Lab Results as of February 10, 2009:
RBC: 3.02 (L) Normal: 3.20-5.40x10^12/L
Decreased numbers of erythrocytes are seen in disorders involving impaired erythropoiesis, excessive blood cell destruction, blood loss, and in chronic inflammatory disorders (Cavanaugh, 2003). A relative decrease may be seen in situations with increased body fluid in the presence of a normal number of RBCs. A low RBC level indicates dietary deficient anemia, which can result from malnutrition as there is a decrease of vitamins and minerals (i.e. iron, Vitamin B12) necessary to maintain RBC numbers and size (Cavanaugh, 2003).
Hemoglobin: 93 (L) Normal: 110-160 g/L
Hemoglobin is the main intracellular protein of erythrocytes. It carries and removes CO2 from RBCs. Its primary function is to transport oxygen to the cells and to remove carbon dioxide from them for excretion by the lungs (Smeltzer & Bare, 2004). A low Hemoglobin level results from the
decrease in RBC numbers and size secondary to a diet deficient of vitamins and
minerals. Juanita is on Total Parenteral Nutrition (TPN) and therefore has a nutritional deficit. A low hemoglobin may also indicate fluid excessively retained in vascular spaces (Smeltzer et al., 2004). Severe hemodilution can lead to cardiac failure and death therefore it is important to monitor Juanita for hypotension and signs of cardiac failure (shortness of breath and edema).
Hematocrit: 0.282 (L) Normal: 0.330-0.480 L/L
Hematocrit is used to identify the presence and extent of anemia. Elevated blood glucose and sodium may produce elevated hematocrit values because of the resultant swelling of the erythrocyte (Cavanaugh, 2003). Juanita is an insulin dependent diabetic with extremely elevated glucose levels. Hematocrit is also used to monitor responses to fluid imbalances. Juanita has vitamin
and mineral deficiencies, therefore the number or size of RBCs is decreased resulting in a decreased hematocrit. Severe hemodilution can lead to cardiac failure and death (Smeltzer & Bare, 2004). Possible interventions for Juanita include diuretics, restriction of fluids, and monitoring her intake and output.
RDW: 15.2 (H) Normal: 11-15%
The Red Blood Cell Distribution Width (RDW) is an indication of variation in RBC size. Iron deficiency anemia initially presents with a varied size distribution of red blood cells, and as such shows an increased RDW (Pagana & Pagana, 2006). In the case of a mixed iron and B12 deficiency, the cells will be both large and small and the RDW will usually be elevated. Juanita therefore has a nutritional deficiency of Iron, folate, and Vitamin B12.
Lymphocyte: 1.4 (L) Normal: 1.5-4.0x10^9/L
Low lymphocytes may indicate the presence of infection. Since lymphocytes are made in the bone marrow, if not enough bone marrow is produced or the activity of the bone marrow decreases, an abnormally low lymphocyte count can occur (Cavanaugh, 2003). Decreased lymphocytes may be seen with immune deficiency diseases and septicemia. Juanita's confusion is getting worse and with the new onset of hallucinations it is evident that she has some sort of infection occurring as a urinary tract infection in the elderly for example, causes confusion and disorientation.
INR: 1.4 (H) Normal: 0.8-1.2s
An International Normalized Ratio (INR) evaluates the extrinsic pathway of coagulation. It is useful in identifying dysfunction of blood clotting. Prolonged time is seen in liver dysfunction and malabsorption of Vitamin K (Cavanaugh, 2003). Increased values put Juanita at risk for bleeding therefore it is important to watch for prolonged bleeding, hematoma formation, melena, and bleeding gums. Increased INR is also indicative of her obstructive jaundice. As bile fails to enter the gut, fat malabsorption results. Vitamins A,D, E, & K are fat soluble and also are not absorbed. Since the synthesis of clotting factors II, VII, IX, & X depend on Vitamin K, these factors are not adequately produced and serum concentrations fall (Pagana & Pagana, 2006). This results in a prolonged INR.
Na: 124 (L) Normal: 135-146 mmol/L
Sodium maintains osmotic pressure of extracellular fluid, regulating potassium and chloride levels and stimulating neuromuscular reactions (Smeltzer & Bare, 2004). Low sodium is an indication of hyponatremia seen with gastrointestinal fluid loss (vomiting, diarrhea), and diuresis. A low sodium level may be caused by the use
of Furosemide, a loop diuretic, which Juanita is taking. Diuretics inhibit sodium reabsorption by the
kidneys and thus sodium levels can diminish. It is also important to note that
symptoms of hyponatremia may begin when sodium levels are below 125 mEq/L, the first symptom to occur is weakness. If levels drop further, lethargy and confusion may
begin (Pagana & Pagana, 2006). It is important to assess Juanita's endocrine and genitourinary systems history, and monitor medications, hydration status, output, and administration of IV saline solutions.
Cl: 90 (L) Normal: 100-110 mmol/L
Chloride is important in extracellular fluid in maintenance of acid-base balance. Chloride contributes to hydrochloric acid for digestion. It follows sodium losses in an
attempt to maintain electrical neutrality (Smeltzer & Bare, 2004). Thus her decreased chloride level
results from sodium loss secondary to being on Furosemide, a loop diuretic. The low value may also indicate GI loss from vomiting as Juanita, due to her confusion, had pulled out her NG tube. It is important to monitor Juanita's need for KCL IV replacement.
Magnesium: 0.57 (L) Normal: 1.5-2.5 mEq/L
There are several factors that may be related to a decrease in magnesium levels. Low magnesium is indicative of Juanita being malnourished (she has not had food orally for a couple of weeks and she is on TPN) because of malabsorption. Moderate hypomagnesia may also occur in patients with diabetes. Insulin is given to these patients to drive glucose into cells, magnesium follows and blood levels drop. Also diuretic therapy (Furosemide) may also cause a decrease. It is essential to monitor Juanita's magnesium levels as hypomagnesia may increase cardiac irritability and aggravate arrhythmias in cardiac patients. Furthermore, as our patient is on the medication Digoxin, it is also important to note that “Hypomagnesemia reduces intracellular potassium by reducing the membrane concentration of the sodium-potassium-ATPase pump and, thus, predisposes to digitoxicity” (McDonald & Struthers, 2004). In addition, a patient on TPN should also have their magnesium levels monitored. Hypomagnesia in combination with hypokalemia & hypophosphatemia may be indicative of refeeding syndrome as she no longer has an NG tube and is beginning oral feeds. (Pagana & Pagana, 2006).
Signs and Symptoms of Digoxin Toxicity:
depression, malaise, anorexia, nausea and vomiting (early effects)
-Changes in heart rhythm: new onset of regular rhythm or new onset of irregular
-ECG changes indicating SA or AV block; new onset of irregular rhythm indicating ventricular dysrrythmias; and atrial tachycardia with block, junctional tachycardia and ventricular tachycardia (Smeltzer & Bare, 2004)
Potassium: 3.4(L) Normal: 3.5-5.1 mmol/L
Potassium is the intracellular cation essential for transmission of electrical impulses in cardiac and skeletal muscle (Smeltzer & Bare, 2004). Low potassium levels in Juanita are indicative of her being malnourished, as potassium is not adequately being provided in her diet. Her potassium levels may also be low due to side effects of Furosemide (increase renal excretion of K+) and insulin (insulin drives glucose and potassium into cells, lowering blood levels). It is important to monitor her potassium as it plays an important role in cardiac function. It is important to consider that hypokalemia increases the likelihood of toxic effects from Digoxin by reducing renal clearance and promoting myocardial binding of the drug. This increases automaticity and cardiac arrythmias (McDonald & Struthers, 2004). Flattened T waves and prominent U waves seen on an ECG may be indicative of hypomagnesia. Hypokalemia may also occur in patients on TPN and should be corrected/monitored as refeeding syndrome may occur.
Urea: 1.7 (L) Normal: 3.7-7.0 mmol/L
Urea is formed in the liver from ammonia as an end product of protein metabolism and is excreted by the kidneys (Smeltzer & Bare, 2004). Blood Urea Nitrogen (BUN) is used to identify impaired liver or kidney function and excessive protein or tissue catabolism. Low urea levels are indicative of malnutrition in Juanita, as with not enough protein in her diet, urea production is reduced. Low urea levels are also indicative of decreased liver function secondary to her obstructive jaundice. It is important to monitor Juanita's intake and output for fluid balance.
ALP: 277 (H) Normal: 30-110 U/L
Alkaline Phosphatase (ALP) is used to detect and monitor disease of the liver or bone. The highest concentrations of ALP are in the liver, biliary tract epithelium, and bone (Pagana & Pagana, 2006). ALP is normally excreted into the bile, thus the obstructive jaundice is the reason for the increase in ALP in our patient.
Lipase: 77 (H) Normal: 0-2.72 µkat/L
Serum lipase derives primarily from pancreatic lipase, which is secreted into the duodenum and participates in fat digestion (Cavanaugh, 2003).The most common cause of increased lipase levels is acute pancreatitis, which is relative to our patient. It is noted that serum lipase is the most reliable enzyme in detecting acute pancreatitis because the levels remain elevated for 5 to 7 days. (Pagana & Pagana, 2006).
GGT: 119 (H) Normal: 0-51 IU/L
The enzyme Gamma-Glutamyl Transpeptidase (GGT) is a sensitive indicator of hepatobiliary disease as the highest levels of this enzyme are in the liver and biliary tract (Pagana & Pagana, 2006). In Juanita, an increased level is indicative of her pancreatic disease. Pancreatic cells also contain GGT and when cells are injured or diseased they lyse and allow GGT to leak into the blood stream (Cavanaugh, 2003). Liver dysfunction associated with malnourishment also causes GGT to rise.
Bilirubin Total: 43 (H) Normal: 5.0-19.0µmol/L
Total bilirubin is indicative of bile flow. An increased bilirubin level is related to the obstruction of Juanita's bile duct, thus restricting bile flow, causing bilirubin blood levels to rise. Upon admission, Juanita was jaundiced, which Pagana & Pagana (2006) state is indicative of a blockage of the bile duct. The patient still presents with mild jaundice notable in the sclera of her eyes.
Albumin: 15 (L) Normal: 35-52 g/L
Albumin is a protein formed within the liver and is indicative of Juanita being malnourished. Lack of amino acids available for building proteins contributes to a decreased level of albumin. The liver dysfunction associated with malnourishment also contributes to low levels as the liver is unable to produce a normal amount of albumin from ingested amino acids (Day, R., Paul, P., Williams, B., Smeltzer, S., & Bare, B., 2007).
C-Reactive Protein: 148.8 (H) Normal: Negative to trace
C-reactive protein (CRP) is an acute-phase reactant protein used primarily by the liver during an acute inflammatory process (Pagana & Pagana, 2006). Failure of CRP to normalize may indicate ongoing damage to the heart tissue, thus making it a strong predictor of cardiovascular events. Juanita dealt with pericarditis early in her first admission and this test may be indicative of acute pericarditis occurring again. It may also be indicative of the damage to the epithelium of her heart as a result of atrial fibrillation, heart failure, hypertension and coronary artery disease (CAD).
Glucose levels are increased in diabetes. Since Juanita has type one diabetes mellitus, it is important to monitor her blood glucose levels frequently and to assess insulin requirements as changes may occur due to stress and a change in eating habits (Smeltzer & Bare, 2004).
Lab Results as of March 5, 2009:
Urea: 8.8 (H) Normal: 3.7-7.0 mmol/L
Juanita's BUN had increased from a previous value of 1.7. A high value indicates decreased renal perfusion therefore it is important to monitor Juanita's intake and output for fluid imbalance in renal dysfunction and dehydration.
ALP: 227 (H) Normal: 30-110 U/L
This level has remained the same and therefore indicates obstructive jaundice is still present.
WBC: 12.0 (H) Normal: 4.0-11.0x10^9/L
White blood cells are used to detect the presence of infection and react against foreign bodies or tissues. An increase in WBCs indicates infection and inflammation (Cavanaugh, 2003). Juanita has just recently developed a yeast infection and therefore was prescribed Nystatin.
RDW: 15.1 Normal: 11-15%
The RDW has only increased by 0.1 and therefore still indicates a nutritional deficiency.
Platelets: 459 (H) Normal: 150-400x10^9/L
Causes of increased numbers of platelets are thrombocytosis and thrombocythemia (Cavanaugh, 2003). This may be related to Juanita's development of an acute infection. It is important to note signs of dehydration.
Neutrophils: 10.30 (H) Normal: 1.50-7.50x10^9/L
Neutrophils are altered with stress, infection, and inflammation (Cavanaugh, 2003).
Lymphocytes: 1.1 (L) Normal: 1.5-4.0x10^9/L
Juanita's values are still low, indicating the presence of infection.
Lab Results as of March 12, 2009:
Hemoglobin: 97 (L) Normal: 110-160g/L
Hematocrit: 0.305 (L) Normal: 0.330-0.480 L/L
Urea: 8.2 (H) Normal: 3.7-7.0 mmol/L
ALP: 170 (H) Normal: 30-110 U/L
GGT: 81 (H) Normal: 0-51 IU/L
Lipase: 81 (H) Normal: 0-2.72µkat/L
RDW: 15.9 (H) Normal: 11-15%
Platelets: 638 (H) Normal: 150-400 10^9/L
None of the above lab results need to be defined as these values are consistently out of the normal ranges and indicate that Juanita's health conditon and nutritional status are not being corrected at this time.
Cavanaugh, B. (2003). Nurse's manual of laboratory and diagnostic tests (4th Ed.). Philadelphia, PA: F.A. Davis Company.
Day, R., Paul, P., Williams, B., Smeltzer, S., & Bare, B. (2007). Brunner & Suddarth's textbook of medical-surgical nursing: First Canadian edition. Lippincott, Williams & Wilkins: New York, NY.
Mcdonald & Struthers, (2004):http://content.onlinejacc.org/cgi/content/full/43/2/155.
Pagana, K.D. & Pagana T.J. (2006). Mosby's manual of diagnostic and laboratory tests (3rd Ed.). St. Louis, Missouri: Mosby Elsevier.
Smeltzer, S., & Bare, B. (2004). Brunner & Suddarth's textbook of medical-surgical nursing (10th Ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.