Ch 8 Laboratory Values and Diagnostics Hematological Testing

RBC Count
120 day lifespan, produced primarily in bone marrow speed at which RBC's can be produced is reduced in old age, decreased marrow reserve NORMAL AGING Recovery from blood loss takes longer, increases risk for falling, delirium, and other geriatric syndromes Hemaglobin and Hematocrit- elevations may be pathologic, but often are early markers of hypovolemia saturated gram of Hb carries 1.39 mL oxygen Hb <5gr/dL or >20 defines "critical values" requiring urgent intervention Anemia= Hb <12gr/dL men <11 women Hematocrit about 3x Hb level. Critical values <15% or >60%

White Blood Cells

granulocytes- neutrophils, basophils, eosinophils monocytes,lymphocytes Agranulocytes-

13-20 day lifespan, produced in bone marrow & thymus, stored in lymph nodes, spleen, and tonsils 5000-10,000 WBC- ELEVATED WHITE COUNT MAJOR CONCERN IN ELDERY often caused by bacteremia Critical values <2,500 or >30,000 Younger adults you see elevated temperature, lymph node enlargement, increase in total WBC count BUT NOT NECESSARILY IN OLDER ADULTS *Change in aging* "left shift" immature band cells, precursors to neutrophils, may be elevated value in labs to indicate early infection

only

implications for gerontological nurse: waiting for usual signs may result in death (THIS IS FUCKING BAD) must be sensitive to more subtle signs i.e. increased confusion, falling, or incontinence WBC count should remain the same in a healthy older adult, the response to elevate is

whats slow. High or low WBC count is often a reaction of medications, NOT A NORMAL RESULT OF AGING

Neutrophils produced in 7-10 days in bone marrow in circulation for about 6 hours;
phagocytize bacteria neurtrophilia, increas ein neutrophils, may be indicator of infections

Lymphocytes
T-Cells: produced by thymus: make up 80% of lymphocytes. NORMAL AGING slight decrease in T and increase in B cells

Monocytes
largest of leukocytes, mature into macrophages. macrophages migrate to site in body and phagocytize the bad things (all that shit, dead RBC's microorganisms, foreign debris, you know, all that bad shit)

Eiosinophils
involved in allergic reactions, ingest antigen-antibody complexes, attack allergens and parasites

Basophils
transport histamine and heparin, play a role in allergic reactions, do not fight viruses or bacteria

Platelets
thrombocytes, formed in bone marrow, lungs, and spleen. arrive at injury site and activate becoming sticky and helping trigger 'clotting cascade' PLATELET COUNT DOES NOT CHANGE WITH AGING, though clotting enzymes may increase 150k-400k/mm3 normal value thrombocytopenia <100k thrombocytothemia >1million

critical values <20k spontaneous hemorraging can occur <40k serious risk in elderly, if they fall internal bleeding may not stop and can cause death, other related risks involving bleeding more significant

Measures of Inflammation
Erythrocyte Sedimentation Rate rate at which RBC's fall in saline soltion/time, highly nonspecific cannot diagnose any disease may be slightly elevated in older persons due to chronic disease, NOT healthy aging

C-Reactive Protein-produced by liver, strong predictor/indicator of cardiovascular events/inflammation. No mention of normal or abnormal values or concerns for the elderly

Iron Studies-include iron, ferritin, total iron binding capacity TIBC, transferrin measures
anemia-reduced # of RBCs, NOT A NORMAL PART OF AGING but it is a common pathology in older adults 3 most prevelant in older adults are anemia from: chronic disease and inflammation, blood loss, protein deficiency ferritin reflects iron body stores; TIBC measures iron and transferrin available to transport it

Vitamins
mild deficiencies common BUT NOT NORMAL in later life. May cause cognitive impairment, delayed wound healing, or anemia B Vitamins folic acid and B12 two most important of 8 folic acid decrease NOT NORMAL but common B12 decrease NORMAL but still may need to be treated Tests of B12 and folic acid part of standard workup for dementia Vitamin D critical values 20ng/mL deficient 20-30 insufficient >30 sufficient, essential for healthy aging and proper amount of calcium in body

Blood Chemistry Studies

used both for screening and monitoring; glucose, proteins, amino acids, nutritive materials, excretion products, hormones, enzymes, vitamins, and minerals many done in panels Hormones Thyroid hormones receive most attention in older adults T3, T4, Thyroid stimulating hormone TSH Changes in thyroid function NOT A NORMAL PART OF AGING but are frequent, hypothyroidism most common in older adults, both hyper and hypo often iatrogenic in older adults (related to medical procedure or treatment) screening for thyroid disease is part of primary care for older adults esp. women, ppl w/ depression, anxiety, dementia, arrhythmias THS produced by pituitary to stimulate thyroid to make T3 which is converted to T4 hyperthyroidism less common in older adults, often not the same etiology as in younger people Electrolytes minor electrolyte imbalnce may have no effect in younger adult but have profound effect in older adult, dehydration is the most common cause in older adults most common concerns in older adults include sodium, potassium, chloride, calcium, phosphorus,

glucose Sodium and Chloride balance influenced by renal filtration, blood flow, cardiac output, glomular filtration rate GFR. Changes in sodium accompanied by changes in chloride Hyponatremia <130mmol/L common in long term care facilities can cause coma secondary to brain edema; one common cause of delirium in older adults Hypernatremia >145mEq/L mortality rate 40% in elders associated w/ seizures, delirium, coma, death Potassium found primarily inside cells hypokalemia <3.5 mEq/L mild cases assymptomatic <2.5 mEq/L critical value causes confusion, cramps, weakness, sudden death all bad things can lead to renal problems if chronic hyperkalemia >5mEq/L usually only in advanced kidney disease, or over supplementation. may be assymptomatic until its lethal

I dont want to type all of this but box 8-2 on pg 122 is very important. It lays out lab values that are expected to change with age. I recommend making flashcards. It lists those that increase with age on one side, and those that decrease with age on the other. I don't think the exam will be that specific, but it will be nice to have under your belt when it's time for taking boards.

Calcium and Phosphorus Serum Ca levels DO NOT change with age, but calcium metabolism does.result is decreased bone stores. when enough occurs, osteoporosis occurs half of serum calcium is bound to albumin, so if nutrition is poor and albumin is low, Ca serum will be artificially low; this artificial low is common in medically fragile persons true hypocalcemia <8.5 mg/dL most commonly caused by hypoparathyroidism hypercalcemia >12mg/dL calcium levels inversely related to phosphorus Glucose fasting glucose 70-110mg/dL DOES NOT CHANGE WITH AGING but signs and symptoms might. slightl changes in elderly may cause confusion and other problems. older adults have a reduced sensitivity to insulin 7% of Hb in RBC can combine with glucose, 120 lifespan of RBC gives good idea of blood glucose nondiabetics 4-5.9% is normal; <7 good diabetic control >9% poor diabetic control

URIC ACID- usually measured in serum chemistry but also found in urine elevation is >7.5 mg/dL and hyperuricemia >13, varies btw men and women serum levels INCREASE SLIGHTLY WITH AGE (no numbers provided) affected by many factors e.g. medications such as diuretics Prostate Specific Antigen- along with digital rectal exam are the two primary screening tools for prostate cancer. many false positive, controversial, only recommended for men over 75 or at high risk. Chages in PSA levels over time >5%-8% more meaningful than absolute number in serum

LAB TESTS FOR CARDIAC HEALTH Creatinine Kinase (CK), specifically one of its isoenzymes (subgroup) CK-MB associated with cardiac tissue. CK-MB rises 3-6 hours after an acute myocardial infarction AMI (heart attack), returns to normal after 12-48 hours. used to diagnose AMI, unstable angina, shock, malignant hyperthermia, myopathies, and myocarditis. many drugs commonly used by elderly can give false highs MEDICATION HISTORY IS VERY IMPORTANT WITH THIS TEST this test is used in combination with troponin values for diagnosis Troponin I and Troponin T- gold standard for diagnosis of heart injury, become elevated as early as 3 hours after incident. Troponin I remains elevated for 7-10 days, Troponin T for 10-14 days Normal values Troponin I <0.03 ng/ml Troponin T <0.2 ng/ml Homocysteine -If you are confident enough, every zoo is a petting zoo. - a natrually occuring amino acid, promotes atherosclerosis (bad) normal findings 4-14 micro mols/L elevated values are a predictor of coronary, peripheral, and cerebral vascular disease; also elevated with b12 and folic acid deficiencies and is used to monitor nutrition elevated values put person at 5x risk for stroke, dementia, and alzheimers. also a risk factor for osteoporotic fractures Brain Natriuretic Peptide BNP neuroendocrine peptide secreted by the ventricles in response to excess pressure identify congestive heart failure, hypertension, and atherosclerosis Lipids major predictor of coronary heart disease typically includes cholesterol and triglycerides; used as health screen and to monitor response to treatments, must fast 12-15 hours before tests Cholesterol- stabilizes cell membranes, metabolized in liver where it combines with Low density lipoproteins LDL and high density lipoproteins HDL and very low density lipoproteins VLDL Men's Cholesterol slowly increases from puberty until 60, stabilizes until 80, then rises again While the cholesterol levels of women remain stable until menopause then start to rise THIS IS A NORMAL PART OF AGING!! cholesterol levels also change throughout the day and is influenced by position low serum cholesterol <200mg/dL could be malnutrition is indicative of further evaluation total cholesterol is in whole blood not just serum <160mg/dL in a frail elder is a risk factor for

increased mortality Triglycerides are primary lipids found in blood and are bound to protein; produced in liver, excess blood levels deposited in fatty tissue abnormally low suggests malnutrition, elevated could mean chronic renal failure, poorly controlled diabetes. Severely elevated >2000mg/dL strong risk factor for pancreatiti. Lipid panel values Total cholestrerol <200 is desirable >240 is high LDL <100 optimal, 160-189 high, >190 very high HDL 40-60 tightly in this range, above or below is problematic Triglycerides <150 normal, 200-500 high, >500 very high

Total Protein- amount of albumin and globulin in serum, a SLIGHT decrease is a NORMAL PART OF AGING neither sensitive nor specific; prealbumin has a shorter half life and is a more sensitive marker for change Normal Findings Total Protein- 6.4-8.3 g/dL; Globulin 2.3-3.4 g/dL; Prealbumin 15-36mg/dL RENAL HEALTH early signs of kidney disease are asymptomatic, urinalysis results important early indicator Blood Urea Nitrogen BUN urea end product of protein metabolism critical value of >100mg/dL indicates serious renal dysfunction azotemia is an elevation in BUN; but normal adult values are 10-20 mg/dL Creatinine-used to diagnose and monitor impaired renal function, but can overestimate renal health in older adults; BUN/Creatinine ratio is a good indicator of GFR Cockcroft-Gault equation estimates creatinine clearance, used to estimate drug dosages in elders with probable diminished renal function, esp drugs that are potentially a strain on the kidneys (140-age)x(weight in kg)/(72xserum creatinine) for men, in women value is 85% of this value due to smaller muscle mass REDUCED MUSCLE MASS OF NORMAL AGING WILL RESULT IN DECREASED CREATININE LEVELS

Monitoring for Therapeutic Blood Levels- drugs that have a narrow therapeutic window (too

low ineffective, too high adverse affects) Anticoagulents, warfarin (Coumadin) and heparin elderly ppl often on these, must have coagulation time monitored closely due to narrow therapeutic windows prothrombin- produced by liver, key component in blood clotting, in clotting prothrombin is converted to thrombin at the beginning of the coagulation cascade. Body must have adequate vitamin k intake and absorption to produce prothrombin Prothrombin Time PT is a sensitive measure of deficiencies in vitamin K-dependent clotting factors II, VII, IX, and X. It is not sensitive to Heparin or fibrinogen deficiencies. Partial Prothrombin Time PPT is used to monitor patients on heparin PT is among tests gerontological nurses will see most often. It is evaluated by a set Internationalized Normal Ratio INR. too high an INR can result in life threatening bleeding PT of 20 seconds= INR >5.5 is considered a panic level Too low an INR means the drugs are not working and the patient is probably in a hypercoagulative state

Antiarrhythmics: DIGOXIN (Personally I'd take particular care to commit this section to memory, Dr. O loves to talk about it, I think it's safe to assume it will appear not just on this test, but many tests). Digoxin (Lanoxin) is a drug commonly used to control ventricular response to chronic atrial fibrillation. normal therapeutic range is 0.9-2.0 ng/mL; TOXICITY occurs at levels above 3.0ng/mL a dose of 0.125 mg can be quite effective in older adults blood levels can miss problems with toxicity, so they are only a guide for nurses. clinical presentation must be monitored carefully even when blood levels are normal.

URINE STUDIES
urinalysis done by nurse macroscopically at bedside (color, odor, clarity, and urine dips, using dipsticks that react to certain elements outside specific concentrations and comparing to a standard dipstick) and microscopically in lab. Both measure specific gravity, pH, presence of urine protein, glucose, ketones, blood, bilirubin, nitrates, and leukocytes results should be the same REGARDLESS OF AGE, but frequently have abnormalities due to complications common in the elderly. THIS IS NOT NORMAL AGING. clean catch or catheterization to collect, should be sent to lab immediately but may be refridgerated up to two hours. You should never leave it unlabeled as it can be confused with lemonade rather easily leading to lawsuits in the hospital. specific gravity in adults is usually between 1.005 and 1.030. These values decrease with aging because

of the 33-50% decline in nephrons. THIS IS A NORMAL PART OF AGING. Nephron function measured by GFR which is determined by creatinine clearance

Urine pH indicates acid base balance. Does not provide normal range in text. protein- proteineuria is defined as albumin level >150mg/dL in a 24 hour period glucose- can be affected by ascorbic acid or aspirin ketones may be high from crash diets high protein diets or starvation Nitrates and leukocytes often found in infection. if urinalysis suggests infection a further analysis, probably a culture of the urine, is necessary due to danger of infection in elderly, clinical evidence of infection may require treatment before test results can be obtained, often taking 3 or 4 days

Implications for Gerontological Nurses screening is important we may find that normal values for the population over 65 may be different than the younger population, but this has not yet been determined. (IT DEPENDS? I pulled this word for word from the book, pg 130. Sooo which values change as a normal part of aging? apparently they don't actually know yet.) Many elderly are on many medications which may affect lab values. It is a nurses job to watch for empirical clinical evidence and interpret lab values. Deep thoughts: If death is a natural result of aging, and death needs a cause, aren't all changes a natural part of aging? Somehow I doubt that argument is gonna fly on the exam. Enjoy your weekends.