Lab analysis assistance pls

deeDawntee, RN · Oct 14, 2007

I think you are definitely on the right track in your analysis. The elevated BUN could certainly be secondary to GI bleeding, but I would bet that it is renal because with the Creatinine being elevated the BUN elevation would most likely be renal as well. The Creatinine would not be changed by a GI bleed. (but the BUN could be, unless it was lower GI). This guy looks like he has some pretty significant renal insufficiency going on here, but what is strange is that his potassium is low. If this were a chronic problem, one would expect to see a higher K+. Did he recently have an angiogram or something with dye that put him into acute kidney failure? What meds does he take? If he is on a loop diuretic (lasix) his K+ could be low from that. Now, that all of the lytes that they show you are low, I also wonder about his nutritional status. I will bet he is malnourished. Maybe he is malnourished because his gut hurts, thus the GI series?

Of course I would want to know his medical history and the medications that he is on. Is he being seen by Renal? If not, he should be. If the guy has long term uncontrolled HTN, the renal failure could be from that. They don't tell you a whole lot do they?

Also, remember that when the NA levels drop, confusion usually increases, although he is not very low, at this point, it is something to consider.

leslie :-D · Oct 14, 2007

me too, dee.

i would have definitely said renal, except i'm used to seeing the hyperkalemia.

leslie

Daytonite, BSN, RN · Oct 14, 2007

Hi, litlamp, and welcome to allnurses! :welcome:

Don't forget your hint that the patient is to have a GI series. With the low electrolytes there is either a lot of vomiting or diarrhea going on. Creatinine and BUN will be elevated when there is dehydration, perhaps a result of all the fluid loss secondary to vomiting or diarrhea? I don't think there is a renal problem here at all.

litlamp · Oct 14, 2007

Thanks sooo much for the responses!

Dee, What makes this tough is that this is the only information I have to go by, but those inferences are, well, not exactly what I was thinking but (I'll get their soon, just takes me lots of research =)) That is the type of information I think she's looking for me to ask the pt in an assessment, and what I would be looking for in the pt chart.

One thing she did stress was not to put a diagnosis that was not pertinent to the hint. Would renal be unrelated to a GI series? That is, if a renal problem is suspected, would a GI series be ordered?

Daytonite, Thats one thing that I suspected, well sort of but I don't know why I didn't think dehydration. I think I'm stuck on the protein factor. At first, I was thinking diet, as in that would be one thing I would assess and ask the pt. but I didn't get beyond the bleeding in my mode of thought. The WHY for some reason I couldn't get to but makes complete sense.

So, in essence, if this did persist for a lengthy period, renal failure/kidney problems would result.? Long term.

I was really off base with thinking an ulcer then? (but may come into play with excessive vomiting?) whew.. wheels are turning, sorry I know this is probably obvious to you but I'm getting there, I just need to wrap my head around it.

I think I didn't put enough emphasis on his electrolyte levels. I know he's on the low end, I just questioned how low is low (does that make sense). I should have put it all together first before getting stuck on bleeding = ulcer.

Sorry this is so long, but it's really helping me to put it out there. I know how to improve my analysis on the other two I have, and I will post what I've come up with after putting it all together (and to not get hung up on just one value so much.)

I'm so happy I posted!!!! I only want to better myself and be a good nurse, so your help is very appreciated!!

litlamp · Oct 14, 2007

Ok, so.... lol (it's my nature to "over" analyze hehe)

Per pt labs, he's dehydrated (decreased electrolytes), which would be a result in a decreased fluid intake or vomiting/diarrhea and decreased urinary output resulting in elevated urea in the bloodstream. Pt vomits/diarrhea, and trauma to the Upper/lower GI results in bleeding. This elevates the BUN (digested blood is a source of urea) and decreases the electrolytes (dehydration).

I did read that increased protein would effect BUN levels, do I understand that correctly? Maybe thats why I got hung up on the proteins. Water to salt plays a part here as well, right?

I'm not dense! I promise, just trying to put it all together in a flow chart aspect for better understanding. If this, then this, then this relates to this kinda thing.

One thing, if you all don't mind me asking is, when you looked at the lab values, what jumped out at you first? Was it the electrolytes or bun/creatinine levels? I think what my problem may have been is I looked at the BUN first because there was such a difference. I think what I need to do in the future is know that any abnormality is important even in the slightest to determine a possible diagnosis.

Looking forward to your responses!! Thanks so much!

~=)

deeDawntee, RN · Oct 14, 2007

If this pt were dehydrated his lytes would be elevated not decreased. And creatinine is not affected much by dehydration, certainly not THAT much.

Creatinine jumped out first.

deeDawntee, RN · Oct 14, 2007

Hey, I would bet that this guy overuses Ibuprofen. That would account for both his GI bleed and high creatinine!

And, also if this patient had gone into shock and was severely hypotensive along with dehydrated, he could have a high creatinine secondary to acute tubular necrosis (but dehydration without shock just does not elevate a creatinine level that much). Or if there were MASSIVE muscle loss which caused Rhabdomyolisis; that elevated protein could cause all sorts of organ dysfunction.

Daytonite, BSN, RN · Oct 14, 2007

One thing, if you all don't mind me asking is, when you looked at the lab values, what jumped out at you first? Was it the electrolytes or bun/creatinine levels? I think what my problem may have been is I looked at the BUN first because there was such a difference. I think what I need to do in the future is know that any abnormality is important even in the slightest to determine a possible diagnosis.

I was hospitalized 3 years ago with dehydration secondary to a bad gastritis. What brought me to the ER was I was dry heaving. Up to that point I had been having diarrhea for over a month. I had curtailed my eating to control the diarrhea to the point that I wasn't eating enough. However, on the night I went to the ER I still got so nauseated I was trying to vomit although I hadn't eaten. This occurred over a month or so. All my electrolytes were out of whack including sodium, chloride and potassium. I also have a mild case of renal insufficiency and my creatinine levels are usually elevated at about 1.5 or so. So, when they told me my BUN was in the 40's and my creatinine was 3.something I was worried I had gone into renal failure. The ER doctor assured me it was a case of good old-fashioned dehydration and what I needed was slow hydration and an investigation of my GI problem. I was admitted and on IV fluids for 4 days. The first tests done were CT of abdomen and then upper endoscopy where the bad case of gastritis was discovered. The electrolytes, BUN and creatinine resolved as I was rehydrated. My creatinine never returned to normal, but is because of the previous kidney damage I have and it will never be normal again.

It takes a lot for a ulcer and subsequent bleeding from it to form, so I wouldn't presume that an ulcer or GI bleeding is at the heart of this case scenario. The facts support dehydration with the likely culprits being loss of fluids as a result of vomiting or diarrhea. That's why they are going to investigate GI causes.

leslie :-D · Oct 14, 2007

i definitely agree w/the dehydration.

bun/creatinine will rise proportionately in response to the decreased blood flow to kidneys.

there are different types and causes of hyponatremia, with dehydration potentially causing either hyper or hypo.

and whether the hypokalemia is r/t diarrhea, vomiting or mass gi hemorrhage (unlikely), it's another expected outcome.

to answer your question, the creatinine stood out to me first.

you will see the bun increased in many different situations.

yet they all need attention.

best of luck.

leslie

litlamp · Oct 14, 2007

Thank you so much everyone!!

I've been working on the other two mock lab reports I have, I'll post my theory/assessment when I get it finalized.

Whew, did it take anyone else a while to get used to the values/abnormal levels and how they work together? I suppose it will come in time and practice. Knowing what abnormal is for one value is one thing, but when you put the whole lab report together with multiple values and then have to provide a possible diagnosis... sure gives my brain a workout . I just worry I'll be waaay off base sometimes, so I need to practice this more.

Thanks again! =)