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So H&H are 2 different labs: why only say one value?

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by COVIDNURSE COVIDNURSE (New) New Nurse

Has 2 years experience.

Hey guys! New nurse here. Kinda confused. If hemoglobin and hematocrit are two different values why do I hear people say things like “her H&H was 6.6”.

Is that just the hemoglobin? Why don’t they say 2 different values for the 2 different labs?

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

It’s only the value of one H. My guess would be they know the normals but aren’t sure which H it belongs to, so they just say both.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

Because everybody knows how to work with "upper H" (hemoglobin), but people who know how to access "lower H" (hematocrit) and what to do with it are mostly within Hematology/Oncology specialty.

Yeah, we never combine them. We report the Hgb singularly. If the crit is pertinent to the patient’s diagnosis we will also report it on its own. This goes along with nurses calling O2 saturations “O2 stats”. Both make me wonder if the person saying it actually knows what they are reporting. 🤷🏼‍♀️

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

Those who are interested, solve the clinical problem 🙂

45 years old male w/o significant PMH brought in rehab after 2 weeks in hospital due to MVA, b/l hip fracture s/p ORIF x2, shock (combined), emergency HD due to hyperkalemia x3, VAP (treated with vanco/cefepime/flagyl), critical care myopathy. Extubated 1 week ago, now on RA. HD was discontinued before discharge. Report says "now making urine". Abxs completed. Progresses very well rehab-wise.

Hb/Ht day before discharge: Hb 8.5 Ht 25 Na 135 K 4

After 24 h in rehab, patient made 4 L of clear pale urine. Hb 8.8 Ht 35 Na 128 K 3.1

- what is going on pathophysiologically? ("hypokalemia" is not counted as an answer)

This is USMLE Step 1 type and level question. I do not give pertinent multiple choices so not to make things too simple 🙂

Edited by KatieMI

buckchaser10

Has 4 years experience.

11 hours ago, Wuzzie said:

Yeah, we never combine them. We report the Hgb singularly. If the crit is pertinent to the patient’s diagnosis we will also report it on its own. This goes along with nurses calling O2 saturations “O2 stats”. Both make me wonder if the person saying it actually knows what they are reporting. 🤷🏼‍♀️

O2 stats is one of my biggest pet peeves. Drives me nuts.

Aquachecks make me want to pinch somebody!

BSNbeDONE, ASN, BSN, LPN, RN

Specializes in Med/Surg, LTACH, LTC, Home Health. Has 35 years experience.

19 hours ago, KatieMI said:

Those who are interested, solve the clinical problem 🙂

45 years old male w/o significant PMH brought in rehab after 2 weeks in hospital due to MVA, b/l hip fracture s/p ORIF x2, shock (combined), emergency HD due to hyperkalemia x3, VAP (treated with vanco/cefepime/flagyl), critical care myopathy. Extubated 1 week ago, now on RA. HD was discontinued before discharge. Report says "now making urine". Abxs completed. Progresses very well rehab-wise.

Hb/Ht day before discharge: Hb 8.5 Ht 25 Na 135 K 4

After 24 h in rehab, patient made 4 L of clear pale urine. Hb 8.8 Ht 35 Na 128 K 3.1

- what is going on pathophysiologically? ("hypokalemia" is not counted as an answer)

This is USMLE Step 1 type and level question. I do not give pertinent multiple choices so not to make things too simple 🙂

Only guessing on the fly, but I’d say diabetes insipidus might be worth a discussion, given the volume and characteristics of the urinary output, which is depleting the patient’s electrolytes.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

10 minutes ago, BSNbeDONE said:

Only guessing on the fly, but I’d say diabetes insipidus might be worth a discussion, given the volume and characteristics of the urinary output, which is depleting the patient’s electrolytes.

Sorry, that's incorrect. You're going for zebra hunt but you need to find your horse first.

Classic mistake (for USMLE, NCLEX, AANP and ANCC board exams and pretty much every such exam): you think about a process about which you nothing written in the question, just because "it might look like it". But you have no info about that "might be". Think ONLY about what you have 🙂

BSNbeDONE, ASN, BSN, LPN, RN

Specializes in Med/Surg, LTACH, LTC, Home Health. Has 35 years experience.

9 minutes ago, KatieMI said:

Sorry, that's incorrect. You're going for zebra hunt but you need to find your horse first.

Classic mistake (for USMLE, NCLEX, AANP and ANCC board exams and pretty much every such exam): you think about a process about which you nothing written in the question, just because "it might look like it". But you have no info about that "might be". Think ONLY about what you have 🙂

OK, then my initial thought was hyperdiuresis. This, along with my ‘incorrect’ response, were the only two conditions that I came to mind. If this one is incorrect as well, I have nothing else since the h/h appears to be stable and increasing. 🙂

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

12 minutes ago, BSNbeDONE said:

OK, then my initial thought was hyperdiuresis. This, along with my ‘incorrect’ response, were the only two conditions that I came to mind. If this one is incorrect as well, I have nothing else since the h/h appears to be stable and increasing. 🙂

"Hyperdiuresis" is not an answer, as well as "hypokalemia" or "hyponatremia". These are just facts. The answer should explain them both as well as change in Hb/Ht ratio.

Think WHY patient pees like a faucet and WHY Ht is growing MORE than Hb (pay attention to the change of Hb/Ht ratio - it is a cue). Also, think what might happen with kidneys as a result of shock and massive soft tissue injury (rhabdomyolysis is not the answer as well but a step to the right one).

The body is now correcting itself. We often see this happen with traumas. They get a ton of fluid and product in the beginning. They can go into AKI and require short term dialysis. With shock, I’m surprised HD is used instead of CRRT with shock. CRRT is better with blood pressure.

They body holds onto this fluid. The amount of fluid can also dilute blood making the Hgb lower. Those numbers will go up as they don’t receive lots of IV fluids anymore. The electrolytes will go down with the immense urine output but are easily corrected.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

54 minutes ago, LovingLife123 said:

The body is now correcting itself. We often see this happen with traumas. They get a ton of fluid and product in the beginning. They can go into AKI and require short term dialysis. With shock, I’m surprised HD is used instead of CRRT with shock. CRRT is better with blood pressure.

They body holds onto this fluid. The amount of fluid can also dilute blood making the Hgb lower. Those numbers will go up as they don’t receive lots of IV fluids anymore. The electrolytes will go down with the immense urine output but are easily corrected.

Kind of closer...although "body" DOESN'T "holds onto this fluid", it is losing water through already active filtration. But, yes, lytes are getting lost with accelerated speed because there is no reabsorption yet.

0lus, it doesn't matter what they were using in ICU. You have this patient right now, it doesn't matter what was done a week ago.

Edited by KatieMI

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

Right answer: resolution of acure renal failure, specifically acute tubular necrosis (ATN) polyuric stage.

Why Ht going up faster than Hb? Because of water moving to the intravascular space out of third space (where it was before due to shock, inflammation and renal failure - HD DOES NOT correct that by itself, that's why HD doesn't treat lymphedema) and dilutes plasma, but now renal filtration started and patient quickly pees it out. Patient likely has anemia as a result of polytrauma and in 2 weeks after he just starts to get bone marrow responce (which is also supressed by inflammatory responce) up, so erythrocyte count is low, Hb is low and on hemoconcentration elevation of Ht is seen more than Hb.

Is it significant for anything? NO. Please do not call for that.

BTW, normal Ht/Hb = 3.

In patient's kidneys, FILTRATION (glomerular component) now going full blown but REABSORPTION (tubular component) is still suffering (ATN), patient loses water and electrolytes.

Main dangers? Dehydration and heart arrythmias (loss of all electrolytes at once)

What a nurse MUST inform the provider about? LYTES (no Hb or Ht, patient is not gonna die from them).

What to suggest? Daily lytes and renal profile and replacement. Diet changes (no low sodium/low potassium/renal diet).

What to pay attention on assessment? VSs (dehydration), muscle weakness and twitches (low potassium, calcium, mag, phos), mucouds dryness, consciousness level (low sodium)

What to teach the patient: DRINK and eat. What to drink - fluids which contain lytes and some nutrition instead of water.

What NOT to recommend to drink? Coke/pop, especially with sugar and/or caffeine (have no lytes and increase free water loss) plus high acid load with some (pH renal regulation is affected as well).

What to monitor very closely and document: level of consciousness, blood pressure, heart rate and rhythm, I/O, daily weight.

beachbabe86

Specializes in Oceanfront Living. Has 21 years experience.

On 4/11/2020 at 10:06 PM, buckchaser10 said:

O2 stats is one of my biggest pet peeves. Drives me nuts.

I first heard this when moving to a different part of the country. I was thinking, hmmm, wonder if we are talking about the same thing.

Edited by beachbabe86

beachbabe86

Specializes in Oceanfront Living. Has 21 years experience.

2 hours ago, KatieMI said:

Right answer: resolution of acure renal failure, specifically acute tubular necrosis (ATN) polyuric stage.

thank you bringing up an ancient teaching case. When I was a new grad in SICU, I noticed hct changing in a renal patient and asked the other nurses and his doc about this very same situation. So many years ago and it was a valuable lesson. Gotta respect the kidneys.

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 8 years experience.

1 hour ago, beachbabe86 said:

thank you bringing up an ancient teaching case. When I was a new grad in SICU, I noticed hct changing in a renal patient and asked the other nurses and his doc about this very same situation. So many years ago and it was a valuable lesson. Gotta respect the kidneys.

The case may be ancient but the situation is directly from life. I lost count of how many times I had to explain nurses that polyuric stage of ATN is a very dangerous time and, since at this point patients are frequently considered to be outta of the woods and ICU, precisely the one when nursing assessment can save the day and the life. The CNA report of "just kind of funny finger twitches when I took his BP" and nurse assessment of "him being otherwise comfortable but, you know, TOO comfortable, too sleepy and inactive" once equaled phosphorus of 0.5 and ionized calcium of 0.04, plus potassium of about 1.5 - one of my personal records of metabolic train wrecks (patient survived).

beachbabe86

Specializes in Oceanfront Living. Has 21 years experience.

30 minutes ago, KatieMI said:

The case may be ancient but the situation is directly from life. I lost count of how many times I had to explain nurses that polyuric stage of ATN is a very dangerous time and, since at this point patients are frequently considered to be outta of the woods and ICU, precisely the one when nursing assessment can save the day and the life.

YES! It is ancient to me and obviously made a lasting impression as I remember it so clearly after all this time. I appreciate the time and effort on your part to explain this critical situation to the nurses. My patient was improving and about to be transferred to the floor. I noticed his labs were out of whack, and being a new grad I was curious to know why.