Professional Documents
Culture Documents
Interpreting Laboratory Values in Older Adults
Interpreting Laboratory Values in Older Adults
net/publication/7558400
Article in Medsurg nursing: official journal of the Academy of Medical-Surgical Nurses · September 2005
Source: PubMed
CITATIONS READS
4 14,822
2 authors, including:
Nancy Edwards
Purdue University
31 PUBLICATIONS 369 CITATIONS
SEE PROFILE
All content following this page was uploaded by Nancy Edwards on 15 May 2014.
Reference ranges may be more logic conditions in certain older absorption (Giddens, 2004). Im-
appropriate. Normal ranges are adults. Nurses working with older paired erythrocyte production,
obtained by determining the adults should consider the total blood loss, increased erythrocyte
mean of a random sample of assessment rather than simply destruction, or a combination of
healthy individuals, usually ages relying on laboratory diagnostic conditions have also been identi-
20 to 40 years, in order to identify testing. For example, goals of fied as causes for lowered hemo-
two standard deviations on either management of diabetes should globin (Giddens, 2004). Kee
side of the mean. The concept of be individualized. The principal (2002) defines hemoglobin as
normal range, however, is not goal would be to enhance quality abnormal if less than 13.5 gm/dl
useful in determining age-related of life without undue risk of hypo- for males and 12.0 gm/dl for
norms for older adults (Luggen, glycemia. It usually is best to females. Recent studies with
2004). achieve fasting blood glucose lev- older adults, however, suggest
Reference ranges or reference els of less than 140 mg/dl. lower levels may be acceptable.
values are preferred concepts. However, in the frail elderly, it is The currently reported lowest
Reference ranges or reference best to avoid fasting or bedtime acceptable value for older adults
values are those intervals within plasma glucose levels of less than is 11.5 gm/dl for males and 11.0
which 95% of the values fall for a 100 mg/dl if the patient is on gm/dl for females (Brigden &
specific population (Lab Tests insulin or sulfonylurea treatment Heathcote, 2000) (see Table 1).
Online, 2001). For example, geri- (Reed & Mooradian, 1998). Hemoglobin may be lower in
atric reference ranges are those Serum creatinine is a second older adults due either to normal
intervals within which 95% of val- example of a laboratory test in aging changes or illnesses such
ues for persons over 70 years of which results may be within the as anemia. Manson and McCance
age would fall. It must be cau- specified reference range and yet (2004) identify impaired erythro-
tioned, however, that some indicate pathology for the older cyte production, blood loss,
researchers recommend not adult. Creatinine is a product of increased erythrocyte destruc-
using reference ranges for labora- creatine phosphate, used in tion, or a combination of condi-
tory test parameters pertaining skeletal muscle contraction. tions as causes for anemia. Most
to older adults because it is diffi- Endogenous creatinine produc- instances of anemia are associat-
cult to differentiate whether tion is constant as long as muscle ed with chronic conditions such
results are a sign of a disease or mass remains constant (Pagana & as renal insufficiency or gastric
are related to normal aging Pagana, 2002). The mechanisms bleeding (Giddens, 2004). Anemia
(Luggen, 2004). However, refer- that regulate the older individ- may be a serious condition
ence ranges are useful in some ual’s serum creatinine levels with- because it places the older indi-
situations. The use of reference in the accepted reference range vidual at greater risk for circula-
ranges allows for recognition of tend to overestimate renal func- tory and oxygenation problems
the special needs of the popula- tioning as a measure of glomeru- (Tripp, 2000). A reduction of
tion in question. Reference lar filtration rate. Serum creati- hemoglobin can result in a
ranges are calculated not just for nine and blood urea nitrogen decrease in oxygen content and
older adults, but also for (BUN) levels in the high-normal an increase in fatigue. Signs of
neonates (especially low-birth- category may represent signifi- anemia may not be noticed if the
rate infants), adolescents, and cant renal dysfunction in the anemia is mild, but some individ-
pregnant women. In addition, spe- older adult who has inadequate uals may present with shortness
cific reference ranges are known protein intake (Daniels, 2002). of breath, fatigue, and paresthe-
for tests for other special popula- sia (Manson & McCance, 2004). A
tions (for example, serum ery- Specific Laboratory Tests combination of vague symptoms
thropoietin in adult athletes such Hemoglobin (HGB). While the and an unclear clinical picture
as marathon runners). results of studies of the effects of may lead the health care provider
Laboratory values falling out- aging on the hematologic system to attribute the symptoms to “old
side the normal ranges may indi- vary (Brigden & Heathcote, 2000; age” and not to a treatable condi-
cate benign or pathologic condi- Nilsson-Ehle, Jagenburg, Landahl, tion.
tions in the older adult & Swanborg, 2000), research does Hematocrit (HCT). Changes in
(Fischbach, 2004). Values within indicate that older individuals hematocrit may reflect fluid
the expected normal reference may have changes in hemoglobin and/or nutritional status in the
ranges, however, may also indi- and erythrocyte synthesis caused older adult (Fischbach, 2004;
cate new or progressing patho- by changes in iron and vitamin B12 Giddens, 2004). An increase in the
Table 1.
Geriatric Laboratory Values and Interpretations of Hematology
White Blood Cells 4,500 - 10,000 µl/mm3 3,000 - 9,000 µl/mm3 ↓: Hemotopoietic diseases, viral infections,
alcoholism, systemic lupus erythematous
(SLE), rheumatoid arthritis
↑: Acute infection, tissue necrosis,
leukemias, hemolytic anemia, parasitic dis-
eases, stress
hematocrit may signal volume (Rybka et al., 2003) (see Table 1). fever, or pain, may be decreased
depletion, while a decrease may A decreased WBC value may in severity or absent in the older
be a result of conditions accom- result from specific disease adult (Beers & Berkow, 2000).
panied by fluid overload or (myeloma, collagen vascular dis- Nurses should be vigilant in
dietary deficiencies. Hematocrit, orders), infection or sepsis efforts to detect other signs of
the percentage of total blood vol- (pneumonia, urinary tract infec- infections in the older adult, such
ume that represents erythro- tions), or medications (cytotoxic as confusion. Because of the con-
cytes, may be normal if values are agents, analgesics, phenoth- cern for serious undetected infec-
30% to 45% for older males and iazides), and should not be attrib- tion, nurses should educate older
36% to 65% for older females uted to advancing age (Fischbach, adults about infection prevention
(Desai & Isa-Pratt, 2002) (see 2004). This lowered WBC count in techniques, such as hand wash-
Table 1). a healthy individual may result in ing and timely vaccination for
White blood cells (WBC). an absence of elevated white influenza and pneumonia.
Whether total leukocyte count is blood cells in the presence of Platelets (Plt). Aging usually
affected by aging is controversial. severe infection. Medications causes a decline in bone marrow
However, there are definite such as steroids also may influ- function, which may contribute
changes in that the T cells are ence the immune response to lowered platelet counts and
less responsive to infection (Giddens, 2004). Because of the decreased platelet function
(Fulop et al., 2001; Sester et al., slower immune response, com- (Luggen, 2004). Studies also sug-
2002). Immunity gradually de- mon symptoms of infections, gest that platelet adhesiveness
clines after age 30 to 40 years such as enlarged lymph glands, increases with age, with no
Table 2.
Geriatric Laboratory Values and Interpretations of Erythrocyte Sedimentation Rate,
Iron Metabolism, and Vitamin B12
Serum Iron 50-150 µg/dl 60 - 80 µg/dl ↓: Iron deficiency anemia, cancer (stom-
ach, intestine, rectum, breast), bleeding
peptic ulcers, protein malnutrition
↑: Hemolytic, pernicious, and folic acid
anemias; liver damage; lead toxicity
Vitamin B12 200 - 900 pg/ml 150 pg/ml ↓: Pernicious anemia, malabsorption
syndrome, liver disease, hypothyroidism
↑: Acute hepatitis
Source: Brigden, 1999; Brigden & Heathcote, 2000; Kee, 2000; Tripp, 2000
Table 3.
Geriatric Laboratory Values and Interpretations of Serum Proteins
Test Normal Adult Value Geriatric Value Implications
Total Protein 6.0 - 8.0 g/dl 5.6 - 7.6 g/dl ↓: Prolonged malnutrition, low-protein diet,
cancer (GI tract), severe liver disease, chronic
renal failure
↑: Dehydration, vomiting, multiple myeloma
Albumin 3.0 - 5.0 g/dl Slight decrease ↓: Severe malnutrition, liver failure, renal
52 - 68% of total protein disorders, prolonged immobilization
↑: Dehydration, severe vomiting, diarrhea
thesis (Lab Tests Online, 2004). decline in older adults (Beers & or creatinine clearance, because
Decreased iron storage and iron- Berkow, 2000). Changes in protein of the changes in body composi-
deficiency anemia, however, com- may reflect decreased liver func- tion (Engelberg, McDowell, &
monly are caused by inadequate tioning or inadequate nutritional Lovell, 2000; Luggen, 2004). A
dietary intake of iron or loss of intake (Beers & Berkow, 2000). decrease in the lean body mass,
iron through chronic or acute While all serum proteins are relatively common in older
blood loss (Beers & Berkow, reduced, albumin is the most sig- adults, results in reduced protein
2000). Nursing assessment should nificantly influenced by aging degradation and nitrogen byprod-
include a dietary assessment for (Beers & Berkow, 2000). Albumin ucts of metabolism (BUN). The
reduced intake of iron-containing levels decrease each decade over decline in muscle mass also
foods and assessment of occult the age of 60, with a marked results in less creatinine produc-
bleeding from the gastrointestinal decrease over 90 years of age tion; serum creatinine values thus
tract. (Daniels, 2002). In addition to remain within normal limits
Vitamin B12. Brigden and being an indicator of disease or despite diminished renal clear-
Heathcote (2000) report that malnutrition, low serum albumin ance capacity (Brigden &
serum vitamin B12 levels may is the most common cause of a Heathcote, 2000) (see Table 4).
decrease slightly with age (see low serum calcium level in older When considering age-related
Table 2). The deficiency in B12 adults, because most serum calci- changes, most physicians and
may be due to chronic atrophic um is protein-bound (Beers & advanced practice nurses ques-
gastritis, an immune dysfunction Berkow, 2000) (see Table 3). tion the adequacy of BUN and cre-
that occurs more often in older Renal function. As mentioned atinine as indicators of renal func-
adults, or from a deficiency of previously, relying on commonly tion (Kennedy-Malone, Fletcher, &
HCl, both leading to insufficient accepted laboratory values in Plank, 2004). Therefore, measure-
intrinsic factor and insufficient determining renal function in the ment of urinary creatinine clear-
absorption of vitamin B12 (Beers & older adult is difficult. The age- ance takes on special significance
Berkow, 2000). The low end of the related 30% to 45% decrease in in the older adult. Serum creati-
reference range for vitamin B12 is functioning renal tissue and the nine is affected by both
150 pg/mL in the older adult as glomerular filtration rate (GFR) decreased GFR and body mass,
opposed to 190 pg/mL in a leads to a decline in the creati- while urinary creatinine clear-
younger adult (Brigden & nine clearance (Brigden & ance is affected only by glomeru-
Heathcote, 2000) (see Table 2). Heathcote, 2000). Commonly lar filtration (Lewis et al., 2004).
Assessment for pernicious ane- occurring reduction in lean body Determining renal function by
mia, including checking for neu- mass, decreased dietary protein creatinine clearance examination
ropathies, such as weakness, dif- intake, or decreased hepatic func- is especially useful when treating
ficulty walking, and numbness or tion may lead to decreases in the the older adult with medications
tingling, should be considered end products of metabolism, because of the potential for the
whenever anemia is present. BUN, and creatinine (Brigden & development of drug toxicity,
Total protein and albumin. Heathcote, 2000). BUN and creati- even with usual doses (Daniels,
Some serum protein levels, such nine levels overestimate renal 2002). Because it may be difficult
as albumin and total protein, functioning, as measured by GFR
Table 4.
Geriatric Laboratory Values and Interpretations of Selected Renal Function Tests
Test Normal Adult Value Geriatric Value Implications
BUN 5 - 25 mg/dl 8 - 28 mg/dl or slightly ↓: Liver damage, low protein diet, overhy-
higher dration, malnutrition
↑: Dehydration, high protein diet, GI bleed-
ing, pre-renal failure
Creatinine 0.5 - 1.5 mg/dl 0.6 - 1.2 mg/dl ↓: None for older adult
↑: Renal failure, shock, leukemia, SLE,
acute MI, CHF, diabetic neuropathy
Source: Brigden & Heathcote, 2000; Engelberg et al., 2000; Kennedy-Malone et al., 2004.
Table 5.
Estimating Creatinine Clearance Values for Men
(140 - age in years) x (body weight in kilograms)
Creatinine clearance =
(72 x serum creatinine in mg/dl)
Table 6.
Geriatric Laboratory Values and Interpretations of Hepatic Enzymes
Table 7.
Geriatric Laboratory Values and Interpretations of Blood Lipids
Table 8.
Geriatric Laboratory Values and Interpretations of Glucose, Selected Electrolytes
Serum Glucose 70 - 110 mg/dl 70 - 120 mg/dl ↓: Hypoglycemia, cancer (stomach, liver),
malnutrition, alcoholism, cirrhosis of liver
↑: Diabetes mellitus, adrenal gland hyper-
function, acute MI, stress, crushing injury,
renal failure, cancer (pancreas), CHF
Calcium 4.5 - 5.5 mEq/l No change ↓: Diarrhea, lack of calcium intake, chronic
renal failure, alcoholism, pancreatitis
↑: Hyperparathyroidism, malignant neo-
plasms (bone, lung, breast, bladder, kid-
ney), malignant myeloma, prolonged
immobilization, multiple fractures, renal
calculi
Potassium 3.5 - 5.3 mEq/l Slight increase ↓: Vomiting, diarrhea, dehydration, malnu-
trition, starvation, stress, diabetic acidosis
↑: Acute renal failure, acidosis (metabolic or
lactic), crushing injury, Addison’s disease
Source: Kee, 2002; Kennedy-Malone et al., 2004; Martin et al., 1997; Tripp, 2000
to perform a creatinine clearance from the formula is multiplied by are due to aging. Chronic urinary
on the older patient, a formula 0.85. Normal ranges for creatinine tract infections, benign prostatic
can be used to estimate creati- clearance are 104 to 140 hypertrophy, prostatic tumors,
nine clearance values. For men, ml/minute for men and 87 to 107 and diabetic neuropathy are also
the formula is shown in Table 5 ml/minute for women (see Table causes and should be ruled out
(Brigden & Heathcote, 2000). For 4). Nurses should not assume (Lewis et al., 2004).
women, the value determined that all changes in renal function Hepatic enzymes. The aging
Table 9.
Geriatric Laboratory Values and Interpretations of Selected Blood Gases
Test Normal Adult Value Geriatric Value Implications
Source: Brigden & Heathcote, 2000; Kee, 2002; Martin et al., 1997
process does not significantly adults will have decreased choles- in years (for patients over age
influence most hepatic laborato- terol levels (Tietz et al., 1997). 40)
ry test values (for example, biliru- The mean HDL increases 30% in Serum electrolytes. In most
bin, ammonia, and lipids.) While men but decreases 30% in women reports, electrolyte values remain
lactic dehydrogenase (LDH) is between ages 30 and 80 (Brigden well within the standard refer-
not affected by aging, the & Heathcote, 2000). Triglyceride ence values for older adults.
enzymes gamma-glutamyl-trans- levels increase by 30% in men and Calcium levels increase in older
ferase (GGT), serum aspartate 50% in women between the ages patients (ages 60 to 90) but
aminotransferase (AST, SGOT), of 30 and 80 years (see Table 7). decrease in the very old over age
and alkaline phosphatase are Glucose. Serum glucose levels 90 (Martin, Larsen, & Hazen,
affected (Brigden & Heathcote, increase slightly but steadily with 1997). The initial increase can be
2000). GGT levels increase with age in parallel with a decrease in explained by a decrease in serum
aging (Tietz, Shuey, & Wekstein, glucose tolerance. The normal pH and an increase in parathyroid
1997). AST increases slightly for reference range for serum glu- hormone levels found in older
individuals 60 to 90 years of age cose is broader for older adults, individuals (Tietz et al., 1997). If
to 18 U/L to 30 U/L (Tietz et al., from 70 mg to 120 mg/100 ml the individual has a low serum
1997). Serum alanine aminotrans- (Tripp, 2000) (see Table 8). Older albumin, however, the serum cal-
ferase (ALT, SGTP) levels peak individuals may have lower glu- cium level will most likely be low
about 50 years of age and gradu- cose levels, reflecting poor nutri- as mentioned previously. Serum
ally fall to levels below those of tional status or overall loss in potassium has been reported to
younger adults by age 65 (Kelso, body mass (Kennedy-Malone et increase slightly with age
1990). Alkaline phosphate (AP) al., 2004). However, higher serum (Kennedy-Malone et al., 2004);
increases with age to a level of 30 insulin levels are more commonly however, most researchers use
U/L to 140 U/L and is associated seen in older adults and may sug- the same reference values as for
with age-related malabsorption, gest insulin resistance, which is younger adults (see Table 8).
bone disorders, or decreased responsible for impaired glucose Arterial blood gases (ABGs).
liver or renal functioning tolerance in 25% of individuals Reference values for ABGs differ
(Brigden & Heathcote, 2000) (see over age 75 (Kennedy-Malone et in older adults from those of
Table 6). al., 2004). If insulin receptors do younger adults. Stiffening of the
Lipid profile. Lipid-related not respond to the same fasting elastic lung structures, decreased
changes in aging adults younger level of glucose in old age as they number of functioning alveoli,
than 70 years old are initially did when the patient was and decreased strength of the
noted as increases in cholesterol, younger, glucose intolerance diaphragm are age-related changes
high-density lipoproteins (HDL), without insulin-secretion changes that decrease respiratory function-
very low-density lipoprotein (VLDL), could be the explanation. A refer- ing (Martin et al., 1997). The
and triglycerides. Serum cholesterol ence value for the 2-hour post- decreased respiratory functioning
increases as much as 40 mg/dl by prandial glucose tolerance blood results in a decrease in the partial
age 60 in men and age 55 in women sugar test (PPBS) is calculated pressure of arterial oxygen ten-
(Brigden & Heathcote, 2000). No with the following formula sion (PaO2). The arterial pressure
increase is seen in adults over 90 (Brigden & Heathcote, 2000): decreases approximately 5%
years old; in fact, some very old • 2-hr PPBS (mg/dl) = 100 + age every 15 years starting at age 30
Table 10.
Geriatric Laboratory Values and Interpretations of Thyroxine, Triiodothyronine, Prostate-Specific Antigen
Normal Adult Value
Male (M)
Test Female (F) Geriatric Value Implications
Thyroxine (T4) 4.5 - 11.5 µg/dl 3.3 - 8.6 µg/dl ↓: Hypothyroidism, protein malnutrition,
corticosteroids
↑: Hyperthyroidism, viral hepatitis,
thyroiditis, myasthenia gravis
Thyroid- 0.5 - 5.0 µlU/ml Slight increase ↓: Excessive thyroid hormone replacement,
Stimulating Graves’ disease, primary hyperthyroidism
Hormone TSH) ↑: Primary hypothyroidism, thyroid
hormone resistance
Prostate-Specific PSA 1.45 ng/ml Ages 50 - 59: 0.0 - 2.45 ↑: Prostate cancer, benign prostatic
Antigen (PSA) ng/ml hyperplasia
Ages 60 - 69: 0.0 - 5.0
ng/ml
Ages 70 - 79: 0.0 - 6.3
ng/ml
Post-radical prostatecto-
my 0.0 - 0.3 ng/ml
Perhaps the slightly elevated Fischbach, F.T. (2004). A manual of labora- ed.) (pp. 537-578). St. Louis: Mosby.
renal function tests indicate nor- tory and diagnostic tests (7th ed.). Martin, J., Larsen, P., & Hazen, S. (1997).
Philadelphia: Lippincott. Interpreting laboratory values in older
mal changes of aging. However, Fulop, T., Douziech, N., Goulet, A.C., surgical patients. AORN Journal,
they also might be due to protein Desgeorges, S., Linteau, A., & 65(3), 621-626.
malnutrition, which is suspected Lacombe, G., et al. (2001). National Cancer Institute. (2004). The
because of his low body weight Cyclodextrin modulation of T lympho- prostate-specific antigen (PSA) test:
cyte signal transduction with aging. Questions and answers. Retrieved
and recent weight loss. Obtaining Mechanisms of Aging and November 15, 2004, from
serum protein and urinary creati- Development, 122(13), 1413-1430. http://cis.nci.nih.gov/fact/5_29.htm
nine studies as well as a thorough Giddens, J. (2004). Nursing assessment: Nilsson-Ehle, H., Jagenburg, R., Landahl,
nutritional assessment might Hematologic system. In S. Lewis, M. S., & Swanborg, A. (2000). Blood
assist in defining the diagnosis. Heitkemper, & S.R. Dirkson, (Eds.), haemaglobin declines in the elderly:
Medical-surgical nursing (6th ed.) (pp. Implications for reference intervals
Interpretation of laboratory 688-704). St. Louis: Mosby. from age 70 to 88. European Journal
test results allows nurses to rule Kee, J. (2002). Laboratory and diagnostic of Haematology, 65(5), 297- 305.
out diagnoses that are not perti- tests with nursing implications (6th Pagana, K., & Pagana, T. (2002). Mosby’s
nent, but also assists in the exam- ed.). Upper Saddle River, NJ: Pearson manual of diagnostic and laboratory
Education, Inc. tests (2nd ed). St. Louis: Mosby.
ination of a broad spectrum of Kelso, T. (1990). Laboratory values in the Reed, R.L., & Mooradian, A.D. (1998).
possibilities. Each laboratory older adult. Emergency Medicine Management of diabetes mellitus in
may have variations in the refer- Clinics of North America, 8(2), 241- the nursing home. Annals of Long
ence ranges due to techniques 254. Term Care Nursing Home, 6, 100-107.
and equipment. Nurses must Kennedy-Malone, L., Fletcher, K., & Plank, Rybka, K., Orzechowska, B., Siemieniec, I.,
L. (2004). Management guidelines for Leszek, J., Zacynska, E., Pajak, J., et
work closely with laboratory per- nurse practitioners working with older al. (2003). Age-related antiviral non-
sonnel and pathologists to be adults. Philadelphia: F.A. Davis. specific immunity of human leuko-
informed about changes in refer- Lab Tests Online. (2001). Reference ranges cytes. Medical Sciences Monitor,
ence ranges for older adults in a and what they mean. Retrieved 9(12), BR413-417.
November 15, 2004, from http://www. Sester, M., Sester, U., Alarcon, S.S., Heine,
specific laboratory. Nurses also labtestsonline.org/understanding/ G., Lipfert, S., Gerndt, M., et al.
should educate other health care features/ref_ranges-6.html (2002). Age-related decrease in aden-
professionals about age-related Lab Tests Online. (2004). TIBC and trans- ovirus-specific T cell responses.
variations in acceptable laborato- ferrin. Retrieved November 15, 2004, Journal of Infectious Diseases,
ry values. Better understanding from http://labtestsonline.org/under 185(10), 1379-1387.
standing/analytes/tibc/test.html Thibodeau, G., & Patton, K. (2004).
of interpretation of diagnostic Luggen, A. (2004). Laboratory values and Structure and function of the body
test results in older adults will implications for the aged. In P. (12th ed.). St. Louis: Mosby.
allow nurses to feel confident Ebersole & P. Hess (Eds.), Toward Tietz, N.W., Shuey, D.F., & Wekstein, D.R.
about the care they provide. ■ healthy aging: Human needs and (1997). Clinical laboratory values in
nursing response (6th ed.) (pp. 115- the aging population. Pure & Applied
135). St. Louis: Mosby. Chemistry, 69, 51-53.
References Manson, T., & McCance, K. (2004). Tripp, T. (2000). Laboratory and diagnostic
Beers, M.H., & Berkow, R. (Eds). (2000). Alterations in hematologic function. In tests. In A. Lueckenotte (Ed.),
The Merck manual of geriatrics (Vol. S. Huether, & K. McCance (Eds.), Gerontologic nursing (2nd ed.), pp.
3). Whitehouse Station, NJ: Merck Understanding pathophysiology (3rd 405-424. St. Louis: Mosby.
Research Laboratories.
Brigden, M.L. (1999). Clinical utility of the
erythrocyte sedimentation rate.
American Family Physician, 60, 1443-
1450.
Brigden, M., & Heathcote, J.C. (2000).
Problems in interpreting laboratory
tests. Postgraduate Medicine, 107(7),
Need Additional CE Credits?
145-158.
Daniels, R. (2002). Delmar’s guide to labo-
ratory and diagnostic tests. New York:
Visit the MEDSURG Nursing Journal section
Delmar-Thomson.
Desai, S., & Isa-Pratt, S. (2002). Clinician’s
of the AMSN Web site for online CE articles.
guide to laboratory medicine.
Cleveland: Lexi-Comp. Pharmacology CE articles now available.
Duthie, E., & Abbasi, A. (1991). Laboratory
testing: Current recommendations for
older adults. Geriatrics, 46(10), 41-50.
Engelberg, S.J.H., McDowell, B.J., & Lovell,
www.medsurgnurse.org
A. (2000). In A.G. Lueckenotte (Ed.),
Gerontologic nursing (2nd ed.) (pp.
586-614). St. Louis: Mosby.