Abnormal Labs?

Nursing Students Student Assist

Published

Hi

My instructor did not give out lab sheets until late in our clinical so I did not get a chance to question my RN about my patient's abnormal labs. Instructor gave me labs at 1945 and I had a 2000 medpass and postconference at 2020.

Patient is elderly woman, 2nd day post OP left hip replacement.

Medical Hx: DM 2, HTN, Silent MI, A-fib, GERD, osteoarthritis.

Allergic to morphine and latex.

patient is currently on lovenox, senokot, zantac, celebrex, atenolol and chlorthalizone.

Her fluid intake was limited to ~100 cc's water my shift. Output was 125 cc's.

Abnormal labs are as follows:

Na+ 130, K+ 3.1, Chloride 95, Ca 7.9, Magnesium 1.6, WBC 11.7, RBC 3.78, HCT 35, RDW 14.1

Also on another page, I have a reading that says "Postitive Antibody screen, Anti-K and Anti-E were previously identified in the patient's specimen. Current reaction strengths have not increased since previous testing and antibody identification studies were not performed."

Patient had a 240 cc blood loss during surgery.

Thank you for your help

Na+ 130, K+ 3.1, Chloride 95, Ca 7.9, Magnesium 1.6, WBC 11.7, RBC 3.78, HCT 35, RDW 14.1

The clinical picture you provide here is very sketchy. Was this an elective hip replacement or did the patient fall? Is she a nursing home patient?

If the lab values being off were due to hemodilution, you would not see the WBC's elevated (unless they are truly MUCH higher).

What I see here is a patient with poor nutrition. All of her lytes are depleted. She needs everything replaced. Is she being monitored via telemetry? I would bet she is throwing a lot of PVC's. Does she abuse alcohol? What is her mental status? When the sodium goes low, the confusion goes up.

Why is she on Lovenox? Is she currently in a fib? What IS her heart rhythm? Does she ordinarily take Coumadin?

How long did you take care of her with a urine output of only 125 ccs? What were her blood pressures?

The elevated WBC's could be due to surgery. Did they do a UA?

There are sooo many possible variables here.

Hi

Yes it was an elective hip replacement. She is not being monitored on telemetry.

This is an orthopedics floor. Her chemstick was 148 but she is on SS insulin so if her chemstick is 200 or over she will get insulin. She is A&Ox3, not confused or distressed. 125 cc urine output in an entire shift (1500-2300), but, I know from being on this floor that is not an unusual output for post-op patients. She does not abuse alcohol, nor did she have an EtOH history. Her blood pressure was 85/54, but she is normally hypertensive and in the 160/100 range. Her chart started that she has medical history of a-fib but I dont believe she was currently in a-fib. Her pulse (aplical) was 83, and regular. I am guessing the WBC's were high due to the surgery, she is only 2nd day post-op. Lovenox and Coumadin are thrown around this floor like candy for DVT prophylaxis. Although I don't understand where the Coumadin came in, because her MAR said she was going to be D/C'ed with daily lovenox injections x 14 days, but that could always change on D/C. From what I know, correct me if I'm wrong, but doesn't coumadin take a couple days before it becomes effective? Maybe she was going to take coumadin for a couple more days, INR drawn and then she would be D/C'ed on coumdain, so that is a possibility as well.

Thanks for your help!

Up Vote Up Vote ×
Specializes in Travel Nursing, ICU, tele, etc.

A BP of 85/54 and a urine output of 125 ccs in 8 hours are two danger signs that this patient needs help fast. There are 2 possibilities: 1) the patient is dry and needs a fluid flush to bring up her blood pressure and kick in some diuresis so her kidneys can produce the required 30 ccs/hr of urine to ensure adequate kidney function. 2) the patient is going into septic shock, (if she is fluid overloaded), and needs pressors and diuresis to maintain her blood pressure and to prevent acute renal failure. How were the nurses handling this issue? This well may be a patient that needs managing on the ICU. Was she febrile? What were her postop weights?

(I suspect that the first scenario is the case... as a new nurse, never be satisfied with those signs...a low urine output and hypotension should be called to the surgeon and I wouldn't wait until the end of my shift, in 4 hours if you had about 75 cc's of urine output and those low pressures, I would call, run your fluid flush and you could have her all fixed by the time you left! Remember to assess your lung sounds, because the Doc is going to want to be sure that respiratory-wise she is going to be able to handle the extra fluids and not develop flash pulmonary edema...something you should monitor closely while your are giving the fluid flush).

She needs some NS running, K+, Mag and Calcium replacement. But I am far more concerned about the BP and low urine output. There is such a thing as Acute Tubular Necrosis (acute renal failure) which this patient is in danger of acquiring.

I asked about the Coumadin, because if she has chronic a fib, she would be on Coumadin long term. I have seen patients go home with either Coumadin or Lovenox for postop DVT and PE prophylaxis. There are advantages and disadvantages to both. (And Coumadin's action is immediate, patients are on a daily sliding scale based on their INR in the hospital, and need frequent office visits for INR monitoring if they are taking Coumadin oupatient.) The advantage of Lovenox is that those frequent labs aren't required but the disadvantage is that those sub q shots in the abdomen really HURT.

It doesn't sound as if her DM is much a factor in her clinical picture as it sounds well managed.

I would warn you not to develop bad habits from seeing the staff nurses not address those glaring problems...it is your license and you conscience.

Great patient for learning, by the way and you are asking the right questions. Good job!

Up Vote Up Vote ×

me thinks it's the chlorthalidone...a potent diuretic.

leslie

Up Vote Up Vote ×
Specializes in Travel Nursing, ICU, tele, etc.
me thinks it's the chlorthalidone...a potent diuretic.

leslie

good point, leslie, hey I couldn't find out crap about it, only that it is often used in combination with other drugs...is it potassium sparing?

To the OP were the holding it post-op?

Up Vote Up Vote ×
good point, leslie, hey I couldn't find out crap about it, only that it is often used in combination with other drugs...is it potassium sparing?

To the OP were the holding it post-op?

no, it's not.

hypokalemia is an expected se and suggest k+ supplements.

intervention is only required if pt becomes symptomatic.

most (if not all) of pt's abnormals, can be attributed to the chlorthalidone.

leslie

Up Vote Up Vote ×
+ Add a Comment