Your method for analyzing lab values

BelgianRN · Mar 7, 2012

Hey,

I'm very happy with the options our PDMS offers us for organizing labs. Basically I can select any period of time and draw different labs in if I want to see the trend over days/hours/weeks even. Other than that we have some presets.

E.G. We have a tab called infections and it shows leukocyte count, CRP, temperature, antibiotic use, cultures taken and days lines are in situ for several days. I find it very handy because basically it gives me a quick glance overview of the infectious status of my patient.

Another predefined set is ST-analysis. It shows the analysis of all ST-segments over the selected period including medications like NTG-drips or patches and cardiac enzymes in the blood.

We also have a renal set which includes In and Out data, all diuretics administered and values for Creatinine, BUN, sodium and potassium.

Generally for myself I go over labs when I see my patient for the first time by myself bedside. So this means I'll do the bedside check up and then I'll enter all computer data. Afterwards since I'm at the computer anyway I'll look at history, admission data, medical follow up notes of the past days and the nursing shift reports for the last 24 - 48 hours and the specific care plan. Then it's generally time for labs. Our labs are organized already under different headings and the tab is organized so that every draw has a separate column so generally I'll see 5 - 10 days of labs in one scren. For me I'll follow this order:

HIT - status (heparin induced thrombocytopenia). This is not always known, but I generally check it (we have a separate box lighting up when HIT positive) since it requires extra attention to heparin use etc.
Renal Function - Creatinin/BUN, GFR, Na, K.
CRRT? - if yes I'll make sure that Mg, Ca and phosphate are being drawn daily (as per our institution policy that needs to be done). If any of these are low I'll ask for orders for suppletion (usually we have standing orders to correct PRN).
Cardiac enzymes - CK, CK-MB, TnI, ASAT, ALAT, LDH (sometimes we'll have BNP/ANP and myoglobine as well but that isn't the standard).
Liver function - ASAT, ALAT, LDH, Bilirubin + fractions, yGT and Alk. Phosph. I'll generally differentiate between primary liver dysfunction (focussing more on ASAT, ALAT) or cannalicular abnormalities (isolated yGT and Alk. Phosph abnormalities).
TPN? - If yes I'll make sure the liver functions aren't too abnormal, otherwise I might suggest cyclic TPN. And if they're under TPN or massive amounts of propofol generally we'll check triglycerides once a week, so I make sure those orders are in our PDMS as well.
Hepatic encephalopathy? - If yes I'll check for ammonia levels (NH3) if they are drawn. If not I'll generally get the intensivist to order them or cancel them if they have been stable for days...
Hepatic dysfunction? - If yes I'll make sure to check coags extra carefully and see if they need to be corrected.
Bleeding, Coag and DIC. I'll check to see if the hemoglobin and hematocrit stays stable (and rule out dilutional effects from colloids/cristalloids over true loss). I'll check APTT, PTT, INR, platelets and fibrinogen for abnormalities. And if suspected of DIC I'll check schistocytes, plasmahemoglobin, haptoglobin, D-dimers and Fibrinomonomeres.
bleeding? - if yes I'll check for use of thrombocyte aggregation blockers: acetylsalicylate, thienopyridines and GPIIb/IIIa-inhibitors and if they're post ECC. If so the platelet count can be normal but they'll have dysfunctional patelets and as a result they'll probably need thrombocyte transfusions during bleeding problems.
iv Heparin? - if yes I'll check to make sure orders are in for ACT or APTT checks and if we find less and less effect from heparin (e.g. it continues to be titrated up) I'll get an order for antithrombin III if not drawn already.
Thrombolysis? - if yes I'll make sure fibrinogen is above the lowest critical value (as per order of the vascular surgeon).
Infection - I'll check leukocyte count and formula (if drawn) and CRP. If leukocyte and CRP seem to be inconclusive I'll include platelet count and fibrinogen in the analysis since they both raise during infections too (platelets sometimes drop during serious sepsis or rise sometimes in reaction to certain medication, e.g. furosemide).
Recently administered corticosteroids? - If yes leukocyte count will rise since corticosteroids prevent leukocyte diapedesis.
Severe liver failure? - If yes the body's ability to produce CRP is reduced/absent so it might not accurately reflect the infectious state of the body.
Recent major surgery? - If yes CRP will most likely rise and doesn't have to be a sign of infection.
I'll make sure to check for recently administered corticosteroids since they'll raise leukocyte count anyway. And keep in mind when a patient is in severe liver function they might not be able to produce CRP in light of an infection.
Thyroid status - FT3, FT4, TSH. They aren't drawn routinely but usually somewhere around admission and ons special indications. I'll check it and see if they need correction.
Drug levels - I'll generally see if they were sub-, supra- or eutherapeutic or toxic. And if appropriate actions were taken to correct these.
ABG's
VBG's
mVBG's

The above list is the schematic playing in my head. It sounds much longer than it takes. If you do this daily on multiple patients it takes less than two minutes. But if you don't work with multi-organ failure patients you could trim the list to include the most common problems in your unit.

I don't think the problem is nurses not paying attention to labs but some fail to incorporate disease status when analyzing labs.

For example. They'll freak out over a new leukocytosis but 24 hours before the patient has been put on corticosteroids. They'll jump at slightly raised troponin I levels but the patient is in acute renal failure which can cause light raises in TnI.

The question is of course is it our task as RN's to have an extensive knowledge about labs and how disease processes interact with these values. I wouldn't dare to formulate an answer to that. But I hate when we have families that are freaking out and are fearing serious infection because the nurse told them the leukocytes were going up in the above situation.

FYI I have a great book on lab values and wonderfully written. So I don't know how good your Dutch is ^^.

Vespertinas · Mar 7, 2012

. Basically I can select any period of time and draw different labs in if I want to see the trend over days/hours/weeks even. Other than that we have some presets.
E.G. We have a tab called infections ......
Another predefined set is ST-analysis. ...
We also have a renal set ...

Amazing

BelgianRN · Mar 7, 2012

Amazing

Yeah it's pretty neat. The MD in our department does parttime programming of the system and he introduced many features to help us and the MD's out in our work. Only thing he can't seem to get right is the stool alert ^^.

Advanced Practice Columnist / Guide · Mar 7, 2012

When I was a bedside nurse, I approached lab values based on body systems. Whenever I receive report, I jot down the data being reported to me based on body systems as well. After report, I immediately go to a workstation and plug in whatever lab values were reported that day. I only write the current labs but also write the previous day's values (in parenthesis) if they needed to be trended. When I have a lot of time, I even write the abnormals in red. In terms of writing labs, I do the following:

Neuro: ammonia level, CSF cytology, triglyceride level (if on Propofol)

Pulm: ABG and/or VBG

CV: cardiac enzymes

GI/Nutrition: LFT's, amylase, lipase, nutritional labs (fat stain, prealbumin, CRP)

Fluids and Electrolyes/Renal: I write chem panel using this diagram

Na / Cl / BUN

K / CO2/ crea

ICa/Mg/Phos

Heme/ID: I write CBC and coags using this diagram:

.......\ Hgb /

WBC / Hct \ Plt

PT/INR/PTT Fibrinogen

then I look up Microbiology results and also write them.

Endocrine: glucose, thryoid function tests, cortisol

This was how I did it so I don't forget a lab value that could affect my care that day.

brainkandy87 · Mar 8, 2012

I kind of did the same thing on the floor as I do in the ER, i.e. focused assessment. On the floor, I'd look at everything, but I'd focus on labs specific to their condition first. So if they were on a Heparin gtt, I'd check PTT real quick, ARF -> CMP, etc. The main thing I do first though is look to see if any values are very high or very low. Our lab sheets tell us if a value is critical and will show VH or VL. So if I catch any of those, I'll look back to see the trend.

Tiffanybaybay · Mar 9, 2012

Check them every single shift, check all that are ordered. Look them up if you don't know them and if they are out of range, look up the time period you have available to you maybe at least a week... something like that or whenever they were last admitted if they just came to you. If you follow those rules you'll never mess up.

APRN., DNP, RN, APRN, NP · Mar 9, 2012

When I was a bedside nurse, I approached lab values based on body systems. Whenever I receive report, I jot down the data being reported to me based on body systems as well. After report, I immediately go to a workstation and plug in whatever lab values were reported that day. I only write the current labs but also write the previous day's values (in parenthesis) if they needed to be trended. When I have a lot of time, I even write the abnormals in red. In terms of writing labs, I do the following:
Neuro: ammonia level, CSF cytology, triglyceride level (if on Propofol)
Pulm: ABG and/or VBG
CV: cardiac enzymes
GI/Nutrition: LFT's, amylase, lipase, nutritional labs (fat stain, prealbumin, CRP)
Fluids and Electrolyes/Renal: I write chem panel using this diagram
Na / Cl / BUN
K / CO2/ crea
ICa/Mg/Phos
Heme/ID: I write CBC and coags using this diagram:
.......\ Hgb /
WBC / Hct \ Plt
PT/INR/PTT Fibrinogen
then I look up Microbiology results and also write them.
Endocrine: glucose, thryoid function tests, cortisol
This was how I did it so I don't forget a lab value that could affect my care that day.

OH MY GOODNESS!! We're Same-ies! I've always done that too. Works like a charm.

Advanced Practice Columnist / Guide · Mar 9, 2012

OH MY GOODNESS!! We're Same-ies! I've always done that too. Works like a charm.

It sure does. It keeps me organized to the point that the goal of not missing anything is doable.

Stevenyzwife · Mar 24, 2012

As an Australian ICU nurse I am having a huge study to do when we move to the USA next year because of the different drug names, our metirc system, and blood levels. Can someone please email me a page or information on what the "norm" values are in the USA.

It is another thing I need to learn before the NCLEX exam. Anybody think of what else I need to learn that is diffferent. Which ventilators do you use? I know the Purretn Bennets 2000, Avea's and have only seen a Draeger but never used one.

If you can help me, please pm me and I will give you my email address.

Thanks! :)

Vespertinas · Mar 24, 2012

For the most part, we also use the metric scale in medicine. The only holdover I can think of is that some places still use Fahrenheit. As for norms, it varies by which standards the facility has adopted but if it's computer based, their particular reference ranges should be easily found in the screen near the value.

wanderlust99 · Mar 24, 2012

Something nurses neglect in report almost always in my experience is infectious disease status. They may mention an elevated WBC, but antibiotics that the patient are on and why we are using those antibiotics...that's rarely talked about, and it's important in an ICU pt IMO.

All our labs are in the computer, so I don't really have a system, I just look at the numbers, compare them to what they were yesterday.