline-high total cholesterol numbers with normal levels of LDL (bad) cholesterol

balanced by high HDL (good) cholesterol. Make lifestyle changes, including eating a heart- healthy diet, getting regular physical activity and avoiding tobacco smoke. Depending on

your LDL

other risk

(bad) cholesterol levels and your factors, you may also need

240

mg/dL

and

over:

High

Risk

People who have a total cholesterol level of

240 mg/dL or more typically have twice the risk of coronary heart disease as people whose

cholesterol level is desirable (200 mg/dL). If your test didn’t show your LDL cholesterol, HDL cholesterol and triglycerides, your doctor

should order a fasting profile. You need cholesterol-regulating medication, make lifestyle changes, including eating a heart- healthy diet, getting regular physical activity and avoiding tobacco smoke.

Your HDL (Good) Cholesterol Level

With HDL (good) cholesterol, higher levels are better. Low HDL cholesterol (less than

40 mg/dL for men, less than 50 mg/dL for

women) puts

you at higher risk for heart

disease. In the average man, HDL

cholesterol levels range from 40 to 50 mg/dL. In the average woman, they range

from 50 to 60 mg/dL. An HDL cholesterol

of 60 mg/dL or higher gives some protection against heart disease.

Smoking, being overweight and being sedentary can all result in lower HDL cholesterol. To raise your HDL level, avoid tobacco smoke, maintain a healthy weight and get at least 3060 minutes of physical activity more days than not.

People with high blood triglycerides usually also have lower HDL cholesterol and a higher risk of heart attack and

stroke. Progesterone, anabolic steroids

and male sex hormones (testosterone) also lower HDL cholesterol levels. Female

sex hormones raise HDL cholesterol levels

Your LDL (Bad) Cholesterol Level

The lower your LDL cholesterol,

the

lower

your

risk

of

heart

attack and stroke. In fact, it's a

better gauge of

risk than total

blood cholesterol.

In general, LDL levels fall into these categories:

LDL Cholesterol Levels

Less than 100 mg/dL- Optimal

100

to

129

mg/dL

-

Near

Optimal/ Above

Optimal 130 to 159 mg/dL - Borderline High 160 to 189 mg/dL -High 190 mg/dL and above - Very High

Your Triglyceride Level

Triglyceride

is

a

form

of

fat.

People

with

high

triglycerides

often have a high total cholesterol

level, including

high

LDL (bad)

cholesterol and low HDL (good)

cholesterol levels.

Your triglyceride level will fall into one of

these categories:

Normal: less than 150 mg/dL Borderline-High: 150199 mg/dL High: 200499 mg/dL Very High: 500 mg/dL

Many people have high triglyceride levels due to being overweight/obese, physical inactivity, cigarette smoking, excess

alcohol consumption and/or a diet very

high in carbohydrates (60 percent of more of calories). High triglycerides are a

lifestyle-related risk factor; however,

underlying diseases or genetic disorders can be the cause.

The

main therapy

to reduce triglyceride

levels is to change your lifestyle.

Sometimes,

is

needed

in

addition to a healthy diet and lifestyle.

Nursing considerations

The patient must fast for 12 hours before

the test, eating nothing and drinking only

water.

The person should not have alcohol for 24

hours before the test.

 

There should be

a stable

diet

(free of

high cholesterol foods the night before the

test

No illnesses occurring in the preceding two weeks.

Glucose Studies

A blood glucose test measures the amount of a type of sugar, called glucose, in your

blood.

Glucose comes from carbohydrate foods. It is the main source of energy used by the

body.

Insulin is a hormone that helps your body's cells use the glucose.

Insulin

is

produced in the pancreas

and

released into the blood when the amount

of glucose in the blood rises.

Normally,

our

blood

glucose

levels

increase slightly

after

we

eat.

This

increase causes our pancreas to release insulin so that our blood glucose levels do

not get too high.

Blood glucose levels that remain high over

time

can

damage

your

eyes,

kidneys,

nerves, and blood vessels.

Different types of blood glucose

tests

Fasting blood sugar (FBS) measures blood glucose after you have not eaten for at least 8 hours. It often is the first test done to check for diabetes.

Normal Values

N.V. 70 110 mg/dL

If your fasting blood glucose level measures in the range of 100 mg/dL (5.5 mmol/L) to 125

mg/dL (6.9 mmol/L), you are considered to have prediabetes (impaired fasting glucose), and you have an increased chance of getting diabetes.

A

fasting glucose level

below 40 mg/dL

(2.2

mmol/L) in women or below 50 mg/dL (2.8

mmol/L) in men that is accompanied by symptoms of hypoglycemia may mean you have an insulinoma, a tumor that produces abnormally high amounts of insulin.

Nursing Consideration

For a fasting blood sugar test, do not eat or drink anything other than water for at least 8 hours before the blood

sample is taken.

If

you

have diabetes, you

may

be

asked to wait until you have had your

blood tested

before

taking

your

morning dose of insulin or diabetes

medication.

2-hour

postprandial

sugar measures

blood

blood

glucose exactly 2 hours after

you eat a meal. -

N.V.

70145

mg/dL

than 7.9 mmol/L)

(less

Nursing Consideration

For a 2-hour postprandial test, eat a meal exactly 2 hours before the blood sample is

taken.

Random blood sugar (RBS) measures blood glucose regardless of when you last ate. Several random measurements may

be taken throughout the day.

Random testing is useful because glucose levels in healthy people do not vary widely throughout the day.

Blood glucose levels that vary widely may indicate a problem.

This

test

is

also called a casual blood

glucose test.

N.V.

-

mmol/L)

70125

mg/dL

(less

than

7.0

No special preparation is required before having a random blood sugar test.

Oral glucose tolerance test is used to diagnose prediabetes and diabetes. An oral glucose tolerance test is a series of blood glucose measurements taken after you drink a sweet liquid that contains glucose. This test is commonly used to diagnose diabetes that occurs during pregnancy (gestational diabetes).

Nursing Considerations

Instruct the client to eat a high carbohydrate (200 300 mg/dL) diet for 3 days before the test.

Instruct the client to avoid alcohol, coffee, and smoking for 36 hours before the test.

Instruct the client to fast for 10 before the test

to 16 hours

Instruct the client to avoid strenuous exercise for 8 hours before and after the test.

Withhold morning insulin or oral hypoglycemic meds.

Instruct the client that the test will take 3 to 5 hours, requires intravenous or oral

administration of glucose, and multiple blood samples.

Glycosylated hemoglobin

Glycosylated

hemoglobin

is

blood

glucose bound to hemoglobin.

Hemoglobin

A1

c (Glycosylated

hemoglobin A) is a reflection of how

well blood glucose levels have been controlled for up to 4 months

Normal Values

Values are expressed as a percentage of the total hemoglobin

Diabetic with good control: 7.5% or less Diabetic with fair control: 7.6% to 8.9% Diabetic with poor control: 9% or greater

Nursing Consideration

Fasting is not required before the test.

The American Diabetes Association (ADA) criteria for diagnosing diabetes are met when any of the following results have been repeated on at least two different days:

A fasting blood glucose level is 126 mg/dL (7.0 mmol/L) or higher.

A 2-hour oral glucose tolerance test result is 200 mg/dL (11.1 mmol/L) or higher. For more information, see the medical test Oral Glucose Tolerance Test.

Symptoms of diabetes are present and a random blood glucose test is 200 mg/dL (11.1 mmol/L) or higher. Symptoms of diabetes include increased thirst and frequent urination (especially at night), unexplained increase in appetite, unexplained weight loss, fatigue, erection problems, blurred vision, and tingling or numbness in the hands or feet.