Introduction to Vital Signs and

Basic Laboratory Tests

Joel N. Kniep, M.D.
Dept. of Pathology
 Objectives
Introduce vital signs and their use in
clinical practice
Introduce basic laboratory tests and their
use in clinical practice
Discuss normal values and test
interpretation
 Clinical Vital Signs (Vitals)
Temperature
Pulse rate
Respiration rate (RR)
Blood pressure (bp)
 Temp
Measure of bodys core temp (temp of
internal organs)
in F (or C)
Locations: oral, rectum, axilla, ear
Rectal = 0.5 0.7 F higher than oral temp
Axilla = 0.3 0.4 F lower than oral temp
Normal: 97.8 99 F (36.5 37.2 C)
Critical: > 98.6 F orally or 99.8 F rectally
(pyrexia [fever]); < 95 F (hypothermia)
 Pulse rate
Heart rate (HR) or number of heart
beats/min
Normal: 60 100/min
(tachycardia): Na+ intake, Na+ loss,
Excessive free body H2O loss
(bradycardia): Na+ intake, Na+ loss,
free body H2O
 RR
Number of breaths/min
At rest
Also note breathing effort or difficulty
Normal: 15 20/min
Critical: < 12 or > 25
(hyperventilation): Na+ intake, Na+
loss, Excessive free body H2O loss
(hypoventilation): Na+ intake, Na+
loss, free body H2O
 Bp
Measures the force of blood against the arterial vessel
walls
Measured while seated, after resting for 5 mins, arm resting @
heart level (if possible)
Reported as a fraction (systolic/diastolic) & consists of 2
separate measurements:
Systolic pressure within artery during cardiac contraction
Diastolic pressure within artery during cardiac relaxation and filling
Normal: < 120 mm Hg systolic and < 80 mm Hg diastolic
Critical: > 220 mm Hg systolic or > 125 mm Hg diastolic
(hypertension [htn]): Na+ intake, Na+ loss,
Excessive free body H2O loss
(hypotention): Na+ intake, Na+ loss, free body
H2O
 Complete Blood Count (CBC)
Provides information on cellular
components of blood
Includes RBC count, Hemoglobin (Hgb),
Hematocrit (Hct), RBC indices, White
blood cell (WBC) count and differential,
Platelet count
 Total WBCs (leukocytes)
Measurement of total WBC count
Consists of total # of WBCs/mm3 of peripheral venous blood
Part of routine testing
Useful for evaluation of infection, neoplasm, allergy &
immunosuppression
Normal: 4,000 10,000/mm3
Critical: < 2,500 or > 30,000/mm3
(leukocytosis): infection, malignancy, trauma, stress,
hemorrhage, tissue necrosis, inflammation, dehydration,
thyroid storm
(leukopenia): drug toxicity, bone marrow failure,
overwhelming infections, dietary deficiency, congenital
marrow aplasia, bone marrow infiltration, autoimmune
disease, hypersplenism
 Erythrocyte count (RBC)
Measures # of circulating RBCs/mm3 of peripheral
venous blood
Direct measure of RBC count
Part of routine testing and anemia evaluation
Normal: 3.5 5.5 x 106/L
: erythrocytosis, congenital heart disease, severe
COPD, polycythemia vera, severe dehydration,
hemoglobinopathies
: anemia, hemoglobinopathy, hemorrhage, bone
marrow failure, renal disease, leukemia, prosthetic
valves, normal pregnancy, multiple myeloma, Hodgkin
disease, lymphoma, dietary deficiency
 Hgb
Measures total amount of Hgb in blood
Indirect measure of RBC count
Part of routine testing and anemia evaluation
Normal: 12 15 g/dL
Critical: < 5 or > 20 g/dL
: erythrocytosis, congenital heart disease, severe
COPD, polycythemia vera, severe dehydration
: anemia, hemoglobinopathy, hemorrhage, bone marrow
failure, renal disease, leukemia, prosthetic valves,
normal pregnancy, multiple myeloma, Hodgkin disease,
lymphoma, dietary deficiency
 Hct
Measure of RBC percent of total blood vol
Indirect measure of RBC # & volume
Part of routine testing and anemia evaluation
Normal: 36 48%
Critical: < 15% or > 60%
: erythrocytosis, congenital heart disease, severe
COPD, polycythemia vera, severe dehydration
: anemia, hemoglobinopathy, hemorrhage, bone
marrow failure, renal disease, leukemia, prosthetic
valves, normal pregnancy, multiple myeloma, Hodgkin
disease, lymphoma, dietary deficiency
 RBC indices
Measures size and hgb content of RBCs
Used to classify anemias
Includes Mean corpuscular volume (MCV),
mean corpuscular hemoglobin (MCH),
mean corpuscular hemoglobin
concentration (MCHC), red blood cell
distribution width (RDW)
 MCV
Measure of average volume/size of single RBC
MCV = Hct (%) x 10/RBC (million/mm3)
Useful in anemia classification
Normal: 80 100 mm3
(macrocytic): pernicious anemia (vit B12 deficiency),
folic acid deficiency, antimetabolic therapy, alcoholism,
chronic liver disease, hypothyroidism
Normocytic: bone marrow failure/replacement, acute
blood loss, chronic diseases, hemolytic anemias
(microcytic): Fe deficiency anemia, thalassemia,
anemia of chronic illness
 MCH
Measure of average amount of hgb within
a single RBC
MCH = Hgb (g/dL) x 10/RBC (million/mm3)
Provides little additional info to other indices
Normal: 24 32 pg
: macrocytic anemias
: microcytic anemia, hypochromic
anemia
 MCHC
Measure of average [hgb] within a single RBC
MCHC = Hgb (g/dL) x 100/Hct (%)
37 g/dL = maximum Hgb able to fit into an RBC
(cannot be hyperchromic)
Normal (normochromic): 32 36 g/dL
: spherocytosis, intravascular hemolysis, cold
agglutinins
(hypochromic): Fe deficiency anemia,
thalassemia
 RDW
Measure of variation of RBC size
(indicator of degree of anisocytosis)
Useful in anemia classification
Normal: variation of 11.5 16.9%
: Fe deficiency anemia, vit B12 or folate
deficiency anemia, hemoglobinopathies,
hemolytic anemias, posthemorrhagic
anemias
 Platelet count
Measurement of platelets (thrombocytes)
Consists of actual # of platelets/mm3 of peripheral venous blood
Part of routine testing
Useful for evaluation of petechiae, spontaneous bleeding, increasingly
heavy menses or thrombocytopenia
Useful for monitoring discourse/therapy of thrombocytopenia/bone
marrow failure
Normal: 150,000 400,000/mm3
Critical: < 50,000 or > 1,000,000/mm3
(thrombocytosis): malignant disorders, polycythemia vera,
postsplenectomy syndrome, rheumatoid arthritis, Fe deficiency
anemia
(thrombocytopenia): Hypersplenism, hemorrhage, immune
thrombocytopenia, leukemia & other myelofibrosis disorders, TTP,
DIC, SLE, chemotherapy, pernicious anemia
 WBC definitions
Leukocytosis abnormally large number
of leukocytes; generally indicated by WBC
count of 10,000 cells/mm3
Lymphocytosis form of actual or relative
leukocytosis due to increase in numbers of
lymphocytes
Left shift increase in the number of
immature neutrophils (bands/stabs) found
in the blood
 WBC differential
Measurement of percentage of each WBC type
in specimen
Useful for infection, neoplasm, allergy &
immunosuppression evaluations
Normal: Neutrophils (50 70%), Lymphocytes
(20 40%), Monocytes (2 8%), Eosinophils (0
5%), Basophils (0 2%)
: refer to individual cell types on chart
: refer to individual cell types on chart
 Basic Metabolic Panel (BMP)
Measures electrolytes, chemicals,
metabolic end products & substrates
Consists of Glucose, Blood Urea Nitrogen
(BUN), Creatinine, Na+, K+, Cl-,
Bicarbonate (HCO3-), Ca2+
 Glucose
Direct measure of blood glucose
Commonly used to evaluate diabetic pts
Part of routine testing
Normal: 70 - 100 mg/dL
Critical: < 50 and > 400 mg/dL () or < 40 and > 400
mg/dL ()
(hyperglycemia): DM, acute stress response, Cushing
syndrome, pheochromocytoma, chronic renal failure,
acute pancreatitis, acromegaly, corticosteroid therapy
(hypoglycemia): insulinoma, hypothyroidism,
hypopituitarism, Addison disease, extensive liver
disease, insulin overdose, starvation
 BUN
Measures urea nitrogen in blood
End product of protein metabolism (produced in liver)
Indirect measure of renal function & glomerular function
(excretion)
Measure of liver metabolic function
Part of routine labs
Usually interpreted along with Cr (less accurate than Cr for renal
disease)
Normal: 6 -21 mg/dL
Critical: > 100 mg/dL
: prerenal causes, renal causes, postrenal azotemia
: liver failure, overhydration because of SIADH, neg
nitrogen balance, pregnancy, nephrotic syndrome
 Creatinine
Measures serum creatinine
Catabolic product of creatine phosphate (skeletal muscle
contraction)
Excreted entirely by kidneys direct measure of renal function
Minimally affected by liver function
Elevation occurs slower than BUN
Doubling 50% reduction in GFR
Normal: 0.44 1.03 mg/dL
Critical: > 4 mg/dL
: diseases affecting renal function (glomerulonephritis,
pyelonephritis, ATN, urinary tract obstruction, reduced
renal blood flow, diabetic nephropathy, nephritis),
rhabdomyolysis, acromegaly, gigantism
: debilitation, decreased muscle mass
 Na+
Measures serum sodium level
Major cation in EC space
Balance between dietary intake and renal excretion
Normal: 136 146 mEq/L
Critical: < 120 or > 160 mEq/L
(hypernatremia): Na+ intake, Na+ loss,
Excessive free body H2O loss
(hyponatremia): Na+ intake, Na+ loss,
free body H2O
 K+
Measures serum potassium level
Major cation within cell
Normal: 3.4 5.2 mEq/L
Critical: < 2.5 or > 6.5 mEq/L
(hyperkalemia): excessive intake, acidosis,
acute/chronic renal failure, Addison disease,
hypoaldosteronism, infection, dehydration
(hypokalemia): deficient intake, burns,
hyperaldosteronism, Cushing syndrome, RTA,
licorice ingestion, alkalosis, renal artery stenosis
 Cl-
Measures serum chloride level
Major anion in EC space
Helps maintain electrical neutrality; follows sodium
Normal: 98 108 mEq/L
Critical: < 80 or > 115 mEq/L
(hyperchloremia): dehydration, metabolic acidosis,
RTA, Cushing syndrome, renal dysfunction, respiratory
alkalosis, hyperparathyroidism
(hypochloremia): overhydration, SIADH, CHF, chronic
respiratory acidosis, metabolic alkalosis, Addison
disease, Aldosteronism, vomiting/prolonged gastric
suction, hypokalemia
 HCO3-
Measures CO2 content of blood
Major role in acid-base balance
Regulated by kidneys
Used to evaluate pt pH status & electrolytes
Normal: 22 32 mEq/L
Critical: < 6 mEq/L
: severe vomiting, high-volume gastric suction,
aldosteronism, mercurial diuretic use, COPD, metabolic
alkalosis
: chronic diarrhea, chronic loop diuretic use, renal
failure, DKA, starvation, metabolic acidosis, shock
 Ca2+
Measures serum calcium level
Direct measurement
Used to evaluate parathyroid function & Ca metabolism
Used to monitor renal failure, renal transplantation,
hyperparathyroidism, various malignancies, & Ca level when giving
large-volume blood transfusions
Normal: Total = 8.3 10.3 mg/dL, Ionized = 4.5 5.6 mg/dL
Critical: Total < 6 or > 13 mg/dL, Ionized < 2.2 or > 7 mg/dL
(hypercalcemia): hyperparathyroidism, bone mets, Paget disease
of bone, prolonged immobilization, milk-alkali syndrome, vit D
intoxication, hyperthyroidism
(hypocalcemia): hypoparathyroidism, renal failure, rickets, vit D
deficiency, osteomalacia, pancreatitis, alkalosis, malabsorption, fat
embolism
 Comprehensive Metabolic Panel
(CMP)
Includes all components of BMP plus
Albumin, Total protein, Alkaline
phosphatase (ALP), Alanine
aminotransferase (ALT), Aspartate
aminotransferase (AST) and Bilirubin
 Albumin
Measures amount of albumin in blood
Formed within liver & comprises 60% of total protein in blood
Maintains colloidal osmotic pressure & transports blood
constituents
Measure of both hepatic function and nutritional state
Normal: 3.5 5 g/dL
: dehydration
: malnutrition, pregnancy, liver disease, protein-losing
enteropathies, protein-losing nephropathies, 3rd space
losses, overhydration, capillary permeability,
inflammatory disease, familial idiopathic dysproteinemia
 Total Protein
Measures total protein in blood
Combination of prealbumin, albumin &
globulins
Normal: 6.4 8.3 g/dL
 ALP
Measures serum ALP concentration
Detect & monitor liver and bone disease
Normal: 30 -120 units/L
: 1 cirrhosis, intrahepatic/extrahepatic biliary
obstruction, 1/metastic liver tumor,
hyperparathyroidism, Paget disease, normal
growing bones in children, bone mets, RA, MI,
sarcoidosis, healing fracture, normal pregnancy,
intestinal ischemia or infarction
: hypophosphatemia, malnutrition, milk-alkali
syndrome, pernicious anemia, scurvy
 ALT
Found predominantly in liver
Injury/disease to parenchyma release into blood
ID & monitor hepatocellular diseases of liver
If jaundiced, implicates liver rather than RBC hemolysis
Normal: 4 36 international units/L @ 37C
Sig : hepatitis, hepatic necrosis, hepatic ischemia
Mod : cirrhosis, cholestasis, hepatic tumor, hepatotoxic
drugs, obstructive jaundice, severe burns, trauma to
striated muscle
Mild : myositis, pancreatitis, MI, infectious mono, shock
 AST
Found in highly metabolic tissue (cardiac &
skeletal muscle, liver cells)
Disease/injury lysing of cells & release into blood
Elevation proportional to # of cells injured
Used for evaluation of suspected coronary artery
disease or hepatocellular disease
Normal: 0 35 units/L
: heart diseases, liver diseases, skeletal
muscle diseases
: acute renal disease, beriberi, DKA,
pregnancy, chronic renal dialysis
 Bilirubin
Measures level of total bilirubin in blood
End product of RBC metabolism (RBCs Hgb
Heme (+ globin) Biliverdin Bilirubin
(unconjugated/indirect) Bilirubin (conjugated/direct)
Component of bile
Consists of conjugated (direct) & unconjugated
(indirect) bilirubin
Used to evaluate liver function; hemolytic anemia
workup in adults & jaundice in newborns
Jaundice occurs when total bilirubin > 2.5 mg/dL
Normal: 0.3 1 mg/dL
Critical: > 12 mg/dL
 Unconjugated bilirubin
Measures level of indirect bilirubin in blood
Normal: 0.2 0.8 mg/dL
: erythroblastosis fetalis, transfusion rxn,
sickle cell anemia, hemolytic jaundice,
hemolytic anemia, pernicious anemia,
large-volume blood transfusion, large
hematoma resolution, hepatitis, cirrhosis,
sepsis, neonatal hyperbilirubinemia,
Crigler-Najjar syndrome, Gilbert syndrome
 Conjugated bilirubin
Measures level of direct bilirubin in blood
Produced by conjugating glucuronide w/
unconjugated/indirect bilirubin in liver
Normal: 0.1 0.3 mg/dL
: gallstones, extrahepatic duct
obstruction, extensive liver mets,
cholestasis from drugs, Dubin-Johnson
syndrome, Rotor syndrome
 Urinary Analysis (UA)
Provides information about kidneys &
other metabolic processes
Used for diagnosis, screening &
monitoring
Frequently used to test for urinary tract
infections (UTIs)
 UA Normal Values
Appearance: clear
Color: amber yellow
Odor: aromatic
pH: 4.6 8
Protein: 0 8 mg/dL
Specific gravity: 1.005 1.030
Leukocyte esterase: negative
Nitrites: none
Ketones: none
 UA Normal Values cont.
Bilirubin: none
Urobilinogen: 0.01 1 Ehrlich unit/mL
Crystals: none
Casts: none
Glucose: negative
White Blood Cells: 0 4/low-power field
WBC casts: none
Red Blood Cells (RBCs): 2
RBC casts: none
 Urinary Protein
Used to monitor kidney function
Normally not present in normal kidney due to
size barrier in glomerulous
Normally tested by dipstick method,
quantification requires 24-hour urine collection
Presence (proteinuria) can indicate nephrotic
syndrome, multiple myeloma or complications of
DM, glomerulonephritis, amyloidosis
 Urinary Glucose
Glucosuria presence of glucose in urine
Reflection of serum glucose levels
Helpful in monitoring DM therapy
Renal glucose reabsorption threshold = 180 mg/dL (in proximal
renal tubules)
Not always abnormal
Can occur after a high-carbohydrate meal or IV dextrose fluids
Can occur in diseases affecting renal tubules; genetic defects of
metabolism & glucose excretion
: DM & other causes of hyperglycemia, pregnancy,
renal glycosuria, Fanconi syndrome, Hereditary defects
in metabolism of other reducing substances, ICP,
nephrotoxic chemicals
 Urinary Leukocyte esterase
Screen to detect leukocytes in urine
(dipstick method)
Presence indicates UTI
90% accurate
 Urinary Ketones
End products of fatty acid catabolism
Examples: -hydroxybutyric acid,
acetoacetic acid, acetone
Associated with poorly controlled diabetes
Used to evaluate ketoacidosis associated
w/ alcoholism, fasting, starvation, high-
protein diets, isopropanol ingestion
 Urinary Nitrites
Screen for UTI (dipstick method)
Test based on chemical rxn by bacterial
reductase (reduces nitrate to nitrite)
50% accurate
Enhances leukocyte esterase sensitivity
 Urinary Casts
Hyaline conglomerations of protein; indicative
of proteinuria; few = normal especially after
exercise
Cellular conglomerations of degenerated cells
Granular glomerular disease
Fatty nephrotic syndrome
Waxy chronic renal disease
Epithelial cells & casts (renal tubular casts)
WBCs & casts acute pyelonephritis
RBCs & casts glomerular diseases
 Cerebral Spinal Fluid (CSF)
Analysis
Collected via lumbar puncture (LP)
Useful for the diagnosis of 1 or metastatic
brain/spinal cord neoplasm, cerebral
hemorrhage, meningitis, encephalitis,
degenerative brain disease, autoimmune
diseases w/ CNS involvement,
neurosyphilis, demyelinating diseases
 CSF analysis Normal Values
Opening pressure: <20 cm H2O
Color: clear & colorless
Blood: none
RBCs: 0
WBCs: 0 5 cells/L
Neutrophils: 0 6%
Lymphocytes: 40 80%
Monocytes: 15 45%
CSF analysis Normal Values cont.
Protein: 15 45 mg/dL
Glucose: 50 75 mg/dL or 60 70% of
blood glucose level
 CSF WBC count
Pleocytosis turbidity of CSF due to
increased #s of cells
 CSF PMNs
Causes of PMNs: bacterial meningitis,
tubercular meningitis, cerebral abscess,
subarachnoid bleeding, tumor
 CSF Lymphs
Causes of lymphs/plasma cells: viral,
tubercular, fungal or syphilitic meningitis;
multiple sclerosis (MS), Guillain-Barr
syndrome
 CSF Monos
Causes of monos: tubercular or fungal
meningitis, hemorrhage, brain infarction
 CSF Profile
RBCs/mm WBCs/m Glucose Protein Opening Appearan -globulin
3
m3 (mg/dL) (mg/dL) pressure ce (%
(cm H2O) protein)
Bacterial (> 1,000 (< 45 (> 250 Cloudy
meningitis PNMs) mg/dL) mg/dL)
Viral
meningitis (lymphs/m
onos)
Aseptic
meningitis
SAH

Guillain-
Barr
syndrome
MS Normal in
2/3 pts; >
15 in < 5%
of pts
Pseudotu
mor
cerebri
 References
Pagana, K.D. & Pagna, T.J. (2006). Mosbys Manual of
Diagnostic and Laboratory Tests. St. Louis: Mosby
Elsevier.
27th edition (2000). Stedmans Medical Dictionary.
Baltimore: Lippincott Williams & Wilkins.
UpToDate. Retrieved July 26, 2009, from
http://www.uptodateonline.com
Urinalysis. Retrieved July 17, 2009, from
http://library.med.utah.edu/WebPath/TUTORIAL/URINE/
URINE.html
Vital Signs. Retrieved July 17, 2009, from
http://www.healthsystem.virginia.edu/uvahealth/adult_no
ntrauma/vital.cfm
 Additional Resources
Corbett, J.V. (2008). Laboratory Tests and Diagnostic Procedures
with Nursing Diagnoses 7th Edition. Upper Saddle River: Prentice
Hall.
Fischbach, F.T. & Dunning, M.B. (2008). A Manual of Laboratory &
Diagnostic Tests 8th Edition. Philadelphia: Lippincott Williams &
Wilkins.
Jacobs, D.S., De Mott, W.R. & Oxley, D.K. (2001). Jacobs & DeMott
Laboratory Test Handbook with Key Word Index 5th Edition. Hudson:
Lexi Comp, Inc.
Wu, A. (2006). Tietz Clinical Guide to Laboratory Tests 4th Edition.
St. Louis: Saunders Elsevier.
Young, R.H. & Hicks, J. (2002). Directory of Rare Analyses 2000-
2002. St. Louis: AACC Press.
http://www.labtestsonline.org/
 Special Thanks
Dr. Amira F. Gohara, M.D.
Dr. Carol Bennett-Clarke, Ph.D.
Dr. Constance Shriner, Ph.D.
Cynthia R. OConnell, BSMT (ASCP)