Introduction to Vital Signs and Basic Laboratory Tests

1
Introduction to Vital Signs and Basic Laboratory
Tests

• Joel N. Kniep, M.D.
• Dept. of Pathology

2
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

3
Clinical Vital Signs (Vitals)

• Temperature
• Pulse rate
• Respiration rate (RR)
• Blood pressure (bp)

4
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 gt 98.6 F orally or 99.8 F rectally
  (pyrexia fever) lt 95 F (hypothermia)

5
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

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RR

• Number of breaths/min
• At rest
• Also note breathing effort or difficulty
• Normal 15 20/min
• Critical lt 12 or gt 25
• ? (hyperventilation) ? Na intake, ? Na loss,
  Excessive free body H2O loss
• ? (hypoventilation) ? Na intake, ? Na loss, ?
  free body H2O

7
Bp

• Measures the force of blood against the arterial
  vessel walls
• Measured while seated, after resting for 5 mins,
  arm resting _at_ 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 lt 120 mm Hg systolic and lt 80 mm Hg
  diastolic
• Critical gt 220 mm Hg systolic or gt 125 mm Hg
  diastolic
• ? (hypertension htn) ? Na intake, ? Na
  loss, Excessive free body H2O loss
• ? (hypotention) ? Na intake, ? Na loss, ?
  free body H2O

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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

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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 lt 2,500 or gt 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

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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/µL
• ? 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

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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 lt 5 or gt 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

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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 lt 15 or gt 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

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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)

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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

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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

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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

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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

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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 lt 50,000 or gt 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

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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

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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

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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

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Glucose

• Direct measure of blood glucose
• Commonly used to evaluate diabetic pts
• Part of routine testing
• Normal 70 - 100 mg/dL
• Critical lt 50 and gt 400 mg/dL (?) or lt 40 and gt
  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

23
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 gt 100 mg/dL
• ? prerenal causes, renal causes, postrenal
  azotemia
• ? liver failure, overhydration because of
  SIADH, neg nitrogen balance, pregnancy, nephrotic
  syndrome

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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 gt 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

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Na

• Measures serum sodium level
• Major cation in EC space
• Balance between dietary intake and renal
  excretion
• Normal 136 146 mEq/L
• Critical lt 120 or gt 160 mEq/L
• ? (hypernatremia) ? Na intake, ? Na loss,
  Excessive free body H2O loss
• ? (hyponatremia) ? Na intake, ? Na loss, ?
  free body H2O

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K

• Measures serum potassium level
• Major cation within cell
• Normal 3.4 5.2 mEq/L
• Critical lt 2.5 or gt 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

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Cl-

• Measures serum chloride level
• Major anion in EC space
• Helps maintain electrical neutrality follows
  sodium
• Normal 98 108 mEq/L
• Critical lt 80 or gt 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

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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 lt 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

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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 lt 6 or gt 13 mg/dL, Ionized lt 2.2
  or gt 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

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Comprehensive Metabolic Panel (CMP)

• Includes all components of BMP plus Albumin,
  Total protein, Alkaline phosphatase (ALP),
  Alanine aminotransferase (ALT), Aspartate
  aminotransferase (AST) and Bilirubin

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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

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Total Protein

• Measures total protein in blood
• Combination of prealbumin, albumin globulins
• Normal 6.4 8.3 g/dL

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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

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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 _at_ 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

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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

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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 gt 2.5 mg/dL
• Normal 0.3 1 mg/dL
• Critical gt 12 mg/dL

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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

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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

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Urinary Analysis (UA)

• Provides information about kidneys other
  metabolic processes
• Used for diagnosis, screening monitoring
• Frequently used to test for urinary tract
  infections (UTIs)

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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

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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

42
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

43
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

44
Urinary Leukocyte esterase

• Screen to detect leukocytes in urine (dipstick
  method)
• Presence indicates UTI
• 90 accurate

45
Urinary Ketones

• End products of fatty acid catabolism
• Examples ß-hydroxybutyric acid, acetoacetic
  acid, acetone
• Associated with poorly controlled diabetes
• Used to evaluate ketoacidosis associated w/
  alcoholism, fasting, starvation, high-protein
  diets, isopropanol ingestion

46
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

47
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

48
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

49
CSF analysis Normal Values

• Opening pressure lt20 cm H2O
• Color clear colorless
• Blood none
• RBCs 0
• WBCs 0 5 cells/µL
• Neutrophils 0 6
• Lymphocytes 40 80
• Monocytes 15 45

50
CSF analysis Normal Values cont.

• Protein 15 45 mg/dL
• Glucose 50 75 mg/dL or 60 70 of blood
  glucose level

51
CSF WBC count

• Pleocytosis turbidity of CSF due to increased
  s of cells

52
CSF PMNs

• Causes of ? PMNs bacterial meningitis,
  tubercular meningitis, cerebral abscess,
  subarachnoid bleeding, tumor

53
CSF Lymphs

• Causes of ? lymphs/plasma cells viral,
  tubercular, fungal or syphilitic meningitis
  multiple sclerosis (MS), Guillain-Barré syndrome

54
CSF Monos

• Causes of ? monos tubercular or fungal
  meningitis, hemorrhage, brain infarction

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CSF Profile
RBCs/mm3 WBCs/mm3 Glucose (mg/dL) Protein (mg/dL) Opening pressure (cm H2O) Appearance ?-globulin ( protein)
Bacterial meningitis ? (gt 1,000 PNMs) ? (lt 45 mg/dL) ? (gt 250 mg/dL) ? Cloudy
Viral meningitis ? (lymphs/monos)
Aseptic meningitis ?
SAH ? ? ? ?
Guillain-Barré syndrome ? ?
MS Normal in 2/3 pts gt 15 in lt 5 of pts ? ?
Pseudotumor cerebri ? ? ?
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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/adu
  lt_nontrauma/vital.cfm

57
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/

58
Special Thanks

• Dr. Amira F. Gohara, M.D.
• Dr. Carol Bennett-Clarke, Ph.D.
• Dr. Constance Shriner, Ph.D.
• Cynthia R. OConnell, BSMT (ASCP)