H&H trending down...why??

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Need help with a rationale for low H&H values!

87yr male had a total knee replacement. H&H were WNL for the first 2 days after surgery. On day 3, they began trending down and have continued to drop a little bit every day for 5 days.) Current values: 8.9 & 27%.

He is otherwise healing well. Up to ambulate every couple of hours, vital signs are stable, etc etc. The incision site looks good; no S/S of infection, no drainage.

Food & fluid intake is good. Output is normal. No visible blood in urine or stools.

He is not on IV fluids.

PMHx:

bladder cancer a few years ago - bladder was removed.

high cholesterol (on a statin)

hypothyroidism (taking levothyroxine)

HTN (taking Norvasc)

He has been medically cleared for discharge. His extended hospital stay (8 days for a TKR) was NOT due to any medical need (it was due to some other unrelated social stuff). In the doctor's progress note, he acknowledged the low H&H but gave no explanation/didn't seem concerned.

possibilities:

-he has hypothyroidism, but he's taking levothyroixine for it

-possible low iron intake (but would it really drop that quickly?)

-possible internal bleed....GI bleed? He was not symptomatic

thoughts?? Unfortunately, no other labs have been done for this patient, so I'm only working with H&H and what I was able to assess during my one clinical day with him.

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There are a gazillion reasons why the H/H may be slowly dropping--post-op fluid shifting, multiple blood draws over the past couple of days, etc. Also his H/H may have been WNL for the first couple of days post-op, but what is HIS normal H/H range (i.e., prior to surgery)?

While knowing WHY his H/H is slowly dropping may be interesting, from what you've posted here the way more important question to ask is "Does it matter?" You've demonstrated good critical thinking and assessments, and from that the main take away should be that the patient is AYSYMPTOMATIC. We don't treat just numbers, we treat the patient. So if his values are on the lower side, we continue to assess the patient for a change in condition and trend lab values. From the information posted and the physician note, there isn't a definite reason why the H/H is dropping in his case (although there are many reasons why it COULD be, as stated before), but quite frankly it would be a waste of clinical time and resources to chase something that wouldn't change the plan of care. His H/H, after all, may be lower than normal limits, but they're hardly critical and he remains asymptomatic. As a physician once told me (only half-jokingly, I'm sure), the quickest way to fix an abnormal lab value is to stop checking it. I believe there's some truth to that here. Ready for discharge, I say.

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Specializes in Critical Care.

8.9? Oh lord he's gonna die. Massive transfusion protocol STAT!!!! FFPs Cryo and PRBC now plz

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Thank you for your input :) I agree that it does seem like a waste of clinical time to dig into this, but it's all part of my weekly clinical paperwork :(

I ended up giving a few examples of possible causes and things to keep an eye on and that was sufficient for a passing grade.

You bring up a good point: "does it matter?"

During my clinical time with him: no, it didn't. For homework purposes, it's good for leaning and making connections, but sometimes it's hard to give rationales when it could be a variety of causes. I just wanted to make sure I wasn't overlooking something with the given information. Thanks for confirming it's just too broad to tell! :)

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8.9? Oh lord he's gonna die. Massive transfusion protocol STAT!!!! FFPs Cryo and PRBC now plz

Umm...I was just looking for some help with homework...geez

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The key to note in your nursing plan is education. Specifically explain to the patient to look for what signs and symptoms that are associated with low H&H. I would not tell the patient that these are sign of low H&H (because then he will suddenly get all the S/S) but if he experiences X,Y,Z to contact his physician or go the ER etc. The values, as others said are probably not significant now but you want the patient to be aware of when they need to follow up. Also note the education in his chart and when his followup appointment is. Suggest he ask to have his blood counts drawn on next visit to doc as a couple values are slightly low and the doctor may want to see if they have stabilized. Of course you pointed this out the the physician on daily rounds too. (simple as stating, his H&H today was X value)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

It is a good question. Has anyone addressed the lab in the progress notes? Typically ortho surgeries are very bloody...do you know what the surgical EBL (estimated blood loss)documented. It is in the anesthesia note or the OR note. I would follow the blood loss. Do you have his pre-op H/H? The MD culd guiac a stool specimen to R/O a GI source.

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Specializes in retired LTC.

Just thinking - was this pt given any blood PRIOR to his surgery? And now a slow drift back to his USUAL baseline.

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