Stuff in CBC I've never seen before

lisalott · Feb 10, 2009

stuff happends all the time it is called C.Y.A. and someone is covering hers.

UM Review RN, ASN, RN · Feb 10, 2009

With blood pressures like that, I would hope someone called the doc to report that the patient was unable to sustain a blood pressure.

There are many possible causes, but one that might cross my mind with a BP like that and lowering temps is -- sepsis. So yeah, I'd be calling the doc on this one.

http://www.sepsis.com/pdf/2004%20Nurse%20Tear%20Sheet%20DR31792.pdf

Another thought: what was the patient's H&H? Her low BP is caused from something -- could be low fluid volume, the wrong BP meds, an infection....there are a few possiblities, but the point is, the doc needs to be called in order to get to the bottom of this before the patient bottoms out and you have a real problem on your hands.

Daytonite, BSN, RN · Feb 10, 2009

Patient has signs of infection. The bands and monos indicate that as well. The other indices in the blood count are what are called RBC morphologies and have to do with the size and shape of the RBCs. If you have a medical dictionary you can look up these various terms and find the definitions of them. They are rated on scales of 0 to 2+ and 0 to 5+. I couldn't find any more specific information about their importance in my lab reference books.

Tympanic temperatures are one degree lower than oral temperatures. Not all people with infections will have fever. (page 171, Differential Diagnosis in Primary Care, 4th edition, by R. Douglas Collins) "Increased heat in the body is caused by increased production or decreased elimination or dysfunction of the thermoregulatory system in the brain. Increased production of heat occurs in conditions with increased metabolic rate such as hyper thyroidism, pheochromocytomas, and malignant neoplasms. Poor elimination of heat may occur in congestive heart failure (CHF) (poor circulation through the skin) and conditions where sweat glands are absent (congenital) or poorly functioning (heat stroke). Most cases of fever are caused by the effect of toxins on the thermoregulatory centers in the brain. These toxins may be exogenous from drugs, bacteria (endotoxins), parasites, fungi, rickettsiae, and virus particles, or they may be endogenous from tissue injury (trauma) and breakdown (carcinomas, leukemia, infarctions and autoimmune disease)."

The hypothalamus of the body is responsible for regulating body temperature. A fever is an elevation of the hypothalmic set point. This is caused by

central nervous system disease
malignant hyperthermia
strenuous exercise
stress
chills (produce more heat and, thus, raise the body temperature)
thyrotoxicosis
heatstroke
heart failure
congenital absence of sweat glands (sweating helps the body get rid of heat)
drugs that impair sweating

I would be concerned with a B/P as low as 58/33 and 64/22 might mean that there is shock going on. Was this patient a DNR?

lainith · Feb 10, 2009

Pt H&H both were within normal limits as of admit but yesterday or today - no idea. No new CBC or Chem work was posted after her admit.

Pt DNR unable to be ascertained is what the chart said. Nice, huh? I will be shocked if my pt is there today. I saw all this yesterday when I was doing my chart study for today. Will let you know what I find out.

I just couldn't believe her temps and BPs were like that all day and no one contacted the Dr as far as I could tell.

*sigh* I dread what I could walk into today if my pt is still there.

Valerie Salva, BSN, RN · Feb 10, 2009

Sounds like possible septic shock?

hypocaffeinemia, BSN, RN · Feb 10, 2009

The increase in bands, known as a left shift, tells you there's an acute infectious process at work.

Daytonite, BSN, RN · Feb 11, 2009

Read the H&P as well as the doctor's progress notes. There should be something there to tell you what is going on.

lainith · Feb 11, 2009

Checked all the progress notes and everything in the pt's chart today to see if there was anything new. Only note from DR was an order for fentanyl because he thought the pt seemed to be in pain. At a loss as to what else is going on with this pt but she seems to just want to die. She has refused to eat for the last three days it seems and she's still having diarrhea. Urine output today was 75mL this morning of very dark amber - almost brown - fluid and then next to nothing more for the rest of the day. Spent the day trying to get her to drink, putting her nasal cannula back on her every time I walked in the room because she kept taking it off, etc. Day shift SN claimed pt asked her to sit in her room and hold her hand but pt was not verbally responsive to me, RNs, or CNAs. Did not want to be touched in any way. *sigh* I feel so bad I wish I could do something to help her.

Daytonite, BSN, RN · Feb 11, 2009

Sounds like she is probably a DNR and comfort measure only? Time for transfer to a nursing home it sounds like.

RochesterRN-BSN, BSN, RN · Feb 11, 2009

I am a little confused as one of the posters was talking about heat and fever and what not .....the OP said the temp was down to 94.......thats hypothermic not febrile. ????? Just wondering if I missed something. And How was this patient even responsive with a diastolic of 22!?!?!? Seriously. How is that data found by anyone and the team not contacted stat? When I was on a med floor they called a code blue for a patient that had a BP like that low.....I always thought that was weird as I thought the patient had to not be breathing or pulseless but I was told that if a complete crash was really near--pending, it was okay to call. So maybe like one post said maybe this patient was DNR/Hospice or comfort care and you just didn't realize it...other wise sounds like a hell of a lot of neglect! LOL

Valerie Salva, BSN, RN · Feb 12, 2009

Sounds like she's in renal failure, too.