Lab Values Podcast by NURSING.com (Nursing Podcast, normal lab values for nurses for NCLEX®) by NURSING.com (NRSNG)

Normal 135-145 mEq/L

Indications

Description Sodium (Na+) is the most abundant cation in extracellular fluid. Sodium aids in osmotic pressure, renal retention and excretion of water, acid-base balance, regulation of other cations and anions in the body. Sodium plays a role in blood pressure regulation and stimulation of neuromuscular reactions. Sodium and water have a direct relationship; water follows salt.

What would cause increased levels?

What would cause decreased levels?

Normal 3.5 - 5.0 mEq/L

Indications

Description

Potassium (K+) is the most abundant intracellular cation and plays a vital role in the transmission of electrical impulses in cardiac and skeletal muscle. It plays a role in acid base equilibrium. In states of acidosis hydrogen will enter the cell which will force potassium out of the cell. A 0.1 decrease in pH will cause a 0.5 increase in K+.

What would cause increased levels?

What would cause decreased levels?

Normal 25 - 35 seconds

Indications

Description

Partial Thromboplastin Time (PTT)evaluates the function of factors I, II, V, VIII, IX, X, XI, and XII. PTT represents the amount of time required for a fibrin clot to form. Monitors therapeutic ranges for people taking Heparin.

What would cause increased levels?

What would cause decreased levels?

Normal 95 - 100%

Indications

Description Oxygen saturation (SaO2) is a measurement of the percentage of how much hemoglobin is saturated with oxygen. Oxygen is transported in the blood in two ways: oxygen dissolved in blood plasma (pO2) and oxygen bound to hemoglobin (SaO2). About 97% of oxygen is bound to hemoglobin while 3% is dissolved in plasma. SaO2 and pO2 have direct relationships, if one is decreased so is the other. The relationship between oxygen saturation (SaO2) and partial pressure O2 (PaO2) is referred to as the oxyhemoglobin (HbO2) dissociation curve. SaO2 of about 90% is associated with PaO2 of about 60 mmHg.

What would cause increased levels?

What would cause decreased levels?

Normal 261 – 280 mOsm/kg

Indications

Description Osmolality is a measure of the particles in solution. The size, shape, and charge of the particles do not impact the osmolality

What would cause increased levels?

What would cause decreased levels?

Normal 1.6 – 2.6 mg/dL

Indications

Description Magnesium (Mg) is a cation necessary for protein synthesis, nucleic acid synthesis, muscle contraction, ATP (adenosine triphosphate) use, nerve impulse conduction, and blood clotting. Magnesium affects the absorption of sodium, calcium, phosphorus, potassium.

What would cause increased levels?

What would cause decreased levels?

Normal 0.3 -2.6 mmol/L

Indications

Description Lactate (Lactic Acid) is a byproduct of anaerobic metabolism. Normally, the tissues use aerobic metabolism to breakdown glucose for energy and the byproduct is CO2 and H2O which we excrete through our kidneys and exhalation. However, if the tissues are starved of oxygen (hypoxic), they use anaerobic metabolism. This can be compounded if the liver is also hypoxic causing the liver to be unable to clear the lactic acid.

What would cause increased levels?

What would cause decreased levels?

Normal 0.8 - 1.2 Therapeutic Levels of Warfarin 2.0 – 3.5

Indications

Description International normalized ratio(INR) takes results from a prothrombin time test and standardizes it regardless of collection method.

What would cause increased levels?

What would cause decreased levels?

Normal >60 optimal mg/dL

Indications

Description Cholesterol is transported via lipoproteins. There are multiple types of lipoproteins and they each have slightly different functions: high-density lipoprotein (HDL), low-density lipoprotein (LDL) very low-density lipoprotein (VLDL). HDL cholesterol is considered the good cholesterol because it travels through the blood picking up extra cholesterol and taking it back to the liver.

What would cause increased levels?

What would cause decreased levels?

Normal 5.6-7.5 % of total Hgb

Indications

Description

Glycosylated Hemoglobin (HbA1c) is the combination of glucose and hemoglobin. When glucose is elevated in the blood the amount of glycosylated hemoglobin increases proportionally. A red blood cells lifespan is about 4 months, so you can get an idea of blood sugar control over the last several months.

What would cause increased levels?

What would cause decreased levels?

Normal 2 - 20 ng/mL

Indications

Description Folic acid is an essential water soluble B vitamin. It is stored in the liver and is an important part of Red Blood Cell (RBC) and White Blood Cell (WBC) function, DNA replication, and cell division.

What would cause increased levels?

What would cause decreased levels?

Normal 20-300 ng/mL

Indications

Description

Ferritin is a protein that stores iron. It is formed in the liver spleen and bone marrow. Ferritin in the blood is usually proportional to stored ferritin. Ferritin is a more sensitive and specific test for identifying iron-deficiency anemia, however, it is usually measured in conjunction with total iron binding capacity and iron.

What would cause increased levels?

What would cause decreased levels?

Normal 96-108 mEq/L

Indications

Description

Chloride (Cl-), an anion found in the blood, works together with sodium to help maintain oncotic pressure and water balance in the body. Chloride is inversely related to bicarbonate levels in the blood. Chloride is also part of hydrochloric acid (HCL) which is utilized in the stomach to breakdown food. When red blood cells (RBCs) take up CO2 they take up chloride as well. The negative ion bicarbonate then leaves the red blood cell so that the electrical charge is maintained. Extra chloride is excreted into the urine by the kidneys.

What would cause increased levels?

What would cause decreased levels?

Normal 8.4-10.2 mg/dL

Indications

Description

Calcium (Ca+), a positive ion in the body, is necessary for neuromuscular processes, bone mineralization, and hormonal secretion. The parathyroid gland and vitamin D are responsible for calcium regulation in the body. In the blood, about half of calcium travels in ion form, the other half is bound to proteins like albumin. When albumin levels are low, calcium levels will appear lower. Calcium has an important relationship with phosphorus: they are inversely proportional.

What would cause increased levels?

What would cause decreased levels?

Normal 12-37 U/L

Indications

Description Aspartate Aminotransferase (AST) is an enzyme primarily found in liver and heart cells, and to a smaller extent, AST can also be found in the pancreas, kidneys, skeletal muscle, and brain. Levels of AST increase from cell death (necrosis) because the AST enzyme is released into the blood.

What would cause increased levels?

What would cause decreased levels?

Normal 0-130 U/L

Indications

Description Amylase is made in the pancreas. It is an enzyme that breaks down carbohydrates to allow our body to absorb it. Monitoring amylase levels can help identify problems with the pancreas.

What would cause increased levels?

What would cause decreased levels?

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Normal 30-40 seconds

Indications

Description Activated Partial Thromboplastin Time (aPTT) is a test that measures the amount of time it takes for a fibrin clot to form after reagents have been added to the specimen. It is useful in diagnosing clotting disorders. In conjunction with PT it can be used to differentiate the specific factor that may be missing.

What would cause increased (Prolonged) levels?

What would cause decreased levels?

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Overview

Urinalysis
Color & Clarity Protein RBC WBC Glucose Specific gravity Ketones pH Bilirubin/Urobilinogen

Normal value range
Color & Clarity
Normal – Yellow
Other colors
Drug interactions
Propofol  – green Methylene blue – blue/green
Trauma
Red/Brown
Liver failure
Brown/tea colored
Clear – Normal
Cloudy
Cell or contaminant related
Turbid
Severe presence of cells (WBC, RBC)
pH
~6
Changes in body condition can change pH Metabolic acidosis/alkalosis
Protein
0-trace Glomerular permeability/infection
RBC
0-2 Bleeding Trauma/injury  below kidneys
WBC
Negative Sepsis/Infection/UTI
Glucose
Negative Diabetes
Ketones
Negative Presence of ketones can indicate endocrine disease like Diabetes
Urine Specific Gravity
1.010-1.030 Facilities vary Ability to concentrate urine Hydration
Overhydration
Decreased USG
Dehydration
Increased USG
Diabetes insipidus
Causes increased diuresis
SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
Causes decreased diuresis
Bilirubin/Urobilinogen
Negative
Presence indicates potential liver problems

Lab Values Elimination

Overview

White Blood Cells
Normal Value Range Pathophysiology Special considerations Abnormal values (high) Abnormal values (low)

Normal value range
WBC
4500-10000/mcL
Differential
Neutrophils
40-60%
Bands
3-5%
>8% indicates signal to WBC for more production Infection or inflammation is severe
Eosinophils
1-4%
Basophils
0.5-1%
Lymphocytes
20-40%
Monocytes
2-8%
Pathophysiology
WBC
Formed in the bone marrow Responsible for responding to foreign invaders
Creating antibodies (immunity) Phagocytosis (eating bacteria or fungi)
Multiple types with different purposes
Neutrophils –
inflammation and first response to invader
Eosinophils –
Inflammation Allergic response Parasites
Basophils
Inflammation Allergic response
Lymphocytes
Create antibodies Recognize antigens Destroy cells
T Cells B Cells Natural Killer cells
Monocytes
Macrophages
Engulf and destroy invaders
Indicative of infection
Special considerations
Lavender top tube Will commonly be submitted for Complete Blood Count with differential
Abnormal lab values
Increased White Blood Cell count (leukocytosis)
Infection Inflammation Trauma/Stress Pregnancy Asthma Allergic Reaction
Decreased lab values (leukopenia)
Systemic Lupus Erythematosus (SLE)/Rheumatoid arthritis Cancers Chemotherapy/Radiation Medications
Neutropenic precautions
Masks Gloves Wash hands Consider yourself infectious
Prevent spread of infection to the patient

Consider the overall WBC count plus abnormalities in differential
Evaluate patient
Signs or symptoms of:
Trauma Inflammation Infection

Antibiotic therapies where indicated by infection (followed by cultures to determine efficacy of antibiotics) Anti-inflammatories for inflammation Provide neutropenic precautions when necessary

Lab Values Infection Control

Educate patient on the finishing any antibiotics completely. Do not stop prior, even if the patient says they are feeling better.

Overview

Troponin I
Normal value range Pathophysiology Special considerations Elevations in lab values

Normal value range
Typically, less than 0.035 ng/mL or less Can vary among institutions Has to be greater than the 99th percentile
Pathophysiology
Troponin is released during myocardial cell damage Decreased perfusion causes myocardial cell damage Causes of myocardial cell damage
Myocardial infarction Demand ischemia
Cardiogenic
ACS
Noncardiogenic
Sepsis Renal failure Extreme exercise
Special considerations
Submitted in green top tube Value peak
Detection 6-12 hours after acute injury Peaks 24 hours after injury Can stay elevated for a week
Knowing patient history is critical
Increased values
Any elevated value is typically considered critical Acute elevations warrant immediate investigation
Typically PCI (percutaneous coronary intervention)/Angiography and EKG to rule out MI or ACS (acute coronary syndrome)
Other elevations
CABG Extreme exercise End Stage Renal Failure

Assess for:
Acute chest pain Symptoms of MI
Nausea Vomiting Angina in any form Reflux (especially in women)

EKG Angiography or PCI Management of non-cardiogenic etiology

Lab Values Perfusion

Educate patient on keeping history of elevated levels or cardiac disease for future reference Educate patient on duration of elevated troponin levels, post injury

Objective:

Determine the significance and clinical use of  Thyroid Stimulating Hormone in clinical practice

Thyroid Stimulating Hormone

Thyroid Stimulating Hormone (TSH) is released from the anterior pituitary in response to low levels of thyroid hormone. 

TSH stimulates the thyroid gland to release thyroid hormones

Aids to diagnose:

Monitor: 

Normal – 

2-10 mU/L

Collection:

TSH levels increase in the following conditions:

Recall the inverse relationship between TSH and T3/T4 labs, and how the negative feedback loop works with these hormones.

TSH levels decrease in the following conditions:

Overview

Red blood cells
Normal Value Range Patho Special considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments

Normal range
Measured in millions Normal values
Males 4.5-5.5 x106/mcL Females 4-4.9×106/mcL
Pathophysiology
Red Blood Cell generation
Formed in bone marrow Stimulated by kidneys by erythropoietin
Function
AKA Erythrocytes
Reticulocytes
Young RBC Indicate regeneration
Carries oxygen
Via Hemoglobin Allows for transfer of CO2
Bioconcave shape
Increases surface area Allows for ability to “squeeze” into capillaries
2.4 M made every 1 second
Special considerations
Submitted via LAVENDER top tube (EDTA) Technique can destroy red blood cells
Allow vacuum in vacutainers to draw blood, never force blood into tubes Consider angiocath/IV size when drawing blood
Elevated RBC results
Dehydration
Result of decreased plasma
Polycythemia
Bone marrow cancer, causes increase in RBC
COPD Pulmonary fibrosis
Decreased RBC results
Anemia
Sickle-cell ↓ EPO due to kidney disease
Hemorrhage Bone marrow failure Pregnancy

Assess for signs of anemia
Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor

Blood transfusions as necessary Treat primary cause of anemia

Nursing Concepts

Lab Values Oxygenation

Objective:

Determine the significance and clinical use of Prostate Specific Antigen in clinical practice

Prostate Specific Antigen – PSA

Measurement of PSA in the bloodstream

Used to diagnose and assess prostate health, size and function.

Evaluate:

Normal – 

Collection:

Increased:

Decreased:

Overview

Platelets
Normal Value Range Pathophysiology Special considerations Elevated platelet levels Decreased platelet levels

Normal value ranges
100,000 – 450,000/mcL Also known as – Thrombocytes
Pathophysiology
Formed from Megakaryocyte
Formed from bone marrow Produces 1000-3000 platelets
Injury occurs at site
Collagen releases activators Thrombocytes activate “sticky fingers”, which allow them to bind together. Travel to site (along with other clotting factors) Adhere to site, increase stimulation for other PLT, until clot is formed with fibrin
Special considerations
Use a lavender top tube (EDTA) Often sent in CBC
Abnormal lab values
Elevated platelets (thrombocytosis)
Cancers Absence of a spleen
Breaks down platelets
Birth control Polycythemia vera
Overproduction of cells Treatment via bloodletting, medications or hydration
Decreased platelets (thrombocytopenia)
ITP (Idiopathic thrombocytopenic purpura)
Autoimmune disease Medications
Hemorrhage
Treated with transfusion
Leukemia
Treated with chemotherapy/radiation
Medications
Some diuretics Nonsteroidal anti-inflammatory drugs (NSAIDs) Ranitidine Some antibiotics

Assess for signs of petechia (small purplish blemishes, indicating bleeding)

Control and stop hemorrhage
Replace platelets via transfusion
Consider stopping or changing medications that cause thrombocytopenia

Lab Values Clotting

For patients who have bleeding disorders, instruct patients to be cautious of injury. If patient has thrombocytopenia, instruct patient to seek emergency treatment in the event of bleeding that does not stop.

**DISCLAIMER – The video states that the normal value of platelets is 100,000 – 400,000 cells/mcL. The correct information is 100,000 – 450,000 cells/mcL.

Objective:

Determine the significance and clinical use of  Lipase in clinical practice

Lipase

Lipase

Measurement of lipase in the blood

Diagnose:

Normal: 

Collection:

N/A

Objective:

Determine the significance and clinical use of iron levels in clinical practice

Iron – Fe

Measures the amount of Fe in the bloodstream. 

Evaluates: 

Iron (Fe) is an element that is an important component of hemoglobin in red blood cells.

Iron aids hemoglobin’s transport of oxygen from the lungs to all the cells of the body. 

The storage form of iron is ferritin. Iron is transported in the blood by a protein called transferrin.

Identify:

Type of anemia:

Normal – 

50-175 μg/dL

Collection:

What would cause Increased Levels of Iron?

What would cause Decreased Levels of Iron?

Overview

Hemoglobin
Normal Value Range Pathophysiology Special considerations Elevated hemoglobin Decreased hemoglobin

Normal value range
Males – 13.5-16.5 g/dL Females – 12.0 – 15.0 g/dL
Pathophysiology
Protein attached to red blood cell Iron based protein 4 groups
2 alpha 2 beta
Has a high affinity (attraction) for oxygen
Oxyhemoglobin
Has oxygen attached
Deoxyhemoglobin
Oxygen has been released
Oxyhemoglobin Dissociation Curve
Oxygen saturation Shift to the right
Partial pressure is higher HGB attraction to oxygen is lower Oxygen becomes less “sticky” and wants to be released Causes
↓pH ↑pCO2 ↑Temperature
Shift to the left
Partial pressure is lower HGB attraction is higher Oxygen wants to stay “stuck” to HGB Causes
↑pH ↓pCO2 ↓Temperature
Special considerations
Submit in lavender top tube Be cautious with phlebotomy technique
Reduce hemolysis with proper tubing and syringes
Elevated HGB values
Polycythemia vera
Treatments
Blood letting Increased water intake Some medications
Dehydration Lung disease
Pulmonary fibrosis COPD
Certain medical therapies
EPO supplementation
Decreased HGB values
Thalassemia Blood loss Sickle Cell anemia Aplastic anemia Cancers

Assess for signs of anemia
Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor

Blood transfusions as necessary Treat primary cause of anemia

Lab Values Oxygenation

Overview

Hematocrit
Normal Value Range Pathophysiology Special considerations Elevations in lab results Decreased HCT levels

Normal value range
HCT measured in percentage Males – 41-50% Females – 36-44%
Pathophysiology
Measurement of total pRBCs compared to rest of blood volume Helps to indicate anemia Often measured with HGB (hemoglobin)
Special considerations
Lavender top tube (EDTA) Be cautious with technique
Do not force sample into tube Can cause hemolysis Alters results
Causes of HCT elevation
Dehydration
Change in % compared to total blood volume
Respiratory disease
COPD Pulmonary fibrosis
Increased need for oxygen -> increased need for RBC production
Polycythemia vera
RBC overproduction due to bone marrow cancer Treatment includes bloodletting and increasing water consumption (also some medications)
Causes of decreased HCT
Blood loss
Trauma Hemorrhage Treatment
Stop bleeding Transfuse blood
Anemia
Kidney disease
Decrease in EPO production Treatment
Supplement with EPO
Pregnancy
Relative to increase total blood volume
Leukemia
Decreased bone marrow production causes ↓ RBC Treat leukemia via oncology pathways
Chemotherapy Radiation Bone marrow transplant

Assess for signs of anemia
Tachycardia Fatigue Shortness of breath Decreased SaO2 Pallor

Blood transfusions as necessary Treat primary cause of anemia Use oncologic methods to treat leukemia Bloodletting (phlebotomy) for polycythemia patients

Lab Values Oxygenation

Objective:

Determine the significance and clinical use of Erythrocyte Sedimentation Rate in clinical practice

Erythrocyte Sedimentation Rate- ESR

The Erythrocyte Sedimentation Rate (ESR) test measures sedimentation of Red Blood Cells (RBCs). 

In normal conditions, RBCs settle or sediment very little. 

Inflammation affects proteins in the blood causing RBCs to stick and settle together out of the liquid portion of the blood.

Identifies inflammation which assists in diagnosing:

Normal – 0-20 mm/hr

Increased

Conditions:

Medications:

What would cause decreased levels?

Decreased

Conditions:

Medications:

Objective:

Determine the significance and clinical use of  D-Dimer in clinical practice

D-Dimer- DDI

Measurement of D-Dimer evaluates the amount of byproduct produced as part of fibrinolysis

D-dimer (DDI) is a product of fibrinolysis

D-dimer levels are elevated in the setting of clot breakdown, and will be significantly elevated in the setting of Disseminated Intravascular Coagulation (DIC).

Identify and monitor 

Disseminated Intravascular Coagulation (DIC)

Rule out a blood clot:

Normal – ≤ 250 ng/mL

Collection:

Increased

Indicates a lack of the substance that is released during the breakdown of a blood clot (i.e. lack of blood clots, or lack of fibrinolysis)

Objective:

Determine the significance and clinical use of C-Reactive Protein in clinical practice

C-Reactive Protein – CRP

C-reactive protein (CRP) is made in the liver in response to inflammation

Measures CRP in the blood

Monitor or Identify:

Evaluate:

Normal –

Overview

Creatinine
Normal Value Range Pathophysiology Special considerations Elevations in creatinine Decreases in creatinine

Normal values
0.7 – 1.4 mg/dL
Pathophysiology
Muscle breakdown and use
Creatine -> creatinine
Released into bloodstream
Filtered through kidneys Excreted in urine
Creatinine more specific to kidney function
Special considerations
Green top Submitted with renal panels or chems Creatinine clearance
Tests creatinine in urine Compare to serum creatinine 24 hour urine
Toss first urine sample, then start On ice
Increased creatinine values
Renal disease Rhabdomyolysis
Muscle breakdown Trauma Extreme workouts
Congestive heart failure Dehydration Shock
Decreased creatinine values
Loss of muscle mass Muscular dystrophy Decreased protein intake Pregnancy Liver disease

Assess patient’s nutritional status Assess urine output Consider other causes for increase in creatinine
Muscle

Treat cause of renal insufficiency
Dialysis vs medication

Lab Values Elimination

Objective:

Determine the significance and clinical use of measuring Creatinine Clearance in clinical practice

Creatinine Clearance – CrCl

Healthy kidneys remove creatinine from the blood. It then passes out of your body through urine. Creatinine is created in the body as a byproduct from normal wear and tear on muscles and protein in your diet.

Creatinine Clearance is a test that compares the level of creatinine in the blood against the level in the urine and evaluates Glomerular Filtration Rate. Hydration, blood volume status, blood pressure, and the state of the glomeruli impact GFR. 

Remember that GFR is the amount of blood cleaned each minute by tiny filters in your kidneys called glomeruli.

An increase in CrCl indicates an increase in GFR.

The creatinine clearance test is done when your healthcare provider thinks that the eGFR result given with your blood creatinine level may not be accurate. This would be in patients who have diabetes, those with HF, those with kidney disease, and is sometimes evaluated in those with hypertension.

Normal – Creatinine clearance rates go down as you age

For every decade after age 40, a normal test result is 6.5 mL/min less than the numbers above.

Collection:

Increased Creatinine Clearance→ Increased GFR

The kidneys are solely responsible for removing Creatinine from the blood. If kidney function is declining, the creatinine level increases in the blood, but less creatinine is excreted into the urine.

Decreased Creatinine Clearance→ Decreased GFR

Overview

Cholesterol
Normal Value Range Pathophysiology Any special considerations when drawing the lab (i.e. on ice, etc.) Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments

Normal values
60 mg/dL
Low Density Lipoprotein (LDL)
Contributes to plaque buildup Goal

Overview

BNP
Normal Value Range Pathophysiology Special considerations Lab value elevations

Normal value range
100 pg/mL
Pathophysiology
Increased pressure overload due to increased SVR or volume Ventricular stretching causes release of BNP into bloodstream BNP released to aid in stress due to overload by:
Increases excretion of sodium in urine = natriuresis
Sodium follows water
Decreased intravascular volume Decreased workload on the heart = improved cardiac function
Special considerations
Lavender tube (EDTA) NT-proBNP may be requested instead
Submit in serum separator tube (tiger top)
Elevated lab values
>100 pg/mL – heart failure likely The higher the value, the more likely the diagnosis of heart failure

Assess patient for acute exacerbation of heart failure
Lung sounds Oxygen status
Need for supplemental oxygen
Radiographic evaluation May need diagnostics for evaluation
Echocardiogram can determine contractility function

Treatment
Treat heart failure
Diurese Improve contractility

Lab Values Perfusion

Overview

Blood Urea Nitrogen (BUN)
Normal Value Range Pathophysiology Special Considerations Elevated Values Decreased Values

Normal value range
7-20 mg/dL
Pathophysiology
Protein broken into amino acids -> Ammonia Ammonia converted to urea Urea excreted via kidneys
Special considerations
Green top tube Submitted in multiple panels
Chem 7/Chem 10 CMP Renal panel
Elevated values
Renal failure Congestive heart failure Myocardial infarction Dehydration Urinary obstruction Diabetes
Decreased values
Liver failure Overhydration Inadequate protein intake
Malnutrition
Pregnancy

Assess patient’s nutritional status Assess urine output Find primary cause for renal impairment (pre-/intra-/post-renal)

Treat cause of renal insufficiency
Dialysis vs medication

Lab Values Elimination

Overview

Total bilirubin
Normal Value Range Pathophysiology Special considerations Elevations in Total bilirubin

Normal values
0.1-1.2 mg/dL
Patho
Breakdown product of RBCs
Specifically heme (iron portion of hemoglobin)
Transported to liver
Bound with bile Excreted via GI tract and kidneys
Conjugated
Water soluble
Unconjugated
Not able to excrete it Carried to liver via albumin Conjugated in liver
Special Considerations
Submit in green top tube Usually submitted with liver function tests
Elevated Total Bilirubin
Newborn jaundice
Treated with phototherapy Liver tumors Liver disease
Cirrhosis Hepatitis Alcoholism
Cholecystitis Biliary obstruction

Assess patients for jaundice or icterus, or changes in color of stool (clay colored)

Phototherapy for newborns, as they are unable to properly breakdown bilirubin Treat primary cause of liver/gallbladder disease

Lab Values Gastrointestinal/Liver Metabolism

Overview

Ammonia
Normal Value Range Pathophysiology Special considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments

Normal value range
19-60 mcg/dL
Pathophysiology
Byproduct of protein metabolism
Proteins → ammonia Ammonia → urea via the liver Urea excreted to the kidneys
If ammonia is not converted to urea
Ammonia ↑ in bloodstream Causes hepatic encephalopathy
Neurotoxic ↓ Level of consciousness Confusion Altered mental status
Refer to Neuro lesson 03.06 Encephalopathies
Special considerations
Sent in either green or lavender tube Typically sent on ice Discuss with facility lab or unit
Elevations in ammonia
Liver failure
Treatment:
Lactulose
Ammonia binding agent Given PO or PR Ammonia excreted via stool
Hepatic encephalopathy TPN GI hemorrhage Reye’s syndrome
Decreased ammonia levels
Antibiotics

Assess patient’s cognition and level of consciousness Assess patient’s ability to swallow and protect airway

Lactulose via rectal tube or PO if patient can tolerate oral medications and follow directions

Lab Values Gastrointestinal/Liver Metabolism

Objective:

Determine the significance and clinical use of  alkaline phosphatase in clinical practice

Alkaline Phosphatase – ALP

Measures amount of ALP in circulation

Located in several places in the body:

Different isoenzymes of ALP are used to determine:

Evaluation of ALP:

Normal – 40-130 U/L

Collection:

Increased levels assessed in:

Overview

Albumin
Normal Value Range Pathophysiology Special Considerations Too High: Causes, Symptoms, Treatments Too Low: Causes, Symptoms, Treatments

Normal value range
3.5 – 6.0 g/dL
Pathophysiology
Produced in the liver Main protein of plasma Responsible for maintaining oncotic pressure
Draws fluid into blood vessel “Protein pulls” Refer to Fluid & Electrolytes lesson  01.02 Fluid Pressures
Transport protein Serves as amino acid Nutrition
Poor indicator of nutrition
Due to long half-life
Pre-Albumin
Better indicator of nutrition
Special considerations
Green top typically Usually sent with several other labs
Chemistries Liver function tests Nutritional labs
Elevated Albumin levels
Dehydration Excess infusion of albumin
Decreased albumin levels
Liver disease Fluid loss
Fistula Hemorrhage Kidney Disease Burns
Congestive heart failure Long term poor nutrition
Inadequate intake
Inflammation

Assess patient’s pre-albumin for nutritional status or indications of acute illness

Lab Values Nutrition

Objective:

Determine the significance and clinical use of Alanine Aminotransferase in clinical practice

Alanine Aminotransferase – ALT

Measures amount of ALT, an enzyme produced by the liver, present in circulation

Found in:

Most abundantly in liver

Heart

Skeletal muscle

kidney

Increases in lab values indicate liver disease or liver damage

Evaluation of ALT:

Normal – 40-130 U/L

Collection:

INCREASED: 

DECREASED:

Overview

Glucose
Normal Value Range Pathophysiology Special considerations Hyperglycemia Hypoglycemia

Normal value
70-115 mg/dL
Pathophysiology
Consumed via diet
Carbohydrates
Glycolysis
Creates net positive energy sources
Insulin
Produced in pancreas Required to force glucose into cell Deficiency in insulin causes high glucose in blood Increase in insulin resistance causes high glucose in blood
Special considerations
Lab
Green or gray tube
Bedside
CBG (Capillary blood glucose) Use glucometer Use gauze and alcohol
Hyperglycemia (high levels of glucose)
Diabetes
Absent or inefficient insulin
Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) Stress
Increases cortisol production
Pancreatitis
Disrupts insulin production
Renal failure Cushing’s syndrome Steroid use
Increases insulin resistance
Hypoglycemia (low levels of glucose)
Insulinoma Hypothyroidism Hypopituitarism Addison’s Disease Insulin overdose Malnutrition

Lab Values Glucose Metabolism

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White Blood Cell

WBC

White blood cells (WBCs) are created in the bone marrow. Their primary function is to defend the body against infection. There are various types of WBCs which have different shapes and functions. Decreased WBC count is called Leukopenia and increased WBC count is called Leukocytosis.

4,500 – 10,000 cells/mcL

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Urinalysis
Color & Clarity Protein RBC WBC Glucose Specific gravity Ketones pH Bilirubin/Urobilinogen

Normal value range
Color & Clarity
Normal – Yellow
Other colors
Drug interactions
Propofol  – green Methylene blue – blue/green
Trauma
Red/Brown
Liver failure
Brown/tea colored
Clear – Normal
Cloudy
Cell or contaminant related
Turbid
Severe presence of cells (WBC, RBC)
pH
~6
Changes in body condition can change pH Metabolic acidosis/alkalosis
Protein
0-trace Glomerular permeability/infection
RBC
0-2 Bleeding Trauma/injury  below kidneys
WBC
Negative Sepsis/Infection/UTI
Glucose
Negative Diabetes
Ketones
Negative Presence of ketones can indicate endocrine disease like Diabetes
Urine Specific Gravity
1.010-1.030 Facilities vary Ability to concentrate urine Hydration
Overhydration
Decreased USG
Dehydration
Increased USG
Diabetes insipidus
Causes increased diuresis
SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
Causes decreased diuresis
Bilirubin/Urobilinogen
Negative
Presence indicates potential liver problems

Lab Values Elimination

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Troponin I

cTNL

Troponins are proteins that initiate contraction of muscle fibers. Troponin I (cTNL) is specific to heart muscle. Troponin levels stay elevated for a week after muscle damage before returning to normal.

There is a wide range of normal values among varying institutions and texts with regard to Troponin I. It is essential to verify institutional norms. < 0.035 ng/mL

N/A

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Triglycerides

TG

Triglycerides (TG) are required to provide energy during the metabolic process, excess triglycerides are stored in adipose tissue.

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Determine the significance and clinical use of  Thyroid Stimulating Hormone in clinical practice

Thyroid Stimulating Hormone

Thyroid Stimulating Hormone (TSH) is released from the anterior pituitary in response to low levels of thyroid hormone. 

TSH stimulates the thyroid gland to release thyroid hormones

Aids to diagnose:

Monitor: 

Normal – 

2-10 mU/L

Collection:

TSH levels increase in the following conditions:

Recall the inverse relationship between TSH and T3/T4 labs, and how the negative feedback loop works with these hormones.

TSH levels decrease in the following conditions:

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Sodium

Na+

Sodium (Na+) is the most abundant cation in extracellular fluid. Sodium aids in osmotic pressure, renal retention and excretion of water, acid-base balance, regulation of other cations and anions in the body, plays a role in blood pressure regulation, and stimulation of neuromuscular reactions. Sodium and water have a direct relationship; Water follows salt.

135-145 mEq/L

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Red Blood Cell

RBC

Red Blood Cells (RBCs) contain hemoglobin which is responsible for oxygen transport throughout the body. RBCs are primarily produced in the bone marrow, they have a life span of 120 days and are destroyed in the spleen and liver. RBC production is regulated by erythropoietin (EPO) which is produced and released from the kidneys.

Male: 4.5 – 5.5 x106/cells/mm3 Female: 4.0 – 4.9 x106/cells/mm3

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Determine the significance and clinical use of Prostate Specific Antigen in clinical practice

Prostate Specific Antigen – PSA

Measurement of PSA in the bloodstream

Used to diagnose and assess prostate health, size and function.

Evaluate:

Normal – 

Collection:

Increased:

Decreased:

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Potassium

K+

Potassium (K+) is the most abundant intracellular cation and plays a vital role in the transmission of electrical impulses in cardiac and skeletal muscle. It plays a role in acid base equilibrium. In states of acidosis hydrogen with enter the cell as this happens it will force potassium out of the cell, a 0.1 decrease in pH will cause a 0.5 increase in K+.

3.5 – 5.0 mEq/L

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Platelets

(PLT)

Platelets (PLT) play a role in coagulation, hemostasis, and thrombus formation. Platelets are the smallest blood cell, damaged vessels send out signals that result in platelets traveling to the area and becoming “active”.

100,000 – 450,000 cells/mcL

What would cause Increased Levels of Platelets?

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Partial Thromboplastin Time

PTT

Partial Thromboplastin Time (PTT)evaluates the function of factors I, II, V, VIII, IX, X, XI, and XII. PTT represents the amount of time required for a fibrin clot to form. Monitors therapeutic ranges for people taking Heparin.

25 – 35 seconds

N/A

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Oxygen Saturation

SaO2

Oxygen saturation (SaO2) is a measurement of the percentage of how much hemoglobin is saturated with oxygen. Oxygen is transported in the blood in two ways: oxygen dissolved in blood plasma (pO2) and oxygen bound to hemoglobin (SaO2). About 97% of oxygen is bound to hemoglobin while 3% is dissolved in plasma. SaO2 and pO2 have direct relationships, if one is decreased so is the other. The relationship between oxygen saturation (SaO2) and partial pressure O2 (PaO2) is referred to as the oxyhemoglobin (HbO2) dissociation curve. SaO2 of about 90% is associated with PaO2 of about 60 mmHg. For more information on PaO2, SaO2 and oxyhemoglobin dissociation curve visit this link HERE.

95 – 100%

What would cause Increased Levels of Oxygen Saturation?

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Osmolality

Osmolality is a measure of the particles in solution. The size, shape, and charge of the particles do not impact the osmolality

261 – 280 mOsm/kg

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Magnesium

Mg

Magnesium (Mg) is a cation necessary for protein synthesis, nucleic acid synthesis, muscle contraction, ATP (adenosine triphosphate) use, nerve impulse conduction, and blood clotting. Magnesium affects the absorption of sodium, calcium, phosphorus, potassium.

1.6 - 2.6mg/dL

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Low Density Lipoprotein

LDL

Cholesterol is transported via lipoproteins. There are multiple types of lipoproteins and they each have slightly different functions: high-density lipoprotein (HDL), low-density lipoprotein, LDL, very low-density lipoprotein (VLDL). LDL cholesterol is considered bad cholesterol because as it travels through the blood, it deposits cholesterol into the lining of blood vessels, causing atherosclerosis and an increase in cardiovascular disease.

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Determine the significance and clinical use of  Lipase in clinical practice

Lipase

Lipase

Measurement of lipase in the blood

Diagnose:

Normal: 

Collection:

N/A

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Lactic Acid

Lactate (Lactic Acid) is a byproduct of anaerobic metabolism. Normally, the tissues use aerobic metabolism to breakdown glucose for energy and the byproduct is CO2 and H2O which we excrete through our kidneys and exhalation. However, if the tissues are starved of oxygen (hypoxic), they use anaerobic metabolism. This can be compounded if the liver is also hypoxic causing the liver to be unable to clear the lactic acid.

0.3 -2.6 mmol/L

What would cause Decreased Levels of Lactic Acid?

N/A

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Determine the significance and clinical use of iron levels in clinical practice

Iron – Fe

Measures the amount of Fe in the bloodstream. 

Evaluates: 

Iron (Fe) is an element that is an important component of hemoglobin in red blood cells.

Iron aids hemoglobin’s transport of oxygen from the lungs to all the cells of the body. 

The storage form of iron is ferritin. Iron is transported in the blood by a protein called transferrin.

Identify:

Type of anemia:

Normal – 

50-175 μg/dL

Collection:

What would cause Increased Levels of Iron?

What would cause Decreased Levels of Iron?

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International Normalized Ratio

INR

International normalized ratio(INR) takes results from a prothrombin time test and standardizes it regardless of collection method.

0.8 – 1.2 Therapeutic Levels on Warfarin 2.0 – 3.5

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High Density Lipoprotein

HDL

Cholesterol is transported via lipoproteins. There are multiple types of lipoproteins and they each have slightly different functions: high-density lipoprotein (HDL), low-density lipoprotein, LDL, very low-density lipoprotein (VLDL). HDL cholesterol is considered the good cholesterol because it travels through the blood picking up extra cholesterol and taking it back to the liver.

60 optimal mg/dL

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Hemoglobin

Hbg

Hemoglobin (Hbg), an iron containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.

Male: 13.5 – 16.5 g/dL | Female: 12.0 – 15.0 g/dL

Identify:

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Hematocrit

Hct

Hematocrit (Hct) is the percentage of the blood that is made up of packed Red Blood Cells (RBCs). A hematocrit level of 40% indicates that there are 40 mL packed red blood cells in 100 mL of blood.

Male: 41 – 50% | Female: 36 – 44%

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Glycosylated Hemoglobin

HbA1c

Glycosylated Hemoglobin (HbA1c) is the combination of glucose and hemoglobin. When glucose is elevated in the blood the amount of glycosylated hemoglobin increases proportionally. A red blood cells lifespan is about 4 months, so you can get an idea of blood sugar control over the last several months.

5.6-7.5 % of total Hgb

What would cause Decreased Levels of Glycosylated Hemoglobin?

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Glucose

Glucose is a sugar molecule that is a component of carbohydrates. Glucose provides energy in the body and is absorbed from the blood to the cells for nourishment via insulin. The pancreas secretes insulin to helps regulate levels of glucose in the blood. Glucose levels naturally rise after meals with the intake of carbohydrates.

70-115 mg/dL

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Folic Acid

Folic acid is an essential water soluble B vitamin. It is stored in the liver and is an important part of Red Blood Cell (RBC) and White Blood Cell (WBC) function, DNA replication, and cell division.

2 – 20 ng/mL

What would cause Decreased Levels of Folic Acid?

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Ferritin

Ferritin is a protein that stores iron. It is formed in the liver spleen and bone marrow. Ferritin in the blood is usually proportional to stored ferritin. Ferritin is a more sensitive and specific test for identifying iron-deficiency anemia, however, it is usually measured in conjunction with total iron binding capacity and iron.

20-300 ng/mL

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Determine the significance and clinical use of Erythrocyte Sedimentation Rate in clinical practice

Erythrocyte Sedimentation Rate- ESR

The Erythrocyte Sedimentation Rate (ESR) test measures sedimentation of Red Blood Cells (RBCs). 

In normal conditions, RBCs settle or sediment very little. 

Inflammation affects proteins in the blood causing RBCs to stick and settle together out of the liquid portion of the blood.

Identifies inflammation which assists in diagnosing:

Normal – 0-20 mm/hr

Increased

Conditions:

Medications:

What would cause decreased levels?

Decreased

Conditions:

Medications:

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Determine the significance and clinical use of  D-Dimer in clinical practice

D-Dimer- DDI

Measurement of D-Dimer evaluates the amount of byproduct produced as part of fibrinolysis

D-dimer (DDI) is a product of fibrinolysis

D-dimer levels are elevated in the setting of clot breakdown, and will be significantly elevated in the setting of Disseminated Intravascular Coagulation (DIC).

Identify and monitor 

Disseminated Intravascular Coagulation (DIC)

Rule out a blood clot:

Normal – ≤ 250 ng/mL

Collection:

Increased

Indicates a lack of the substance that is released during the breakdown of a blood clot (i.e. lack of blood clots, or lack of fibrinolysis)

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Determine the significance and clinical use of C-Reactive Protein in clinical practice

C-Reactive Protein – CRP

C-reactive protein (CRP) is made in the liver in response to inflammation

Measures CRP in the blood

Monitor or Identify:

Evaluate:

Normal –

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Determine the significance and clinical use of measuring Creatinine Clearance in clinical practice

Creatinine Clearance – CrCl

Healthy kidneys remove creatinine from the blood. It then passes out of your body through urine. Creatinine is created in the body as a byproduct from normal wear and tear on muscles and protein in your diet.

Creatinine Clearance is a test that compares the level of creatinine in the blood against the level in the urine and evaluates Glomerular Filtration Rate. Hydration, blood volume status, blood pressure, and the state of the glomeruli impact GFR. 

Remember that GFR is the amount of blood cleaned each minute by tiny filters in your kidneys called glomeruli.

An increase in CrCl indicates an increase in GFR.

The creatinine clearance test is done when your healthcare provider thinks that the eGFR result given with your blood creatinine level may not be accurate. This would be in patients who have diabetes, those with HF, those with kidney disease, and is sometimes evaluated in those with hypertension.

Normal – Creatinine clearance rates go down as you age

For every decade after age 40, a normal test result is 6.5 mL/min less than the numbers above.

Collection:

Increased Creatinine Clearance→ Increased GFR

The kidneys are solely responsible for removing Creatinine from the blood. If kidney function is declining, the creatinine level increases in the blood, but less creatinine is excreted into the urine.

Decreased Creatinine Clearance→ Decreased GFR

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Creatinine

Cr

Creatinine (Cr) is a byproduct of creatine metabolism, and it is excreted by the kidneys. Creatinine is created in proportion to muscle mass and usually stays stable.

0.7-1.4 mg/dL

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Creatine Kinase

CK

Creatine kinase (CK) enzyme is found in heart and skeletal muscle and to a lesser extent brain. When damage is done to these types of tissue CK is released into the blood. There are three isoenzymes, and depending on which one is elevated this lab value can help determine timing, location, extent of damage. The three isoenzymes are CK-MB (cardiac), CK-MM (skeletal), and CK-BB (brain).

55 – 170 U/L

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Cholesterol

Chol

Cholesterol (Chol) is a lipid in the body. It is a part of cell membranes as well as a precursor for vitamin D, steroids, and bile acids. Cholesterol is primarily synthesized in the liver and intestines and is transported via lipoproteins. There are multiple types of lipoproteins, each have slightly different functions. The two most common types of lipoproteins are high-density lipoprotein (HDL) and low-density lipoprotein (LDL).

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Chloride

Cl-

Chloride (Cl–), an anion found in the blood, works together with sodium to help maintain oncotic pressure and water balance in the body. Chloride is inversely related to bicarbonate levels in the blood. Chloride is also part of hydrochloric acid (HCL) which is utilized in the stomach to breakdown food. When Red Blood Cells (RBCs) take up CO2 they take up chloride as well. The negative ion bicarbonate then leaves the red blood cell so that the electrical charge is maintained. Extra chloride is excreted into the urine by the kidneys.

96-108 mEq/L

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Calcium

Ca+

Calcium (Ca+), a positive ion in the body, is necessary for neuromuscular processes, bone mineralization, and hormonal secretion. The parathyroid gland and vitamin D are responsible for calcium regulation in the body. In the blood, about half of calcium travels in ion form, the other half is bound to proteins like albumin. When albumin levels are low, calcium levels will appear lower. Calcium has an important relationship with phosphorus: they are inversely proportional.

8.4-10.2 mg/dL

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Blood Urea Nitrogen

BUN

Blood urea nitrogen (BUN) measures the amount of urea in the blood. When protein is broken down ammonia is formed. Ammonia is converted to urea in the liver and is eventually excreted in the kidneys.

7-20 mg/dL

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Determine the significance and clinical use of measuring Direct or Conjugated Bilirubin in clinical practice

Direct or Conjugated Bilirubin

Bilirubin is a substance made when your body breaks down old red blood cells. This is a normal process. Bilirubin is also part of bile, which your liver makes to help digest the food you eat.

A small amount of bilirubin in your blood is normal.

Some bilirubin is bound to albumin in the blood. This type of bilirubin is called unconjugated, or indirect, bilirubin.

In the liver, bilirubin is changed into a form that your body can get rid of. This is called conjugated bilirubin or direct bilirubin. 

This bilirubin travels from the liver into the small intestine. A very small amount passes into your kidneys and is excreted in your urine. This bilirubin also gives urine its distinctive yellow color and contributes to the brown color of stool.

Normal – 0.0-0.2 mg/dL

Collection:

Increased levels linked to:

Studies are inconclusive regarding risk or association with disease process in the presence of a decreased bilirubin level.

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Aspartate Aminotransferase

AST

Aspartate aminotransferase (AST) is an enzyme primarily found in liver and heart cells and to a smaller extent, AST can also be found in the pancreas, kidneys, skeletal muscle, and brain. Levels of AST increase from cell death (necrosis) because the AST enzyme is released into the blood.

12-37 U/L

N/A

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Amylase

Amylase is made in the pancreas. It is an enzyme that breaks down carbohydrates to allow our body to absorb it. Monitoring amylase levels can identify problems with the pancreas.

0-130 U/L

What would cause Decreased Levels of Amylase?

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Ammonia

NH3

Ammonia (NH3) is a byproduct created when protein is broken down. Ammonia is converted into urea in the liver, and urea is excreted by the kidneys. During liver disease, ammonia levels rise and can have a negative effect on the brain.

19-60 mcg/dL

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Determine the significance and clinical use of  alkaline phosphatase in clinical practice

Alkaline Phosphatase – ALP

Measures amount of ALP in circulation

Located in several places in the body:

Different isoenzymes of ALP are used to determine:

Evaluation of ALP:

Normal – 40-130 U/L

Collection:

Increased levels assessed in:

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Albumin

alb

Albumin is a transport protein in the blood. It helps maintain the oncotic pressure of the blood. Albumin levels will drop if synthesis is slowed, protein intake is inadequate, or there are increased losses. Albumin has a long half life, however, so levels are not a good indicator of acute illness.

3.5 – 6.0 g/dL

What would cause Increased Levels of Albumin?

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Determine the significance and clinical use of Alanine Aminotransferase in clinical practice

Alanine Aminotransferase – ALT

Measures amount of ALT, an enzyme produced by the liver, present in circulation

Found in:

Most abundantly in liver

Heart

Skeletal muscle

kidney

Increases in lab values indicate liver disease or liver damage

Evaluation of ALT:

Normal – 40-130 U/L

Collection:

INCREASED: 

DECREASED:

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Activated Partial Thromboplastin Time

APTT

APPT is a test that measures the amount of time it takes for a fibrin clot to form after reagents have been added to the specimen. It is useful in diagnosis clotting disorders. In conjunction with PT it can be used to differentiate the specific factor that may be missing.

25-39 seconds