Title: Introduction to Vital Signs and Basic Laboratory Tests
1Introduction to Vital Signs and Basic Laboratory
Tests
- Joel N. Kniep, M.D.
- Dept. of Pathology
2Objectives
- 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
3Clinical Vital Signs (Vitals)
- Temperature
- Pulse rate
- Respiration rate (RR)
- Blood pressure (bp)
4Temp
- 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)
5Pulse 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
6RR
- 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
7Bp
- 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
8Complete 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
9Total 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
10Erythrocyte 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
11Hgb
- 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
12Hct
- 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
13RBC 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)
14MCV
- 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
15MCH
- 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
16MCHC
- 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
17RDW
- 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
18Platelet 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
19WBC 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
20WBC 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
21Basic Metabolic Panel (BMP)
- Measures electrolytes, chemicals, metabolic end
products substrates - Consists of Glucose, Blood Urea Nitrogen (BUN),
Creatinine, Na, K, Cl-, Bicarbonate (HCO3-),
Ca2
22Glucose
- 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
23BUN
- 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
24Creatinine
- 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
25Na
- 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
26K
- 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
27Cl-
- 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
28HCO3-
- 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
29Ca2
- 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
30Comprehensive Metabolic Panel (CMP)
- Includes all components of BMP plus Albumin,
Total protein, Alkaline phosphatase (ALP),
Alanine aminotransferase (ALT), Aspartate
aminotransferase (AST) and Bilirubin
31Albumin
- 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
32Total Protein
- Measures total protein in blood
- Combination of prealbumin, albumin globulins
- Normal 6.4 8.3 g/dL
33ALP
- 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
34ALT
- 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
35AST
- 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
36Bilirubin
- 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
37Unconjugated 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
38Conjugated 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
39Urinary Analysis (UA)
- Provides information about kidneys other
metabolic processes - Used for diagnosis, screening monitoring
- Frequently used to test for urinary tract
infections (UTIs)
40UA 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
41UA 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
42Urinary 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
43Urinary 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
44Urinary Leukocyte esterase
- Screen to detect leukocytes in urine (dipstick
method) - Presence indicates UTI
- 90 accurate
45Urinary 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
46Urinary Nitrites
- Screen for UTI (dipstick method)
- Test based on chemical rxn by bacterial reductase
(reduces nitrate to nitrite) - 50 accurate
- Enhances leukocyte esterase sensitivity
47Urinary 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
48Cerebral 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
49CSF 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
50CSF analysis Normal Values cont.
- Protein 15 45 mg/dL
- Glucose 50 75 mg/dL or 60 70 of blood
glucose level
51CSF WBC count
- Pleocytosis turbidity of CSF due to increased
s of cells
52CSF PMNs
- Causes of ? PMNs bacterial meningitis,
tubercular meningitis, cerebral abscess,
subarachnoid bleeding, tumor
53CSF Lymphs
- Causes of ? lymphs/plasma cells viral,
tubercular, fungal or syphilitic meningitis
multiple sclerosis (MS), Guillain-Barré syndrome
54CSF Monos
- Causes of ? monos tubercular or fungal
meningitis, hemorrhage, brain infarction
55CSF 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 ? ? ?
56References
- 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
57Additional 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/
58Special Thanks
- Dr. Amira F. Gohara, M.D.
- Dr. Carol Bennett-Clarke, Ph.D.
- Dr. Constance Shriner, Ph.D.
- Cynthia R. OConnell, BSMT (ASCP)