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

[COVIDNURSE]

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?

[KatieMI, BSN, MSN, RN]

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.

[KatieMI, BSN, MSN, RN]

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]

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.

[beachbabe86]

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]

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]

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.

[beachbabe86]

On 4/11/2020 at 10:23 PM, sevensonnets said:

Aquachecks make me want to pinch somebody!

WOW!, that's a new one.

[BostonFNP, APRN]

On 4/10/2020 at 11:59 PM, COVIDNURSE said:

Why don’t they say 2 different values for the 2 different labs?

Because they don't know what they are talking about. This drives me bonkers. Soapbox rant incoming because it happened last night.

Nurse Newb from rehab calls just after 1am; I've been asleep for 3 hours. I'm covering call for 14 providers.

NN: "Mr. Jones has a H&H of 9."

Who is Mr. Jones. I have never met Mr. Jones. I have zero idea if Mr. Jones is 18 years old and healthy or 104 years old and on hospice. I'm still mostly asleep.

Me: "Can I get a quick SBAR on him?"

NN: "OK please hold I'll go get his chart."

I'm almost sleeping again.

NN: "Mr. Jones is 79 and he was recently in the hospital for pneumonia and came here yesterday."

This is the SBAR I have to work with at 1am on a patient I know absolutely nothing about save for the fact he's (apparently) male, 79, and had pneumonia.

Me: "How's he feeling? I assume you mean his Hb is 9?"

NN: "Yes his Hb. He's asleep."

Me: "When was his blood drawn and why? How was he before he went to sleep?"

NN: "It was drawn at 3pm. I don't know why. He has been feeling fine vitals are 'good'."

Me: "What was his Hb at discharge? What's his past medical history?"

NN: "He's on hospice for lung cancer. His Hb at discharge was 8.1".

Me: "What are your concerns? Are there other abnormalities, is his WBC normal?"

NN: "His H&H is 9. WBC is normal."

Me: "Let Mr. Jones and I sleep."

Seriously, what am I supposed to do with this kind of call?

[KatieMI, BSN, MSN, RN]

8 minutes ago, BostonFNP said:

Because they don't know what they are talking about. This drives me bonkers. Soapbox rant incoming because it happened last night.

...

Seriously, what am I supposed to do with this kind of call?

Oh, yes...

It drives me nuts - this argument "I just want to report/let you know/update you". I do not know what it might be, I do not know patient, I have no idea what is going on but I am doing my job as a nurse and therefore have to report "it" to someone. Doesn't matter to whom, doesn't matter why, but report it and fulfill the resulting orders. God forbid you to think, ever - you are not here for this, you are a NURSE, and you're doing your nursing job by reporting and updating and "advocating" and implementing orders.

Will never forget a nurse who berated and threatened me for TWO HOURS in a row for laziness and lack of safety and all other mortal sins because I did not report INR of 5.3 with upper target 5.2. She woke up a poor soul of intern who was at work for a whole two weeks or so to filfill her high nursing duty and report and dutifully implemented vit K, FFP and everything else.

I'd seen things. I hope I will never again in my life see full blown super-acute DIC. No human being, however awful, deserves this kind of death. I will never forget the eyes of that nurse when she saw bloody tears and bloody sweat and breathing up foaming blood.

After the investigation, I was praised to the sky for professionalism and all that and for two hours of attempts to stop the madness. It took me two months off job to basically recover.

[beachbabe86]

4 hours ago, KatieMI said:

I'd seen things. I hope I will never again in my life see full blown super-acute DIC.

I can relate (again). In the same SICU as a brand new RN, we had several DIC cases and I have never forgotten the horror of it.

[lauranurselaura, BSN, RN]

That's bizarre. I've never heard anyone say that a patient's H&H is 10, for example. I've only ever heard anyone say that a patient's hgb is 10. I've heard providers say "Let's get an H&H on him .." but, I've never heard anyone report an H&H of ... with just one value.

[murseman24, MSN, CRNA]

hct is typically 3 times the hgb, maybe they're just going off the one because they don't know the other off their head.