Lesson 42: Laboratory Values
5 times normal when the client is
Nursing Responsibilities for Obtaining a Blood Specimen
Explain any necessary preparations for the test.
Use strict aseptic technique.
Use standard and other precautions as necessary and follow agency
guidelines when handling hazardous and infectious materials.
Determine the client's risks associated with venipuncture (e.g., low
platelet count, anticoagulant use, bleeding disorder, low white blood
cell count increasing the likelihood of infection).
Assess for allergies (e.g., latex) and contraindicated venipuncture
sites (e.g., extremity with an intravenous infusing, arm on the side
on which a mastectomy was performed, arm fitted with a
hemodialysis access device).
Use the most distal sites of an extremity first for venipuncture.
Use of a tourniquet and clenching and unclenching the hand before
venous sampling can falsely increase the value being measured.
If the client is receiving an anticoagulant, apply pressure to the
venipuncture site for 3 to 5 minutes after withdrawing the needle.
Send specimens for culture to the laboratory immediately.
Check agency procedures for specific guidelines for the collection of
specimens.
Note deviations from normal ranges and report these results.
Be familiar with the procedure for drawing blood from a central
venous access device.
Electrolytes
Description
The normal adult ranges are sodium, 135 to 145 mEq/L (mmol/L);
potassium, 3.5 to 5.1 mEq/L (mmol/L); chloride, 98 to 107 mEq/L
(mmol/L); bicarbonate (venous), 22 to 29 mEq/L (mmol/L).
Nursing Considerations
Drawing blood samples around the time of an infusion of sodium
chloride will falsely increase the sodium and chloride readings.
Any condition accompanied by prolonged vomiting or diarrhea will
alter the serum chloride level.
If the client is receiving potassium supplements, note this on the
laboratory form.
A client with an increased white blood cell (WBC) count and platelet
count may have a falsely increased potassium level.
Coagulation Studies
Activated Partial Thromboplastin Time
Description
The activated partial thromboplastin time (aPTT) is used to evaluate
how well the coagulation sequence is functioning.
aPTT testing is most commonly prescribed to monitor heparin
therapy and screen for coagulation disorders.
The normal range is 20 to 36 seconds, depending on the type of
activator used.
Nursing Considerations
If the client is undergoing intermittent heparin therapy, draw the
blood sample 1 hour before the next scheduled dose.
Do not draw samples from the arm into which heparin is infusing.
Transport the specimen to the laboratory immediately.
aPTT should be 1.5 to 2.
undergoing heparin therapy; if the aPTT is prolonged (longer than 90
seconds), initiate bleeding precautions.
Prothrombin Time and International Normalized Ratio
Description
Prothrombin time (PT), the time required for clot formation, may be
prescribed to monitor the response to warfarin sodium (Coumadin)
therapy or to screen for dysfunction of the extrinsic system resulting
from liver disease, vitamin K deficiency, or disseminated
intravascular coagulation.
Each laboratory establishes a normal PT value or control value on
the basis of the method used to perform the test.
The normal PT range in an adult male is 9.6 to 11.8 seconds; in an
adult female it is 9.5 to 11.3 seconds. A PT value within 2 seconds of
the control (longer or briefer) is considered normal.
The international normalized ratio (INR) is frequently used to
measure the effects of oral anticoagulants.
The normal INR range is 1.00 to 1.30; in the presence of standard
warfarin therapy it is 2.0 to 3.0, and with high-dose warfarin sodium
therapy it is 3.0 to 4.5.
Nursing Considerations
Concurrent warfarin sodium and heparin therapy can lengthen the
PT for as long as 5 hours after a dose.
Diets high in green leafy vegetables can increase the absorption of
vitamin K, which in turn shortens PT.
Oral anticoagulation therapy usually maintains the PT at 1.5 to 2
times the laboratory control value.
A PT longer than 30 seconds indicates that client is at risk for
bleeding.
Bleeding Time and Platelet Count
Description
Bleeding time is a measure of vascular and platelet activity during
hemostasis.
The normal range for bleeding time is 1 to 9 minutes.
Platelets are produced by the bone marrow to function in
hemostasis.
Normal value for platelets range from 150,000 to 400,000
cells/mm3 (150 to 400 x 109/L).
Nursing Considerations
High altitudes, long periods of cold weather, and exercise all
increase the platelet count.
Bleeding precautions should be instituted in the client with a low
platelet count.
Erythrocyte Studies
Erythrocyte Sedimentation Rate
Description
The erythrocyte sedimentation rate (ESR) is the rate at which
erythrocytes settle out of anticoagulated blood in 1 hour.
This nonspecific test is used to detect illnesses associated with acute
and chronic infection, inflammation, advanced neoplasm, and tissue
necrosis or infarction.
Normal values range from 0 to 30 mm/hr, depending on the age of
the client.
Nursing Considerations
Fasting is not necessary before an ESR determination, but a fatty
meal may cause plasma alterations.
 Hemoglobin and Hematocrit
Description
Hemoglobin is the main component of erythrocytes and serves as
the vehicle for the transportation of oxygen and carbon dioxide.
Hemoglobin determinations are important in identifying anemia.
Normal hemoglobin values range from 14 to 16.5 g/dL (140 to 165
mmol/L) in males and 12 to 15 g/dL (120 to 150 mmol/L) in females.
The hematocrit represents red blood cell (RBC) mass and is an
important measurement in the identification of anemia or
polycythemia.
Normal hematocrit values range from 42% to 52% in males and 35%
to 47% in females.
Nursing Considerations
Fasting is not required before either test.
Cardiac Markers
Troponins
Description
Troponin is a regulatory protein found in striated muscle (skeletal
and myocardial).
Increased amounts of troponins are released into the bloodstream
when a myocardial infarction (MI; heart attack) causes damage to
the myocardium.
The troponin T concentration is usually less than 0.1 ng/dL (< 0.1
mcg/L), and a higher value is consistent with MI; the troponin I value
is usually lower than 0.6 ng/mL (<0.6 mcg/L), and a reading higher
than 1.5 ng/mL (1.5 mcg/L) is consistent with MI.
Levels increase as soon as 3 hours after myocardial injury; troponin I
levels may remain increased for 7 to 10 days and troponin T levels
may remain increased for as long as 10 to 14 days.
Serial measurements are important for comparison with baseline
findings.
Nursing Considerations
The client does not need to fast before this test.
Natriuretic Peptides
Description
Natriuretic peptides are neuroendocrine peptides that are used to
identify clients with congestive heart failure (CHF).
Brain natriuretic peptide (BNP), synthesized in the cardiac ventricle
muscle, is the primary marker for identifying CHF as the cause of
dyspnea; The higher the BNP level, the more severe the CHF.
The BNP level should be less than 100 pg/mL (< 100 ng/L).
If the BNP is increased, dyspnea is due to CHF; if it is normal,
dyspnea is due to a pulmonary problem.
Nursing Considerations
The client does not need to fast before the test.
Serum Gastrointestinal Studies
Alanine Aminotransferase, Aspartate Aminotransferase,
and Ammonia
Description
The alanine aminotransferase (ALT) concentration is used to identify
hepatocellular disease of the liver and to monitor improvement or
worsening of the disease.
The normal value of ALT is 4 to 6 units/L.
The AST reading is most commonly used to evaluate a client with
suspected hepatocellular disease but may also be used along with
other cardiac markers to evaluate coronary artery occlusive disease.
The normal range for AST is 0 to 35 units/L.
Ammonia is metabolized by the liver and excreted by the kidneys as
urea.
An increased level of ammonia resulting from hepatic dysfunction
may lead to encephalopathy.
The normal range of ammonia values is 10 to 80 mcg/dL.
Nursing Considerations
Previous intramuscular injections may cause increased levels of ALT
and AST.
No fasting by the client is required before a blood draw for ALT or
AST.
Instruct the client to fast for 8 to 20 hours, except for water, before
the blood draw for ammonia testing and to refrain from smoking for
8 to 10 hours before the test.
Place the specimen in an ice water bath.
Transport the specimen to the laboratory immediately.
Amylase and Lipase
Description
In acute pancreatitis, the amylase level is greatly increased. It starts
rising 3 to 6 hours after the onset of pain, peaks at about 24 hours,
and returns to normal 2 to 3 days after the onset of pain.
The normal range of values for amylase is 25 to 151 units/L.
Increased lipase levels are seen in pancreatic disorders; such
increases may not occur until 24 to 36 hours after onset of illness,
and the concentration may remain increased for as long as 14 days.
The normal lipase range is 10 to 140 units/L.
Nursing Considerations
On the laboratory form, list the medications that the client has taken
in the 24 hours preceding an amylase test, because many
medications cause false-positive or false-negative results.
The result is invalidated if the specimen for amylase was obtained
less than 72 hours after cholecystography with radiopaque dyes.
Endoscopic retrograde cholangiopancreatography may increase
lipase activity.
Bilirubin, Lipids, and Protein
Description
Produced by the liver, spleen, and bone marrow, bilirubin is also a
byproduct of hemoglobin breakdown.
Total bilirubin levels can be broken down into direct bilirubin, which
is primarily excreted by way of the intestinal tract; and indirect
bilirubin, which circulates mainly in the bloodstream.
The total bilirubin level increases with any type of jaundice, whereas
direct and indirect levels increase depending on the origin of
jaundice.
 Normal bilirubin values: direct, 0 to 0.3 mg/dL (0 to 5.1 mcmol/L);
indirect: 0.1 to 1.0 mg/dL (1.7 to 17 mcmol/L); and total, less than
1.5 mg/dL (25.7 mcmol/L).
Lipid assessment includes total cholesterol, high density lipoprotein
(HDL), low density lipoprotein (LDL), and triglycerides.
Normal lipid values: cholesterol, 140 to 199 mg/dL (3.6 to 5.1
mmol/L); LDL, less than 130 mg/dL (3.4 mmol/L); HDL, 30 to 70
mg/dL (0.8 to 1.8 mmol/L); and triglycerides, less than 200 mg/dL
(2.3 mmol/L).
The protein reading reflects the total amount of albumin and
globulins in the serum.
Protein is increased in conditions such as Addison disease,
autoimmune collagen disorders, chronic infection, and Crohn
disease. It is decreased in conditions such as burns, cirrhosis, edema,
and severe hepatic disease.
Normal protein values range from 6.0 to 8.0 g/dL (60 to 80 g/L).
Nursing Considerations
Instruct the client to avoid yellow foods (e.g., carrots, yams, yellow
beans, pumpkin) for 3 to 4 days before blood is drawn for bilirubin
testing.
Instruct the client to fast for 4 hours before blood is drawn for a
bilirubin assay.
Note that bilirubin readings will be increased if the client has
ingested alcohol or taken morphine sulfate, theophylline, ascorbic
acid, or aspirin shortly before the test.
Remember that bilirubin results are invalidated if the client has
undergone a radioactive scan in the 24 hours before the test.
The use of oral contraceptives may increase lipid levels.
Instruct the client to abstain from foods and fluids, except for water,
for 10 to 14 hours and from alcohol for 24 hours before lipid testing.
Tell the client that the evening meal before the blood draw for lipid
testing should be free of high-cholesterol foods.
Instruct the client to avoid high-fat foods for 8 hours before a
protein test.
Glucose Studies
Fasting Blood Glucose
Description
Glucose, the body's main source of cellular energy, is essential for
brain and erythrocyte function.
The fasting blood glucose level is used to help diagnose diabetes
mellitus and hypoglycemia.
The normal fasting glucose concentration ranges from 70 to 110
mg/dL (3.9 to 6.1 mmol/L); the normal range for glucose monitoring,
in which capillary blood is sampled, is 60 to 110 mg/dL (3.3 to 6.1
mmol/L).
Nursing Considerations
Instruct the client to fast for 8 to 12 hours before the fasting blood
glucose test.
Instruct the client with diabetes mellitus to withhold the morning
insulin dose or oral hypoglycemic medication until after blood has
been drawn.
Glycosylated Hemoglobin
Description
Glycosylated hemoglobin is blood glucose bound to hemoglobin.
The HbA1c (glycosylated hemoglobin A) reading is a reflection of how
well the blood glucose level has been controlled in the preceding 3
months.
Hyperglycemia in diabetic individuals is usually a cause of increased
HbA1c.
Values are expressed as a percentage of total hemoglobin: In a
diabetic individual with good control, the reading is 7% or less; in a
diabetic individual with fair control, it is 7% to 8%; and in a diabetic
individual with poor control, it is 8% or greater.
Nursing Considerations
Fasting is not required before the test.
Renal Function Studies
Serum Creatinine and Blood Urea Nitrogen
Description
Serum creatinine is a very specific indicator of renal function.
An increased creatinine level indicates a slowing of the glomerular
filtration rate.
Normal creatinine values range from 0.6 to 1.3 mg/dL (53 to 115
mcmol/L).
Urea nitrogen is the nitrogen portion of urea, a substance formed in
the liver through an enzymatic protein-breakdown process.
Urea is normally freely filtered through the renal glomeruli, with a
small amount reabsorbed in the tubules and the remainder excreted
in the urine.
An increased level indicates slowing of the glomerular filtration rate.
Normal values range from 8 to 25 mg/dL (2.9 to 8.9 mmol/L).
Both creatinine and blood urea nitrogen (BUN) should be analyzed
when renal function is evaluated.
Nursing Considerations
Instruct the client to avoid excessive exercise for 8 hours and
excessive consumption of red meat for 24 hours before a creatinine
test.
Elements
Calcium, Phosphorus (Phosphate), and Magnesium
Description
Calcium functions in bone formation, nerve impulse transmission,
and contraction of myocardial and skeletal muscles; it also aids in
blood clotting by converting prothrombin to thrombin.
Normal calcium values range from 8.6 to 10.0 mg/dL (2.15 to 2.5
mmol/L).
Phosphorus is important in bone formation, energy storage and
release, urinary acid-base buffering, and carbohydrate metabolism.
Normal phosphorus values range from 2.7 to 4.5 mg/dL (0.87 to 1.45
mmol/L).
Magnesium is required in the blood-clotting mechanism; it also
regulates neuromuscular activity, acts as a cofactor that modifies the
activity of many enzymes, and has an effect on the metabolism of
calcium.
Normal magnesium values range from 1.6 to 2.6 mg/dL (0.66 to 1.07
mmol/L).
 Nursing Considerations
Instruct the client to eat a diet with normal calcium levels (800
mg/day) for 3 days before the test.
Inform the client that fasting may be required for 8 hours before a
calcium test.
Instruct the client to fast for 8 hours before a phosphorus test.
Remember that prolonged use of magnesium products will increase
the magnesium level.
Long-term parenteral nutrition therapy or excessive loss of body
fluids may decrease the magnesium level.

White Blood Cell Count

Description
WBCs function in the body's immune defense system.
Normal values range from 4500 to 11,000 cells/mm3 (4.5 to 11 x
109/L).
In the WBC count, the distribution of leukocytes is assessed.

Nursing Considerations
A "shift to the left" means an increased number of immature
neutrophils in the peripheral blood.
A low total WBC count with a leftward shift indicates recovery from
bone marrow depression or an infection of such intensity that the
demand for neutrophils in the tissue is greater than the capacity of
the bone marrow to release them into the circulation.
A high total WBC count with a leftward shift indicates increased
release of neutrophils by the bone marrow in response to an
overwhelming infection or inflammation.
A "shift to the right," found in liver disease, Down's syndrome, and
megaloblastic and pernicious anemia, means that cells have more
than the usual number of nuclear segments.

Urinalysis
Description
Generally urinalysis is a part of the data collection for a physical
examination; the many parameters measured in a standard
urinalysis are used to aid diagnosis of a variety of disorders.
Urinalysis is performed to determine the presence of urological or
renal disorders.

Nursing Considerations
It is best to collect the specimen in the morning, during the first or
second voiding, depending on the laboratory's preference.

Priority Points to Remember!

Maintain strict aseptic technique and use standard precautions
when drawing blood.
Follow agency guidelines for collecting specimens.
Teach the client about the test and test preparation.
Know the normal ranges of common laboratory parameters.
Normal laboratory values may vary, depending on agency standards.
Review laboratory results and recognize deviations from normal.
Report test results to the health care provider.