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Nurse’s Manual
of Laboratory and
Diagnostic Tests
EDITION

Bonita Morrow Cavanaugh, PhD, RN
Clinical Nurse Specialist
Nursing Education
The Children’s Hospital
Denver, Colorado
Clinical Faculty
University of Colorado
Health Sciences Center
School of Nursing
Denver, Colorado
Affiliate Professor
University of Northern Colorado
School of Nursing
Greeley, Colorado

F.A. Davis Company • Philadelphia

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2003 by F. A. Davis Company
Copyright © 1999, 1995, 1989 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it
may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Publisher: Lisa Deitch
Developmental Editor: Diane Blodgett
Cover Designer: Louis J. Forgione
As new scientific information becomes available through basic and clinical research, recommended treatments and drug
therapies undergo changes. The author and publisher have done everything possible to make this book accurate, up to date,
and in accord with accepted standards at the time of publication. The author, editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard
to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional
standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to
check product information (package inserts) for changes and new information regarding dose and contraindications before
administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Cavanaugh, Bonita Morrow, 1952–
Nurse’s manual of laboratory and diagnostic tests. – 4th ed. /
Bonita Morrow Cavanaugh.
p. cm.
Rev. ed. of: Nurse’s manual of laboratory and diagnostic tests /
Juanita Watson. 3rd. ed. c1995.
Includes bibliographical references and index.
ISBN 0-8036-1055-6 (pbk.)
1. Diagnosis, Laboratory —Handbooks, manuals, etc. 2. Nursing-Handbook, manuals, etc. I. Watson, Juanita,
1946–
Nurse’s manual of laboratory and diagnostic tests. II. Title.
[DNLM: 1. Laboratory Techniques and Procedures nurses’ instruction
handbooks. QY 39 C377n 1999]
RT48.5.W38 1999
616.07′5—dc21
DNLM/DLC
for Library of Congress
98-50920
CIP
Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by
F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided
that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that
have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the
Transactional Reporting Service is: 8036-1055/03 0 + $.10.

To Laurie O’Neil Good, the finest nurse I have ever known.
Love,
Bonnie

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Preface

This book is designed to provide both students and practitioners of nursing with the information they need to care for individuals undergoing laboratory and diagnostic tests and procedures. The content is presented as a guiding reference for planning care, providing specific
interventions, and evaluating outcomes of nursing care.
In this edition, the background information and description of the test or procedure are
followed directly by the clinical applications data, starting with reference values, for each test or
group of tests.
The introductory sections include the anatomic, physiological, and pathophysiological
content necessary for a thorough understanding of the purpose of and indications for specific
tests and procedures. The inclusion of this information makes this book unlike many other
references on this subject matter. This feature enhances the integration of basic science knowledge with an understanding of and application to diagnostic testing. This is extremely helpful
for nursing students in developing critical thinking and clinical judgment.
For each test or study within the respective sections, reference values, including variations
related to age or gender, are provided. Critical values, where appropriate, are highlighted. Both
conventional units and international units are provided. Readers are encouraged to be aware of
some variation in laboratory values from agency to agency.
For all tests, interfering factors are noted where appropriate. Contraindications and Nursing
Alerts are included to provide information crucial to safe and reliable testing and nursing care.
Other features of this manual that contribute to its practical use are presentation of detailed
content in tabular format when appropriate and the use of appendices to provide essential
information applicable to most, if not all, tests and procedures.
Every effort has been made to include tests and procedures currently in use in practice
settings. It is recognized that newer tests and procedures may have become available after this
manuscript was prepared. Readers are encouraged to keep abreast of current literature and
consult with laboratories and agencies in their area for new developments in the field of diagnostic tests.
BONITA MORROW CAVANAUGH

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Acknowledgments

This book would not have been possible without the help, support, and encouragement of a
number of people. Special appreciation is due to the staff of the F. A. Davis Company. I am
particularly indebted to Lisa Deitch, Publisher, for her major contribution in developing the
unique format of this text, for her encouragement, and for always being available for help when
I needed it. I would also like to acknowledge Robert Martone, Nursing Publisher, who encouraged me to pursue this project, and Robert H. Craven, Jr., President, for his support and
patience as the book evolved. Special thanks are also due to Ruth De George, Editorial Assistant,
and Michele Reese, Editorial Aide, for their invaluable assistance. Many other individuals at the
F. A. Davis Company contributed to the production of this book, and I wish to extend to all of
them my sincere appreciation for their expertise and dedication to the high standards necessary
to produce a good book. Special recognition in this regard is due to Jessica Howie Martin,
Production Editor, and Bob Butler, Director of Production.
I thank the consultants who served as reviewers of the manuscript for their thoroughness and
generosity in sharing their ideas and suggestions. Your comments proved invaluable! Finally, a
special thanks to those family members, friends, and associates who offered and gave their
support, patience, and encouragement.
B.M.C.

vii

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Consultants

Janice Brownlee, BScN, MAEd

Dolores Philpot, BSMT, AND, MSN

Professor
Canadore College of Applied Arts and
Technology
North Bay, Ontario, Canada

Instructor
University of Tennessee
Knoxville, Tennessee

Sylvan L. Settle, RN
Marie Colucci, BS, MS, EdD
Associate Professor
Riverside Community College
Riverside, California

Vocational Teacher
Tennessee Technology Center
Memphis, Tennessee

Joyce Taylor, RN, MSN, DSN, BA
Mary Jo Goolsby, MSN, ARNP, EdD
Instructor
Florida State University
Tallahassee, Florida

Associate Professor
Henderson State University
Arkadelphia, Arkansas

Shelley M. Tiffin, ART (CSMLS), BMLSc
Shelby Hawk, RN, MSN
Instructor
Mid Michigan Community College
Harrison, Michigan

Priscilla Innocent, RN, MSN
Associate Professor
Indiana Wesleyan University
Marion, Indiana

Dr. Fran Keen, RN, DNSc

Bachelor of Medical Laboratory Science
Program
Department of Pathology and Laboratory
Medicine
University of British Columbia
Vancouver, British Columbia, Canada

Donna Yancey, BSN, MSN, DNS
Assistant Professor
Purdue University
West Lafayette, Indiana

Associate Professor
University of Miami
Coral Gables, Florida

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Contents

SECTION I •

Laboratory Tests, 1

CHAPTER 1

Hematology and Tests of Hematopoietic Function ......................................................................3
CHAPTER 2

Hemostasis and Tests of Hemostatic Functions ........................................................................39
CHAPTER 3

Immunology and Immunologic Testing ........................................................................................60
CHAPTER 4

Immunohematology and Blood Banking......................................................................................96
CHAPTER 5

Blood Chemistry..............................................................................................................................103
CHAPTER 6

Studies of Urine ..............................................................................................................................221
CHAPTER 7

Sputum Analysis ............................................................................................................................268
CHAPTER 8

Cerebrospinal Fluid Analysis ......................................................................................................274
CHAPTER 9

Analysis of Effusions ....................................................................................................................283
CHAPTER 10

Amniotic Fluid Analysis ................................................................................................................297
CHAPTER 11

Semen Analysis ..............................................................................................................................305
CHAPTER 12

Analysis of Gastric and Duodenal Secretions..........................................................................311

xii

Contents
CHAPTER 13

Fecal Analysis ................................................................................................................................321
CHAPTER 14

Analysis of Cells and Tissues ......................................................................................................332
CHAPTER 15

Culture and Sensitivity Tests........................................................................................................352

SECTION II •

Diagnostic Tests and Procedures, 361

CHAPTER 16

Endoscopic Studies........................................................................................................................363
CHAPTER 17

Radiologic Studies ........................................................................................................................397
CHAPTER 18

Radiologic Angiography Studies ................................................................................................438
CHAPTER 19

Ultrasound Studies ........................................................................................................................458
CHAPTER 20

Nuclear Scan and Laboratory Studies ......................................................................................482
CHAPTER 21

Non-Nuclear Scan Studies ..........................................................................................................528
CHAPTER 22

Manometric Studies ......................................................................................................................545
CHAPTER 23

Electrophysiologic Studies ..........................................................................................................558
CHAPTER 24

Studies of Specific Organs or Systems......................................................................................577
CHAPTER 25

Skin Tests ........................................................................................................................................615
APPENDICES
APPENDIX I

Obtaining Various Types of Blood Specimens..........................................................................625
APPENDIX II

Obtaining Various Types of Urine Specimens ..........................................................................631
APPENDIX III

Guidelines for Isolation Precautions in Hospitals ..................................................................634
APPENDIX IV

Units of Measurement (Including SI Units) ..............................................................................636

Contents
APPENDIX V

Profile or Panel Groupings and Laboratory Tests ....................................................................644
APPENDIX VI

Nursing Care Plan for Individuals Experiencing
Laboratory and Diagnostic Testing ............................................................................................649
INDEX

..............................................................................................................................................651

xiii

SECTION

Laboratory
Tests

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CHAPTER

Hematology and Tests of
Hematopoietic Function
TESTS COVERED
Bone Marrow Examination, 7
Reticulocyte Count, 9
Iron Studies, 11
Vitamin B12 and Folic Acid Studies, 13
Complete Blood Count, 14
Erythrocyte (RBC) Count, 20
Hematocrit, 21
Hemoglobin, 21
Red Blood Cell Indices, 22

Stained Red Blood Cell
Examination, 24
Hemoglobin Electrophoresis, 26
Osmotic Fragility, 29
Red Blood Cell Enzymes, 30
Erythrocyte Sedimentation Rate, 31
White Blood Cell Count, 33
Differential White Blood Cell Count, 34
White Blood Cell Enzymes, 37

INTRODUCTION Blood constitutes 6 to 8 percent of total body weight. In terms of
volume, women have 4.5 to 5.5 L of blood and men 5 to 6 L. In infants and children, blood
volume is 50 to 75 mL/kg in girls and 52 to 83 mL/kg in boys. The principal functions of blood
are the transport of oxygen, nutrients, and hormones to all tissues and the removal of metabolic wastes to the organs of excretion. Additional functions of blood are (1) regulation of
temperature by transfer of heat to the skin for dissipation by radiation and convection, (2)
regulation of the pH of body fluids through the buffer systems and facilitation of excretion of
acids and bases, and (3) defense against infection by transportation of antibodies and other
substances as needed.
Blood consists of a fluid portion, called plasma, and a solid portion that includes red blood
cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes). Plasma makes
up 45 to 60 percent of blood volume and is composed of water (90 percent), amino acids,
proteins, carbohydrates, lipids, vitamins, hormones, electrolytes, and cellular wastes.1 Of the
“solid” or cellular portion of the blood, more than 99 percent consists of red blood cells.
Leukocytes and thrombocytes, although functionally essential, occupy a relatively small portion
of the total blood cell mass.2
Erythrocytes remain within the blood throughout their normal life span of 120 days, transporting oxygen in the hemoglobin component and carrying away carbon dioxide. Leukocytes,
while they are in the blood, are merely in transit, because they perform their functions in body
tissue. Platelets exert their effects at the walls of blood vessels, performing no known function
in the bloodstream itself.3
Hematology is traditionally limited to the study of the cellular elements of the blood, the
production of these elements, and the physiological derangements that affect their functions.
Hematologists also are concerned with blood volume, the flow properties of blood, and the
physical relationships of red cells and plasma. The numerous substances dissolved or suspended
in plasma fall within the province of other laboratory disciplines.4
3

SECTION I—Laboratory

Tests

HEMATOPOIESIS
Hematopoiesis is the process of blood cell formation.
In normal, healthy adults, blood cells are manufactured in the red marrow of relatively few bones,
notably the sternum, ribs, vertebral bodies, pelvic
bones, and proximal portions of the humerus and
the femur. This production is in contrast to that
taking place in the embryo, in which blood cells are
derived from the yolk sac mesenchyme. As the fetus
develops, the liver, the spleen, and the marrow cavities of nearly all bones become active hematopoietic
sites (Fig. 1–1). In the newborn, hematopoiesis
occurs primarily in the red marrow, which is found
in most bones at that stage of development.
Beginning at about age 5 years, the red marrow is
gradually replaced by yellowish fat-storage cells
(yellow marrow), which are inactive in the
hematopoietic process. By adulthood, blood cell
production normally occurs in only those bones that
retain red marrow activity.5
Adult reticuloendothelial cells retain the potential
for hematopoiesis, although in the healthy state
reserve sites are not activated. Under conditions of
hematopoietic stress in later life, the liver, the spleen,
and an expanded bone marrow may resume the
production of blood cells.
All blood cells are believed to be derived from the
pluripotential stem cell,6 an immature cell with the

capability of becoming an erythrocyte, a leukocyte,
or a thrombocyte. In the adult, stem cells in
hematopoietic sites undergo a series of divisions and
maturational changes to form the mature cells
found in the blood (Fig. 1–2). As they achieve the
“blast” stage, stem cells are committed to becoming
a specific type of blood cell. This theory also explains
the origin of the several types of white blood cells
(neutrophils, monocytes, eosinophils, basophils, and
lymphocytes). As the cells mature, they lose their
ability to reproduce and cannot further divide to
replace themselves. Thus, there is a need for continuous hematopoietic activity to replenish worn-out
or damaged blood cells.
Erythropoiesis, the production of red blood cells
(RBCs), and leukopoiesis, the production of white
blood cells (WBCs), are components of the
hematopoietic process. Erythropoiesis maintains a
population of approximately 25 1012 circulating
RBCs, or an average of 5 million erythrocytes per
cubic millimeter of blood. The production rate is
about 2 million cells per second, or 35 trillion cells
per day. With maximum stimulation, this rate can be
increased sixfold to eightfold, or one volume per day
equivalent to the cells contained in 0.5 pt of whole
blood.
The level of tissue oxygenation regulates the
production of RBCs; that is, erythropoiesis occurs in
response to tissue hypoxia. Hypoxia does not,

Figure 1–1. Location of active marrow growth in the fetus and adult. (From Hillman, RS, and Finch, CA: Red Cell
Manual, ed 7. FA Davis, Philadelphia, 1996, p 2, with permission.)

CHAPTER 1—Hematology

and Tests of Hematopoietic Function

Image/Text rights unavailable

however, directly stimulate the bone marrow.
Instead, RBC production occurs in response to
erythropoietin, precursors of which are found primarily in the kidney and to a lesser extent in the liver.
When the renal oxygen level falls, an enzyme, renal
erythropoietic factor, is secreted. This enzyme reacts
with a plasma protein to form erythropoietin, which
subsequently stimulates the bone marrow to
produce more RBCs. Specifically, erythropoietin (1)
accelerates production, differentiation, and maturaTABLE 1–1

•

tion of erythrocytes; (2) reduces the time required
for cells to enter the circulation, thereby increasing
the number of circulating immature erythrocytes
such as reticulocytes (see Fig. 1–2); and (3) facilitates
the incorporation of iron into RBCs. When the
number of produced erythrocytes meets the body’s
tissue oxygenation needs, erythropoietin release and
RBC production are reduced. Table 1–1 lists causes
of tissue hypoxia that may stimulate the release of
erythropoietin.

Causes of Tissue Hypoxia That May Stimulate
Erythropoietin Release

Acute blood loss
Impaired oxygen–carbon dioxide exchange in the lungs
Low hemoglobin levels
Impaired binding of oxygen to hemoglobin
Impaired release of oxygen from hemoglobin
Excessive hemolysis of erythrocytes due to hypersplenism or hemolytic disorders of antibody, bacterial, or
chemical origin
Certain anemias in which abnormal red blood cells are produced (e.g., hereditary spherocytosis)
Compromised blood flow to the kidneys

SECTION I—Laboratory

Tests

Threats to normal erythropoiesis occur if sufficient amounts of erythropoietin cannot be
produced or if the bone marrow is unable to
respond to erythropoietic stimulation. People without kidneys or with severe impairment of renal
function are unable to produce adequate amounts of
renal erythropoietic factor. In these individuals, the
liver is the source of erythropoietic factor. The quantity produced, however, is sufficient to maintain only
a fairly stable state of severe anemia that responds
minimally to hypoxemia.
Inadequate erythropoiesis may occur also if the
bone marrow is depressed because of drugs, toxic
chemicals, ionizing radiation, malignancies, or other
disorders such as hypothyroidism. Also, in certain
anemias and hemoglobinopathies, the bone marrow
is unable to produce sufficient normal erythrocytes.
Other substances needed for erythropoiesis are
vitamin B12, folic acid, and iron. Vitamin B12 and

TABLE 1–2

•

folic acid are required for DNA synthesis and are
needed by all cells for growth and reproduction;
because cellular reproduction occurs at such a high
rate in erythropoietic tissue, formation of RBCs is
particularly affected by a deficiency of either of these
substances. Iron is needed for hemoglobin synthesis
and normal RBC production. In addition to dietary
sources, iron from worn-out or damaged RBCs is
available for reuse in erythropoiesis.7
Leukopoiesis, the production of WBCs, maintains
a population of 5,000 to 10,000 leukocytes per cubic
millimeter of blood, with the capability for rapid
and dramatic change in response to a variety of
stimuli. No leukopoietic substance comparable to
erythropoietic factor has been identified, but many
factors are known to influence WBC production,
with a resultant excess (leukocytosis) or deficiency
(leukopenia) in leukocytes (Table 1–2).
Note that WBC levels vary in relation to diurnal

Causes of Altered Leukopoiesis

Physiological
Leukocytosis

Pathological

Pregnancy

All types of infection

Early infancy

Anemias

Emotional stress

Cushing’s disease

Strenuous exercise

Erythroblastosis fetalis

Menstruation

Leukemias

Exposure to cold

Polycythemia vera

Ultraviolet light

Transfusion reactions

Increased epinephrine secretion

Inflammatory disorders
Parasitic infestations

Leukopenia

Diurnal rhythms

Bone marrow depression
Toxic and antineoplastic drugs
Radiation
Severe infection
Viral infections
Myxedema
Lupus erythematosus and other autoimmune disorders
Peptic ulcers
Uremia
Allergies
Malignancies
Metabolic disorders
Malnutrition

CHAPTER 1—Hematology

rhythms; thus, the time at which the sample is
obtained may influence the results. Overall, leukocytes may increase by as many as 2000 cells per milliliter from morning to evening, with a corresponding
overnight decrease. Eosinophils decrease until about
noon and then rise to peak between midnight and 3
AM. This variation may be related to adrenocortical
hormone levels, which peak between 4 and 8 AM,
because an increase in these hormones can cause
circulating lymphocytes and eosinophils to disappear in a few hours.

Evaluation of Hematopoiesis
Abnormal results of studies such as a complete
blood count (CBC)) and WBC count and differential indicate the need to determine the individual’s
hematopoietic function. Evaluation of hematopoiesis begins with the examination of a bone
marrow sample and may subsequently require other
studies and a sample of peripheral blood, either
venous or capillary.
Although the collection of blood specimens is
usually the responsibility of the laboratory technician or phlebotomist, it is often the responsibility
of the nurse in emergency departments, critical

TABLE 1–3
Cell Type
Reticulocytes

Neutrophils (total)

•

and Tests of Hematopoietic Function

care units, and community and home care settings.
A detailed description of procedures for obtaining peripheral blood samples is provided in
Appendix I.

BONE MARROW EXAMINATION
Bone marrow examination (aspiration, biopsy)
requires removal of a small sample of bone marrow
by aspiration, needle biopsy, or open surgical biopsy.
Cells normally present in hematopoietic marrow
include erythrocytes and granulocytes (neutrophils,
basophils, and eosinophils) in all stages of maturation; megakaryocytes (from which platelets
develop); small numbers of lymphocytes; and occasional plasma cells (Fig. 1–2). Nucleated WBCs in
the bone marrow normally outnumber nucleated
(immature) RBCs by about 3:1. This is called the
myeloid-to-erythroid (M:E) ratio.8 Causes of
increased and decreased values on bone marrow
examination are presented in Table 1–3.
Various stains followed by microscopic examination can be performed on bone marrow aspirate to
diagnose and differentiate among the different
types of leukemia. A Sudan B stain differentiates
between acute granulocytic and lymphocytic

Causes of Alterations in Bone Marrow Cells
Increased Values

Decreased Values

Compensated RBC loss

Aplastic crisis of sickle cell disease or hereditary
spherocytosis

Response to vitamin B12 therapy

Aplastic anemia

Myeloid (chronic) leukemias

Leukemias (monocytic and lymphoblastic)

Acute myeloblastic leukemia
Lymphocytes

Lymphatic leukemia
Lymphosarcoma
Lymphomas
Mononucleosis
Aplastic anemia

Plasma cells

Myeloma

Normoblasts

Polycythemia vera

Deficiency of folic acid or vitamin B12
Aplastic anemia
Hemolytic anemia

Eosinophils

Bone marrow carcinoma
Lymphadenoma
Myeloid leukemia

SECTION I—Laboratory

Tests

leukemia. A periodic acid–Schiff stain assists in
the diagnosis of acute lymphocytic leukemia and
erythroleukemia. A terminal deoxynucleotidyl
transferase test differentiates between lymphoblastic
leukemia and lymphoma.9
Because bone marrow examination involves an
invasive procedure with risks of infection, trauma,
and bleeding, a signed consent is required.
INDICATIONS FOR BONE MARROW
EXAMINATION

Evaluation of abnormal results of CBC (e.g.,
anemia), of WBC count with differential (e.g.,
increased numbers of leukocyte precursors), or of
both tests
Monitoring of effects of exposure to bone marrow
depressants

Monitoring of bone marrow response to antineoplastic or radiation therapy for malignancies
Evaluation of hepatomegaly (enlarged liver) or
splenomegaly (enlarged spleen)
Identification of bone marrow hyperplasia or
hypoplasia, although the study may not indicate
the cause of the quantitative abnormality
Determination of marrow differential (proportion of the various types of cells present in the
marrow) and M:E ratio
Diagnosis of various disorders associated with
abnormal hematopoiesis:
Multiple myeloma
Most leukemias, both acute and chronic
Disseminated infections (granulomatous,
bacterial, fungal)
Lipid or glycogen storage diseases

Reference Values
Cell Type (%)

Adults

Infants

Children

0–1.0

—

0.5–2.5

—

56.5

32.4

57.1

Myeloblasts

0.3–5.0

0.62

1.2

Promyelocytes

1.4–8.0

0.76

1.4

Myelocytes

4.2–15.0

2.5

18.4

Neutrophilic

5.0–19.0

—

Eosinophilic

0.5–3.0

—

0–0.5

—

Bands (stabs)

13.0–34.0

14.1

Lymphocytes

14.0–16.0

49.0

16.0

Monocytes

0.3–6.0

—

Plasma cells

0.3–3.9

0.02

0.4

Megakaryocytes

0.1–3.0

0.05

0.1

2.3–3.5:1

4.4:1

2.9:1

0.2–1.3

0.1

0.5

25.6

8.0

23.1

Basophilic

1.4–4.0

0.34

1.7

Polychromatophilic

6.0–29.0

6.9

18.2

Orthochromic

1.0–4.6

0.54

2.7

Eosinophils

0.5–3.0

2.6

3.6

0–0.2

0.07

0.06

Undifferentiated
Reticulocytes
Neutrophils (total)

Basophilic

M:E ratio
Pronormoblasts
Normoblasts

Basophils

Note: There may be differences in normal values among individuals and in values obtained by different laboratory techniques.

CHAPTER 1—Hematology

Hypoplastic anemia (which may be caused by
chronic infection, hypothyroidism, chronic
renal failure, advanced liver disease, and a
number of “idiopathic” conditions)
Erythropoietic hyperplasia (which may be
caused by iron deficiency, thalassemias, hemoglobinopathies, disorders of folate and vitamin
B12 metabolism, hypersplenism, glucose-6phosphate dehydrogenase [G-6-PD] deficiency,
hereditary spherocytosis, and antibody-mediated bacterial or chemical hemolysis)
Lupus erythematosus
Porphyria erythropoietica
Parasitic infestations
Amyloidosis
Polycythemia vera
Aplastic anemia (which may be caused by drug
toxicity, idiopathic marrow failure, or infection)
CONTRAINDICATIONS

Known coagulation defects, although the test may
be performed if the importance of the information to be obtained outweighs the risks involved
in carrying out the test
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
The purpose of the study
That it will be done at the bedside by a physician
and requires about 20 minutes
The general procedure, including the sensations
to be expected (momentary pain as the skin is
injected with local anesthetic and again as the
needle penetrates the periosteum, the “pulling”
sensation as the specimen is withdrawn)
That discomfort will be minimized with local
anesthetics or systemic analgesics
That the site may remain tender for several weeks
Ensure that a signed consent has been obtained.
Then:
Take and record vital signs.
Provide a hospital gown if necessary to provide
access to the biopsy site or to prevent soiling of
the client’s clothes with the solution used for skin
preparation.
Administer premedication prescribed for pain or
anxiety.

and Tests of Hematopoietic Function

preferred. In adults, the sternum or iliac crests are
the preferred sites.
The prone or side-lying position is used if the
spinous processes are the sites to be used. (These
sites are preferred if more than one specimen is to be
obtained.) The client may also be sitting, supported
by a pillow on an overbed table for a spinous process
site. The side-lying position is used if the iliac crest
or tibia is the site. For sternal punctures, the supine
position is used.
The skin is prepared with an antiseptic solution,
draped, and anesthetized, preferably with procaine,
which is painless when injected. Asepsis must be
meticulous to prevent systemic infection.
For aspiration, a large needle with stylet is
advanced into the marrow cavity. Penetration of the
periosteum is painful. The stylet is removed and a
syringe is attached to the needle. An aliquot of 0.5
mL of marrow is withdrawn. At this time, the
discomfort is a “pulling” sensation rather than pain.
The needle is removed and pressure applied to the
site. The aspirate is immediately smeared on slides
and, when dry, sprayed with a fixative.
For needle biopsy, the local anesthetic is introduced deeply enough to include the periosteum. A
special cutting biopsy needle is introduced through
a small skin incision and bored into the marrow
cavity. A core needle is introduced through the
cutting needle and a plug of marrow is removed. The
needles are withdrawn and the specimen placed in a
preservative solution. Pressure is applied to the site
for 5 to 10 minutes and a dressing applied.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client to lie on the biopsied side, if
the iliac crest was entered, or supine, if the vertebral bodies were used, to maintain pressure on the
site for 10 to 15 minutes.
For sternal punctures, place the client in the
supine position or other position of comfort.
Provide bed rest for at least 30 minutes after the
procedure.
Assess puncture site every 10 to 15 minutes for
bleeding. Apply an ice bag to the puncture site to
alleviate discomfort and prevent bleeding.
Assess for infection at the site; note any redness,
swelling, or drainage.
Administer analgesics to alleviate discomfort.

THE PROCEDURE

The client is assisted to the desired position depending on the site to be used. In young children, the
most frequently chosen site is the proximal tibia; in
older children, vertebral bodies T10 to L4 are

RETICULOCYTE COUNT
Reticulocytes are immature RBCs. As RBC precursors mature (Fig. 1–2), the cell nucleus decreases in
size and eventually becomes a dense, structureless

SECTION I—Laboratory

Tests

mass.10 At the same time, the hemoglobin content of
the cell increases. Reticulocytes are cells that have
lost their nuclei but still retain fragments of mitochondria and other organelles. They also are slightly
larger than mature RBCs.11 RBCs normally enter the
circulation as reticulocytes and attain the mature
form (erythrocytes) in 1 to 2 days.
Under the stress of anemia or hypoxia, an
increased output of erythropoietin may lead to an
increased number of circulating reticulocytes (see
Table 1–1). The extent of such an increase depends
on the functional integrity of the bone marrow, the
severity and duration of anemia or hypoxia, the
adequacy of the erythropoietin response, and the
amount of available iron.12 For example, a normal
reticulocyte count in the presence of a normal
hemoglobin level indicates normal marrow activity,
whereas a normal reticulocyte count in the presence
of a low hemoglobin level indicates an inadequate
response to anemia. This may be a result of defective
erythropoietin production, bone marrow function,
or hemoglobin formation. After blood loss or effective therapy for certain kinds of anemia, an elevated
reticulocyte count (reticulocytosis) indicates that
the bone marrow is normally responsive and is
attempting to replace cells lost or destroyed.
Individuals with defects of RBC maturation and
hemoglobin production may show a low reticulocyte count (reticulocytopenia) because the cells
never mature sufficiently to enter the peripheral
circulation.
Performing a reticulocyte count involves examining a stained smear of peripheral blood to determine
the percentage of reticulocytes in relation to the
number of RBCs present.
Reference Values
Newborns

3.2% of RBCs,
declining by 2 mo

Infants

2–5%

Children

0.5–4%

Adults

0.5–2% of RBCs; can be
higher in pregnant
women

Reticulocyte index

1.0

Critical values

20% increase

INDICATIONS FOR RETICULOCYTE COUNT

Evaluation of the adequacy of bone marrow
response to stressors such as anemia or hypoxia:

A normal response is indicated by an increase
in the reticulocyte count.
Failure of the reticulocyte count to increase
may indicate depressed bone marrow functioning, defective erythropoietin production, or
defective hemoglobin production.
Evaluation of anemia of unknown etiology to
determine the type of anemia:
Elevated reticulocyte counts are found in
hemolytic anemias and sickle cell disease.
Decreased counts are seen in pernicious
anemia, thalassemia, aplastic anemia, and
severe iron-deficiency anemia.
Monitoring response to therapy for anemia:
In iron-deficiency anemia, therapeutic administration of iron should produce reticulocytosis
within 3 days and the count should remain
elevated until normal hemoglobin levels are
achieved.
Vitamin B12 therapy for pernicious anemia
should cause a prompt, continuing reticulocytosis.
Monitoring physiologic response to blood loss:
After a single hemorrhagic episode, reticulocytosis should begin within 24 to 48 hours and
peak in 4 to 7 days.
Persistent reticulocytosis or a second rise in the
count indicates continuing blood loss.
Confirmation of aplastic crisis in clients with
known aplastic anemia as evidenced by a drop in
the usually high level of reticulocytes, indicating
that RBC production has stopped despite continuing RBC destruction13
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

If the client is an adult, a venipuncture is performed
and the sample is collected in a lavender-topped
tube. A capillary sample may be obtained in infants
and children as well as in adults for whom venipuncture may not be feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal values: Note and report fatigue, weakness, and color changes associated with a decrease
in counts and pain, and changes in mental state
and visual perception associated with an increase
in counts. Increased counts in 4 to 7 days indicate

CHAPTER 1—Hematology

that the therapy to treat loss of RBCs is effective,
whereas decreased counts indicate an ineffective
production of RBCs, and further testing and evaluation are needed to determine the cause. Assess
for continuing blood loss (pulse, blood pressure,
skin color, weakness, dizziness).
Critical values: Polycythemia with reticulocyte
increases of greater than 20 percent requires
immediate communication to the physician.
Prepare the client for possible phlebotomy to
reduce volume of blood and intravenous fluids
to reduce viscosity of blood. Administer
ordered myelosuppressive drugs.

IRON STUDIES
Iron plays a principal role in erythropoiesis, because
it is necessary for proliferation and maturation of
RBCs and for hemoglobin synthesis. Of the body’s
normal 4 g of iron (somewhat less in women), about
65 percent resides in hemoglobin and about 3
percent in myoglobin. A tiny but vital amount of
iron is found in cellular enzymes, which catalyze the
oxidation and reduction of iron. The remainder is
stored in the liver, bone marrow, and spleen as
ferritin or hemosiderin.14
Except for blood transfusions, the only way iron
enters the body is orally. Normally, only about 10
percent of ingested iron is absorbed, but up to 20
percent or more can be absorbed in cases of irondeficiency anemia. The body is never able to absorb
all ingested iron, no matter how great its need for
iron. In addition to dietary sources, iron from wornout or damaged RBCs is available for reuse in
erythropoiesis.15
SERUM IRON, TRANSFERRIN, AND TOTAL
IRON-BINDING CAPACITY

Any iron present in the serum is in transit among the
alimentary tract, bone marrow, and available ironstorage forms. Iron travels in the bloodstream
bound to transferrin, a protein (-globulin) manufactured by the liver. Unbound iron is highly toxic to
the body, but generally much more transferrin is
available than that needed for iron transport.
Usually, transferrin is only 30 to 35 percent saturated, with a normal range of 20 to 55 percent. If
excess transferrin is available in relation to body
iron, the percentage saturation is low. Conversely, in
situations of iron excess, both serum iron and
percentage saturation are high.
Measurement of serum iron is accomplished by
using a specific color of reagent to quantitate iron
after it is freed from transferrin. Transferrin may be
measured directly through immunoelectrophoretic

and Tests of Hematopoietic Function

techniques or indirectly by exposure of the serum to
sufficient excess iron such that all the transferrin
present can combine with the added iron. The latter
result is expressed as total iron-binding capacity
(TIBC). The percentage saturation is calculated by
dividing the serum iron value by the TIBC value.
FERRITIN

Iron is stored in the body as ferritin or hemosiderin.
Many individuals who are not anemic and who can
adequately synthesize hemoglobin may still have
decreased iron stores. For example, menstruating
women, especially those who have borne children,
usually have less storage iron. In contrast, persons
with disorders of excess iron storage such as
hemochromatosis or hemosiderosis have extremely
high serum ferritin levels.16
Serum ferritin levels are used to measure ironstorage status and are obtained by either radioimmunoassay or enzyme-linked immunoassay. The
amount of ferritin in the circulation usually is
proportional to the amount of storage iron (ferritin
and hemosiderin) in body tissues. Note that serum
ferritin levels vary according to age and gender (Fig.
1–3).
INDICATIONS FOR IRON STUDIES

Anemia of unknown etiology to determine cause
and type of anemia:
Decreased serum iron with increased transferrin levels is seen in iron-deficiency anemia and
blood loss.
Decreased serum iron and decreased transferrin levels may be seen in disorders involving
diminished protein synthesis or defects in
iron absorption (e.g., chronic diseases,
infections, widespread malignancy, malabsorption syndromes, malnutrition, nephrotic
syndrome). Percentage saturation of transferrin

Figure 1–3. Serum ferritin levels according to sex and
age. (From Hillman, RS, and Finch, CA: Red Cell
Manual, ed 7. FA Davis, Philadelphia, 1996, p 64, with
permission.)

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

Serum Iron
Newborns

350–500 mg/dL

62.7–89.5 mmol/L

Children

40–200 mg/dL

7.2–35.8 mmol/L

Men

60–170 mg/dL

10.7–30.4 mmol/L

Women

50–130 mg/dL

9.0–23.3 mmol/L

Elderly persons

40–80 mg/dL

7.2–14.3 mmol/L

Newborns

60–170 mg/dL

0.6–1.7 g/L

Adults

250–450 mg/dL

2.5–4.5 g/L

Newborns

65% saturation

0.65

Adults

20–55% saturation

0.20–0.55

Children

100–350 mg/dL

18–63 mmol/L

Adults

300–360 mg/dL

54–64 mmol/L

Elderly persons

200–310 mg/dL

36–56 mmol/L

20–40 mg/dL

20–40 mg/L

Men

50–200 mg/dL

50–200 mg/L

(average 100 mg/dL)

(avg 100 mg/L)

Women (menstruating)

12–100 mg/dL

(average 30 mg/dL)

(avg 30 mg/L)

Adults

Transferrin

% Saturation (of Transferrin)

TIBC

Ferritin
Children
Adults

may be normal if serum iron and transferrin
levels are proportionately decreased; if the
problem is solely one of protein homeostasis
(with normal iron stores), percentage saturation will be high.
Support for diagnosing hemochromatosis or
other disorders of iron metabolism and storage:
Serum iron and ferritin levels may be elevated
in hemochromatosis and hemosiderosis;
percentage saturation of transferrin is elevated,
whereas TIBC is decreased.
Serum iron levels can be elevated in lead
poisoning, after multiple blood transfusions,
and in severe hemolytic disorders that cause
release of iron from damaged RBCs.

12–100 mg/L

Monitoring hematologic responses during pregnancy, when serum iron is usually decreased,
transferrin levels are increased (in the third
trimester), percentage saturation is low, TIBC
may be increased, and ferritin may be decreased
(Note: Transferrin levels may be increased in
women taking oral contraceptives, whereas
ferritin levels may be decreased in women
who are menstruating or who have borne children.)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

CHAPTER 1—Hematology

and Tests of Hematopoietic Function

Reference Values
Conventional Units

SI Units

Vitamin B12

Serum

200–900 pg/mL

148–664 pmol/L

Folic acid

Serum

1.8–9 ng/mL

4–20 nmol/L

RBCs

95–500 ng/mL

215–1133 nmol/L

Blood for serum iron and TIBC should be drawn
in the morning, in the fasting state, and 24 hours
or more after discontinuing iron-containing
medications.17
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. A capillary sample
may be obtained in infants and children as well
as in adults for whom venipuncture may not be
feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Food, fluids, and medications withheld before
the test may be resumed after the sample is
obtained.
Complications and precautions: Note and report
signs and symptoms of anemia: decreases in test
levels, fatigue and weakness, increased pulse, exertional dyspnea, and dizziness. If anemia is caused
by blood loss, prepare to administer a transfusion
of blood products. If anemia is caused by iron
deficiency, administer ordered oral or parenteral
(intramuscular) iron supplement and instruct
client in dietary inclusion of foods high in iron
content. After 4 to 7 days, check iron studies,
RBC count, reticulocyte count, and hemoglobin
levels to see whether iron stores have been replenished.

VITAMIN B12 AND FOLIC ACID STUDIES
Vitamin B12 (cyanocobalamin) and folic acid
(pteroylglutamic acid) are essential for the production and maturation of erythrocytes. Both must be
present for normal DNA replication and cell division. In humans, vitamin B12 is obtained only by
eating animal proteins, milk, and eggs, which places
strict vegetarians at risk for developing cobalamin
deficiency; hydrochloric acid (HCl) and intrinsic
factor are required for absorption. Folic acid (or
folate) is present in liver and in many foods of

vegetable origin such as lima beans, kidney beans,
and dark-green leafy vegetables. Note that canning
and prolonged cooking destroy folate. Normally
functioning intestinal mucosa is necessary for
absorption of both vitamin B12 and folic acid.
Vitamin B12 is normally stored in the liver in
sufficient quantity to withstand 1 year of zero intake.
In contrast, most of the folic acid absorbed goes
directly to the tissues, with a smaller amount stored
in the liver. Folate stores are adequate for only 2 to 4
months.
INDICATIONS FOR VITAMIN B12 AND
FOLIC ACID STUDIES

Determination of the cause of megaloblastic
anemia:
Diagnosis of pernicious anemia, a megaloblastic anemia characterized by vitamin B12 deficiency despite normal dietary intake
Diagnosis of megaloblastic anemia caused by
deficient folic acid intake or increased folate
requirements (e.g., in pregnancy and hemolytic
anemias) or both, as indicated by decreased
serum levels of folic acid
Monitoring response to disorders that may lead to
vitamin B12 deficiency (e.g., gastric surgery, agerelated atrophy of the gastric mucosa, surgical
resection of the ileum, intestinal parasites, overgrowth of intestinal bacteria)
Monitoring response to disorders that may lead to
folate deficiency (e.g., disease of the small intestine, sprue, cirrhosis, chronic alcoholism, uremia,
some malignancies)18
Monitoring effects of drugs that are folic acid
antagonists (e.g., alcohol, anticonvulsants, antimalarials, and certain drugs used to treat
leukemia)19
Monitoring effects of prolonged parenteral nutrition
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

SECTION I—Laboratory

Tests

Samples should be drawn after the client has
fasted for 8 hours and before injections of vitamin
B12 have been given.
Alcohol also should be avoided for 24 hours
before the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. A capillary sample
may be obtained in infants and children as well as in
adults for whom venipuncture may not be feasible.

The difference between men and women results
partly from menstrual blood loss in women and
partly from the effects of androgens in men.
Castration of men usually causes hemoglobin and
hematocrit to decline to nearly the same levels as
those of women. Note that a decline in erythrocytes
is experienced by both genders in old age.21
More detailed discussions of the RBC and WBC
components of the CBC are included in succeeding
sections of this chapter. Platelets are discussed in
Chapter 2.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Foods and drugs withheld before the test may be
resumed after the sample is obtained.
Complications and precautions (anemia): Note
and report folic acid levels of less than 4 ng and a
normal level of vitamin B12, indicating folic acid
anemia. Prepare to administer ordered oral
replacement therapy of folic acid; dosage and
duration depend on the cause of the deficiency.
Perform nursing activities for vitamin B12 deficiency as in pernicious anemia diagnosed by the
Schilling test (see Chapter 20).

COMPLETE BLOOD COUNT
A CBC includes (1) enumeration of the cellular
elements of the blood, (2) evaluation of RBC
indices, and (3) determination of cell morphology
by means of stained smears. Counting is performed
by automated electronic devices capable of rapid
analysis of blood samples with a measurement error
of less than 2 percent.20
Reference values for the CBC vary across the life
cycle and between the genders. In the neonate, when
oxygen demand is high, the number of erythrocytes
also is high. As demand decreases, destruction of the
excess cells results in decreased erythrocyte, hemoglobin, and hematocrit levels. During childhood,
RBC levels again rise, although hemoglobin levels
may decrease slightly.
In prepubertal children, normal erythrocyte and
hemoglobin levels are the same for boys and girls.
During puberty, however, values for boys rise,
whereas values for girls decrease. In men, these
higher values persist to age 40 or 50, decline slowly
to age 70, and then decrease rapidly thereafter. In
women, the drop in hemoglobin and hematocrit
that begins with puberty reverses at about age 50 but
never rises to prepubertal levels or to that of men of
the same age.

Reference Values
The components of the CBC and their
reference values across the life cycle are shown in
Table 1–4.

INDICATIONS FOR A COMPLETE BLOOD COUNT

Because the CBC provides much information about
the overall health of the individual, it is an essential
component of a complete physical examination,
especially when performed on admission to a
health-care facility or before surgery. Other indications for a CBC are as follows:
Suspected hematologic disorder, neoplasm, or
immunologic abnormality
History of hereditary hematologic abnormality
Suspected infection (local or systemic, acute or
chronic)
Monitoring effects of physical or emotional stress
Monitoring desired responses to drug therapy and
undesired reactions to drugs that may cause blood
dyscrasias (Table 1–5)
Monitoring progression of nonhematologic
disorders such as chronic obstructive pulmonary
disease, malabsorption syndromes, malignancies,
and renal disease
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a lavender-topped tube. A capillary
sample may be obtained in infants and children, as
well as in adults for whom venipuncture may not be
feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the

TABLE 1–4

•

Reference Values for Complete Blood Count
Adult

CBC Component
Red blood cells
(RBCs)

Newborn

1 Mo

4.8–7.1 million/mm3
4.8–7.1 10 /L (SI units)
12

6 Mo

1–10 Yr

Male

Female

4.1–6.4
million/mm3

3.8–5.5
million/mm3

4.5–4.8
million/mm3

4.6–6.2
million/mm3

4.2–5.4 million/mm3

35–49%

30–40%

35–41%

40–54%

38–47%

Hemoglobin (Hgb)

14–24 g/L (SI units)

11–20 g/dL

10–15 g/dL

11–16 g/dL

13.5–18 g/dL

12–16 g/dL

140–240 g/L (SI units)

110–200 g/L

100–150 g/L

110–160 g/L

135–180 g/L

120–160 g/L

96–108 m3

82–91 3

—

80–94 m3

81–99 m3

96–108 fL (SI units)

82–91 fL

—

80–94 fL

81–99 fL

32–34 pg

27–31 pg

—

27–31 pg

32–33%

32–36%

—

32–36%

320–330 S/L (SI units)

320–360 S/L

RBC indices
MCV*

†

MCH

MCHC

‡

Stained RBC
examination
White blood cells
(WBCs)

320–360 S/L
Normochromic and normocytic for all age groups and both sexes (see p. 23)

9,000–30,000/mm3

6,000–18,000/mm3

6,000–16,000/mm3

5,000–13,000/mm3

5,000–10,000/mm3

9,000–30,000 10 /L (SI
units)
9

(Continued on following page)

and Tests of Hematopoietic Function

4.4–64%

CHAPTER 1—Hematology

Hematocrit (Hct)

•

Reference Values for Complete Blood Count (Continued)
Adult

CBC Component

Newborn

1 Mo

6 Mo

1–10 Yr

Male

Female

Neutrophils

45% by 1 wk

40% by 4 wk

32%

60% after age 2 yr

—

54–75%
(3000–7500/mm3)

Bands

—

3–8% (150–700/mm3)

Eosinophils

—

0–3%

—

1–4% (50–400/mm3)

Basophils

—

1–3%

—

0–1% (25–100/mm3)

Monocytes

—

4–9%

—

2–8% (100–500/mm3)

Lymphocytes

41% by 1 wk

56% by 4 wk

61%

59% after age 2 yr

—

25–40%
(1500–4500/mm3)

T lymphocytes

—

60–80% of lymphocytes

B lymphocytes

—

Platelets

140,000–300,000/mm3

150,000–390,000/
mm3

200,000–473,000/
mm3

150,000–450,000/
mm3

150,000–450,000/mm3

140–300 109/L (SI units)

150–390 109/L

200–473 109/L

150–450 109/L

* Mean corpuscular volume.
†
Mean corpuscular hemoglobin.
‡
Mean corpuscular hemoglobin concentration.

10–20% of lymphocytes

Tests

Differential WBC

SECTION I—Laboratory

TABLE 1–4

CHAPTER 1—Hematology

TABLE 1–5

•

and Tests of Hematopoietic Function

Drugs That May Cause Blood Dyscrasias

Generic Name or Class

Trade Names

Acetaminophen and acetaminophen
compounds

Bancap, Capital, Colrex, Comtrex, Darvocet-N, Datril, Dolene,
Duradrin, Duradyne, Esgic, Excedrin, Liquiprin, Midrin,
Neopap Supprettes, NyQuil, Ornex, Panadol, Parafon Forte,
Percogesic, Phrenilin, Sedapap, Sinarest, Sinutab, Supac,
Tylenol, Tempra, Tylenol with Codeine, Valadol, Vanquish,
Wygesic

Acetophenazine maleate

Tindal

Aminosalicylic acid

Pamisyl, PAS, Rezipas

Amphotericin B

Fungizone, Mysteclin F

Antineoplastic agents
Arsenicals
Carbamazepine

Tegretol

Chloramphenicol

Chloromycetin

Chloroquine

Aralen

Ethosuximide (methsuximide, phensuximide)

Zarontin

Furazolidone

Furoxone

Haloperidol

Haldol

Hydantoin derivatives
Ethotoin

Peganone

Mephenytoin

Mesantoin

Phenytoin

Dilantin, Diphenylan

Hydralazine

Apresazide, Apresoline, Bolazine, Ser-Ap-Es, Serpasil-Apresoline

Hydroxychloroquine sulfate

Plaquenil

Indomethacin

Indocin

Isoniazid

INH, Nydrazid, Rifamate

MAO inhibitors

Eutonyl, Nardil, Parnate

Mefenamic acid

Ponstel

Mepacrine

Atabrine

Mephenoxalone

Lenetron

Mercurial diuretics

Thiomerin

Metaxalone

Skelaxin

Methaqualone

Quaalude, Sopor

Methyldopa

Aldoclor, Aldomet, Aldoril

Nitrites
Nitrofurantoin

Cyantin, Furadantin, Macrodantin

Novobiocin

Albamycin

Oleandomycin

Matromycin
(Continued on following page)

SECTION I—Laboratory

TABLE 1–5

•

Tests

Drugs That May Cause Blood Dyscrasias (Continued)

Generic Name or Class

Trade Names

Oxyphenbutazone

Oxalid, Tandearil

Paramethadione

Paradione

Penicillamine

Cuprimine, Depen

Penicillins
Phenacemide

Phenurone

Phenobarbital
Phenylbutazone

Azolid, Butazolidin

Phytonadione

AquaMEPHYTON, Konakion

Primaquine
Primidone

Mysoline

Pyrazolone derivatives

Butazolidin, Tandearil, Oxalid

Pyrimethamine

Daraprim

Rifampin

Rifadin, Rifamate, Rimactane

Radioisotopes
Spectinomycin

Trobicin

Sulfonamides
Mafenide

Sulfamylon cream

Phthalylsulfathiazole

Sulfathalidine

Sulfabenzamide

Sultrin vaginal cream

Sulfacetamide

Bleph-10, Cetamide ointment, Isopto Cetamide, Sulamyd, Sultrin
vaginal cream

Sulfachloropyridazine

Sonilyn

Sulfacytine

Renoquid

Sulfadiazine

Silvadene

Sulfameter

Sulla

Sulfamethiozole

Thiosulfil Forte

Sulfamethoxazole

Azo Gantanol, Bactrim, Gantanol, Septra

Sulfamethoxypyridazine

Midicel

Sulfanilamide

AVC vaginal cream

Sulfasalazine

Azulfidine

Sulfathiazole

Sultrin vaginal cream, Triple Sulfa cream

Sulfinpyrazone

Anturane

Sulfisoxazole

Azo Gantrisin, Gantrisin

Sulfones
Dapsone
DDS
Sulfoxone

CHAPTER 1—Hematology

TABLE 1–5

•

and Tests of Hematopoietic Function

Drugs That May Cause Blood Dyscrasias

Generic Name or Class

Trade Names

Sulfonylureas
Acetohexamide

Dymelor

Chlorpropamide

Diabinese

Tolazamide

Tolinase

Tolbutamide

Orinase

Tetracyclines

Achromycin

Chlortetracycline

Aureomycin

Demeclocycline

Declomycin

Doxycycline

Doxychel, Doxy, Vibramycin, Vibra-Tabs

Meclocycline

Meclan

Methacycline

Rondomycin

Minocycline

Minocin

Oxytetracycline

Oxlopar, Terramycin

Thiazide diuretics (rare hematologic
side effects)

Ademol, Diuril, Enduron, Exna, Naturetin, Naqua, Renese,
Saluron

Thiocyanates
Trimethadione

Tridione

Tripelennamine

Pyribenzamine, PBZ

Troleandomycin

Cyclamycin, Tao capsules and suspension

Valproic acid
Valproate
Vitamin A

Aquasol A, Alphalin

same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal range of values: Note and report
decreases in individual or entire CBC (pancytopenia) panel. Prepare to administer drugs and treatments, or both, that have been ordered to manage
anemia (RBC, hematocrit [Hct], hemoglobin
[Hgb], RBC indices), clotting process (platelet),
or infectious process (WBC, differential).

ERYTHROCYTE STUDIES
The mature RBC (erythrocyte) is a biconcave disk
with an average life span of 120 days. Because it lacks
a nucleus and mitochondria, it is unable to synthesize protein, and its limited metabolism is barely
enough to sustain it. Erythrocytes function primarily as containers for Hgb. As such, they transport

oxygen from the lungs to all body cells and transfer
carbon dioxide from the cells to the organs of excretion. The RBC is resilient and capable of extreme
changes in shape. It is admirably designed to survive
its many trips through the circulation.22
Old, damaged, and abnormal erythrocytes are
removed mainly by the spleen and also by the liver
and the red bone marrow. The iron is returned to
plasma transferrin and is transported back to the
erythroid marrow or stored within the liver and
spleen as ferritin and hemosiderin. The bilirubin
component of Hgb is carried by plasma albumin to
the liver, where it is conjugated and excreted into the
bile. Most of this conjugated bilirubin is ultimately
excreted in the stool, although some appears in the
urine or is returned to bile.
The hematologist determines the numbers, structure, color, size, and shape of erythrocytes; the types

SECTION I—Laboratory

Tests

and amount of Hgb they contain; their fragility; and
any abnormal components.

INDICATIONS FOR AN ERYTHROCYTE (RBC)
COUNT

Routine screening as part of a CBC
Suspected hematologic disorder involving RBC
destruction (e.g., hemolytic anemia)
Monitoring effects of acute or chronic blood loss
Monitoring response to drug therapy that may
alter the RBC count (see Table 1–5)
Monitoring clients with disorders associated with
elevated RBC counts (e.g., polycythemia vera,
chronic obstructive pulmonary disease)
Monitoring clients with disorders associated with
decreased RBC counts (e.g., malabsorption
syndromes, malnutrition, liver disease, renal
disease, hypothyroidism, adrenal dysfunction,
bone marrow failure)

ERYTHROCYTE (RBC) COUNT
The erythrocyte (RBC) count, a component of the
CBC, is the determination of the number of RBCs
per cubic millimeter. In international units, this is
expressed as the number of RBCs per liter of blood.
The test is less significant by itself than it is in
computing Hgb, Hct, and RBC indices.
Many factors influence the level of circulating
erythrocytes. Decreased numbers are seen in disorders involving impaired erythropoiesis excessive
blood cell destruction (e.g., hemolytic anemia), and
blood loss, and in chronic inflammatory diseases. A
relative decrease also may be seen in situations with
increased body fluid in the presence of a normal
number of RBCs (e.g., pregnancy). Increases in the
RBC count are most commonly seen in polycythemia vera, chronic pulmonary disease with
hypoxia and secondary polycythemia, and dehydration with hemoconcentration. Excessive exercise,
anxiety, and pain also produce higher RBC counts.
Many drugs can cause a decrease in circulating RBCs
(see Table 1–5), whereas a few drugs, such as methyldopa and gentamicin, can cause an increase.23

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

INTERFERING FACTORS

NURSING CARE AFTER THE PROCEDURE

Excessive exercise, anxiety, pain, and dehydration
may lead to false elevations.
Hemodilution in the presence of a normal
number of RBCs may lead to false decreases (e.g.,
excessive administration of intravenous fluids,
normal pregnancy).
Many drugs may cause a decrease in circulating
RBCs (see Table 1–5).
Drugs such as methyldopa and gentamicin may
cause an elevated RBC count.

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Anemia: Note and report signs and symptoms of
anemia associated with decreased counts in
combination with Hgb and Hct decreases. Prepare
to administer ordered oral or parenteral iron
preparation or a transfusion of whole blood or
packed RBCs. Prepare for phlebotomy if levels are

Reference Values
Conventional Units

SI Units

Newborns

4.8–7.1 million/mm

4.8–7.1 1012/L

1 mo

4.1–6.4 million/mm3

4.1–6.4 1012/L

6 mo

3.8–5.5 million/mm3

3.8–5.5 1012/L

1–10 yr

4.5–4.8 million/mm3

4.5–4.8 1012/L

Men

4.6–6.2 million/mm3

4.6–6.2 1012/L

Women

4.2–5.4 million/mm3

4.2–5.4 1012/L

Adults

CHAPTER 1—Hematology

increased in polycythemia vera or secondary polycythemia.

HEMATOCRIT
Blood consists of a fluid portion (plasma) and a
solid portion that includes RBCs, WBCs, and
platelets. More than 99 percent of the total blood cell
mass is composed of RBCs. The Hct or packed RBC
volume measures the proportion of RBCs in a
volume of whole blood and is expressed as a
percentage.
Several methods can be used to perform the test.
In the classic method, anticoagulated venous blood
is pipetted into a tube 100 mm long and then
centrifuged for 30 minutes so that the plasma and
blood cells separate. The volumes of packed RBCs
and plasma are read directly from the millimeter
marks along the side of the tube. In the micro
method, venous or capillary blood is used to fill a
small capillary tube, which is then centrifuged for 4
to 5 minutes. The proportions of plasma and RBCs
are determined by means of a calibrated reading
device. Both techniques allow visual estimation of
the volume of WBCs and platelets.24
With the newer, automated methods of cell
counting, the Hct is calculated indirectly as the
product of the RBC count and mean cell volume.
Although this method is generally quite accurate,
certain clinical situations may cause errors in interpreting the Hct. Abnormalities in RBC size and
extremely elevated WBC counts may produce false
Hct values. Elevated blood glucose and sodium may
produce elevated Hct values because of the resultant
swelling of the erythrocyte.25
Normally, the Hct parallels the RBC count. Thus,
factors influencing the RBC count also affect the
results of the Hct.
Reference Values
Conventional Units

SI Units

Newborns

44–64%

0.44–64

1 mo

35–49%

0.35–0.49

6 mo

30–40%

0.30–0.40

1–10 yr

35–41%

0.35–0.41

Men

40–54%

0.40–0.54

Women

38–47%

0.38–0.47

Adults

and Tests of Hematopoietic Function

INTERFERING FACTORS

Abnormalities in RBC size and extremely elevated
WBC counts may alter Hct values.
Elevated blood glucose and sodium may produce
elevated Hct values because of swelling of the
erythrocyte.
Factors that alter the RBC count such as hemodilution and dehydration also influence the Hct.
INDICATIONS FOR A HEMATOCRIT TEST

Routine screening as part of a CBC
Along with an Hgb (i.e., an “H and H”), to monitor blood loss and response to blood replacement
Along with an Hgb, to evaluate known or
suspected anemia and related treatment
Along with an Hgb, to monitor hematologic
status during pregnancy
Monitoring responses to fluid imbalances or to
therapy for fluid imbalances:
A decreased Hct may indicate hemodilution.
An increased Hct may indicate dehydration.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

The volume of the sample needed depends on the
method used to determine the Hct. With the exception of the classic method of Hct determination, a
capillary sample is usually sufficient to perform the
test. If a venipuncture is performed, the sample is
collected in a lavender-topped tube.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Critical values: Notify the physician at once if
the Hct is greater than 60 percent or less than
14 percent. Prepare the client for possible
transfusion of blood products or infusion of
intravenous fluids and for further procedures
to evaluate the cause or source of the blood
loss or hemoconcentration.

HEMOGLOBIN

Critical values 14% or 60%

0.14–0.60

Note: Values vary across the life cycle and between genders.

Hemoglobin is the main intracellular protein of the
RBC. Its primary function is to transport oxygen to
the cells and to remove carbon dioxide from them
for excretion by the lungs. The Hgb molecule
consists of two main components: heme and globin.

SECTION I—Laboratory

Tests

Heme is composed of the red pigment porphyrin
and iron, which is capable of combining loosely with
oxygen. Globin is a protein that consists of nearly
600 amino acids organized into four polypeptide
chains. Each chain of globin is associated with a
heme group.
Each RBC contains approximately 250 million
molecules of hemoglobin, with some erythrocytes containing more hemoglobin than others.
The oxygen-binding, -carrying, and -releasing
capacity of Hgb depends on the ability of the
globin chains to shift position normally during the
oxygenation–deoxygenation process. Structurally
abnormal chains that are unable to shift normally
have decreased oxygen-carrying ability. This
decreased oxygen transport capacity is characteristic
of anemia.
Hemoglobin also functions as a buffer in the
maintenance of acid–base balance. During transport, carbon dioxide (CO2) reacts with water (H2O)
to form carbonic acid (H2CO3). This reaction is
speeded by carbonic anhydrase, an enzyme
contained in RBCs. The carbonic acid rapidly dissociates to form hydrogen ions (H) and bicarbonate
ions (HCO3–). The hydrogen ions combine with the
Hgb molecule, thus preventing a buildup of hydrogen ions in the blood. The bicarbonate ions diffuse
into the plasma and play a role in the bicarbonate
buffer system. As bicarbonate ions enter the bloodstream, chloride ions (Cl) are repelled and move
back into the erythrocyte. This “chloride shift”
maintains the electrical balance between RBCs and
plasma.26
Hemoglobin determinations are of greatest use in
the evaluation of anemia, because the oxygen-carrying capacity of the blood is directly related to the
Hgb level rather than to the number of erythrocytes.
To interpret results accurately, the Hgb level must be
determined in combination with the Hct level.
Normally, Hgb and Hct levels parallel each other and
are commonly used together to express the degree of
anemia. The combined values are also useful in evaluating situations involving blood loss and related
treatment. The Hct level is normally three times the
Hgb level. If erythrocytes are abnormal in shape or
size or if Hgb manufacture is defective, the relationship between Hgb and Hct is disproportionate.27,28

Reference Values
Conventional Units

SI Units

Newborns

14–24 g/dL

140–240 g/L

1 mo

11–20 g/dL

110–200 g/L

6 mo

10–15 g/dL

100–150 g/L

1–10 yr

11–16 g/dL

110–160 g/L

13.5–18 g/dL

135–180 g/L

12–16 g/dL

120–160 g/L

6.0 g/dL
200 g/dL

60 g/L
200 g/L

Adults
Men
Women
Critical values

Note: Ratio of hemoglobin to hematocrit

3:1.

ate known or suspected anemia and related treatment
Along with an Hct, to monitor blood loss and
response to blood replacement
Along with an Hct, to monitor hematologic status
during pregnancy
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Critical values: Notify the physician at once if
the Hgb is less than 6.0 g/dL. Prepare the client
for possible transfusion of blood products and
for further procedures to evaluate cause or
source of blood loss.

INTERFERING FACTORS

Factors that alter the RBC count may also influence
Hgb levels
INDICATIONS FOR HEMOGLOBIN DETERMINATION

Routine screening as part of a CBC
Along with an Hct (i.e., an “H and H”), to evalu-

RED BLOOD CELL INDICES
RBC indices are calculated mean values that reflect
the size, weight, and Hgb content of individual
erythrocytes. They consist of the mean corpuscular
volume (MCV), the mean corpuscular hemoglobin
(MCH), and the mean corpuscular hemoglobin

CHAPTER 1—Hematology

TABLE 1–6

Microcytic,
normochromic
Microcytic,
hypochromic
Macrocytic,
normochromic

Classification of Anemias
MCV*
(mm3)

MCH†
(pg)

MCHC‡
(%)

Sepsis, hemorrhage, hemolysis,
drug-induced aplastic anemia,
radiation, hereditary spherocytosis

82–92

25–30

32–36

Renal disease, infection, liver
disease, malignancies

20–25

Iron deficiency, lead poisoning,
thalassemia, rheumatoid arthritis

50–80

12–25

25–30

95–150

30–50

32–36

Anemia
Normocytic,
normochromic

•

and Tests of Hematopoietic Function

Examples of Causes

Vitamin B12 and folic acid deficiency,
some drugs, pernicious anemia

* Mean corpuscular volume.
†
Mean corpuscular hemoglobin.
‡
Mean corpuscular hemoglobin concentration.

concentration (MCHC). MCV indicates the volume
of the Hgb in each RBC, MCH is the weight of the
Hgb in each RBC, and MCHC is the proportion of
Hgb contained in each RBC. MCHC is a valuable
indicator of Hgb deficiency and of the oxygen-carrying capacity of the individual erythrocyte. A cell of
abnormal size, abnormal shape, or both may contain
an inadequate proportion of Hgb.
RBC indices are used mainly in identifying
and classifying types of anemias. Anemias are
generally classified according to RBC size and Hgb
content. Cell size is indicated by the terms normocytic, microcytic, and macrocytic. Hemoglobin
content is indicated by the terms normochromic,
hypochromic, and hyperchromic. Table 1–6 shows

anemias classified according to these terms and in
relation to the results of RBC indices.
To calculate the RBC indices, the results of an
RBC count, Hct, and Hgb are necessary. Thus,
factors that influence these three determinations
(e.g., abnormalities of RBC size or extremely
elevated WBC counts) may result in misleading RBC
indices. For this reason, a stained blood smear may
be used to compare appearance with calculated
values and to determine the etiology of identified
abnormalities.
INTERFERING FACTORS

Because RBC indices are calculated from the results
of the RBC count, Hgb, and Hct, factors that influ-

Reference Values
Men
MCV

Women

80–94 m

Newborns

81–99 m

SI Units

96–108 m

81–99 fL (women)
96–108 fL (newborns)

MCH

27–31 pg

32–34 pg

32–34 pg (women)
32–34 pg (newborns)

MCHC

32–36%

32–33%

320–360 g/L (women)
320–330 g/L (newborns)

Normal values for RBC indices are shown in Table 1–4 in relation to the CBC and also are repeated above for adults. Values in
newborn infants are slightly different, but adult levels are achieved within approximately 1 month of age.

SECTION I—Laboratory

Tests

ence the latter three tests (e.g., abnormalities of RBC
size, extremely elevated WBC counts) also influence
RBC indices.
INDICATIONS FOR RED BLOOD CELL INDICES

Routine screening as part of a CBC
Identification and classification of anemias (see
Table 1–6)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).

TABLE 1–7
Descriptive Term
Macrocytosis

•

STAINED RED BLOOD CELL
EXAMINATION
The stained RBC examination (RBC morphology)
involves examination of RBCs under a microscope.
It is usually performed to compare the actual
appearance of the cells with the calculated values
for RBC indices. Cells are examined for abnormalities in color, size, shape, and contents. The test is
performed by spreading a drop of fresh anticoagulated blood on a glass slide. The addition of stain
to the specimen is used to enhance RBC characteristics.
As with RBC indices, RBC color is described as
normochromic, hypochromic, or hyperchromic,
indicating, respectively, normal, reduced, or elevated
amounts of Hgb. Cell size may be described as
normocytic, microcytic, or macrocytic, depending
on whether cell size is normal, small, or abnormally
large, respectively. Cell shape is described using
terms such as poikilocyte, anisocyte, leptocyte, and
spherocyte (Table 1–7). The cells are examined also
for inclusions or abnormal cell contents, for example, Heinz bodies, Howell-Jolly bodies, Cabot’s rings,
and siderotic granules (Table 1–8).

Red Blood Cell Abnormalities Seen on Stained Smear
Observation

Significance

Cell diameter 8 m

Megaloblastic anemias

MCV* 95 m3

Severe liver disease
Hypothyroidism

Microcytosis

Cell diameter 6 m

Iron-deficiency anemia

MCV 80 m

Thalassemias

MCHC† 27

Anemia of chronic disease

Hypochromia

Increased zone of central pallor

Diminished Hgb content

Hyperchromia

Microcytic, hyperchromic cells

Chronic inflammation

Increased bone marrow stores of
iron

Defect in ability to use iron for Hgb synthesis

Polychromatophilia

Presence of red cells not fully
hemoglobinized

Reticulocytosis

Poikilocytosis

Variability of cell shape

Sickle cell disease

Microangiopathic hemolysis
Leukemias
Extramedullary hematopoiesis
Marrow stress of any cause

CHAPTER 1—Hematology

TABLE 1–7

•

Red Blood Cell Abnormalities Seen on Stained Smear

Descriptive Term
Anisocytosis

and Tests of Hematopoietic Function

Observation

Significance
Reticulocytosis

Variability of cell size

Transfusing normal blood into microcytic or
macrocytic cell population
Leptocytosis

Spherocytosis

Hypochromic cells with small
central zone of Hgb (“target
cells”)

Thalassemias

Cells with no central pallor,
loss of biconcave shape

Loss of membrane relative to cell volume

Obstructive jaundice

Hereditary spherocytosis
Schistocytosis

MCHC high

Accelerated red blood cell destruction by
reticuloendothelial system

Acanthocytosis

Presence of cell fragments in
circulation

Increased intravascular mechanical trauma

Echinocytosis

Irregularly spiculated surface

Microangiopathic hemolysis
Irreversibly abnormal membrane
lipid content
Liver disease
Abetalipoproteinemia
Regularly spiculated cell surface

Reversible abnormalities of membrane lipids
High plasma-free fatty acids
Bile acid abnormalities
Effects of barbiturates, salicylates, and so on

Stomatocytosis

Elongated, slitlike zone of central
pallor

Hereditary defect in membrane sodium
metabolism
Severe liver disease

Elliptocytosis

Oval cells

Hereditary anomaly, usually harmless

Source: Adapted from Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests,
ed 11. FA Davis, Philadelphia, 2000 p. 68, with permission.
* Mean corpuscular volume.
†Mean corpuscular hemoglobin concentration.

Reference Values
In a normal smear, all cells are uniform in color,
size, and shape and are free of abnormal
contents. A normal RBC may be described as a
normochromic, normocytic cell.

INDICATIONS FOR A STAINED RED BLOOD CELL
EXAMINATION

Abnormal calculated values for RBC indices

Evaluation of anemia and related disorders
involving RBCs (see Tables 1–6, 1–7, and 1–8)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a lavender-topped tube. A capillary

SECTION I—Laboratory

TABLE 1–8

•

Tests

Types of Abnormal Red Blood Cell Inclusions and Their Causes

Type (Composition)
Heinz bodies (denatured Hgb)

Causes of Inclusions
-Thalassemia
G-6-PD deficiency
Hemolytic anemias
Methemoglobinemia
Splenectomy
Drugs: analgesics, antimalarials, antipyretics, nitrofurantoin (Furadantin),
nitrofurazone (Furacin), phenylhydrazine, sulfonamides, tolbutamide,
vitamin K (large doses)

Basophilic stippling (residual
cytoplasmic RNA)

Anemia caused by liver disease
Lead poisoning
Thalassemia

Howell-Jolly bodies (fragments of residual DNA)

Splenectomy
Intense or abnormal RBC production resulting from hemolysis or inefficient erythropoiesis

Cabot’s rings (composition
unknown)

Same as for Howell-Jolly bodies

Siderotic granules (ironcontaining granules)

Abnormal iron metabolism
Abnormal hemoglobin manufacture

sample may be obtained in infants and children as
well as in adults for whom venipuncture may not be
feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).

HEMOGLOBIN ELECTROPHORESIS
The Hgb molecule consists of four polypeptide
globin chains and four heme components containing iron and the red pigment porphyrin.
Hemoglobin formation is genetically determined,
and the types of globin chains normally formed are
termed alpha ( ), beta (), gamma ( ), and delta
( ). Combinations of these chains form various
types of Hgb. Disorders of synthesis and production
of globin chains result in the formation of abnormal
Hgb.
Hemoglobin electrophoresis is a technique for
identifying the types of Hgb present and for determining the percentage of each type. Exposed to an
electrical current, the several types of Hgb migrate
toward the positive pole at different rates. The
patterns created are compared with standard
patterns.

At birth, most RBCs contain fetal hemoglobin
(Hgb F), which is made up of two chains and two
chains. Within a few months, through sequential
suppression and activation of individual genes, Hgb
F largely disappears and is replaced by adult hemoglobin (Hgb A). Hgb A, composed of two chains
and two chains, makes up more than 95 percent of
Hgb in adults. A minor type of Hgb, Hgb A2, consisting of two chains and two chains, also is found
in small amounts (2 to 3 percent) in adults. Traces of
Hgb F persist throughout life (Fig. 1–4).29
More than 150 genetic abnormalities in the Hgb
molecule have been identified. These are termed
thalassemias and hemoglobinopathies. Thalassemias
are genetic disorders in globin chain synthesis that
result in decreased production rates of - or globin chains. Hemoglobinopathies refer to disorders involving an abnormal amino acid sequence in
the globin chains.
In -thalassemia, for example, production of
chains and Hgb A is decreased. The oversupply of
chains results in the formation of hemoglobin H
(Hgb H), which consists of four chains (Fig. 1–5).
Complete absence of a chain production (homozygous thalassemia A) is incompatible with life and
generally results in stillbirth during the second
trimester of pregnancy. The cord blood of such
fetuses shows high levels of hemoglobin Barts, a type

CHAPTER 1—Hematology

Figure 1–4. Changes in hemoglobin with development. (From Hillman, RS, and Finch, CA: Red Cell
Manual, ed 7. FA Davis, Philadelphia, 1996, p. 11, with
permission.)

of Hgb that evolves from unpaired
chains.
Hemoglobin Barts itself has such a high affinity for
oxygen that it releases none to the tissues.
In -thalassemia minor, a decrease is seen in chain production and, therefore, a reduction in the
amount of Hgb A formed. In -thalassemia major,
all -chain production is lost and no Hgb A is
formed. The chains are then used to form Hgb F
and Hgb A2.
Among the most common Hgb abnormalities are
the sickle cell disorders, which exhibit a double
gene defect that results in the production of hemoglobin S (Hgb S). In Hgb S, the amino acid valine is
substituted for glutamine at a critical position on the
globin chain, which causes the chains to “lock”
when deoxygenated, deforming the erythrocyte into
the sickled shape. Repeated sickling damages RBC
membranes and shortens the cells’ life spans. The
abnormally shaped cells pass more sluggishly
through the circulation, leading to impaired tissue
oxygenation.
The gene for Hgb S is most prevalent in black
populations and may be present as either sickle cell
trait (having one recessive gene for Hgb S) or sickle
cell disease (having both recessive genes for Hgb S).

and Tests of Hematopoietic Function

The Sickledex test, a screening test for sickle cell
disorders, detects sickled erythrocytes under conditions of oxygen deprivation. Hemoglobin electrophoresis is necessary, however, to differentiate
sickle cell trait (20 to 40 percent Hgb S) from sickle
cell disease (70 percent Hgb S).
Many other types of abnormal Hgb are caused by
defects in globin chain synthesis. Hemoglobin C
(Hgb C), for example, has an abnormal amino acid
substitution on the chain and can lead to a form of
mild hemolytic anemia. Other examples of abnormal Hgb resulting from rearrangement or substitution of the amino acids on the globin chains include
hemoglobin E (Hgb E), hemoglobin Lepore (chain abnormalities), and hemoglobin Constant
Spring ( -chain abnormality).30
Other disorders involving Hgb pertain to the
oxygen-combining ability of the heme portion of
the molecule. Examples of types of Hgb associated
with such disorders are methemoglobin (Hgb M),
sulfhemoglobin, and carboxyhemoglobin. Hgb M is
formed when the iron contained in the heme
portion of the Hgb molecule is oxidized to a ferric
instead of a ferrous form, thus impairing its oxygencombining ability. Methemoglobinemia may be
hereditary or acquired. The acquired form may be
caused by excessive radiation or by the toxic effects
of chemicals and drugs (e.g., nitrates, phenacetin,
lidocaine). Note that Hgb F is more easily converted
to Hgb M than is Hgb A.
Sulfhemoglobin is a pigment that results from
Hgb combining with inorganic sulfides. It occurs in
those who take sulfonamides or acetanilid.
Carboxyhemoglobin results when Hgb is exposed
to carbon monoxide. Although this type of Hgb is
most commonly seen in individuals with excessive
exposure to automobile exhaust fumes, it may also
occur in heavy smokers.31 Tests other than Hgb electrophoresis are used to determine the presence of
Hgb M and carboxyhemoglobin.
INDICATIONS FOR HEMOGLOBIN
ELECTROPHORESIS

Suspected thalassemia, especially in individuals
with positive family history for the disorder
Differentiation among the types of thalassemias
Evaluation of a positive Sickledex test to differentiate sickle cell trait (20 to 40 percent Hgb S) from
sickle cell disease (70 percent Hgb S)
Evaluation of hemolytic anemia of unknown
etiology
Diagnosis of Hgb C anemia
Identification of the numerous types of abnormal
Hgb, most of which do not produce clinical
disease

SECTION I—Laboratory

Tests

Figure 1–5. Formation of manual and abnormal hemoglobin. (From Hillman, RS, and Finch, CA: Red Cell Manual, ed
7. FA Davis, Philadelphia, 1996, with permission.)

Reference Values
The normal values shown for Hgb electrophoresis are for adults. In
newborn infants, 60 to 90 percent of Hgb may consist of Hgb F. This
amount decreases to 10 to 20 percent by 6 months of age and to 2 to
4 percent by 1 year. Abnormal forms of Hgb (e.g., Hgb S, Hgb H) are
not normally present.
Conventional Units

SI Units

Hgb A

95–97%

0.95

Hgb A2

2–3%

0.02–0.03

Hgb F

0.01

Methemoglobin
(Hgb M)

2% or 0.06–0.24 g/dL

Sulfhemoglobin

Minute amounts

Carboxyhemoglobin

0–2.3%
4–5% in smokers

CHAPTER 1—Hematology

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

and Tests of Hematopoietic Function

The test is performed by exposing RBCs to
increasingly dilute saline solutions. The percentage
of the solution at which the cells swell and rupture is
then noted.

THE PROCEDURE

Reference Values

Normal erythrocytes rupture in saline solutions
of 0.30 to 0.45 percent. RBC rupture in solutions
of greater than 0.50 percent saline indicates
increased fragility. Lack of rupture in solutions
of less than 0.30 percent saline indicates
decreased RBC fragility.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Complications and precautions: Note and report
signs and symptoms associated with the specific
type of anemia identified by electrophoresis.
Prepare to instruct in therapy and prevention of
complications. Offer information about genetic
factors and counseling or both, if appropriate.

INDICATIONS FOR OSMOTIC FRAGILITY TEST

Confirmation of disorders that alter RBC fragility,
including hereditary anemias (see Table 1–9)
Evaluation of the extent of extrinsic damage to
RBCs from burns, inadvertent instillation of
hypotonic intravenous fluids, microorganisms,
and excessive exercise
NURSING CARE BEFORE THE PROCEDURE

OSMOTIC FRAGILITY
The osmotic fragility test determines the ability of
the RCB membrane to resist rupturing in a hypotonic saline solution. Normal disk-shaped cells can
imbibe water and swell significantly before
membrane capacity is exceeded, but spherocytes
(RBCs that lack the normal biconcave shape) and
cells with damaged membranes burst in saline solutions only slightly less concentrated than normal
saline. Conversely, in thalassemia, sickle cell disease,
and other disorders, RBCs are more than normally
resistant to osmotic damage (Table 1–9).

TABLE 1–9

•

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube. A capillary sample
may be obtained in infants and children as well as in
adults for whom a venipuncture may not be feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the

Causes of Altered Erythrocyte Osmotic Fragility

Decreased Fragility

Increased Fragility

Iron-deficiency anemias

Hereditary spherocytosis

Hereditary anemias (sickle cell, hemoglobin C,
thalassemias)

Hemolytic anemias

Liver diseases

Autoimmune anemias

Polycythemia vera

Burns

Splenectomy

Toxins (bacterial, chemical)

Obstructive jaundice

Hypotonic infusions
Transfusion with incompatible blood
Mechanical trauma to RBCs (prosthetic heart valves,
disseminated intravascular clotting, parasites)
Enzyme deficiencies (PK kinase, G-6-PD)

SECTION I—Laboratory

Tests

same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal test results, complications, and
precautions: Respond as for any laboratory analysis to determine RBC abnormalities leading to
anemia.

RED BLOOD CELL ENZYMES
To maintain normal shape and flexibility as well as
to combine with and release oxygen, RBCs must
generate energy. The needed energy is produced
almost exclusively through the breakdown of
glucose, a process that is catalyzed by a number of
enzymes. Deficiencies of these enzymes are associated with hemolytic anemia. Two of the most
common deficiencies, both hereditary, involve the
RBC enzymes glucose-6-phosphate dehydrogenase
and pyruvate kinase.
GLUCOSE-6-PHOSPHATE DEHYDROGENASE

Glucose-6-phosphate dehydrogenase is an enzyme
pivotal in generating the reduced form of nicotinamide adenine dinucleotide phosphate (NADPH)
through the pentose pathway in glucose metabolism.
More than 100 structural and functional variants of
the normal G-6-PD molecule (called type B) have
been identified, most of which are clinically insignificant. One variant form (called type A) does,
however, produce clinical disease. The type A variant
is caused by a sex-linked genetic defect. The abnormal gene is carried by women and is transmitted to
men who inherit the disorder.
Persons with the type A enzyme (15 percent of
blacks) experience no difficulty until challenged by
an oxidative stressor, which induces rapid intravascular hemolysis of susceptible cells. Among these
stressors are systemic infections, septicemia, metabolic acidosis, and exposure to oxidant drugs
(aspirin, chloramphenicol [Chloromycetin], nitrofurantoin [Furadantin], phenacetin, primaquine,

probenecid [Benemid], quinidine, quinine, sulfonamides, thiazide diuretics, and tolbutamide
[Orinase]).
A Mediterranean variant also may occur, especially in individuals of Greek and Italian descent and
in some small, inbred Jewish populations. This variant severely reduces enzymatic activity and leads to
more severe hemolytic episodes, which are triggered
by a greater variety of stimuli and are less likely to be
self-limited than in persons with the type A variant.
In addition to the oxidative stressors just listed,
ingestion of fava beans is known to precipitate
hemolytic events in individuals with Mediterraneantype G-6-PD deficiency.32
PYRUVATE KINASE

Pyruvate kinase (PK) functions in the formation of
pyruvate and adenosine diphosphate (ADP) in
glycolysis. The pyruvate thus formed is subsequently
converted to lactate. RBCs that lack PK have a low
affinity for oxygen. Episodes of hemolysis in individuals lacking this enzyme are severe and chronic and
are exacerbated by stressors such as infection.
The inherited form of this disorder is transmitted
as an autosomal recessive trait; both parents must
carry the abnormal gene for the child to be affected.
The acquired form of PK deficiency is usually caused
by either drug ingestion or metabolic liver disease.
INTERFERING FACTORS

Young RBCs have higher enzyme levels than do
older ones; thus, if the tests are performed within 10
days of a hemolytic episode (when the body is
actively replacing lost cells through increased
erythropoiesis) or after a recent blood transfusion,
the results may be falsely normal.
INDICATIONS FOR RED BLOOD CELL
ENZYMES STUDY

Hemolytic anemia of uncertain etiology, especially when it occurs in infancy or early childhood

Reference Values
Conventional Units
G-6-PD

4.3–11.8 IU/g Hgb

0.28–0.76 mm/mol Hgb

125–281 U/dL packed RBCs (PRBCs)

1.25–2.81 kU/L RBC

251–511 U/10 cells
1211–2111 IU/mL PRBCs
PK

SI Units

2.0–8.8 U/g Hgb
0.3–0.91 mg/dL

0.25–0.51 nU/L RBC

CHAPTER 1—Hematology

Suspected G-6-PD or PK deficiency, especially in
individuals with positive family history or with
jaundice occurring in response to stressors,
oxidant drugs, or foods such as fava beans
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a lavender-topped tube. A capillary
sample may be collected in infants and children as
well as in adults for whom venipuncture may not be
feasible.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal test results, complications, and precautions: Respond as for any laboratory analysis to
determine RBC abnormalities leading to anemia.

ERYTHROCYTE SEDIMENTATION RATE
The erythrocyte sedimentation rate (ESR or sed
rate) measures the rate at which RBCs in anticoaguTABLE 1–10

•

and Tests of Hematopoietic Function

lated blood settle to the bottom of a calibrated tube.
In normal blood, relatively little settling occurs
because the gravitational pull on the RBCs is almost
balanced by the upward force exerted by the plasma.
If plasma is extremely viscous or if cholesterol levels
are very high, the upward trend may virtually
neutralize the downward pull on the RBCs. In
contrast, anything that encourages RBCs to aggregate or stick together increases the rate of settling.
Inflammatory and necrotic processes, for example,
cause an alteration in blood proteins that results in
clumping together of RBCs because of surface
attraction. These clumps are called rouleaux. If the
proportion of globin to albumin increases or if
fibrinogen 3 levels are especially high, rouleaux
formation is enhanced and the sed rate increases.33
Specific causes of altered ESRs are presented in Table
1–10.
INTERFERING FACTORS

Delays in performing the test after the sample is
collected may retard the ESR and cause abnormally
low results; the test should be performed within 3
hours of collecting the sample.
INDICATIONS FOR ERYTHROCYTE
SEDIMENTATION RATE TEST

Suspected organic disease when symptoms are
vague and clinical findings uncertain

Causes of Altered Erythrocyte Sedimentation Rates

Increased Rate

Decreased Rate

Pregnancy (uterine and ectopic)

Polycythemia vera

Toxemia of pregnancy

Congestive heart failure

Collagen disorders (immune disorders of connective
tissue)

Sickle cell, Hgb C disease

Inflammatory disorders

Degenerative joint disease

Infections

Cryoglobulinemia

Acute myocardial infarction

Drug toxicity (salicylates, quinine derivatives,
adrenal corticosteroids)

Most malignancies
Drugs (oral contraceptives, dextran, penicillamine,
methyldopa, procainamide, theophylline, vitamin A)
Severe anemias
Myeloproliferative disorders
Renal disease (nephritis)
Hepatic cirrhosis
Thyroid disorders
Acute heavy metal poisoning

SECTION I—Laboratory

Tests

Reference Values
Normal values for the ESR follow. Note that several laboratory methods can be
used to determine the ESR. Values vary according to the method used.
Wintrobe (mm/hr)

Westergren (mm/hr)

Men

Cutler (mm/hr)
0–8

50 yr

0–7

0–15

50 yr

5–7

0–20

Women

0–10

50 yr

0–15

0–20

50 yr

25–30

0–30

Landau Micro Method

Smith Micro Method

Children
Newborn–2 yr

1–6

0–1 (newborns)

4–14 yr

1–9

3–13

Identification of the presence of an inflammatory
or necrotic process
Monitoring response to treatment for various
inflammatory disorders (e.g., rheumatoid arthritis, systemic lupus erythematosus)
Support for diagnosing disorders associated with
altered ESRs (see Table 1–10)

increases, note signs of infection or inflammation
(pain, temperature) and activity intolerance
(fatigue, weakness), and perform activities that
conserve the client’s energy. Administer ordered
anti-inflammatory or antibiotic therapy. As the
rate decreases, evaluate for improvement in
condition and possible increases in client activity.

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a lavender-topped tube. A capillary
sample may be obtained in infants and children as
well as in adults for whom venipuncture may not be
feasible.
The sample should be transported promptly to
the laboratory, because the test must be performed
within 3 hours of collecting the sample. Delays may
retard the ESR and cause abnormally low results.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal values: Note and report increases or
decreases in the rate in relation to other test
results used to determine the presence of or to
monitor the progress of a disease. As the rate

LEUKOCYTE STUDIES
Leukocytes (white blood cells, WBCs) constitute the
body’s primary defense against “foreignness”; that is,
leukocytes protect the body from foreign organisms,
substances, and tissues. The main types of leukocytes are neutrophils, monocytes, eosinophils,
basophils, and lymphocytes. All of these cells are
produced in the bone marrow. However, lymphocytes may be produced in additional sites. Each of
these types of leukocytes has different functions, and
each behaves as a related but different system.34
Neutrophils and monocytes, the most mobile and
active phagocytic leukocytes, are capable of breaking
down various proteins and lipids such as those in
bacterial cell membranes. The function of
eosinophils is uncertain, although they are believed
to detoxify foreign proteins that enter the body
through the lungs or intestinal tract. The function of
basophils also is not clearly understood, but the cells
themselves are known to contain heparin, histamine,
and serotonin. Basophils are believed to cause
increased blood flow to injured tissues while
preventing excessive intravascular clotting.

CHAPTER 1—Hematology

Lymphocytes play an important role in immunity
and may be divided into two main categories, B
lymphocytes and T lymphocytes. B lymphocytes are
responsible for humoral immunity and antibody
production. It is B lymphocytes that ultimately
develop into the antibody-producing plasma cells
(see Fig. 1–2). T lymphocytes are responsible for
cellular immunity and they interact directly with the
antigen.35,36 Lymphocytes and related studies are
discussed in greater detail in Chapter 3.
Note that leukocytes perform their functions
outside the vascular bed. Thus, WBCs are merely in
transit while in the blood. Because of the many
leukocyte functions, alterations in the number and
types of cells may be indicative of numerous pathophysiologic problems.

WHITE BLOOD CELL COUNT
The WBC count determines the number of leukocytes per cubic millimeter of whole blood. The
counting is performed very rapidly by electronic
devices. The WBC may be performed as part of a
CBC, alone, or with differential WBC count. An
elevated WBC count is termed leukocytosis; a
decreased count, leukopenia. In addition to the
normal physiological variations in WBC count,
many pathological problems may result in an abnormal WBC count (see Table 1–2).
If the WBC count is low, a buffy coat smear can be
performed to identify leukemia or solid tumor cells
in the blood. An alteration in total WBC count indicates the degree of response to a pathological process
but is not specifically diagnostic for any one disorder. A more complete evaluation is obtained through
the differential WBC count.
INDICATIONS FOR A WHITE BLOOD CELL COUNT

Routine screening as part of a CBC
Suspected inflammatory or infectious process (see
Table 1–2)

and Tests of Hematopoietic Function

Suspected leukemia, autoimmune disorder, or
allergy
Suspected bone marrow depression
Monitoring response to stress, malnutrition, and therapy for infectious or malignant
processes
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a lavender-topped tube. A capillary
sample may be obtained in infants and children as
well as in adults for whom venipuncture may not be
feasible.
Because of the normal diurnal variation of WBC
levels, it is important to note the time when the
sample was obtained.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
Abnormal test results: Provide support when
diagnostic findings are revealed, especially if
malignancy is a possibility or is confirmed.
Reinforce information given by the physician, and
answer questions or direct them to the appropriate professionals.
Abnormal values: Note and report signs and
symptoms of infection or inflammation associated with an increased count (temperature,
chills), including those reflective of the site
affected (pain, edema, redness, drainage). Carry
out appropriate standard precautions to prevent
spread to other sites. Collect a specimen for
culture and sensitivities. Administer ordered
antipyretic and antibiotic therapy to treat infec-

Reference Values
The normal range of WBCs for adults is 5,000 to 10,000. Variations in the WBC count across the life cycle
are shown in Table 1–4 . Abnormal results may be classified by degree of severity as indicated.
Elevations

Decreases

Conventional Units

SI Units

Conventional Units

SI Units

Slight

11,000–20,000

11.0–20.0 109 L

3000–4500

3.4–4.5 109 L

Moderate

20,000–30,000

20.0–30.0 109 L

1500–3000

1.5–3.0 109 L

50,000

50.0 109 L

Severe

1500

1.5 109 L

SECTION I—Laboratory

Tests

tion. Administer chemotherapeutic agents for
malignancy identified and monitored by WBC
and differential counts. Note and report decreased
count and carry out reverse isolation procedures
to protect immunosuppressed client from infection.
Critical values: Notify the physician at once if a
new client has a WBC count of less than 2,000
per microliter or greater than 50,000 per microliter or if a client whose WBC count was less
than 4,000 per microliter has a change of 1,000
per microliter. Take precautions to protect the
client from infection. Prepare for further diagnostic procedures to identify the cause or
source of increases or decreases in the count.

DIFFERENTIAL WHITE BLOOD
CELL COUNT
The differential WBC count indicates the percentage
of each type of leukocyte present per cubic millime-

TABLE 1–11

•

Causes of Altered White Blood Cell Differential by Cell Type

Cell Type
Neutrophils

ter of whole blood. If necessary for further evaluation of results, the percentage for each cell type can
be multiplied by the total WBC count to obtain the
absolute number of each cell type present.
Causes of alterations in the differential WBC
count according to type of leukocyte are presented
in Table 1–11. An increase in immature neutrophils
(i.e., bands, stabs) indicates the body’s attempt to
produce more neutrophils in response to the pathological process. A decreased neutrophil count is
fairly common in children during viral infections.
An increase in bands is sometimes referred to as a
“shift to the left.” This terminology derives from the
following traditional headings used on laboratory
slips to report WBC differential results: Bands,
Neutrophils, Eosinophils, Basophils, Monocytes, and
Lymphocytes.
In contrast, the meaning of a “shift to the right” is
less well defined. This may refer to an increase in
neutrophils or other granulocytes or to an increase
in lymphocytes or monocytes.

Increased Levels
Stress (allergies, exercise, childbirth,
surgery)
Acute hemorrhage or hemolysis

Bone marrow depression (viruses, toxic
chemicals, overwhelming infection,
Felty’s syndrome, Gaucher’s disease,
myelofibrosis, hypersplenism, pernicious anemia, radiation)

Infectious diseases

Anorexia nervosa, starvation, malnutrition

Inflammatory disorders (rheumatic fever,
gout, rheumatoid arthritis, drug reactions, vasculitis, myositis)

Folic acid deficiency

Tissue necrosis (burns, crushing injuries,
abscesses

Acromegaly

Malignancies

Addison’s disease

Metabolic disorders (uremia, eclampsia,
diabetic ketoacidosis, thyroid crisis,
Cushing’s syndrome)

Thyrotoxicosis

Drugs (epinephrine, histamine, lithium,
heavy metals, heparin, digitalis, ACTH)

Disseminated lupus erythematosus

Toxins and venoms (turpentine, benzene)

Drugs (alcohol, phenylbutazone
[Butazolidin], phenacetin, penicillin,
chloramphenicol, streptomycin, phenytoin [Dilantin], mephenytoin
[Mesantoin], phenacemide [Phenurone],
tripelennamine [PBZ], aminophylline,
quinine, chlorpromazine, barbiturates,
dinitrophenols, sulfonamides, antineoplastics)

Extremes of temperature

Leukemia (myelocytic)

Bands (immature
neutrophils)

Decreased Levels

Infections

Vitamin B12 deficiency

Anaphylaxis

None, as bands should be absent or present only in small numbers
(Continued )

CHAPTER 1—Hematology

TABLE 1–11

•

and Tests of Hematopoietic Function

Causes of Altered White Blood Cell Differential by Cell Type

Cell Type

Increased Levels

Decreased Levels

Antineoplastic drugs
Any condition that causes neutrophilia
Leukemia

Basophils

None, as normal value is 0–1%

Hodgkin’s disease
Polycythemia vera
Ulcerative colitis
Nephrosis
Chronic hypersensitivity states
Eosinophils

Sickle cell disease

Disseminated lupus erythematosus

Asthma

Acromegaly

Chorea

Elevated steroid levels

Hypersensitivity reactions

Stress

Parasitic infestations

Infectious mononucleosis

Autoimmune diseases

Hypersplenism

Addison’s disease

Cushing’s syndrome

Malignancies

Congestive heart failure

Sarcoidosis

Hyperplastic anemia

Chronic inflammatory diseases and
dermatoses

Hormones (ACTH, thyroxine, epinephrine)

Leprosy
Hodgkin’s disease
Polycythemias
Ulcerative colitis
Autoallergies
Pernicious anemia
Splenectomy
(Continued on following page)

Reference Values
The normal percentage of each WBC type in
adults is shown next. Variations across the life
cycle are listed in Table 1–4.
Conventional Units
Bands

SI Units

3–8%

0.03–0.08

Neutrophils

54–75%

0.54–0.75

Eosinophils

1–4%

0.01–0.04

Basophils

0–1%

0–0.01

2–8%

0.02–0.08

25–40%

0.25–0.40

Monocytes
Lymphocytes

INDICATIONS FOR DIFFERENTIAL WHITE
BLOOD CELL COUNT

Routine screening as part of a CBC
Abnormal total WBC count to determine the
source of the elevation
Confirmation of the presence of various disorders associated with increases and decreases in
the several types of WBCs (see Table 1–11)
Monitoring of response to treatment for acute
infections, with a therapeutic response indicated
by a decreasing number of bands and a stabilizing
number of neutrophils
Monitoring of physiological responses to
chemotherapy

SECTION I—Laboratory

TABLE 1–11

•

Tests

Causes of Altered White Blood Cell Differential by
Cell Type (Continued)

Cell Type
Monocytes

Increased Levels
Infections (bacterial, viral, mycotic, rickettsial, amebic)

Decreased Levels
Not characteristic of specific disorders

Cirrhosis
Collagen diseases
Ulcerative colitis
Regional enteritis
Gaucher’s disease
Hodgkin’s disease
Lymphomas
Carcinomas
Monocytic leukemia
Radiation
Polycythemia vera
Sarcoidosis
Weil’s disease
Systemic lupus erythematosus
Hemolytic anemias
Thrombocytopenic purpura
Lymphocytes

Infections (bacterial, viral)

Immune deficiency diseases

Lymphosarcoma

Hodgkin’s disease

Ulcerative colitis

Rheumatic fever

Banti’s disease

Aplastic anemia

Felty’s syndrome

Bone marrow failure

Myeloma

Gaucher’s disease

Lymphomas

Hemolytic disease of the newborn

Addison’s disease

Hypersplenism

Thyrotoxicosis

Thrombocytopenic purpura

Malnutrition

Transfusion reaction

Rickets

Massive transfusions

Waldenström’s macroglobulinemia

Pernicious anemia

Lymphocytic leukemia

Septicemia
Pneumonia
Burns
Radiation
Toxic chemicals (benzene, bismuth, DDT)
Antineoplastic agents
Adrenal corticosteroids (high doses)

CHAPTER 1—Hematology

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).

WHITE BLOOD CELL ENZYMES

LEUKOCYTE ALKALINE PHOSPHATASE

WBCs in peripheral blood samples retain enzymatic
activity and can alter substrates added in the labora-

•

tory. The presence of enzymatic activity is useful in
studying cells that are so morphologically abnormal
on stained smear that it is difficult to determine their
cell line of origin (see Fig. 1–2). The two most
common WBC enzyme tests are the test for leukocyte alkaline phosphatase, an enzyme found in
neutrophils, and the periodic acid–Schiff stain,
which tests for enzymes found in granulocytes and
erythrocytes. Both tests are used to diagnose hematologic disorders, especially leukemias. Specific
causes of alterations in WBC enzymes are presented
in Table 1–12. Another WBC enzyme test, tartrateresistant acid phosphatase (TRAP), is performed to
diagnose hairy cell leukemia, because this enzyme
activity is present in the lymphocytic cells of this
type of leukemia. Additional details for each test are
briefly discussed subsequently.

NURSING CARE BEFORE THE PROCEDURE

TABLE 1–12

and Tests of Hematopoietic Function

Leukocyte alkaline phosphatase (LAP) is an enzyme

Causes of Alterations in White Blood Cell Enzymes
Causes of Alterations

Enzyme
Leukocyte alkaline phosphatase
(LAP)

Elevated Levels

Decreased Levels

Chronic myelocytic leukemia

Acute myelocytic leukemia

Polycythemia vera

Acute monocytic leukemia

Myelofibrosis

Chronic granulocytic leukemia

Leukemoid reactions

Anemias (aplastic, pernicious)

Oral contraceptives

Thrombocytopenia

Pregnancy

Infectious mononucleosis

Adrenocorticotropic hormone (ACTH)
excess

Paroxysmal nocturnal hemoglobinuria

Cushing’s syndrome

Hereditary hypophosphatasia

Down syndrome

Collagen diseases

Multiple myeloma
Lymphomas
Positive
Periodic
acid–Schiff (PAS)
stain

Negative

Acute granulocytic leukemia

Early granulocyte precursors

Acute lymphoblastic leukemia

Severe iron-deficiency anemia

Erythroleukemia

Normal erythrocyte precursors

Amyloidosis

Mature RBCs

Thalassemia
Lymphomas

SECTION I—Laboratory

Tests

Reference Values
Leukocyte alkaline phosphatase

13–130 U

Periodic acid–Schiff stain

Granulocytes—positive
Agranulocytes—negative
Granulocytic precursors—negative
Erythrocytes—negative
Erythrocytic precursors—negative

Tartrate-resistant acid phosphatase
found in neutrophils. This enzyme is completely
independent of serum alkaline phosphatase, which
reflects osteoblastic activity and hepatic function.
The LAP content of neutrophils increases as the cells
mature; therefore, the LAP study is useful in assessing cellular maturation and in evaluating departures
from normal differentiation.
The LAP study is used to distinguish among various hematologic disorders. For example, LAP
increases in polycythemia vera, myelofibrosis, and
leukemoid reactions to infections, but decreases in
chronic granulocytic leukemia. Because all of these
conditions have increased numbers of immature
circulating neutrophils, LAP scores can be helpful in
differentiating among them.
PERIODIC ACID–SCHIFF STAIN

In the periodic acid–Schiff (PAS) stain, compounds
that can be oxidized to aldehydes are localized by
brilliant fuschia staining. Many elements in many
tissues are PAS-positive, but in blood cells the PASpositive material of diagnostic importance is cytoplasmic glycogen. Early granulocytic precursors and
normal erythrocytic precursors are PAS-negative.
Mature RBCs remain PAS-negative, but granulocytes acquire increasing PAS positivity as they
mature.37
INDICATIONS FOR WHITE BLOOD CELL
ENZYMES STUDY

Identification of morphologically abnormal
WBCs on stained smear
Suspected leukemia or other hematologic disorders (see Table 1–12, p. 37)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A capillary sample is generally preferred for these

Activity absent
tests. The sample is spread on a slide, fixed, and
stained.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample (see Appendix I).
REFERENCES
1. Porth, CM: Pathophysiology: Concepts of Altered States, ed 5. JB
Lippincott, Philadelphia, 1998, p 113.
2. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 21.
3. Ibid, p 21.
4. Ibid, p 21.
5. Hillman, RS, and Finch, CA: Red Cell Manual, ed 7. FA Davis,
Philadelphia,1996, p 2.
6. Price, S, and Wilson, L: Pathophysiology, ed 3. McGraw-Hill, New
York, 1986, p 180.
7. Porth, op cit, p 114.
8. Sacher and McPherson, op cit, p 30.
9. Fischbach, FT: A Manual of Laboratory and Diagnostic Tests, ed 4.
JB Lippincott, Philadelphia, 1992, pp 89–91.
10. Hillman and Finch, op cit, pp 4–5.
11. Sacher and McPherson, op cit, p 32.
12. Hillman and Finch, op cit, pp 6–7.
13. Sacher and McPherson, op cit, p 32.
14. Ibid, p 41.
15. Ibid, p 41.
16. Ibid, p 43.
17. Ibid, p 32.
18. Hillman and Finch, op cit, pp 95–96.
19. Fischbach, op cit, p 88.
20. Hillman and Finch, op cit, p 42.
21. Sacher and McPherson, op cit, p 45.
22. Hillman and Finch, op cit, p 12.
23. Fischbach, op cit, p 43.
24. Sacher and McPherson, op cit, p 46.
25. Hillman and Finch, op cit, p 43.
26. Hole, JW: Human Anatomy and Physiology, ed 4. Wm C Brown,
Dubuque, Iowa, p 603.
27. Hillman and Finch, op cit, p 43.
28. Sacher and McPherson, op cit, p 44.
29. Hillman and Finch, op cit, pp 10–11.
30. Ibid, pp 87, 110.
31. Fischbach, op cit, p 82.
32. Sacher and McPherson, op cit, pp 99–100.
33. Ibid, pp 67–68.
34. Boggs, DR, and Winkelstein, A: White Cell Manual, ed 4. FA Davis,
Philadelphia, 1983, p 1.
35. Hole, op cit, pp 625–627.
36. Boggs and Winkelstein, op cit, pp 63–65.
37. Sacher and McPherson, op cit, pp 70–71.

CHAPTER

Hemostasis and Tests of
Hemostatic Functions
TESTS COVERED
Platelet Count, 42
Bleeding Time, 44
Platelet Aggregation Test, 46
Clot Retraction Test, 47
Rumple-Leeds Capillary Fragility Test
(Tourniquet Test), 48
Prothrombin Time, 49
Partial Thromboplastin Time/Activated
Partial Thromboplastin Time, 51

Whole Blood Clotting Time
(Coagulation Time, Lee-White
Coagulation Time), 52
Thrombin Clotting Time, 53
Prothrombin Consumption Time, 54
Factor Assays, 55
Plasma Fibrinogen, 57
Fibrin Split Products, 58
Euglobulin Lysis Time, 58

INTRODUCTION Hemostasis is the collective term for all the mechanisms the body uses to
protect itself from blood loss. In other words, failure of hemostasis leads to hemorrhage.
Hemostatic mechanisms are organized into three categories: (1) vascular activity, (2) platelet
function, and (3) coagulation.

VASCULAR ACTIVITY
Vascular activity consists of constriction of muscles
within the walls of the blood vessels in response to
vascular damage. This vasoconstriction narrows the
path through which the blood flows and may sometimes entirely halt blood flow. The vascular phase of
hemostasis affects only arterioles and their dependent capillaries; large vessels cannot constrict sufficiently to prevent blood loss. Even in small vessels,
vasoconstriction provides only a brief hemostasis.

PLATELET FUNCTION
Platelets serve two main functions: (1) to protect
intact blood vessels from endothelial damage
provoked by the countless microtraumas of day-today existence and (2) to initiate repair through the

formation of platelet plugs when blood vessel walls
are damaged.
When overt trauma or microtrauma damages
blood vessels, platelets adhere to the altered surface.
Adherence requires the presence of ionized calcium
(coagulation factor IV), fibrinogen (coagulation
factor I), and a protein associated with coagulation
factor VIII, called von Willebrand’s factor (vWF).
The process of adherence involves reversible changes
in platelet shape and, usually, the release of adenosine diphosphate (ADP), adenosine triphosphate
(ATP), calcium, and serotonin. With a strong
enough stimulus, the next phase of platelet activity,
platelet aggregation, occurs and results in the
formation of a loose plug in the damaged endothelium. The platelet plug aids in controlling bleeding
until a blood clot has had time to form.1
39

SECTION I—Laboratory

Tests

Platelets generate prostaglandins that ultimately
promote platelet adherence, whereas the endothelial
cells lining the blood vessels produce a different
prostaglandin that inhibits platelet aggregation.
Ingestion of aspirin inhibits the actions of the
prostaglandins released by platelets, an effect that
may persist for many days after a person takes even
a small amount of aspirin. Aspirin also may affect
the actions of the prostaglandins produced by
endothelial cells, but not to the extent that it affects
platelet prostaglandins.2 Thus, the net effect of
aspirin is to inhibit hemostasis.
Thrombin, which is generated by the coagulation
sequence (see the next section), independently
promotes the release of substances from the
platelets. Release of platelet factor 3 enhances coagulation mechanisms, thereby increasing thrombin
generation. Platelet factor 4, also released by
platelets, reinforces the interactions between coagulation and platelet aggregation by neutralizing the
naturally generated anticoagulant, endogenous
heparin.3

COAGULATION
Coagulation is a complex process by which plasma
proteins interact to form a stable fibrin gel.4 The
fibrin strands thus formed create a meshwork that
cements blood components together, a process
known as syneresis. Ultimately, a blood clot is
formed.5,6 Normal coagulation depends on the presence of all clotting factors and follows specific
sequences known as pathways or cascades.
At least 30 substances are believed to be involved
in the clotting process. The most significant ones
are shown in Table 2–1. Note that clotting factors
are now designated by Roman numerals. The
“a” indicates an activated clotting factor.7 There is
no factor VI because that number was originally assigned to what is now known to be activated
factor V.8
Each of the clotting factors is involved at a specific
step in the coagulation process, with one clotting
factor leading to activation of the next factor in the
sequence. Three major clotting sequences have been
identified: (1) the intrinsic pathway, (2) the extrinsic
pathway, and (3) the common final pathway.
The intrinsic pathway is activated when blood
comes in contact with the injured vessel wall; the
extrinsic pathway is activated when blood is exposed
to damaged tissues. Both pathways are needed for
normal hemostasis, and both lead to the common
final pathway.9 A schematic representation of the
intrinsic, extrinsic, and common pathways is shown
in Figure 2–1.

TABLE 2–1

•

Clotting Factors

Fibrinogen

Fibrin

Prothrombin

IIa

Thrombin

III

Thromboplastin, tissue
thromboplastin

Calcium, ionized calcium

Accelerator globulin (AcG),
proaccelerin, labile factor

VII

Proconvertin, autoprothrombin
I, serum prothrombin conversion
accelerator (SPCA)

VIIa

Convertin

VIII

Antihemophilic factor (AHF),
antihemophilic globulin (AHG)

Christmas factor, antihemophilic
factor B, plasma thromboplastin
component (PTC), autoprothrombin II

Stuart factor, Stuart-Prower
factor, autoprothrombin III

Plasma thromboplastin
antecedent (PTA)

XII

Hageman factor

XIII

Fibrin-stabilizing factor

The common final pathway is initiated with the
activation of factor X. Factors X and V, along with
platelet phospholipid and calcium, combine to form
prothrombin activator, which converts prothrombin
to thrombin. Thrombin subsequently converts
fibrinogen to fibrin gel. Thrombin also enhances
platelet release reactions, augments the activation of
factors V and VIII, and activates factor XIII.10 Stable
(insoluble) fibrin is formed in the presence of activated factor XIII.
Calcium plays an important role throughout the
coagulation process. It is necessary for the activation
of factors VII, IX, X, and XI; for the conversion of
prothrombin (factor II) to thrombin; and for the
formation of fibrin. However, hypocalcemia does
not usually cause bleeding difficulties because
cardiac arrest occurs before levels are low enough to
precipitate abnormal hemostasis. Citrate, oxalate,
and ethylenediaminetetra-acetic acid (EDTA) are
anticoagulants because they bind calcium and
prevent it from participating in the clotting process.
Any one of these substances may be added to the
vacuum tubes used to collect peripheral blood

CHAPTER 2—Hemostasis

and Tests of Hemostatic Functions

Image/Text rights unavailable

samples when an uncoagulated specimen is needed
(see Appendix I, Table A–1).11

ANTAGONISTS TO HEMOSTASIS
Both platelet activation and coagulation are selfperpetuating processes that could potentially
continue until an injured vessel is completely
occluded. Coagulation inhibitors are present to
prevent excessive clotting and to dissolve the clot as
tissue repair occurs.
Maintaining adequate blood flow aids in diluting
and removing clotting factors and in dispersing
aggregated platelets. Partially activated coagulation
factors are carried to the liver and the reticuloendothelial system, where they are degraded.12 Two
specific anticoagulation mechanisms also help to
prevent excessive clotting: (1) the fibrinolytic system
and (2) the antithrombin system.
In the fibrinolytic system, fibrin strands are
broken down into progressively smaller fragments
by a proteolytic enzyme, plasmin. Although plasmin
does not circulate in active form, its precursor, plas-

minogen, does. Plasminogen is converted into plasmin by several plasminogen activators, among them
factor XII, urokinase, and streptokinase. Once activated, plasmin digests fibrin, splits fibrinogen into
peptide fragments (fibrin split products [FSP]), and
degrades factors V, VIII, and XIII. In addition, the
FSP interfere with platelet aggregation, reduce
prothrombin, and interfere with conversion of soluble fibrin to insoluble fibrin. Plasma also contains
agents that neutralize plasmin itself. Among these
are antiplasmin and 1-antitrypsin. A balance
between proplasmin and antiplasmin substances
aids in maintaining normal coagulation.13
The antithrombin system protects the body from
excessive clotting by neutralizing the clotting capability of thrombin.14 Although various substances
inhibit thrombin, the most important one is
antithrombin III (AT III), a substance that abolishes
the activity of thrombin (activated factor II); activated factors X, XI, and XII; and plasmin. Another
name for AT III is heparin cofactor. Heparin
augments by approximately 100 times the affinity of
AT III and the activated clotting factors on which it

SECTION I—Laboratory

Tests

acts. A deficiency of AT III, which can be congenital
or acquired, makes an individual prone to excessive
clotting. Platelet factor 4, which is released when
platelets are broken down, inhibits AT III activity.15

• Overview of Causes
of Altered Platelet Function

TABLE 2–2

Increased
Function

Decreased
Function

PLATELET STUDIES

Trauma

Circulating platelets (thrombocytes) are anuclear,
cytoplasmic disks that bud off from megakaryocytes,
large multinucleated cells found in the bone
marrow16,17 (see Fig. 1–2). Platelets survive in the
circulation for about 10 days.
Regulation of platelet production is ascribed to
thrombopoietin by analogy to erythropoietin (see
Chapter 1), although no single substance has been
specifically identified. With pronounced hemostatic
stress or marrow stimulation, platelet production
can increase to seven to eight times that of normal
production. Newly generated platelets are larger and
have greater hemostatic capacity than mature circulating platelets.18
Two thirds of the total number of platelets are in
the systemic circulation, and the remaining third
exists as a pool of platelets in the spleen. The pool
exchanges freely with the general circulation.19 The
spleen also aids in removing old or damaged
platelets from the circulation. In disorders involving
exaggerated splenic activity (hypersplenism), 90
percent of the body’s platelets may be trapped in the
enlarged spleen, and the client is predisposed to
excessive bleeding. Hypersplenism is seen in certain
acute infections (e.g., infectious mononucleosis,
miliary tuberculosis), connective tissue diseases
(e.g., rheumatoid arthritis, lupus erythematosus),
myeloproliferative diseases (e.g., leukemias,
lymphomas, hemolytic anemias), and chronic liver
diseases (e.g., cirrhosis).20
The functions of platelets are discussed in the
introduction to this chapter. In general, individuals
with too few platelets or with platelets that function
poorly experience numerous pinpoint-sized hemorrhages (petechiae) and multiple small, superficial
bruises (ecchymoses). Frequently, there is generalized oozing from mucosal surfaces and from
venipuncture sites or other small, localized injuries.
Large, deep hematomas and bleeding into joints are
not characteristic of platelet deficiency (thrombocytopenia).21
Platelet studies involve evaluating the number
and function of circulating platelets. Platelet
numbers are assessed by the platelet count (see the
next section). Disorders of platelet function (thrombopathies) are less common than disorders of
platelet number. An overview of the causes of altered
platelet function is provided in Table 2–2.

Surgery

Uremia

Fractures

Myeloproliferative disorders

Strenuous
exercise

Dysproteinemias

Severe liver disease

Glanzmann’s thrombasthenia
Pregnancy

Bernard-Soulier syndrome
(hereditary giant platelet
syndrome)
Idiopathic thrombocytopenic
purpura
Infectious mononucleosis
von Willebrand’s disease
Drugs such as aspirin and
other anti-inflammatory
agents, antihistamines, antidepressants, alcohol,
methylxanthines

PLATELET COUNT
Platelets may be counted manually or with electronic counting devices. Although larger numbers of
platelets are capable of being examined with electronic counting, the procedure is subject to error if
(1) the white blood cell (WBC) count is greater than
10,000 cells per cubic millimeter, (2) there is severe
red blood cell fragmentation, (3) the diluting fluid
contains extraneous particles, (4) the plasma sample
settles too long during processing, or (5) platelets
adhere to one another.
Causes of increased numbers of platelets (thrombocytosis, thrombocythemia) and decreased
numbers of platelets (thrombocytopenia) are
presented in Table 2–3.
Mean platelet volume can also be determined by
the electronic automated method. The test reveals
the size of platelets important in the diagnosis of
disorders affecting the hematologic system. An
increased volume of platelets that are larger than
normal in diameter is found in lupus erythematosus, thrombocytopenic purpura, B12-deficiency
anemia, hyperthyroidism, and myelogenic and other
myeloproliferative diseases. A decreased volume of
the larger sized platelets is found in Wiskott-Aldrich
syndrome.22

CHAPTER 2—Hemostasis

TABLE 2–3

•

and Tests of Hemostatic Functions

Causes of Altered Platelet Levels
Decreased Levels (Thrombocytopenia)

Increased Levels
(Thrombocytosis)

Decreased
Production

Increased
Destruction

Leukemias (chronic)

Vitamin B12/folic acid deficiencies

Idiopathic thrombocytopenic purpura

Polycythemia vera

Radiation

Splenomegaly caused by liver
disease

Anemias (posthemorrhagic
and iron-deficiency)

Viral infections

Lymphomas

Splenectomy

Leukemias (acute)

Hemolytic anemias

Tuberculosis and other
acute infections

Histiocytosis

Rocky Mountain spotted fever

Hemorrhage

Bone marrow malignancies

Sarcoidosis

Carcinomatosis

Fanconi’s syndrome

Meningococcemia

Trauma

Wiskott-Aldrich syndrome

Antibody/HLA-antigen reactions

Surgery

Uremia

Hemolytic disease of the newborn

Chronic heart disease

Drugs such as anticancer drugs,
anticonvulsants, alcohol, carbamates, chloramphenicol,
chlorothiazides, isoniazid, pyrazolones, streptomycin, sulfonamides, sulfonylureas

Congenital infections
(cytomegalovirus [CMV], herpes,
syphilis, toxoplasmosis)

Cirrhosis
Chronic pancreatitis
Childbirth
Drugs such as epinephrine

Disseminated intravascular coagulation (DIC)
Immune complex formation
Chronic cor pulmonale
Miliary tuberculosis
Burns
Drugs and chemicals such as aspirin,
benzenes, DDT, digitoxin, gold
salts, heparin, quinidine, quinine,
thiazides

Reference Values
Values vary slightly across the life cycle, with
lower platelet counts seen in newborns (see
Table 1–4).
150,000 to 450,000 per cubic millimeter (average 250,000 per cubic millimeter)
Mean platelet volume 25 m diameter

Critical values: 20,000 U/L or 1,000,000
U/L

INTERFERING FACTORS

Altered test results may occur if:
The WBC count is greater than 100,000 per
cubic millimeter.
There is severe red blood cell fragmentation.

The fluid used to dilute the sample contains
extraneous particles.
The plasma sample settles too long during
processing.
Platelets adhere to one another.
The client is receiving drugs that alter
platelet functions and numbers (see Tables 2–2
and 2–3).
Traumatic venipunctures may lead to erroneous
results as a result of activation of the coagulation
sequence.
Excessive agitation of the sample may cause the
platelets to clump together and adhere to the walls
of the test tube, thus altering test results.
INDICATIONS FOR PLATELET COUNT

Family history of bleeding disorder

SECTION I—Laboratory

Tests

Signs of abnormal bleeding such as epistaxis, easy
bruising, bleeding gums, hematuria, and menorrhagia
Determination of effects of diseases and drugs
known to alter platelet levels (see Table 2–3)
Identification of individuals who may be prone to
bleeding during surgical, obstetric, dental, or
invasive diagnostic procedures, as indicated by a
platelet count of approximately 50,000 to 100,000
per cubic millimeter
Identification of individuals who may be prone to
spontaneous bleeding, as indicated by a platelet
count of less than 15,000 to 20,000 per cubic
millimeter
Differentiation between decreased platelet
production and decreased platelet function:
Platelet dysfunction is defined as a long bleeding time with a platelet count of greater than
100,000/mm3.23
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are essentially the same as for any study involving the collection of a peripheral blood sample. Because the client
may have a platelet deficiency, maintain digital pressure directly on the puncture site for 3 to 5 minutes
after the needle is withdrawn. Also, inspect the site
for excessive bruising after the procedure.
Abnormal increase (thrombocytosis): Note and
report signs of dehydration and input and output
(I&O) ratio that can contribute to venous stasis,
possible thrombosis, or bleeding tendency if the
coagulation process is affected. Administer
ordered aspirin and antacid, and observe for
bleeding tendency if prothrombin time is
increased.
Abnormal decrease (thrombocytopenia): Note
and report petechiae, bruising, or hematoma.
Administer ordered corticosteroids. Protect children from trauma, advise adults to use soft toothbrushes and electric razors, and prevent other
trauma by padding side rails and avoiding intramuscular and subcutaneous injections. Assess

bleeding from skin and mucous membranes
(petechiae, ecchymoses, epistaxis, feces, urine,
emesis, sputum). Administer platelet transfusion
and assess for any allergic responses, sepsis, or
hypervolemia.
Critical values: Notify the physician immediately if the platelet count is less than 20,000/mL
or greater than 1 million/mL. Prepare for transfusion of platelets by intravenous drip or bolus
infusion.

BLEEDING TIME
One of the best indicators of platelet deficiency is
prolonged bleeding after a controlled superficial
injury; that is, capillaries subjected to a small, clean
incision bleed until the defect is plugged by aggregating platelets. When platelets are inadequate in
number or if their function is impaired, bleeding
time is prolonged.
If the platelet count falls below 10,000/mm3,
bleeding time is prolonged. Prolonged bleeding time
with a platelet count of greater than 100,000/mm3
indicates platelet dysfunction. Bleeding time is
prolonged in von Willebrand’s disease, an inherited
deficiency of vWF, a protein associated with clotting
factor VIII that is necessary for normal platelet
adherence. Aspirin ingestion also prevents platelet
aggregation and may prolong bleeding time for as
long as 5 days after a single 300-mg dose.24 Other
causes of prolonged bleeding times are listed in
Table 2–4.
Reference Values
Method

Normal Values

Duke

1–3 min

Ivy

3–6 min

Template

3–6 min

Values vary according to the method used to
perform the test (see the section on procedure).
When the platelet count is low, bleeding time may
be calculated from platelet numbers using the
following formula. The result should be evaluated in
relation to the normal values for the Ivy and
template methods.
Bleeding time 30.5 – platelet count/mm3
3850
The calculated value also may be compared with
the actual results of bleeding time obtained by the
Ivy and template methods. An actual bleeding time

CHAPTER 2—Hemostasis

TABLE 2–4

•

and Tests of Hemostatic Functions

Causes of Prolonged Bleeding Time

Drugs

Diseases

Alcohol

Aplastic anemia

Anticoagulants

Bernard-Soulier syndrome (hereditary
giant plate syndrome)

Aspirin and other salicylates
(OTC cold remedies, analgesics)

Connective tissue diseases

Chlorothiazides

Glanzmann’s thrombasthenia

High-molecular-weight dextran

Hepatic cirrhosis

Mithramycin

Hypersplenism

Streptokinase

Hypothyroidism

Sulfonamides

Leukemias

Thiazide diuretics

Malignancies such as Hodgkin’s disease and
multiple myeloma

Disseminated intravascular coagulation (DIC)

Measles
Mumps
Scurvy
von Willebrand’s disease

longer than the calculated result suggests defective
platelet function in addition to reduced numbers. It
is also possible to detect above-normal hemostatic
capacity in cases in which active young platelets
compose the entire population of circulating
platelets, because young platelets have enhanced
hemostatic capabilities.25 This phenomenon may be
seen in disorders involving increased platelet
destruction (see Table 2–3).
INTERFERING FACTORS

Ingestion of aspirin and aspirin-containing
medications within 5 days of the test may prolong
the bleeding time. Other drugs that may prolong
bleeding time are listed in Table 2–4.
INDICATIONS FOR BLEEDING TIME TEST

Family history of bleeding disorders, especially
von Willebrand’s disease (Tests of platelet adhesiveness and levels of factor VIII also are necessary
to confirm the diagnosis of von Willebrand’s
disease.)
Signs of abnormal bleeding such as epistaxis, easy
bruising, bleeding gums, hematuria, and menorrhagia
Thrombocytopenia as indicated by platelet count
Identification of individuals who may be prone to

bleeding during surgical, obstetric, dental, or
invasive diagnostic procedures
Determination of platelet dysfunction as indicated by a prolonged bleeding time with a platelet
count of greater than 100,000 per cubic millimeter
Determination of effects of diseases and drugs
known to affect bleeding time (see Table 2–4)
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That the test will be performed by a laboratory
technician and requires approximately 15 minutes
The procedure, including the momentary
discomfort to be expected when the skin is incised
Aspirin and aspirin-containing medications
should be withheld for at least 5 days before the test.
Other drugs that may prolong bleeding time (see
Table 2–4) should also be withheld.
THE PROCEDURE

The test may be performed using the Duke, Ivy, or
template method. All three methods involve piercing
the skin and observing the duration of bleeding time
from the puncture site. Welling blood must be
removed, but gently so as not to disrupt the fragile
platelet plug. After the skin is pierced, oozing blood

SECTION I—Laboratory

Tests

is removed at 15-second intervals by touching filter
paper to the drop of blood without touching the
wound itself. As platelets accumulate, bleeding slows
and the oozing drop of blood gets smaller. The end
point occurs when there is no fluid blood left to
produce a spot on the filter paper.26 The test is timed
with a stopwatch.
For all methods, the site to be used is cleansed
with antiseptic and allowed to dry. In the Duke
method, the earlobe is incised 3 mm deep with a
sterile lancet. For the Ivy and template methods, the
volar surface of the forearm is used. A blood pressure cuff is applied above the elbow and inflated to
40 mm Hg; the pressure is maintained throughout
the test. In the Ivy method, two incisions 3 mm deep
are made freehand with sterile lancets. In the
template method, two incisions, each 1 mm deep
and 9 mm long, are made with a standardized
template. The advantage of the template method is
the fact that it provides the ability to achieve a reproducible, precise incision every time.
The elapsed time at the point when bleeding
ceases is recorded. If bleeding persists beyond 10
minutes, the test is discontinued and a pressure
dressing is applied to the puncture site(s).
NURSING CARE AFTER THE PROCEDURE

When the test is completed, a sterile dressing or
Band-Aid is applied to the site. For persistent bleeding, ice may be applied to the site in addition to the
pressure dressing.
Observe the puncture site(s) every 5 minutes for
bleeding. Clients with clotting factor disorders
may rebleed after initial bleeding has stopped.
This may occur approximately 20 to 30 minutes
after the initial procedure.
Check the puncture site(s) at least twice daily for
infection or failure to heal.
For the Ivy and template methods, assess for
excessive bruising at the blood pressure cuff application site.

• Drugs That Impair
Platelet Aggregation

TABLE 2–5

Aminophylline

Phenothiazines

Antihistamines

Phenylbutazone

Anti-inflammatory drugs,
both steroids and
nonsteroidal types

Salicylates
Sulfinpyrazone

Caffeine

Tricyclic
antidepressants

Dipyridamole

of a test tube. Normally, platelet aggregates should
be visible in less than 5 minutes.
Platelet aggregation in response to specific inducing agents is diagnostic for specific disorders.
Aspirin, other anti-inflammatory agents, and many
phenothiazines markedly inhibit the aggregating
effect of collagen and epinephrine but do not interfere with the direct action of added ADP. Also,
conditions that depress the release-inducing effects
of collagen and epinephrine and of directly added
ADP affect platelet aggregation.
Individuals with von Willebrand’s disease have
platelets that respond normally to epinephrine,
collagen, and ADP. Without vWF in their plasma,
however, the platelets will not be aggregated by ristocetin.28
Other disorders that may impair platelet aggregation include Glanzmann’s thrombasthenia, BernardSoulier syndrome (hereditary giant platelet
syndrome), idiopathic thrombocytopenic purpura,
and infectious mononucleosis. Drugs that interfere
with platelet aggregation are listed in Table 2–5.
Reference Values
Platelet aggregates should be visible in less than
5 minutes.

PLATELET AGGREGATION TEST
Platelet aggregation can be measured by bringing
platelet-rich plasma into contact with known inducers of platelet aggregation. Most inducers, such as
collagen, epinephrine, and thrombin, act through
the effects of ADP, which is released by the platelets
themselves. Adding exogenous ADP causes platelet
aggregation directly. Ristocetin, an antibiotic, may
also be used for this test.27
Platelet aggregation is quantified by determining
whether platelet-rich plasma becomes clear as evenly
suspended platelets aggregate and fall to the bottom

INTERFERING FACTORS

Ingestion of aspirin and other drugs known to
interfere with platelet aggregation within 5 to 7
days of the test (see Table 2–5).
Delay in processing the sample or excessive agitation of the sample may alter test results.
INDICATIONS FOR PLATELET AGGREGATION TEST

Suspected von Willebrand’s disease or other
inherited platelet disorder
Evaluation of platelet aggregation in clients with

CHAPTER 2—Hemostasis

disorders known to cause alterations (e.g.,
uremia, severe liver disease, myeloproliferative
disorders, dysproteinemias)
Therapy with drugs known to alter platelet aggregation (see Table 2–5)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I). It is generally recommended that the person abstain from food for 8
hours before the test and, if possible, from drugs that
may impair platelet aggregation for 5 to 7 days
before the test.
THE PROCEDURE

and Tests of Hemostatic Functions

If fibrinogen levels are low, the initial clot is so
fragile that the fibrin strands rupture, and red blood
cells spill into serum when retraction begins. If there
is excessive fibrinolysis, as often happens with
reduced fibrinogen levels, the incubated tube may
contain only cells and fibrin with no fibrin clot at all.
Low fibrinogen levels and excessive fibrinolysis are
seen in disseminated intravascular coagulation
(DIC).29
The clot retraction test also can be modified to
demonstrate the inhibitory effect of antiplatelet
antibodies, especially those associated with drugs.
Clot retraction is abolished if more than 90 percent
of platelet activity is neutralized. Serum suspected of
containing antibodies can be added to normal blood
to see if retraction is inhibited.30

A venipuncture is performed and the sample
collected in a light-blue-topped tube.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as for any study involving the collection of a peripheral blood sample. Because the client
may have platelet deficiency, maintain digital pressure directly on the puncture site for 3 to 5 minutes
after the needle is withdrawn. Also, inspect the site
for excessive bruising after the procedure.
Complications and precautions: Note and report
drugs that alter platelet aggregation and discontinue if test results indicate prolonged aggregation. Report any abnormal test results to the
physician.

CLOT RETRACTION TEST
When blood collected in a test tube first clots, the
entire column of blood solidifies. As time passes, the
clot diminishes in size. Serum (the fluid remaining
after blood coagulates) is expressed, and only the red
blood cells remain in the shrunken fibrin clot.
Because platelets are necessary for this process, the
speed and extent of clot retraction roughly reflect
the adequacy of platelet function. Individuals with
thrombocytopenia or platelet dysfunction, for
example, have samples with scant serum and a soft,
plump, poorly demarcated clot.
The results of the clot retraction test should be
evaluated in relation to other hematologic, platelet,
and coagulation studies. If the client has a low hematocrit, for example, the clot is small and the volume
of serum is great. In contrast, individuals with polycythemia or hemoconcentration have poor clot
retraction because the numerous red blood cells
contained in the clot separate the fibrin strands and
interfere with normal retraction.

Reference Values
A normal clot, gently separated from the side of
the test tube and incubated at 98.6F (37C),
shrinks to about half its original size within 1
hour. The result is a firm, cylindrical fibrin clot
that contains all of the red blood cells and is
sharply demarcated from the clear serum.

INTERFERING FACTORS

Rough handling of the sample alters clot formation.
INDICATIONS FOR CLOT RETRACTION TEST

Evaluation of adequacy of platelet function
Evaluation of thrombocytopenia of unknown
etiology
Suspected antiplatelet antibodies resulting from
immune disorders or drug-antibody reactions
Suspected abnormalities of fibrinogen or fibrinolytic activity
Monitoring of response to conditions that predispose to DIC
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and approximately 5
mL of blood is collected in a red-topped tube. The
sample is promptly sent to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essen-

SECTION I—Laboratory

TABLE 2–6

•

Tests

Causes of Positive Rumple-Leeds Capillary Fragility Test

Strongly positive (grade 4)

Aplastic anemia
Chronic renal disease
Glanzmann’s thrombasthenia
Idiopathic thrombocytopenic purpura (ITP)
Leukemia
Thrombocytopenia caused by acute infectious disease
(measles, influenza, scarlet fever)

Moderately positive (grade 3)

Hepatic cirrhosis

Slightly positive (grade 2)

Allergic and senile purpuras
Decreased estrogen levels
Deficiency of vitamin K, factor VII, fibrinogen, or prothrombin
Dysproteinemia
Polycythemia vera
von Willebrand’s disease

tially the same as for any study involving the collection of a peripheral blood sample.
Because the client may have platelet dysfunction
or deficiency, maintain digital pressure directly on
the puncture site for 3 to 5 minutes after the
needle is withdrawn.
Inspect the site for excessive bruising after the
procedure.

RUMPLE-LEEDS CAPILLARY FRAGILITY
TEST (TOURNIQUET TEST)
The capillary fragility test indicates the ability of
capillaries to resist rupturing under pressure.
Excessive capillary fragility may be caused by either
abnormalities of capillary walls or thrombocytopenia. The causes of positive test results are listed in
Table 2–6.
The test is performed by applying a blood pressure cuff inflated to 100 mm Hg to the client’s arm
for 5 minutes. The resulting petechiae in a circumscribed area are then counted.
This test is unnecessary in the presence of obvious
petechiae or large ecchymoses. It also should not be
performed on clients known to have or suspected of
having DIC.
INTERFERING FACTORS

Repetition of the test on the same extremity
within 1 week will yield inaccurate results.
INDICATIONS FOR RUMPLE-LEEDS CAPILLARY
FRAGILITY TEST (TOURNIQUET TEST)

History of “easy bruising” or production of

Reference Values
Fewer than 10 petechiae (excluding those that
may have been present before the test) in a 2inch circle is considered normal. Results may
also be reported according to the following scale,
with grade 1 indicating a normal or negative
result. Causes of positive results are listed in
Table 2–6.
Grade

Petechiae per 2-Inch Circle

0–10

10–20

20–50

petechiae by the application of a tourniquet for
venipuncture
Verification of increased capillary fragility,
although the test itself is not specific for any
particular bleeding disorder (see Table 2–6)
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
The procedure, including the degree of discomfort to be expected from the inflated blood pressure cuff
Inspect the client’s forearms and select a site that
is as free as possible of petechiae. Measure an area 2
inches in diameter; the site may be circled lightly
with a felt-tipped marker if necessary for reference.

CHAPTER 2—Hemostasis

If petechiae are present in the site to be measured,
note and record the number.
THE PROCEDURE

A blood pressure cuff is applied to the arm and
inflated to 100 mm Hg. The pressure is maintained
for 5 minutes. The blood pressure cuff is then
removed and the petechiae counted and the number
recorded.
NURSING CARE AFTER THE PROCEDURE

There is no specific aftercare. If the arm feels
“tense” or “full,” it may be elevated for a few
minutes to hasten venous drainage.
Complications and precautions: Note and report
tendency for easy bruising or presence of
petechiae. Take measures to prevent trauma to the
skin and mucous membranes if results are above
the normal values.

COAGULATION STUDIES
Coagulation studies are performed to evaluate the
components and pathways of the coagulation
sequence. Innumerable tests have been devised to
diagnose inherited, acquired, and iatrogenic deficiencies of coagulation. Some of these require
specialized techniques or rare reagents available only
in laboratories that perform many such tests. Other
tests are less precisely diagnostic but more available
and more readily applicable to immediate clinical
situations. The tests included here are widely available.
Screening tests of hemostatic function include the
platelet count, bleeding time, prothrombin time,
and partial thromboplastin time. When a “coagulation profile” or “coagulogram” is ordered, it includes
the four screening tests plus clotting time and activated partial thromboplastin time.

PROTHROMBIN TIME
The prothrombin time (PT, pro time) test is used to
evaluate the extrinsic pathway of the coagulation
sequence. It represents the time required for a firm
fibrin clot to form after tissue thromboplastin (coagulation factor III) and calcium are added to the
sample. These added substances directly activate
factor X, the key factor in all three coagulation pathways (see Fig. 2–1). Neither platelets nor the factors
involved in the intrinsic pathway are necessary for
the clot to form.
To give a normal PT result, plasma must have at
least 100 mg/dL of fibrinogen (normal: 150 to 400
mg/dL) and adequate levels of factors X, VII, V, and
II (prothrombin). Because the test bypasses the clot-

and Tests of Hemostatic Functions

ting factors of the intrinsic pathway, the PT cannot
detect the two most common congenital coagulation disorders: (1) deficiency of factor VIII (hemophilia A, or “classic” hemophilia) and (2) deficiency of factor IX (hemophilia B, or Christmas
disease). Also, thrombocytopenia does not prolong
the PT.
PT measurements are reported as time in seconds
or as a percentage of normal activity, or both. Time
in seconds indicates the length of time for the blood
to clot when chemicals are added in comparison to
normal blood with the same chemicals added
(control value). A value that is higher than the
control sample is considered to be deficient in
prothrombin. Some laboratories report the results in
percentages that are derived from a plotted graph
based on dilutions of the control samples and the
time in seconds it takes for the sample to clot; the
seconds are then converted to percentages. The time
then reflects the percentage of normal clotting time
by comparing the client’s clotting time to its intersection point with the percentage on the graph.
Usually an increase in time for clotting equals a
decrease in the percentage of activity, although
different laboratories can obtain different results
when determining the percentages. This difference is
because of the different thromboplastins used as
reagents in the testing procedure.
Because the variability in responsiveness to the
different thromboplastins has resulted in dosing
differences, a thromboplastin has been developed by
the first International Reference Preparation. This
reagent is used to monitor the therapeutic levels for
coagulation during coumarin-type therapy. A standardization of reporting the PT assay test results
developed by the World Health Organization has
been adopted for this reagent. It is known as the
International Normalized Ratio (INR). The INR is
calculated with the use of a nomogram developed to
demonstrate the relationship between the INR and
the prothrombin ratios with the International
Sensitivity Index range (values associated with the
available thromboplastin reagents from the various
companies that develop them). PT evaluation can
now be based on the INR and both are reported as
PT and its equivalent INR for evaluation and decisions in oral anticoagulation therapy as endorsed
by the Committee on Antithrombotic Therapy of
the American College of Chest Physicians, the
Committee for Thrombosis and Hemostasis, and the
International Committee for Standardization in
Hematology. The recommended INR therapeutic
range for oral anticoagulant therapy is 2.0 to 3.0 in
the treatment of venous thrombosis, pulmonary
embolism, and the prevention or treatment of
systemic embolism. A pro time test system is now

SECTION I—Laboratory

Tests

Reference Values
Conventional Units
Newborns

SI Units

12–21 sec

12–21 s

Men

9.6–11.8 sec

9.6–11.8 s

Women

9.5–11.3 sec

9.5–11.3 s

2.0–3.0 sec for anticoagulation,
higher (3.0–4.5 sec) for recurrent
systemic embolization

2.0–3.0 s
3.0–4.5 s for recurrent systemic
embolization

Adults

INR

Critical values 8–9 sec below control or 40 sec

available to perform immediate measurement of PT
at the bedside using a fresh whole blood sample,
reagent cartridges, and a monitor that operates on
rechargeable batteries.
Prothrombin is a vitamin K–dependent protein
produced by the liver. Thus, any disorder that
impairs the liver’s ability to use vitamin K or to form
proteins (e.g., the various types of cirrhosis)
prolongs the PT. Anticoagulants of the coumarin
family act by inhibiting hepatic synthesis of the vitamin K–dependent factors II, VII, IX, and X. A natural anticoagulant system dependent on the action of
vitamin K on the proteins C and S is different from
the activity of this vitamin on coagulation factors II,
VII, IX, and X. Protein C acts to neutralize the activity of factors VIIIa and Va, and protein S increases
the inactivation of VIIIa and Va by the protein C.
Any deficiency of the various factors can alter the
balance between the two proteins and result in
thrombotic disorders. The tests are performed to
determine their functional activity and reveal a
tendency toward hypercoagulation and thrombosis
or to diagnose a hereditary deficiency.
Because values may vary according to the source
of the substances added to the sample and the type
of laboratory equipment used, the result is usually
evaluated in relation to a control sample obtained
from an individual with normal hemostatic function.
Test results are sometimes given as a percentage of
normal activity, comparing the client’s results
against a curve that shows the normal clotting rate of
diluted plasma. The normal value in this case is 100
percent; however, the method itself is thought to be
inaccurate because dilution affects the clotting
process.

8–9 s below control or 40 s

INTERFERING FACTORS

Numerous drugs may alter the PT results, including
the following:
Drugs that prolong the PT, such as coumarin
derivatives, quinidine, quinine, thyroid hormones,
adrenocorticotropic hormone, steroids, alcohol,
phenytoin, indomethacin, and salicylates
Drugs that may shorten the PT, such as barbiturates (especially chloral hydrate), oral contraceptives, and vitamin K31
Traumatic venipuncture may lead to erroneous
results because of activation of the coagulation
sequence.
Excessive agitation of the sample may erroneously prolong the PT.
A fibrinogen level of less than 100 mg/dL
(SI units, 1.00 g/L) (normal: 150 to 400 mg/dL
[SI units, 1.50–4.00 g/L]) may prolong the
PT.
INDICATIONS FOR PROTHROMBIN TIME

Signs of abnormal bleeding such as epistaxis, easy
bruising, bleeding gums, hematuria, and menorrhagia
Identification of individuals who may be prone to
bleeding during surgical, obstetric, dental, or
invasive diagnostic procedures
Evaluation of response to anticoagulant therapy
with coumarin derivatives and determination of
dosage required to achieve therapeutic results
Differentiation of clotting factor deficiencies of V,
VII, and X, which prolong the PT, from congenital coagulation disorders such as hemophilia A
(factor VIII) and hemophilia B (factor IX), which
do not alter the PT

CHAPTER 2—Hemostasis

Monitoring of effects on hemostasis of conditions
such as liver disease, protein deficiency, and fat
malabsorption
NURSING CARE BEFORE THE PROCEDURE

In general, client preparation is the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
Because many drugs may affect the PT result, all
medications taken by the client should be noted.
If the individual is receiving anticoagulant therapy, the time and the amount of the last dose
should be noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a light-blue-topped tube. Traumatic
venipunctures and excessive agitation of the sample
should be avoided.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as for any study involving the collection of a peripheral blood sample.
Because the client may have a coagulation deficiency, maintain digital pressure directly on the
puncture site for 3 to 5 minutes after the needle is
withdrawn.
Inspect the site for excessive bruising after the
procedure.
Bleeding episode: Note and report increase in
PT, medications taken that affect the PT and
expected test values, symptoms such as bleeding
from any area (blood in sputum, feces, urine;
bleeding from nose, skin), headache, increased
pulse, or pain in the abdomen or back. Report
changes related to administration of coumarintype medication and adjust drug dosage as
ordered until desired INR is reached. Protect
skin, mucous membranes, and organs from
trauma (shaving, brushing teeth, suctioning,
intramuscular [IM], subcutaneous [SC], and
intravenous [IV] injections, falls, activities that
are strenuous, straining). Test for occult blood
in body secretions and excretions. Inform
client to avoid drugs that potentiate the effect
of coumarin-type drugs. Instruct client in
importance and frequency of PT laboratory
testing.
Venous thrombosis: Note and report decreases
in PT or other factors predisposing to formation of venous thrombi. Provide leg exercises
and adequate fluid intake. Advise client to avoid
crossing legs, wearing constrictive clothing, or
participating in other activities that impair

and Tests of Hemostatic Functions

circulation. Inform client of importance and
frequency of PT testing.
Critical values: Notify the physician immediately of an increase of greater than 40 seconds
or 15 seconds above the control time. Prepare
the client for administration of IM vitamin K or
IV frozen plasma. Notify the physician immediately of an increase of greater than 24
seconds in individuals with a liver disease if
they are experiencing hypoprothrombinemia
from vitamin K deficiency. Notify the physician immediately if there is a decrease of less
than 8 to 9 seconds or 11 to 12 seconds below
the control time. Prepare the client for possible SC administrations of heparin.

PARTIAL THROMBOPLASTIN
TIME/ACTIVATED PARTIAL
THROMBOPLASTIN TIME
The partial thromboplastin time (PTT) test is used
to evaluate the intrinsic and common pathways of
the coagulation sequence. It represents the time
required for a firm fibrin clot to form after phospholipid reagents similar to thromboplastin reagent
are added to the specimen. Because coagulation
factor VII is not required for the PTT, the test
bypasses the extrinsic pathway (see Fig. 2–1).
To give a normal PTT result, factors XII, XI, IX,
VIII, X, V, II (prothrombin), and I (fibrinogen) must
be present in the plasma. The PTT is more sensitive
than the PT in detecting minor deficiencies of clotting factors because factor levels below 30 percent of
normal prolong the PTT.
The activated partial thromboplastin time (aPTT)
is essentially the same as the PTT but is faster and
more reliably reproducible. In this test, the thromboplastin reagent may be kaolin, celite, or ellagic
acid, all of which more rapidly activate factor XII.
It is possible to infer which factors are deficient by
comparing the results of the PTT with those of the
PT. A prolonged PTT with a normal PT points to a
deficiency of factors XII, XI, IX, and VIII and to von
Willebrand’s disease. In contrast, a normal PTT with
a prolonged PT occurs only in factor VII deficiency.32
In addition to heparin therapy and coagulation
factor deficiencies, the following also prolong the
PTT: circulating products of fibrin and fibrinogen
degradation, polycythemia, severe liver disease, vitamin K deficiency, DIC, and established therapy with
coumarin anticoagulants.
INTERFERING FACTORS

Heparin and established therapy with coumarin
derivatives alter the PTT.

SECTION I—Laboratory

Tests

Reference Values
Newborns

Time in seconds is higher up to 3 mo of age than for adults

Adults
PTT

30–45 sec

aPTT

35–45 sec*

Critical values

>20 sec more than control if not receiving heparin therapy
53 sec or >2.5 times control if receiving heparin therapy

* Values can vary among laboratories.

Traumatic venipunctures may lead to erroneous
results because of activation of the coagulation
sequence.
Excessive agitation of the sample may prolong the
PTT.
INDICATIONS FOR PTT/APTT TEST

Signs of abnormal bleeding such as epistaxis, easy
bruising, bleeding gums, hematuria, and menorrhagia
Identification of individuals who may be prone to
bleeding during surgical, obstetric, dental, or
invasive diagnostic procedures
Evaluation of responses to anticoagulant therapy
with heparin or established therapy, or both, with
coumarin derivatives and determination of
dosage required to achieve therapeutic results
Detection of congenital deficiencies in clotting
factors such as hemophilia A (factor VIII) and
hemophilia B (factor IX), which alter the PTT
Monitoring of effects on hemostasis of conditions
such as liver disease, protein deficiency, and fat
malabsorption
NURSING CARE BEFORE THE PROCEDURE

In general, client preparation is the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
If the individual is receiving anticoagulant therapy, the time and the amount of the last dose
should be noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a light-blue-topped tube. Traumatic
venipunctures and excessive agitation of the sample
should be avoided.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as for any study involving the collection of a peripheral blood sample.

Because the client may have a coagulation deficiency, maintain digital pressure directly on the
puncture site for 3 to 5 minutes after the needle is
withdrawn.
Inspect the site for excessive bruising after the
procedure.
Bleeding episode: Report increase in PTT or
aPTT during heparin therapy; note that a therapeutic range is maintained (usually 1.5 to 2.5
times the control). Note also (1) drugs taken
that can interfere with the action of heparin
therapy, (2) the administration of prophylactic
low-dose heparin that does not require PTT
testing, and (3) symptoms such as bleeding
from any area (blood in sputum, urine, feces;
bleeding from nose, skin, mucous membranes).
Adjust dosage according to physician order.
Protect from trauma to skin, mucous
membranes, organs, and joints (falls; rough
handling of extremities; shaving; brushing
teeth; IM, SC, and IV injections; suctioning).
Test for occult blood in body secretions and
excretions. Inform client to avoid drugs that
affect the PTT. Provide special considerations to
allay anxiety related to possible bleeding
tendencies.
Critical values: Notify the physician at once
of an increase of greater than 20 seconds
above the control if the individual is not
receiving heparin therapy. If heparin therapy
is administered, a PTT level of less than 53
seconds indicates an inadequate anticoagulation effect; the physician should be told
immediately if a level is greater than 2.5
times the control time level.

WHOLE BLOOD CLOTTING TIME
(COAGULATION TIME, LEE-WHITE
COAGULATION TIME)
Whole blood clotting time, also known as coagulation time (CT) or Lee-White coagulation time, is the

CHAPTER 2—Hemostasis

oldest but least accurate of the coagulation tests. It
measures the time it takes blood to clot in a test tube.
Because the sensitivity of the test is low, coagulation
problems of mild to moderate severity are not
apparent. Heparin prolongs clotting time; therefore,
the test was once used to monitor heparin therapy.
PTT or aPTT is currently used to evaluate such therapy.
Reference Values
4 to 8 minutes
Because this test is relatively insensitive and
difficult to standardize, a normal result does not
rule out a coagulation defect.

INTERFERING FACTORS

Heparin prolongs the whole blood clotting time.
Traumatic venipuncture may lead to erroneous
results.
INDICATIONS FOR WHOLE BLOOD CLOTTING
TIME TEST

Evaluation of response to heparin therapy
Adequate anticoagulation is indicated by a clotting time of about 20 minutes.
Signs of abnormal bleeding such as epistaxis, easy
bruising, bleeding gums, hematuria, and menorrhagia
Suspected congenital coagulation defect that
involves the intrinsic coagulation pathway (e.g.,
deficiencies of factors VIII, IX, XI, and XII)
NURSING CARE BEFORE THE PROCEDURE

In general, client preparation is the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
If the individual is receiving heparin anticoagulant therapy, the time and the amount of the last
dose should be noted.
THE PROCEDURE

A venipuncture is performed and 3 mL of blood
collected in a syringe and then discarded. A new
syringe, glass or plastic, is attached to the venipuncture needle, and an additional 3 mL of blood is withdrawn. Traumatic venipunctures and excessive
movement of the needle in the vein must be avoided
if accurate results are to be obtained.
As the second sample is withdrawn, timing is
begun with a stopwatch. The sample is immediately
and gently transferred into three glass tubes (1 mL in
each). The test tubes are placed in a water bath at

and Tests of Hemostatic Functions

98.6F (37C) and are tilted gently every 30 seconds
until a firm clot has formed in each tube.
Timing is completed when all tubes contain firm
clots, and the interval is recorded as the clotting
time.
NURSING CARE AFTER THE PROCEDURE

THROMBIN CLOTTING TIME
The thrombin clotting time (TCT, plasma thrombin
time) test is used to evaluate the common final pathway of the coagulation sequence. Preformed thrombin (coagulation factor IIa), usually of bovine origin,
can be added to the blood sample to convert fibrinogen (factor I) directly to a fibrin clot. Because the
test bypasses the intrinsic and extrinsic pathways,
deficiencies in either one do not affect the TCT (see
Fig. 2–1).
Thrombin-induced clotting is very rapid, and
the test result can be standardized to any desired
normal value (usually 10 to 15 seconds). The TCT is
prolonged if fibrinogen levels are below 100 mg/dL
(normal: 150 to 400 mg/dL), if the fibrinogen present is functioning abnormally, or if fibrinogen
inhibitors (e.g., streptokinase, urokinase) are present
(see below). In all of these conditions, the PT and
PTT also are prolonged.33
Reference Values
10 to 15 seconds (Values vary among laboratories.)

INTERFERING FACTORS

A fibrinogen level of less than 100 mg/dL (SI
units, 1.00 g/L) (normal: 150 to 400 mg/dL [SI
units, 1.50 to 4.00 g/L) prolongs the TCT.

SECTION I—Laboratory

Tests

Abnormally functioning fibrinogen prolongs the
TCT.
Fibrinogen inhibitors such as streptokinase and
urokinase prolong the TCT.
Traumatic venipunctures and excessive agitation
of the sample may alter results.

therapy or in those with DIC, hypoprothrombinemia, and cirrhosis.
Abnormal PCT results must be evaluated in relation to coagulation studies such as PT, PTT, and
factor assays, to differentiate platelet factor deficiencies from clotting factor deficiencies.

INDICATIONS FOR THROMBIN CLOTTING
TIME TEST

Confirmation of suspected DIC as indicated by a
prolonged TCT
Detection of hypofibrinogenemia or defective
fibrinogen
Monitoring of effects of heparin or fibrinolytic
therapy (e.g., with streptokinase)
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a light-blue-topped tube. Traumatic
venipunctures and excessive agitation of the sample
should be avoided.

Reference Values
Fifteen to 20 seconds with more than 80 percent
of the prothrombin consumed

INTERFERING FACTORS

Traumatic venipunctures and excessive agitation
of the sample may alter test results.
Therapy with anticoagulants may shorten the
PCT.
INDICATIONS FOR PROTHROMBIN CONSUMPTION
TIME TEST

Suspected deficiency of platelet factor 3 or of the
clotting factors involved in the intrinsic coagulation pathway (i.e., factors VIII, IX, XI, and XII), as
indicated by a shortened PCT
Suspected DIC, as indicated by a shortened PCT
Monitoring of effects on hemostasis of conditions
such as liver disease and protein deficiency

NURSING CARE AFTER THE PROCEDURE

PROTHROMBIN CONSUMPTION TIME
The prothrombin consumption time (PCT, serum
prothrombin time) test measures utilization of
prothrombin when a blood clot forms. Normally,
the formation of a clot “consumes” prothrombin
by converting it to thrombin. Individuals with
deficiencies in platelets, platelet factor 3, or
factors involved in the intrinsic coagulation pathway
(see Fig. 2–1) are not able to convert as much
prothrombin to thrombin. In such cases, excess
prothrombin remains in the serum after the clot is
formed, thus shortening the PCT. The PCT also may
be shortened in persons receiving anticoagulant

NURSING CARE BEFORE THE PROCEDURE

In general, client preparation is the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
If the client is receiving anticoagulant therapy, the
time and the amount of the last dose should be
noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. As with other coagulation studies, traumatic venipunctures and excessive agitation of the sample should be avoided.
NURSING CARE AFTER THE PROCEDURE

CHAPTER 2—Hemostasis

FACTOR ASSAYS
If the PT or PTT/aPTT is abnormal, but the nature
of the factor deficiency is unknown, specific coagulation factors may be measured. Factor assays
require specialized techniques not available in many
laboratories. Factor assays are used to discriminate
among mild, moderate, and severe deficiencies and

TABLE 2–7

•

and Tests of Hemostatic Functions

to follow the course of acquired factor inhibitors.
States associated with particular factor deficiencies
are presented in Table 2–7.
Factors of the extrinsic (II, V, VII, X) and intrinsic
(VIII, IX, XI, XII) coagulation pathways are usually
measured separately. The factor XIII assay is a separate test in which a blood clot is observed for 24
hours. Clot dissolution within this time indicates

States Associated with Coagulation Factor Deficiencies
States Associated with Deficiency

Factor

Synonym(s)

Congenital

Acquired

EXTRINSIC PATHWAY

Prothrombin

Hypoprothrombinemia

Vitamin K deficiency
Liver disease

Accelerator globulin (AcG),
proaccelerin, labile factor

Parahemophilia

Liver disease
Acute leukemia
Surgery

VII

Proconvertin, autoprothrombin I,
serum prothrombin conversion
accelerator (SPCA)

Factor VII deficiency

Liver disease

Vitamin K deficiency
Antibiotic therapy
X

Stuart factor, Stuart-Prower
factor, autoprothrombin III

Stuart factor deficiency

Liver disease
Vitamin K deficiency
Anticoagulants
Normal pregnancy
Disseminated intravascular
coagulation (DIC)
Hemorrhagic disease of the
newborn

INTRINSIC PATHWAY

VIII*

Antihemophilic factor (AHF), antihemophilic globulin (AHG)

Christmas factor, antihemophilic
factor B, plasma thromboplastin component (PTC), autoprothrombin II

Hemophilia A (classic
hemophilia)

Disseminated intravascular
coagulation (DIC)

von Willebrand’s disease

Fibrinolysis

Hemophilia B (Christmas
disease)

Liver disease
Vitamin K deficiency
Anticoagulants
Nephrotic syndrome

Plasma thromboplastin
antecedent (PTA)

Factor XI deficiency

Liver disease
(Continued on following page)

SECTION I—Laboratory

TABLE 2–7

Tests

•

States Associated with Coagulation Factor
Deficiencies (Continued)
States Associated with Deficiency

Factor

Synonym(s)

Congenital

Acquired
Vitamin K deficiency
Anticoagulants
Congenital heart disease

XII

Hageman factor

Hageman trait

Normal pregnancy
Nephrotic syndrome

COMMON PATHWAY

XIII

Fibrin-stabilizing factor

Factor XIII deficiency

Liver disease
Lead poisoning
Multiple myeloma
Agammaglobulinemia
Elevated fibrinogen levels
Postoperatively

* Factor VIII is increased in normal pregnancy (as is factor X) and in states of inflammation and other physiologic
stress.

severe factor XIII deficiency. The test for fibrinogen
(factor I) is discussed later.
INTERFERING FACTORS

Traumatic venipunctures and excessive agitation
of the sample may alter test results
INDICATIONS FOR FACTOR ASSAYS

Therapy with anticoagulants and other drugs
known to alter hemostasis

Prolonged PT or PTT of unknown etiology:
If the PT is prolonged but the PTT is normal,

Reference Values
Conventional Units

SI Units

Extrinsic Pathway
Factor II

70–130 mg/100 mL

0.7–1.3 U

Factor V

70–130 mg/100 mL

0.7–1.3 U

Factor VII

70–150 mg/100 mL

0.7–1.5 U

Factor X

70–130 mg/100 mL

0.7–1.3 U

Factor VIII

50–200 mg/100 mL

0.5–2.0 U

Factor IX

70–130 mg/100 mL

0.7–1.3 U

Factor XI

70–130 mg/100 mL

0.7–1.3 U

Factor XII

30–225 mg/100 mL

0.3–2.2 U

Intrinsic Pathway

Common Pathway
Factor XIII

Dissolution of a formed clot within 24 hr

Note: Normal values vary among laboratories.

CHAPTER 2—Hemostasis

factors of the extrinsic pathway are evaluated
(i.e., factors, II, V, VII, and X).
If the PTT is prolonged but the PT is normal,
factors of the intrinsic pathway are evaluated
(i.e., factors VIII, IX, XI, XII).
Monitoring of effects of disorders and drugs
known to lead to deficiencies in clotting factors
(see Table 2–7, p. 55)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
If the individual is receiving anticoagulant therapy, the time and the amount of the last dose
should be noted.
THE PROCEDURE

For assays of the factors involved in the intrinsic and
extrinsic coagulation pathways, a venipuncture is
performed and the sample collected in a light-bluetopped tube. For factor XIII assays, the sample is
collected in a red-topped tube. As with other coagulation studies, traumatic venipunctures and excessive agitation of the sample should be avoided. The
samples should be sent to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

and Tests of Hemostatic Functions

fibrinogen present is then extrapolated from this
value. In the immunologic technique, the degree of
reactivity between the plasma sample and antifibrinogen antibodies is measured. The assumption
underlying this method is that any plasma
constituent that reacts with antifibrinogen antibodies is, indeed, fibrinogen. Heat-precipitation tests are
based on a similar assumption that all of the material responsive to the precipitation technique is
really fibrinogen.34
Reference Values
150–450 mg/dL

INTERFERING FACTORS

Transfusions of whole blood, plasma, or fractions
within 4 weeks of the test may lead to erroneous
results.
Traumatic venipuncture and excessive agitation of
the sample may alter test results.
INDICATIONS FOR PLASMA FIBRINOGEN TEST

Confirmation of suspected DIC, as indicated by
decreased fibrinogen levels
Evaluation of congenital or acquired dysfibrinogenemias
Monitoring of hemostasis in disorders associated
with low fibrinogen levels (e.g., severe liver
diseases and cancer of the prostate, lung, or
pancreas)
Detection of elevated fibrinogen levels, which
may predispose to excessive thrombosis in
various situations (e.g., immune disorders of
connective tissue; glomerulonephritis; oral
contraceptive use; cancer of the breast, stomach,
or kidney)
NURSING CARE BEFORE THE PROCEDURE

PLASMA FIBRINOGEN
In the common final pathway, fibrinogen (factor I) is
converted to fibrin by thrombin (see Fig. 2–1).
Plasma fibrinogen studies are based on the fact that,
in normal healthy individuals, the serum should
contain no residual fibrinogen after clotting has
occurred.
Three different techniques can be used to perform
the test: (1) standard assay (classical procedure), (2)
immunologic technique, and (3) heat-precipitation
tests. In the standard assay, thrombin is added to the
blood sample to induce clotting. Because fibrinogen
is a plasma protein, the amount of protein in the
resulting clot is measured. The quantity of precursor

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
If the individual is receiving anticoagulant therapy, the time and amount of the last dose should
be noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a light-blue-topped tube. As with other
coagulation studies, traumatic venipunctures and
excessive agitation of the sample should be avoided.
The sample should be sent to the laboratory immediately.

SECTION I—Laboratory

Tests

NURSING CARE AFTER THE PROCEDURE

FIBRIN SPLIT PRODUCTS
After a fibrin clot has formed, the fibrinolytic system
acts to prevent excessive clotting. In this system,
plasmin digests fibrin. Fibrinogen also may be
degraded if there is a disproportion among plasmin,
fibrin, and fibrinogen. The substances that result
from this degradation—fibrin split products (FSP)
or fibrinogen degradation products (FDP)—interfere with normal coagulation and with formation of
the hemostatic platelet plug.
Normally, FSP are removed from the circulation
by the liver and the reticuloendothelial system. In
situations such as widespread bleeding or DIC,
however, FSP are found in the serum.
Tests for FSP are performed on serum using
immunologic techniques. Because FSP do not coagulate, they remain in the serum after fibrinogen is
removed through clot formation. Antifibrinogen
antibodies are added to the serum to detect the presence of FSP. Because normal serum contains neither
FSP nor fibrinogen, there should be nothing present
to react with the antibodies. If a reaction occurs, FSP
are present.35
Reference Values
2 to 10 mg/mL

INTERFERING FACTORS

Heparin, fibrinolytic drugs such as streptokinase
and urokinase, and large doses of barbiturates
may produce elevated levels of FSP.
Traumatic venipunctures and excessive agitation
of the sample may alter test results.
INDICATIONS FOR FIBRIN SPLIT PRODUCTS TEST

Confirmation of suspected DIC, as indicated by
elevated FSP levels
Evaluation of response to therapy with fibrinolytic drugs

Monitoring of effects on hemostasis of trauma,
extensive surgery, obstetric complications, and
disorders such as liver disease
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or in a special tube
provided for the FSP test by the laboratory. As with
other coagulation studies, traumatic venipunctures
and excessive agitation of the sample should be
avoided. The sample should be sent to the laboratory
promptly.
NURSING CARE AFTER THE PROCEDURE

EUGLOBULIN LYSIS TIME
The euglobulin lysis time test is used to document
excessive fibrinolytic activity. Euglobulins are
proteins that precipitate from acidified dilute
plasma; these include fibrinogen, plasminogen, and
plasminogen activator but very little antiplasmin
activity. In euglobulins prepared from normal
blood, the initial clot dissolves in 2 to 6 hours. With
excessive fibrinolytic activity, a clot forms if thrombin is added to the sample.
Shortened euglobulin lysis times are seen in fibrinolytic therapy with streptokinase or urokinase,
prostatic cancer, severe liver disease, extensive vascular trauma or surgery, and shock.
Reference Values
Lysis in 2 to 6 hours
INTERFERING FACTORS

Decreased fibrinogen levels may lead to falsely

CHAPTER 2—Hemostasis

shortened lysis time because of the reduced
amount of fibrin to be lysed.36
Traumatic venipunctures and excessive agitation
of the sample may alter results.
INDICATIONS FOR EUGLOBULIN LYSIS TIME TEST

Suspected abnormal fibrinolytic activity as indicated by lysis of the clot within about 1 hour
Differentiation of primary fibrinolysis from DIC,
which usually presents with a normal euglobulin
lysis time
Monitoring of effects of fibrinolytic therapy on
normal coagulation
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a light-blue-topped tube. As with other
coagulation studies, traumatic venipuncture and
excessive agitation of the sample should be avoided.
The sample should be sent to the laboratory
promptly.
NURSING CARE AFTER THE PROCEDURE

and Tests of Hemostatic Functions

Inspect the site for excessive bruising after the
procedure.
Clot lysis: Note and report decreases in lysis level
during fibrinolytic therapy. Monitor client
response and effect of therapy on coagulation.
REFERENCES
1. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, pp 182–183.
2. Ibid, p 185.
3. Ibid, p 185.
4. Ibid, p 190.
5. Porth, CM: Pathophysiology: Concepts of Altered Health States, ed
5. JB Lippincott, Philadelphia,1998, p 122.
6. Fischbach, FT: A Manual of Laboratory and Diagnostic Tests, ed 4.
JB Lippincott, Philadelphia, 1992, p 95.
7. Ibid, p 118.
8. Porth, op cit.
9. Ibid, p 121.
10. Sacher and McPherson, op cit, pp 192–193.
11. Ibid, p 195.
12. Ibid, p 195.
13. Ibid, p 196.
14. Fischbach, op cit, p 98.
15. Sacher and McPherson, op cit, p 197.
16. Porth, op cit, p 121.
17. Sacher and McPherson, op cit, p 182.
18. Ibid, p 182.
19. Porth, op cit, p 121.
20. Porth, op cit, p 126.
21. Sacher and McPherson, op cit, p 187.
22. Fischbach, op cit, pp 125–126.
23. Porth, op cit, p 126.
24. Sacher and McPherson, op cit, p 190.
25. Ibid, p 190.
26. Ibid, p 190.
27. Ibid, pp 188–189.
28. Ibid, p 189.
29. Ibid, p 187.
30. Ibid, pp 187–188.
31. Ibid, p 193.
32. Ibid, p 201.
33. Ibid, p 200.
34. Ibid, p 200.
35. Ibid, pp 139–140.
36. Ibid, p 203.

CHAPTER

Immunology and
Immunologic Testing
TESTS COVERED
T- and B-Lymphocyte Assays, 62
Immunoblast Transformation Tests, 66
Immunoglobulin Assays, 68
Serum Complement Assays, 71
Immune Complex Assays, 73
Radioallergosorbent Test for IgE, 73
Autoantibody Tests, 74
Fungal Infection Antibody Tests, 78
Staphylococcal Tests, 80
Streptococcal Tests, 81
Febrile/Cold Agglutinin Tests, 82
Fluorescent Treponemal AntibodyAbsorption Test, 83

INTRODUCTION

Venereal Disease Research
Laboratory and Rapid Plasma Reagin
Tests, 84
Viral Infection Antibody Tests, 85
Infectious Mononucleosis Tests, 85
Hepatitis Tests, 87
Acquired Immunodeficiency Syndrome
Tests, 88
Serum -Fetoprotein Test, 90
Carcinoembryonic Antigen Test, 92
CA 15-3, CA 19-9, CA 50, and CA 125
Antigen Tests, 93

The immune system protects the body from invasion by foreign elements
ranging from microorganisms and pollens to transplanted organs and subtly altered autologous proteins. An antigen is any substance that elicits an immune response in an immunocompetent host to whom that substance is foreign.
The cells responsible for immune reactivity are lymphocytes and macrophages. The primary
function of the lymphocytes is to react with antigens and thus initiate immune responses.
There are two main categories of immune response: (1) the cell-mediated response, produced
by locally active T lymphocytes present at the same time and place as the specific antigen, and
(2) the humoral response, the manufacture by B lymphocytes of antibody proteins that enter
body fluids for widespread distribution throughout the body.1
The immune system also removes damaged or worn-out cells and destroys abnormal cells as
they develop in the body. The cells responsible for these functions are the macrophages, which
engulf particulate debris (phagocytosis) and also secrete a vast array of enzymes, enzyme
inhibitors, oxidizing agents, chemotactic agents, bioactive lipids (prostaglandins and related
substances), complement components, and products that stimulate or inhibit multiplication of
other cells. These phagocytic and secretory activities help mediate responses to immune stimulation. Macrophages also are critically important in the induction of immunity. Only after
macrophages process antigen and present it to lymphocytes can immunologic reactivity
develop.

CHAPTER 3—Immunology

and Immunologic Testing

Laboratory tests can demonstrate with remarkable sensitivity many of the body’s immune
activities. In general, quantification of cellular components, the presence and activities of antibodies and antigens, and measurement of biologically active secretions constitute the laboratory tests of immune functions.

TESTS OF LYMPHOCYTE
FUNCTIONS
Lymphocytes, the second most numerous of the
several types of white cells in the peripheral blood
(see Table 1–4), are essential components of the
immune system. Diseases affecting lymphocytes
frequently manifest as an inability to protect the individual against environmental pathogens (immune
deficiency disorders) or as the development of
immune reactions to the individual’s own cells.2
The lymphocytes in the circulation represent only
a small fraction of the total body pool of these cells.
The majority are located in the spleen, lymph nodes,
and other organized lymphatic tissues. The lymphocytes in the blood are able to enter and leave the
circulation freely. Thus, the movement of cells from
one area or compartment to another is continuous.
Despite this process, the number of lymphocytes in
the blood and tissues is kept quite constant.
Lymphocytes have been divided into two major categories based on their immunologic activity: T
lymphocytes and B lymphocytes. There also is a
third group of lymphocytes that lack the characteristics of either T or B cells; they are called null cells.3
T lymphocytes are primarily responsible for cellmediated immunity, which requires direct cell
contact between the antigen and the lymphocyte.
This immune reaction occurs at the local site and
generally develops slowly. Examples of cell-mediated
immune responses include reactions against intracellular pathogens such as bacteria, viruses, fungi,
and protozoa; positive tuberculin skin test results;
contact dermatitis; transplant rejection (acute and
chronic reactions); and tumor immunity.
As with other blood cells, T lymphocytes develop
from stem cells (see Fig. 1–2) and then migrate to the
thymus, where they proliferate and mature.
Thymopoiesis is, however, an ineffective process, and
many T lymphocytes die either within the thymus or
shortly after leaving it. Only a small portion of the T
lymphocytes reaches the peripheral tissues as mature
T cells capable of effecting cell-mediated immunity.4
Note that the thymus functions primarily during
fetal life. The peripheral T-lymphoid system is fully
developed at birth and normally does not require a
constant input of new cells for maintenance after
birth. Thus, it is possible to surgically remove the

thymus (e.g., as is done to treat myasthenia gravis)
without impairing the individual’s cell-mediated
immune system. In contrast, failure of the thymus to
develop during fetal life leads to a severe defect in
cellular immunity (Di George’s syndrome), usually
resulting in death during infancy as a consequence
of repeated infections.5
Two subsets of T lymphocytes have been identified: helper T cells and suppressor T cells. Helper T
cells promote the proliferation of T lymphocytes,
stimulate B-lymphocyte reactivity, and activate
macrophages, thereby increasing their bactericidal
and cytotoxic functions. Suppressor T cells limit the
magnitude of the immune response. In normal individuals, there is a balance between helper and
suppressor activities. Many immune diseases are
associated with deficiencies or excesses of the Tlymphocyte subtypes (Fig. 3–1).6
The B lymphocytes are responsible for humoral
immunity through the production of circulating
antibodies. Examples of humoral immunity include
elimination of encapsulated bacteria, neutralization
of soluble toxins, protection against viruses, transplant rejection (hyperacute reaction), and possible

Figure 3–1. In normal, healthy individuals, there is a
balance between helper and suppressor activities.
Many immunodeficiency syndromes appear to be
caused by a disturbance of this balance such that a
state of unresponsiveness is created. This could result
from either a lack of helper activity or an excess of
suppressor activity. Conversely, autoimmunity, which
results from aberrant responses directed at the host’s
own antigens, could result from abnormal immunoregulation from either excessive helper or reduced
suppressor activities. (From Boggs, DR, and
Winkelstein, A: White Cell Manual, ed 4. FA Davis,
Philadelphia, 1983, p 71, with permission.)

SECTION I—Laboratory

Tests

tumor immunity. Pathological alterations in antibody production are responsible for disorders such
as autoimmune hemolytic anemia, immune thrombocytopenia, allergic responses, some forms of
glomerulonephritis and vasculitis, and transfusion
reactions.7
Actual production of antibodies (immunoglobulins) occurs in plasma cells, the most differentiated
form of B lymphocyte. All B lymphocytes have
immunoglobulins (Ig) on their surfaces. These serve
as receptors for specific antibodies. Five classes of
immunoglobulins are currently identified: IgG, IgM,
IgA, IgD, and IgE. Immune activation requires interaction not only of surface Ig with the specific antigen
but also of B lymphocytes with the helper T cells.
The activated B lymphocytes undergo transformation into immunoblasts that replicate and then
differentiate into either plasma cells, which produce
antibodies, or memory cells (“small lymphocytes”),
which retain the ability to recognize the antigen.
Similar memory cells have been found in the Tlymphocyte system.8
The relationships between the T-lymphocyte and
B-lymphocyte systems are diagrammed in Figure
3–2. In both cellular and humoral immune
responses, initial exposure to specific antigens initiates the primary immune response. Depending on
the nature and quantity of the antigen, it may take
days, weeks, or months for the cells to recognize and
respond to the antigen. Subsequent exposure to the
same antigen, however, elicits the secondary
(anamnestic) response much more rapidly than the
primary response.9
Tests of lymphocyte functions include T- and B-

lymphocyte assays, immunoblast transformation
tests, and immunoglobulin assays.

T- AND B-LYMPHOCYTE ASSAYS
T- and B-lymphocyte assays are used to diagnose a
number of immunologic disorders (Tables 3–1 and
3–2). A variety of methods are used. The most
common way to assess T-cell activity is to measure
the individual’s response to delayed hypersensitivity
skin tests. This involves intradermal injection of
minute amounts of several antigens to which the
individual has previously been sensitized (e.g.,
tuberculin, mumps, Candida). Erythema and
induration should occur at the site within 24 to 48
hours. Absence of response is termed anergy and,
thus, the test is frequently called an anergy panel.
Anergy to skin tests reflects either a temporary or a
permanent failure of cell-mediated immunity.10
Other measures of T and B lymphocytes involve
determination of the number of cell types present. T
lymphocytes are recognized by their ability to form
rosettes with sheep erythrocytes (i.e., the sheep red
cells surround the T lymphocyte). Although the
sheep erythrocytes adhere to the cell membranes of
the T lymphocytes, they react to neither B lymphocytes nor null cells.11
T lymphocytes and their subsets also can be
distinguished by their ability to react with various
monoclonal antibodies. Monoclonal antibodies
constitute a single species of immunoglobulins with
specificity for a single antigen and are produced
by immunizing mice with specific antigens. The
most commonly used monoclonal antibodies to T

Figure 3–2. The relationship between the T-lymphocyte and B-lymphocyte systems. (From Winkelstein, A, et al:
White Cell Manual, ed 5. FA Davis, Philadelphia,1998, with permission.)

CHAPTER 3—Immunology

•

TABLE 3–1

and Immunologic Testing

Causes of Altered Levels of T and B Lymphocytes

Increased Levels

Decreased Levels
T LYMPHOCYTES

Acute lymphocytic leukemia

Di George’s syndrome

Multiple myeloma

Chronic lymphocytic leukemia

Infectious mononucleosis

Acquired immunodeficiency syndrome (AIDS)

Graves’ disease

Hodgkin’s disease
Nezelof syndrome
Wiskott-Aldrich syndrome
Waldenström’s macroglobulinemia
Severe combined immunodeficiency disease (SCID)
Long-term therapy with immunosuppressive drugs
B LYMPHOCYTES

Chronic lymphocytic leukemia

Acute lymphocytic leukemia

Multiple myeloma

X-linked agammaglobulinemia

Di George’s syndrome

SCID

Waldenström’s macroglobulinemia
Acute lupus erythematosus

TABLE 3–2

•

Disorders Associated with Abnormal T-Cell Subsets
IMMUNE DEFICIENCY DISEASES (HELPER AND/OR SUPPRESSOR ACTIVITY)

Common variable hypogammaglobulinemia
Acute viral infections (infectious mononucleosis, cytomegalic inclusion disease)
Chronic graft-versus-host disease
Multiple myeloma
Chronic lymphomocytic leukemia
Primary biliary cirrhosis
Sarcoidosis
Immunosuppressive drugs (azathioprine, corticosteroids, cyclosporin A)
Acquired immunodeficiency syndrome (AIDS)
AUTOIMMUNITY (HELPER AND/OR SUPPRESSOR ACTIVITY)

Connective tissue diseases (e.g., systemic lupus erythematosus)
Acute graft-versus-host disease
Autoimmune hemolytic anemia
Multiple sclerosis
Myasthenia gravis
Inflammatory bowel diseases
Atopic eczema
Adapted from Boggs, DR, and Winkelstein, A: White Cell Manual, ed 4. FA Davis, Philadelphia, 1983, p 72.

SECTION I—Laboratory

Tests

lymphocytes are designated T3, T4, and T8. T3 is a
pan-T-cell antibody that reacts with a determinant
that is present on all mature peripheral T lymphocytes and can, therefore, be used to enumerate the
total number of T cells present. T4 antibodies identify helper T cells, and T8 antibodies identify
suppressor T cells.12
Other monoclonal antibodies include T10, T9,
and T6. T10 and T9 antibodies react with very
immature T lymphocytes (thymocytes) that are
found in the thymus gland but not in the peripheral
circulation. T10 antigen also is seen in mature
thymocytes that are localized primarily in the
medullary regions of the thymus. T6 antibodies also
react with certain immature thymocytes. As T
lymphocytes mature, reactivity to T6 antibodies is
lost. Tests involving reactivity to immature T
lymphocytes are useful in diagnosing T-cell
leukemias and lymphomas.13
B lymphocytes are detected by immunofluorescent techniques. Such techniques involve mixing
lymphocyte suspensions with heterologous antisera
to immunoglobulins that have been labeled with a
dye such as fluorescein. The antisera combine with B
lymphocytes and when the suspension is examined
by fluorescent microscopy, only B lymphocytes
appear.14
T and B lymphocytes can be differentiated by
electron microscopy, because T cells are smooth and
B cells have surface projections. This technique is
not, however, available in many laboratories.
INDICATIONS FOR T- AND B-LYMPHOCYTE
ASSAYS

Diagnosis of disorders associated with abnormal
levels of T and B lymphocytes (see Table 3–1)
Diagnosis of disorders associated with abnormal
T-cell subtypes (see Table 3–2)
Support for diagnosing acquired immunodeficiency syndrome (AIDS), as indicated by
decreased helper T cells, normal or increased

suppressor T cells, and a decreased ratio of helper
to suppressor T cells
Diagnosis of severe combined immunodeficiency
disease (SCID), an inherited disorder characterized by failure of the stem cell to differentiate into
T and B lymphocytes (Fig. 3–3)
Diagnosis of Di George’s syndrome, characterized
by failure of the thymus (and parathyroids) to
develop, with a resulting decrease in T lymphocytes (see Fig. 3–3)
Diagnosis of X-linked agammaglobulinemia,
characterized by severe B-lymphocyte deficiency
(see Fig. 3–3)
Diagnosis of common variable hypogammaglobulinemia (CVH), characterized by absent,
decreased, or defective B cells and most
commonly caused by either lack of helper T
lymphocytes or abnormal suppressor T cells (see
Fig. 3–3)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube or other type of
blood collection tube, depending on laboratory
preference.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Because the client may be immunosuppressed,
assess the site for signs of infection.
Complications and precautions for compromised immune status: Note and report helper Tcell level and relation to suppressor T-cell level or
decreased B cells. Administer chemotherapy or

Reference Values
T lymphocytes

60–80% of circulating lymphocytes*

B lymphocytes

10–20% of circulating lymphocytes

Null cells

5–20% of circulating lymphocytes

Helper T lymphocytes

50–65% of circulating T lymphocytes

Suppressor T lymphocytes

20–35% of circulating T lymphocytes

Ratio of helper to suppressor T lymphocytes 2:1
* A decreased lymphocyte count (lymphopenia) usually indicates a decrease in the number of circulating T lymphocytes.

CHAPTER 3—Immunology

TABLE 3–3

•

and Immunologic Testing

Immunoglobulins
Causes of Altered Levels

Class
IgG

Locations

Functions

Increased

Decreased

Plasma

Produces antibodies
against bacteria,
viruses, and toxins

Infections—all types,
acute and chronic

Lymphocytic leukemia

Interstitial fluid

Protects neonate

Starvation

Agammaglobulinemia

Placenta

Activates the complement system

Liver disease

Amyloidosis

Is a major factor in
secondary (anamnestic) response

Rheumatic fever

Toxemia of pregnancy

Sarcoidosis
IgG myelomas
IgA

Respiratory tract

Protects mucous
membranes from
viruses and bacteria

Autoimmune disease

Lymphocytic leukemia

Gastrointestinal
tract

Includes antitoxins,
antibacterial agglutinins, antinuclear
antibodies, and allergic reagins

Chronic infections

Agammaglobulinemia

Liver disease

Malignancies

Activates complement
through the alternative pathway

Wiskott-Aldrich
syndrome

Hereditary ataxia-telangiectasia

IgA myeloma

Hypogammaglobulinemia

Genitourinary
tract
Tears

Saliva
Milk, colostrum

Malabsorption syndromes

Exocrine secretions
IgM

—

Primary responder to
antigens

Lymphosarcoma

Lymphocytic leukemia

Produces antibody
against rheumatoid
factors, gram-negative organisms, and
the ABO blood group

Brucellosis, actinomycosis

Agammaglobulinemia

Trypanosomiasis

Amyloidosis

Relapsing fever

IgG and IgA myeloma

Activates the complement system

Malaria

Dysgammaglobulinemia

Infectious mononucleosis
Rubella virus in
newborn
Waldenström’s
macroglobulinemia
IgD

Serum
Cord blood

Unknown

Chronic infections

—

IgD myelomas
(Continued on following page)

SECTION I—Laboratory

Tests

TABLE 3–3

•

Immunoglobulins (Continued)
Causes of Altered Levels

Class
IgE

Locations

Functions

Increased

Decreased
Congenital agammaglobulinemia

Serum

Allergic reactions

Atopic skin disorders

Interstitial fluid

Anaphylaxis

Hay fever

Protects against parasitic worm infestations

Asthma

Anaphylaxis
IgE myeloma

other ordered medications. Provide reverse
protective precautions to prevent infection.

IMMUNOBLAST TRANSFORMATION
TESTS
When responding to a specific antigen, mature
lymphocytes undergo a series of morphological and
biochemical changes that enable them to become
actively proliferating cells (immunoblasts). The
lymphocytes enlarge, synthesize new nucleic acids
and proteins, and undergo a series of mitoses. This
proliferative expansion increases the pool of anti-

gen-responsive cells (Fig. 3–4).15 Immunoblast
transformation tests evaluate the capability of
lymphocytes to change to proliferative cells and,
thus, to respond normally to antigenic challenge.
Several methods of performing immunoblast
transformation tests can be used. Nonimmune
transformation tests involve exposing a sample of
the client’s lymphocytes to mitogens, agents that
cause normally responsive lymphocytes to become
immunoblasts independent of any antigenic effect.
Effective mitogens include plant extracts such as
phytohemagglutinin (PHA), concanavalin A (conA),
and pokeweed mitogen. PHA and conA stimulate

Figure 3–3. Several immunodeficiency diseases can be viewed as cellular blocks in the normal maturation of
lymphocytes. (From Winkelstein, A, et al: White Cell Manual, ed 5. FA Davis, Philadelphia, 1998, p 103, with permission.)

CHAPTER 3—Immunology

and Immunologic Testing

Figure 3–4. Responses of mature lymphocytes to antigens. In both the T- and B-cell systems, stimulated cells
undergo a redifferentiation process leading to immature-appearing lymphoblasts. (From Winkelstein, A, et al: White
Cell Manual, ed 5. FA Davis, Philadelphia, 1998, p 83, with permission.)

Reference Values
Nonimmune transformation tests

A stimulation index of greater than 10 indicates
immunocompetence.

Antigen-specific transformation tests

A stimulation index of greater than 3 indicates prior
exposure to the antigen.

Mixed lymphocyte culture

Nonresponsiveness indicates good histocompatibility.

primarily T lymphocytes; pokeweed stimulates both
T and B lymphocytes, although the effect on B
lymphocytes is greater. Approximately 72 hours after
the lymphocytes have been incubated with the mitogens, radiolabeled thymidine is added and then
incorporated into the deoxyribonucleic acid (DNA)
of the proliferating cells. The rate of uptake of
radioactive thymidine indicates the extent of
lymphocyte proliferation.16
After immune capability has been established,
antigen-specific transformation tests can demonstrate whether the person’s T cells have encountered
specific antigens; that is, an individual’s cellmediated immunities can be documented by
observing the way T cells respond to a battery of
known antigens (e.g., soluble viral or bacterial antigens or tissue antigens of human white cells from
organ donors).
The mixed lymphocyte culture (MLC) technique
is widely used in testing before organ transplantation. This test is based on the fact that cultured
lymphocytes can recognize and respond to foreign
antigens that have not previously sensitized the host.
Immunologically responsive lymphocytes cultured

together with cells possessing unfamiliar or
unknown surface antigens gradually develop sensitivity; after a lag period of 48 to 72 hours, the
responding cells undergo immunoblast transformation if the stimulating cells possess antigens different
from those of the host.17
INTERFERING FACTORS

Radioisotope studies performed within 1 week of
the test may alter test results.
Pregnancy or oral contraceptive use may lead to a
decreased response to PHA in nonimmune transformation tests.
INDICATIONS FOR IMMUNOBLAST
TRANSFORMATION TESTS

Support for diagnosing immunodeficiency disorders as indicated by a decreased response to
nonimmune transformation tests
Identification of microorganisms to which the
individual was previously exposed as indicated by
an increased response to antigen-specific transformation tests
Support for identifying compatible organ donors

SECTION I—Laboratory

Tests

and recipients as indicated by nonresponsiveness
on mixed lymphocyte culture
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
All clients should be interviewed to determine
whether they have undergone any radioisotope
tests within the past week; if the client is a woman,
it should be determined whether she is pregnant
or using oral contraceptives.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube or other type of
blood collection tube, depending on laboratory
preference. The sample should be transported to the
laboratory promptly.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Because the client may be immunosuppressed,
assess the site for signs of infection.
Complications and precautions: Note and report
the lymphocyte response to an antigenic challenge
in relation to signs and symptoms of tissue rejection or allergic condition.

IMMUNOGLOBULIN ASSAYS
Immunoglobulins are serum antibodies produced
by the plasma cells of the B lymphocytes.
Immunoglobulins (Ig) have been subdivided into
the five classes: IgG, IgA, IgM, IgD, and IgE. Their
functions are listed in Table 3–3. IgG, IgA, and IgM
have been further divided into subclasses: IgG1,
IgG2, IgG3, and IgG4.
Four techniques can be used to assess Ig: (1)
serum protein electrophoresis, (2) immunoelectrophoresis, (3) radial immunodiffusion, and (4)
radioimmunoassay. Serum protein electrophoresis,
although not specific to the immunoglobulins, may
indicate the presence of immunologic disorders such
that additional testing may not be needed.
Electrophoresis separates the serum proteins into
albumin and globulin components, with the latter
being further broken down into 1, 2, , and
fractions. Most of the fraction derives from IgG
molecules, whereas IgM contributes to the
portion.18
Three types of alterations in immunoglobulins

can be identified by serum protein electrophoresis:
(1) hypogammaglobulinemia, a reduction in the
total quantity of immunoglobulins; (2) monoclonal
gammopathy, excessive amounts of single immunoglobulins or proteins related to immunoglobulins
(seen in multiple myeloma and macroglobulinemia); and (3) polyclonal gammopathy, excessive
amounts of several different immunoglobulins (seen
in many infections and diffuse inflammatory conditions).19,20 Examples of these serum protein electrophoretic patterns are diagrammed in Figure 3–5.
Additional examples of disorders associated with
monoclonal and polyclonal gammopathies are listed
in Table 3–4.
Immunoelectrophoresis is not a quantitative
technique, but it provides such detailed separation
of the individual immunoglobulins that modest
deficiencies are readily detected. It identifies the
presence of monoclonal protein and its type. Radial
immunodiffusion allows measurement of the quantity of individual immunoglobulins to concentrations as low as 10 to 20 mg/dL. Radioimmunoassay
provides better results when immunoglobulin levels
are below 20 mg/dL. Serum IgD and IgE are
normally well below this level, as are immunoglobulin levels in most body fluids other than serum.
Cryoglobulin is an immunoglobulin that
precipitates in the cold and, in those who develop
high concentrations, causes the blockage of small
capillaries in fingers, ears, and toes exposed to
cold temperatures. The test is performed by first
cooling the blood serum in a refrigerator to note
whether a precipitate forms in 2 to 7 days and
then measuring the volume in relation to the
percentage of the total serum to obtain a numerical
value analogous to a hematocrit. Three positive
types of cryoglobulins can be identified by immunoelectrophoresis. Pyroglobulin is a protein identified
by heating the blood serum to obtain a precipitate,
indicating an abnormality. The test is performed to
determine cold sensitivity as well as to assist in the
diagnosis of collagen disorders, malignancies, or
infections.21
INTERFERING FACTORS

Immunizations within 6 months before the test
may alter test results.
Transfusions of either whole blood or fractions
within 2 months may alter test results.
INDICATIONS FOR IMMUNOGLOBULIN ASSAYS

Suspected immunodeficiency, either congenital or
acquired
Suspected immunoproliferative disorders such as

CHAPTER 3—Immunology

and Immunologic Testing

Figure 3–5. Serum protein electrophoretic patterns. (From Winkelstein, A, et al: White Cell Manual, ed 5. FA Davis,
Philadelphia, 1998, p 95, with permission.)

multiple myeloma or Waldenström’s macroglobulinemia
Suspected autoimmune disorder
Suspected malignancy involving the lymphoreticular system

Monitoring of effects of chemotherapy or radiation therapy, or both, which may suppress the
immune system
Identification of hypogammaglobulinemia,
monoclonal gammopathy, and polyclonal

Image/Text rights unavailable

SECTION I—Laboratory

Tests

Reference Values
Percentage of Total Protein
Serum Protein Electrophoresis

Conventional Units

SI Units

Constituent
Albumin

52–68

0.520–0.680

Globulin

32–48

0.320–0.480

1-Globulin

2.4–5.3

0.024–0.053

2-Globulin

6.6–13.5

0.066–0.135

-Globulin

8.5–14.5

0.085–0.145

-Globulin

10.7–21.0

0.107–0.210

Immunoglobulins
Neonates
SI Units
6 mo
SI Units
1 yr
SI Units
6 yr
SI Units
12 yr
SI Units
16 yr
SI Units
Adults
SI Units
Percentage of total
immunoglobulins
in adults

IgG, mg/dL

IgA, mg/dL

IgM, mg/dL

IgD, mg/dL

IgE, mg/dL

650–1250

0–12

5–30

—

6.5–12.5 g/L

0.00–0.12 g/L

0.05–0.30 g/L

200–1100

10–90

10–80

—

2.0–11.0 g/L

0.10–0.90 g/L

0.10–0.80 g/L

300–1400

20–150

20–100

—

3.0–14.0 g/L

0.20–1.50 g/L

0.20–1.0 g/L

550–1500

50–175

22–100

—

5.50–15.0 g/L

0.50–1.75 g/L

0.22–1.0 g/L

660–1450

50–200

30–120

—

6.60–14.5 g/L

0.50–2.0 g/L

0.30–1.20 g/L

700–1050

7–225

35–75

—

7.0–10.5 g/L

0.70–2.25 g/L

0.35–0.75 g/L

800–1800

100–400

55–150

0.5–3

0.01–0.04

8.0–18.0 g/L

1.0–4.0 g/L

0.55–1.50 g/L

0.005–0.03 g/L

0–430 mg/L

75–80%

15%

10%

0.2%

0.0002%

gammopathy by serum protein electrophoresis
(see Fig. 3–5 and Table 3–4)
Support for diagnosing a variety of disorders
associated with altered immunoglobulin levels
(see Table 3–3)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
The client should be interviewed to determine

whether he or she has received immunizations
within 6 months before the test or transfusions of
whole blood or fractions within 2 months before
the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or other type of blood
collection tube, depending on laboratory preference.
The sample should be transported to the laboratory
promptly.

CHAPTER 3—Immunology

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Because the client may be immunosuppressed,
assess the site for signs of infection.
Complications and precautions: Note and report
abnormal levels in relation to immunodeficiency,
malignant, or autoimmune disorders.

TESTS OF THE COMPLEMENT
SYSTEM
Complement is a system of protein molecules, the
sequential interactions of which produce biologic
effects on surface membranes, on cellular behavior,
and on the interactions of other proteins. Each of
the proteins of the complement system is inactive by
itself. Activation occurs through a cascadelike
sequence after contact with substances such as IgG
or IgM antigen-antibody complexes, aggregated IgA,
certain naturally occurring polysaccharides and
lipopolysaccharides, activation products of the coagulation system, and bacterial endotoxins. Activation
of the complement system results in an inflammatory response that destroys or damages cells.
Complement proteins are identified by letters and
numbers and are listed here in order of activation in
the “classical pathway” of the complement cascade:
C1q, C1r, C1s, C4, C2, C3, and then C5 through C9.
The “alternate pathway” bypasses C1, C4, and C2
activation and begins directly with C3. The key step
in the alternate pathway is activation of properdin, a
serum protein without biologic effects in its inactive
form. Contact with aggregated IgA, with bacterial
endotoxins, or with complex molecules such as
dextran, agar, and zymosan alters properdin and
initiates the sequence at C3.22
Complete activation to C9 leads to membrane
disruption and irreversible cell damage. Along the
way to complete activation, the following activities
occur: C2 releases a low-molecular-weight peptide
with kinin activity. Activation of products of C3 and
C5 affects mast cells, smooth muscle, and leukocytes
to produce an anaphylactic effect; other elements of
C3 and C5 bind to cell membranes and render them
more susceptible to phagocytosis, a process called
opsonization. Fragments of C3 and C4 cause
immune adherence, in which complement-coated
particles bind to cells with surface membranes that
have complement receptors; activated C3 and C4 are
also capable of virus neutralization. C3 and C5 exert
chemotactic activity on neutrophils, and the C5 to
C9 complex influences the procoagulant activity of

and Immunologic Testing

platelets. Conversely, procoagulant factor XII can
initiate C1 activation, and plasmin (the substance
that dissolves fibrin) and thrombin (which converts
fibrinogen to fibrin) can cleave C3 into its active
form.23

SERUM COMPLEMENT ASSAYS
Radioimmunoassay and immunodiffusion techniques have made it possible to quantify each of the
complement components. For clinical purposes,
however, only total complement, C3, and C4 are
measured. Total complement (CH50), also known as
a hemolytic assay, is measured by exposing a sample
of human serum to sheep red cells coated with
complement-requiring antibody. Results are
expressed as CH50 units, reflecting the dilution at
which adequate complement exists to lyse one-half
of the test cells. C3 and C4 levels are measured individually by radial immunodiffusion. These latter
tests take 24 to 36 hours to complete, and results are
easily affected by improper handling of the specimen.24
The causes of alterations in C3 and C4 levels are
presented in Table 3–5.
INTERFERING FACTORS

Failure to transport the sample to the laboratory
immediately may alter test results because
complement deteriorates rapidly at room temperature.
Hemolysis of the sample may alter test results.
INDICATIONS FOR SERUM COMPLEMENT ASSAYS

Suspected acute inflammatory disorder as generally indicated by elevated total complement levels
Suspected immune or infectious disorder (e.g.,
acute glomerulonephritis, systemic lupus erythematosus [SLE], rheumatoid arthritis, hepatitis,
subacute bacterial endocarditis, gram-negative
sepsis) or both, as indicated by decreased total
complement levels
Support for diagnosing hereditary deficiencies of
complement components as indicated by
decreased levels of total complement or of specific
components such as C3 and C4, or of both (see
Table 3–5)
Support for diagnosing cancer, especially that of
the breast, lung, digestive system, cervix, ovary,
and bladder, as indicated by increased levels of C3
and C4 (see Table 3–5)
Monitoring for the progression of malignant
disease as indicated by declining complement
levels as the disease progresses
Support for diagnosing a variety of immune and

SECTION I—Laboratory

TABLE 3–5
Component

Tests

•

Causes of Alterations in C3 and C4 Levels

Increased Levels

Decreased Levels

Acute rheumatic fever

Advanced systemic lupus erythematosus
(SLE)

Rheumatoid arthritis

Glomerulonephritis

Early SLE

Renal transplant rejection

Most cancers

Chronic active hepatitis
Cirrhosis
Multiple sclerosis
Anemias
Gram-negative septicemia
Subacute bacterial endocarditis
Inborn C3 deficiency
Serum sickness
Immune complex disease

Rheumatoid spondylitis

SLE

Juvenile rheumatoid arthritis

Lupus nephritis

Most cancers

Acute poststreptococcal glomerulonephritis
Chronic active hepatitis
Cirrhosis
Subacute bacterial endocarditis
Inborn C4 deficiency
Serum sickness
Immune complex disease

Reference Values
Conventional Units
Total complement (CH50)
C3
C4

40–90 U/mL

SI Units
0.4–0.9 g/L

Men

80–180 mg/dL

0.80–1.80 g/L

Women

76–120 mg/dL

0.76–1.20 g/L

Men

15–60 mg/dL

0.15–0.60 g/L

Women

15–52 mg/dL

0.15–0.52 g/L

Note: Values for total complement, C3, and C4 may vary according to laboratory methods
and the reference range established by the laboratory performing the test.

CHAPTER 3—Immunology

inflammatory disorders as indicated by altered C3
and C4 levels (see Table 3–5)
Monitoring of progress after various immune and
inflammatory disorders as indicated by levels
approaching or within the reference ranges
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Note and report
types and deficiencies of complement components and their relation to an inflammatory or
infectious disorder.

and Immunologic Testing

Reference Values
Immune complexes are not normally found in
the serum.

INTERFERING FACTORS

Rough handling of the sample and failure to
transport the sample promptly to the laboratory
may cause deterioration of any immune
complexes present.
INDICATIONS FOR IMMUNE COMPLEX ASSAYS

Suspected immune disorders such as SLE, scleroderma, dermatomyositis, polymyositis, glomerulonephritis, and rheumatic fever as indicated by
the presence of immune complexes
Monitoring of the effects of therapy for various
immune disorders
Suspected serum sickness or allergic reactions to
drugs as indicated by the presence of immune
complexes
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

IMMUNE COMPLEX ASSAYS
Immune complexes are combinations of antigen and
antibody that are capable of activating the complement cascade. Although the activated agent is
directed against the immune complex, tissues that
are “innocent bystanders” may also be severely
damaged, especially when immune complexes are
produced too rapidly for adequate clearance by the
body. Immune complexes are commonly present in
autoimmune disorders and also are found in
immune hypersensitivities that do not involve
autoimmunity.
Two methods can be used to determine the circulating immune complexes (CIC) in the blood in the
diagnosis of autoimmune and infectious diseases.
One involves screening for large amounts of precipitate in serum that has been refrigerated. The other
is the Raji cell assay, in which these specially
prepared cells that bind complement (C3) are
combined with the serum sample and then incubated. Further incubation with a radiolabeled
antihuman immunoglobulin allows for binding of
the CIC on the surface of the Raji cells. This is
followed by washing of the cells and measurement of
the radioactivity to determine the CIC in the
blood.25

THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Note and report
the presence of complexes in relation to signs and
symptoms of an existing or suspected autoimmune disease.

RADIOALLERGOSORBENT TEST
FOR IgE
IgE antibodies are responsible for hypersensitivity
reactions described as atopic (allergic) or anaphylactic. Examples of IgE-mediated diseases include hay
fever, asthma, certain types of eczema, and idiosyncratic, potentially fatal reactions to insect venoms,
penicillin, and other drugs or chemicals.

SECTION I—Laboratory

Tests

Almost all of the body’s active IgE is bound to
tissue cells, with only small amounts in the blood.
Thus, IgE antibodies cannot circulate in search of
antigen but must wait for antigens to appear in their
area. Once this happens, the interaction of IgE antibodies with specific antigens causes mast cells (tissue
basophils) to release histamine and other substances
that promote vascular permeability.26
The radioallergosorbent test (RAST) for IgE
measures the quantity of IgE antibodies in the serum
after exposure to specific antigens selected on the
basis of the person’s history. RAST has replaced skin
tests and provocation procedures, which were inconvenient, painful, and hazardous to the client.
Reference Values
If the client is not allergic to the antigen, IgE
antibody is not detected. A positive test result in
relation to a specific antigen is more than 400
percent of control. Results of the test may vary
depending on the reference serum used for the
control.

INTERFERING FACTORS

Radioisotope tests within 1 week before the test
may alter results.
INDICATIONS FOR RADIOALLERGOSORBENT
TEST FOR IgE

Onset of asthma, hay fever, dermatitis
Systemic reaction to insect venom, drugs, or
chemicals
Identification of the specific antigen(s) to which
the client reacts
Monitoring of response to desensitization procedures
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or other type of blood
collection tube, depending on laboratory preference.
The allergy panel desired should be indicated on the
laboratory request form. Each panel usually consists
of six antigens.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Instruct client
to avoid contact with substances, ingestion of
drugs, or exposure to insects that cause reactions.

AUTOANTIBODY TESTS
Antibodies directed against “self ” components are
believed to be responsible for the pathogenesis of
many diseases. Some show widespread systemic
involvement (Table 3–6), whereas others are
confined to a specific organ system (Table 3–7).
INTERFERING FACTORS

Many drugs may cause false-positive results in
certain autoantibody tests (Table 3–8).
INDICATIONS FOR AUTOANTIBODY TESTS

Signs and symptoms of the disorder for which
each test is pathognomonic or for which the test
provides confirming data (see Tables 3–6 and 3–7)
Monitoring of response to treatment for autoimmune disorders
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Food and fluids are not restricted, except for the
cryoglobulin test, which requires a 4-hour fast
from food.
THE PROCEDURE

The procedure is the same for all autoantibody tests,
except cryoglobulins. A venipuncture is performed
and the sample collected in a red-topped tube. For
cryoglobulins, the sample is collected in a
prewarmed red-topped tube. The sample must be
handled gently to avoid hemolysis and sent
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample. Resume food withheld
before the test.
Complications and precautions: Note and report
the presence of cell-specific or tissue-specific antibodies in relation to a suspected disease and the
presenting signs and symptoms.

CHAPTER 3—Immunology

TABLE 3–6

•

and Immunologic Testing

Summary of Autoantibody-Related Disorders and Tests
Used in Diagnosis
Incidence

Antibody
C-reactive
protein (CRP)

Present in 90% or
More of Cases

Present in
50–90% of Cases

Present in 50%
of Cases

Rheumatic fever

Active tuberculosis

Multiple sclerosis

Rheumatoid arthritis

Gout

Guillain-Barré syndrome

Acute bacterial infections

Advanced cancers

Scarlet fever

Viral hepatitis

Leprosy

Varicella

Cirrhosis

Surgery

Burns

Intrauterine contraceptive
devices

Peritonitis
Rheumatoid
factor (RF)

Antinuclear antibodies (ANA)

Rheumatoid arthritis

Systemic lupus erythematosus (SLE)

Early rheumatoid arthritis

Advanced age

SLE

Juvenile rheumatoid
arthritis (20%)

Scleroderma

Infectious diseases

Dermatomyositis

Healthy adults (5%)

Sjögren’s syndrome

Burns

Scleroderma

Asbestosis

Drug-induced SLE-like
syndrome

Juvenile chronic
polyarthritis

Chronic active hepatitis

Rheumatoid arthritis

Heart disease, with longterm procainamide therapy

Rheumatic fever

Myasthenia gravis
Advanced age
Dermatomyositis
Polyarteritis nodosa
Primary biliary cirrhosis
Anti-DNA

Active SLE

SLE in remission

Juvenile rheumatoid
arthritis
Progressive systemic sclerosis
Drug-induced SLE-like
syndrome
Uveitis

Cold agglutinins

Atypical pneumonia

Viral infections

Congenital syphilis

Influenza

Infectious mononucleosis

Malaria

Pulmonary embolus

Lymphoreticular malignancy

Anemia
Cirrhosis
(Continued on following page)

SECTION I—Laboratory

TABLE 3–6

•

Tests

Summary of Autoantibody-Related Disorders and Tests
Used in Diagnosis (Continued)
Incidence
Present in 90% or
More of Cases

Antibody

Present in 50%
of Cases

Present in
50–90% of Cases

Lupus erythematosus (LE)
cell preparation

SLE

—

Cryoglobulins

Raynaud’s syndrome

—

Cryoglobulinemia

Reference Values
Conventional Units
C-reactive protein (CRP)
Antinuclear antibodies (ANA)
Rheumatoid factor (RF)
Anti-DNA antibodies

Negative to trace
Negative
Negative (1:20)
1 mg/mL

Antimitochondrial antibodies

Negative

Antiskin antibodies

Negative

Antiadrenal cortex antibodies

Negative

Antithyroglobulin, antithyroid microsome antibodies

1:100

Antismooth muscle antibodies

Negative

Antiparietal cell, anti-intrinsic factor antibodies

Negative

Antistriated muscle antibodies

Negative

Antimyocardial antibodies

Negative

Antiglomerular basement membrane antibodies

Negative

Anti-insulin antibodies

Negative

Acetylcholine receptor antibodies

Negative

Anti-SS-A and anti-SS-B antibodies

Negative

Lupus erythematosus cell test (LE prep)

Negative

Cold agglutinins
Cryoglobulins

1:16
Negative

Antiglobulin tests (Coombs’ tests)*
Direct

Negative

Indirect

Negative

* See also Chapter 4.

SI Units

2.0 kU/L

CHAPTER 3—Immunology

TABLE 3–7
Antibody Target
Cell/Tissue

•

and Immunologic Testing

Cell- and Tissue-Specific Antibodies
Diseases for Which the Test
Is Usually Diagnostic

Other Diseases in Which This
Antibody May Also Be Present

Skeletal muscle

Myasthenia gravis

Cardiac muscle

Myocardial infarction

Acute rheumatic fever

Smooth muscle

Chronic active hepatitis

Biliary cirrhosis
Viral hepatitis
Infectious mononucleosis
Systemic lupus erythematosus
(SLE) (10%)

Mitochondria

Primary biliary cirrhosis

Chronic active hepatitis

Drug-induced jaundice

Viral hepatitis
SLE (20%)

Skin

Pemphigus

—

Altered IgG

Rheumatoid arthritis

—

Adrenal cells

Addison’s disease

—

Intrinsic factor, parietal cells

Pernicious anemia

SLE (5%)

Long-acting thyroid stimulator

Graves’ disease

—

Hashimoto’s thyroiditis
Long-acting thyroid microsomes

Primary myxedema

SLE (5%)

Juvenile lymphocytic thyroiditis

Pernicious anemia (25%)

Graves’ disease

Allergies

Healthy adults
Hashimoto’s thyroiditis

Pernicious anemia

Primary myxedema

Allergies

Graves’ disease

Healthy adults (5–10%)

Salivary ducts

Sjögren’s syndrome

Rheumatoid arthritis

Red blood cell membrane

Autoimmune hemolytic anemia

Transfusion reaction

Platelet cell membrane

Idiopathic thrombocytopenic
purpura

—

Basement membranes of
lungs, renal glomeruli

Goodpasture’s syndrome

—

Thyroglobulin

Glomerulonephritis

IMMUNOLOGIC ANTIBODY TESTS
Exposure to bacteria, fungi, viruses, and parasites
induces production of antibodies that either can be
identified only during acute disease or can remain
identifiable for many years. Exposure can be through
immunization, from previous infection so minimal

that it passed unrecognized, or from current symptomatic or prepathogenic infection. Detection and
identification of specific antibodies in the blood by
assays performed in the serology laboratory are
preferred for obtaining diagnostic information. This
is especially true when the antigen assays or culture
techniques performed in the microbiology labora-

SECTION I—Laboratory

Tests

•

Drugs that May Cause
False-Positive Reactions in
Autoantibody Tests*

TABLE 3–8

Antibiotics

Para-aminosalicylic acid

Anti-DNA

Penicillin

Chlorpromazine

Phenylbutazone

Clofibrate

Phenytoin

Ethosuximide

Procainamide

Griseofulvin

Propylthiouracil

Hydralazine

Quinidine

Isoniazid

Radioactive diagnostics

Mephenytoin

Streptomycin

Methyldopa

Sulfonamides

Methysergide

Tetracyclines

Oral contraceptives

Trimethadione

* The drugs listed here may cause false-positive reactions in the following tests: antinuclear antibodies,
lupus erythematosus cell test, and antiglobulin
(Coombs’) tests.

Various methods for detection of antibodies are
used. They include immunoprecipitation, complement fixation, neutralization assay, particle
agglutination/agglutination inhibition, immunofluorescence assay, enzyme immunoassay, and radioimmunoassay. The concentrations of antibody are
referred to as the titer, and their predictable patterns
are useful in both diagnosing a disease and monitoring its course.

Fungal Infection Antibody Tests
Most pathogenic fungi elicit antibodies in immunocompetent hosts. Assays for fungal antibodies are
used to diagnose invasive deep-seated recent or
current infections. Serologic testing for parasitic
organisms or antibodies in the blood sample is also
used in the diagnosis of infections. Depending on
the antibody to be identified, testing uses the various
assay techniques mentioned in the introduction of
this chapter. Table 3–9 indicates the fungal and parasitic infections for which tests are available and the
causes of alteration in the test results.
INTERFERING FACTORS

tory are ineffective in producing a causative agent or
in clients who cannot tolerate the invasive procedure
necessary to collect a specimen for culture.

TABLE 3–9
Organism

•

Recent fungal skin tests may alter results.
Obtaining the sample near fungal skin lesions
may contaminate the specimen and alter test
results.

Fungal and Parasitic Immunologic Tests
Tests Available

Causes of Alterations

Fungi
Histoplasma capsulatum

CF, I, LA

Prior exposure to organism or cross-reactive
agent, recent skin test

Blastomyces dermatitidis

EIA

Blastomycosis

Coccidioides immitis

CF, I, LA

Acute or chronic infection, repeated skin testing
with coccidioidin

Aspergillus fumigatus

CF, I

Pulmonary aspergillosis, aspergillosis allergy

Cryptococcus neoformans

Test demonstrates antigen, not antibodies, in
infection

Sporotrichum schenckii

Deep tissue infection

Candida albicans

Systemic infection, vaginal infection

Toxoplasma gondii

IFA, EIA

Acute or chronic toxoplasmosis

Entamoeba histolytica

A, IFA

Amebic dysentery

Parasites

Aagglutination, CFcomplement fixation, Iimmunodiffusion, IFAindirect fluorescent antibody tests, LAlatex
agglutination, EIAenzyme immunoassay.

CHAPTER 3—Immunology

and Immunologic Testing

Reference Values
Organism

Complement Immunodiffusion
Fixation Titers
Test
Agglutination

Other
Tests

Fungi
Histoplasma
capsulatum

1:8

Negative

—

Blastomyces
dermatitidis

1:8

Negative

—

Coccidioides
immitis

1:2

Negative

—

Aspergillus
fumigatus

1:8

Negative

—

Cryptococcus
neoformans

—

Negative

—

Sporotrichum
schenckii

—

1:40

—

Candida albicans

—

Latex agglutination
(LA) test 1:8

Toxoplasma gondii

—

Indirect fluorescent
antibody tests 1:16

Entamoeba histolytica

—

Indirect hemagglutination
test 1:32

Parasites

INDICATIONS FOR FUNGAL INFECTION
ANTIBODY TESTS

Suspected infection with the fungus for which the
test is performed
Persistent pulmonary symptoms after pneumonia
Acute meningitis of unknown etiology
Identification of the state of infection by rising or
falling titers
Confirmation of previous exposure to the fungus
despite absence of clinical signs of illness
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
The client should be interviewed to determine if
he or she has undergone any recent fungal skin
tests that may alter test results.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. Venipuncture should

not be performed on or near any fungal skin lesions.
The sample must be handled gently and transported
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Note and report
signs and symptoms of fungal infection, superficial or deep-seated presence, and rise of serum
antibodies to a specific fungal or parasitic
microorganism or culture identification of the
microorganism. Assess factors that can cause
infection such as travel or residence in areas where
infection is endemic; antibiotic or corticosteroid
therapy; chemotherapy; presence of an intravenous (IV) line to administer fluids, medications, or parenteral nutrition; or invasive
procedures such as surgery. Note symptoms of
vaginitis such as itching and foul-smelling,
white, cheeselike secretion. Administer ordered
antifungals via oral, IV, or vaginal routes. Monitor

SECTION I—Laboratory

TABLE 3–10

•

Tests

Commonly Performed Serologic Tests for Diagnosis
of Recent Bacterial Infections

Organism

Clinically
Significant Result*

Test

Staphylococcus aureus

Immunodiffusion for teichoic acid antibodies

1:4

Streptococcus pyogenes

Antistreptolysin O (ASO)

1:240

Anti-DNAase B

1:240

Antihyaluronidase

4x titer rise

Salmonella typhi (typhoid fever)

Widal test

4x titer rise

Legionella pneumophila
(Legionnaires’ disease)

Indirect immunofluorescence

1:256

Treponema pallidum

Rapid plasma reagin (RPR)

1:8

Venereal Disease Research Laboratory
(VDRL)

1:8

Fluorescent treponemal antibodyabsorption (FTA-ABS) (IgM)

Positive

Borrelia burgdorferi (Lyme
disease)

Indirect immunofluorescence

1:128

Mycoplasma pneumoniae (atypical pneumonia)

Cold agglutinins
Complement fixation

1:128
1:32

Rickettsia rickettsii (spotted and
typhus fevers)

Weil-Felix (OX-19)

1:320

* Titers greater than or equal to those displayed in the table or fourfold or greater rises in titer between acute and
convalescent sera are only suggestive of recent infection by all of the agents listed. Titers less than those
displayed in the table do not rule out infection.
Adapted from Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA
Davis, Philadelphia 2000, p 709.

respiratory status for changes in rate, ease, depth,
and breath sounds and place on respiratory
precautions according to universal standards, if
appropriate. Prepare client for skin tests if
ordered.

bacterial antibody detection of recent or existing
infectious diseases are individually outlined and
discussed. They include staphylococcal, streptococcal, and febrile/cold agglutinin tests.

STAPHYLOCOCCAL TESTS
Bacterial Infection Antibody Tests
Although most bacterial infections are successfully
diagnosed by culture, serologic testing is performed
for antibodies to screen for past, recent, or existing
infection in those with negative cultures. Clients in
whom these tests are performed usually have
sustained a fever of unknown origin or have been
treated with antimicrobials. Table 3–10 indicates the
commonly performed tests for recent bacterial
infections for identification and titers that are
suggestive of recent infection. Also, specific individual serologic tests that have special applications in

The teichoic acid antibody is measured to diagnose
infections caused by Staphylococcus aureus. Teichoic
acid attaches to the organism’s cell wall. High titers
are associated with invasive infections such as bacterial endocarditis and osteomyelitis.
Reference Values
Teichoic acid antibody titer <1:2
INTERFERING FACTORS

Improper technique in testing

CHAPTER 3—Immunology

INDICATIONS FOR STAPHYLOCOCCAL TESTS

Suspected infection caused by S. aureus
Diagnosis of osteomyelitis or endocarditis caused
by a bacterial infection
Monitoring of ongoing therapy administered for
gram-positive bacterial infections
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Inform the client that repeat or serial blood
sampling and testing can be performed.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The tube should be
labeled as an acute or convalescent sample,
whichever applies.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Inform the client of the time to return for a repeat
test, usually in 2 weeks, to determine the change in
titers between the acute and convalescent stages.
Abnormal values: Note and report increases in
titers. Assess for signs and symptoms associated
with staphylococcal infections such as temperature elevation, bone pain in osteomyelitis, and
changes in heart sounds in endocarditis.
Administer ordered analgesic and antibiotic therapy and instruct in preventive antibiotic therapy
in those at risk.

STREPTOCOCCAL TESTS
Group A -hemolytic streptococci produce a variety
of extracellular products capable of stimulating antibody production. Such antibodies do not act on the
bacteria and have no protective effect, but their existence indicates recent active streptococci. Antibody
production is most reliably noted in response to
streptolysin O, and the test for this antibody is
termed an antistreptolysin O (ASO) titer. Antibodies
in response to hyaluronidase (AH), streptokinase
(anti-SK), deoxyribonuclease B (ADN-B), and
nicotinamide (anti-NADase) also can be produced.
When ASO titers are low, tests for these latter antibodies can be produced to substantiate the diagnosis, because they are more sensitive tests.
Elevated antistreptococcal antibody titers can
occur in healthy carriers of -hemolytic strepto-

and Immunologic Testing

cocci. Elevated levels also are seen in those with
rheumatic fever, glomerulonephritis, bacterial endocarditis, scarlet fever, otitis media, and streptococcal
pharyngitis.
Reference Values
ASO titer
Preschool children

85 Todd units/mL

School-age children

170 Todd units/mL

Adults

85 Todd units/mL

ADN-B titer
Preschool children

60 Todd units/mL

School-age children

170 Todd units/mL

Adults

85 Todd units/mL

AH titer

128 Todd units/mL

Anti-SK titer

128 Todd units/mL

INTERFERING FACTORS

Therapy with antibiotics and adrenal corticosteroids may result in falsely decreased levels.
Elevated blood -lipoproteins may result in
falsely elevated levels.
INDICATIONS FOR STREPTOCOCCAL TESTS

Suspected streptococcal infection, to confirm the
diagnosis
Detection and monitoring of response to therapy
for poststreptococcal illnesses such as rheumatic
fever and glomerulonephritis
Differentiation of rheumatic fever from rheumatoid arthritis, with the former indicated by
elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Medications that the client is currently taking or
has recently taken should be noted, because therapy with antibiotics and adrenal corticosteroids
may alter test results.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. A capillary sample
may be obtained in infants and children as well as in
adults for whom a venipuncture may not be feasible.
The sample must be handled gently and sent
promptly to the laboratory.

SECTION I—Laboratory

Tests

Reference Values
Weil-Felix reaction (Proteus antigen test)

1:80

Widal’s test (O and H antigen tests)

1:160

Brucella agglutination test (slide agglutination test)

1:80

Tularemia agglutination test (tube dilution test)

1:40

M. pneumoniae (cold agglutinin test)

1:32

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report increased
levels of specific tests in relation to signs and symptoms of joint or renal disease. Assess for joint pain,
elevated temperature, sore throat, and history of a
recent infection. Administer ordered antipyretics,
analgesics, and antibiotic therapy. Prepare for additional tests if more specificity is needed.

FEBRILE/COLD AGGLUTININ TESTS
Febrile agglutinin tests are performed concurrently
with blood culture for microorganism identification
to diagnose the infectious cause of a febrile condition. The test is performed with the use of antigens
to specific organisms and their reaction (agglutination) with antibodies in the client’s blood serum.
Diseases that can be diagnosed using these tests,
along with the type of febrile agglutinin test used,
are listed in Table 3–11.
The cold agglutinin test is performed to identify

TABLE 3–11

•

cold agglutinins, antibodies that result from
Mycoplasma pneumoniae infection. This infection is
caused by a nonbacterial agent, but it still manifests
a febrile condition. The antibodies cause agglutination of red blood cells at temperature ranges of 35.6
to 46.4F (2 to 8C), with a positive titer resulting in
those with atypical pneumonia or cold agglutination
disorders, depending on the severity of the disease.
INTERFERING FACTORS

Vaccination, chronic exposure to infected
animals, and cross-reactions with other antibodies may result in falsely elevated titers.
Individuals who are immunosuppressed or are
receiving antibiotic therapy may have false-negative results.
INDICATIONS FOR FEBRILE/COLD
AGGLUTININ TESTS

Determination of possible cause of fever of
unknown origin (FUO)
Suspected typhus, Rocky Mountain spotted fever,
or other disorder for which selected tests are
specific

Febrile Agglutinin Tests

Diseases

Test

Rickettsial Infections
Rocky Mountain spotted fever, typhus (murine, scrub,
epidemic, and recrudescent)

Weil-Felix reaction (Proteus antigen test)

Salmonella Infections
Typhoid and paratyphoid fevers

Widal’s test (O and H antigen tests)

Brucella Infections
Cattle, hog, goat (Hosts may transmit infections to
humans.)

Brucella agglutination test (slide agglutination
test)

Tularemia
Rabbit fever and deer fly fever

Tularemia agglutination test (tube dilution test)

CHAPTER 3—Immunology

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample must be
handled gently to avoid hemolysis and transported
immediately to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report increased titers
in cold agglutinin test in relation to specific signs
and symptoms of the disease such as fever, change
in respiratory status, and nonproductive cough;
also note increased titers in febrile disorders in
relation to specific infectious processes. Assess for
culture results or need to obtain culture for organism identification; place on enteric precautions as
appropriate. Administer ordered antimicrobial
therapy. Inform client of the need for serial testing
during acute and convalescent stages.

•

Infection with Treponema pallidum provides two
distinct categories of antibodies: (1) reagin (a
nonspecific antibacterial antibody) and (2) antitreponemal antibody. Reagin tests, by their nature
nonspecific, include the Wassermann and Reiter
complement fixation tests, now seldom used. Reagin
tests currently used for screening are the Venereal
Disease Research Laboratory (VDRL) and rapid
plasma reagin (RPR) flocculation tests. Because
reagin screening tests often yield false-positive reactions (Table 3–12), positive test results are confirmed
by means of treponemal antibody tests. The best of
these is the fluorescent treponemal antibodyabsorption test with absorbed serum.27

FLUORESCENT TREPONEMAL
ANTIBODY-ABSORPTION TEST
The fluorescent treponemal antibody-absorption
(FTA-ABS) test is conducted on a sample of the
client’s serum that is layered onto a slide fixed with
T. pallidum organisms. If the antibody is present, it
will attach to the organisms and can subsequently be
demonstrated by its reaction with fluoresceinlabeled antiglobulin serum.
The FTA-ABS test rarely gives false-positive
results, except sporadically in clients with SLE; the

Causes of False-Positive Reactions to Reagin Tests

Transiently Positive

Persistently Positive
OCCURRING IN

10%

OF CLIENTS WITH THE FOLLOWING:

Infectious mononucleosis

Systemic lupus erythematosus

Malaria

Rheumatoid arthritis

Brucellosis

Illicit drug use

Typhus

Hepatitis

Lymphogranuloma venereum

Leprosy

Subacute bacterial endocarditis

Malaria
Advanced age
Nonsyphilitic treponemal disease (pints, yaws, bejel)

OCCURRING RARELY IN CLIENTS WITH THE FOLLOWING:

Hepatitis

Tuberculosis

Measles

Scleroderma

Chickenpox
Mycoplasma pneumonia
After smallpox vaccination

Syphilis Tests

Suspected “carrier” state for typhoid
Positive blood or stool culture for Salmonella

TABLE 3–12

and Immunologic Testing

SECTION I—Laboratory

Tests

pattern of fluorescence may have an atypical beaded
appearance in these cases. Elderly individuals and
clients with immune complex diseases occasionally
also have false-positive results.28

Note that these tests are not specific for antibodies to T. pallidum, and many factors, including laboratory procedures, may cause false-positive results
(see Table 3–12).

Reference Values

Negative

INTERFERING FACTORS

False-positive results may occasionally occur in
elderly individuals and in clients with SLE or
other immune complex diseases.
INDICATIONS FOR FLUORESCENT TREPONEMAL
ANTIBODY-ABSORPTION TEST

Confirmation of the presence of treponemal antibodies in the serum (Note: The test also may be
applied to cerebrospinal fluid [CSF] to diagnose
tertiary syphilis.)
Verification of syphilis as the cause of positive
VDRL and RPR test results
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
The client’s history should be reviewed for possible sources of false-positive results.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample must be
handled gently to avoid hemolysis and must be
transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

VENEREAL DISEASE RESEARCH
LABORATORY AND RAPID PLASMA
REAGIN TESTS
The VDRL and RPR tests are flocculation tests
for reagin and are used in screening for syphilis.
The VDRL test uses heat-inactivated serum and
can be made on slides or in tubes. The RPR test
uses unheated serum or plasma, which is added
to a reagent-treated plasma card. Automated procedures have been adapted for multichannel analyzers.29

Results are reported qualitatively as strongly
reactive, reactive, weakly reactive, or negative. A
degree of quantification is possible by diluting
the serum and reporting the highest titer that
remains positive. Positive results must be further
evaluated either by repeat testing or with tests
specific for antitreponemal antibodies.30

INTERFERING FACTORS

Many factors, including laboratory procedures,
may cause false-positive results (see Table 3–12).
INDICATIONS FOR VENEREAL DISEASE
RESEARCH LABORATORY AND RAPID
PLASMA REAGIN TESTS

Routine screening for possible syphilis
Known or suspected exposure to syphilis, including congenital syphilis
Verification of an antigen-antibody reaction to
reagin, although a positive result is not necessarily
diagnostic for syphilis
Monitoring of response to treatment for syphilis,
with effective treatment indicated by decreasing
titers
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
A thorough history should be obtained to identify
possible causes of false-positive results (see Table
3–12).
It is recommended that alcohol ingestion be
avoided for 24 hours before the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample must be
handled gently to avoid hemolysis and transported
promptly to the laboratory.
For neonates, a sample of cord blood may be
obtained at delivery. Subsequent samples of
venous blood from the infant may be required if
the mother’s titer is lower than that of the infant,
indicating active syphilis in the infant despite
successful treatment of the mother.

CHAPTER 3—Immunology

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report a positive
result and degree of reactivity. Assess for pregnancy and sexual contacts. Ensure that positive
results are reported to the health department for
follow-up and treatment of sexual contacts.
Administer ordered antibiotic medication regimen. Instruct in importance of preventive measures to take during sexual activity, especially if
pregnant, and the screening and treatment of
sexual partner. Inform that the test should be
repeated every 3 months for at least 1 year or until
the reaction becomes negative. Provide a sensitive,
nonjudgmental environment for the client.

Viral Infection Antibody Tests
Viral cultures either are not available or can be
disproportionately expensive in relation to the
potential benefit, because effective antiviral treatment is not available for most organisms. For these
reasons, viral antibody tests are used to determine
exposure to and existing infections with certain
viruses that are difficult to culture, or they are used
to screen donors before blood donation or organ
transplantation (Table 3–13).
Because many types of tests can be performed,
requests for viral antibody tests must be specific and
include enough clinical information to permit selection of the appropriate study. A request for “viral
studies” is meaningless. Antibody assays for detection of some specific disease entities, although
included in Table 3–13, are outlined and discussed in
the next section. They include infectious mononucleosis, hepatitis, and AIDS tests.
Reference Values
In general, lack of exposure to the virus yields a
negative test result. Reference values vary with
the type of viral antibody test. The laboratory
performing the test should be consulted.

INDICATIONS FOR VIRAL INFECTION ANTIBODY
TESTS

Suspected AIDS or exposure to human immunodeficiency virus (HIV)
Retrospective confirmation of viral infection
Determination of immunity to rubella in women
of childbearing age

and Immunologic Testing

Confirmation of exposure to rubella in early pregnancy
Suspected herpes encephalitis
Determination of immunity to chickenpox in
children with leukemia, because this infection
may be fatal in such children
Identification of asymptomatic carriers of
cytomegalovirus (CMV)
Monitoring of the course of prolonged viral
disease
Monitoring of mothers and neonates for exposure
to viral infections that may cause congenital
disease in the newborn infant (usually done by the
toxoplasmosis, other infections, rubella, CMV
infection, and herpes simplex [TORCH] test; see
Table 3–13)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample must be
handled gently to avoid hemolysis and transported
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Women of childbearing age with low rubella titers
should be appropriately immunized.
Abnormal test results, complications, and
precautions: Response is dependent on the type
of viral antibody test and the specific infectious
process identified in Table 3–13. See the specific
tests that follow for nursing implications related
to aftercare and observations.

INFECTIOUS MONONUCLEOSIS TESTS
Diagnosis of infectious mononucleosis, caused by
Epstein-Barr virus (EBV), depends on serologic
(antigen-antibody) confirmation of clinical manifestations of the disease that include fever, sore
throat, and lymphadenopathy. EBV stimulates the
formation of new antigens that, in turn, stimulate a
humoral and cellular immune response. The
humoral response is characterized by an increased
titer of the antibodies IgG and IgM early in the
disease. The cellular response is characterized by the
activation of T cells later in the illness in response to
the EBV-induced infection.

SECTION I—Laboratory

Tests

TABLE 3–13

•

Tests for Viral Diseases

Virus/Disease

Serologic Tests

Respiratory syndromes
Influenza

CF, HI

Parainfluenza
Adenoviruses

CF, HI, NT

Chlamydia

CF, IFA

Respiratory syncytial virus
Arbovirus

CF, HI, NT

Colorado tick fever
Yellow fever
Meningoencephalitis

Antibodies to echo, herpes, polio, and coxsackie viruses by
neutralization tests

Herpes viruses

Fluorescein-tagged antibodies in cells, EIA, indirect HI

Herpes simplex*
Varicella zoster
Cytomegalovirus*
Epstein-Barr virus

Heterophile antibody (Monotest), agglutination test, IFA

Rubella*

IgM titers, CF, HI

Mumps
Measles
Infectious hepatitis

IgM titers, IgG titers, hepatitis A virus antibodies (anti-Ha),
CF, RIA

Serum hepatitis

Antibodies to hepatitis B virus surface antigen (HBsAb)
(HBsAg)

Cytomegalic inclusion disease

CF, HI, EIA

Acquired immunodeficiency syndrome
(AIDS)

Human immunodeficiency virus (HIV-1) antibodies, IFA,
EIA, WIB

Leukemia and tropical spastic paraparesis

HTLV-1 and HTLV-II antibodies, ETA, WIB

* In the TORCH test, antibodies to Toxoplasma gondii (see Table 3–9), rubella virus, cytomegalovirus, and
herpesvirus are measured.
CFcomplement fixation, EIAenzyme immunoassay, HIhemagglutination inhibition, IFAimmunofluorescent
antibody, NTneutralization test, RIAradioimmunoassay, WIBWestern immunoblot assay.

The hallmark of EBV infection is the heterophil
antibody, also called the Paul-Bunnell antibody, the
formation of which is stimulated by the virus. The
heterophil antibody is an IgM that agglutinates
sheep or horse red cells. Forssman antibody, which
can be present in the serum of normal people as
well as in that of individuals with serum sickness,
also agglutinates with sheep erythrocytes. The
Davidsohn differential absorption test can be used
to distinguish between the Paul-Bunnell antibody
and the Forssman antibody. Currently, more rapid

and sensitive tests are available that use red blood
cells from horses in a single-step agglutination test.31
These tests (e.g., Monospot, Monoscreen) are used
as screening tests for infectious mononucleosis and
are gradually replacing the more traditional techniques.
Reference Values
Negative, or a titer of less than 1:56 heterophile
antibodies

CHAPTER 3—Immunology

INTERFERING FACTORS

False-positive results may occur in the presence of
narcotic addiction, serum sickness, lymphomas,
hepatitis, leukemia, cancer of the pancreas, and
phenytoin therapy.
INDICATION FOR INFECTIOUS MONONUCLEOSIS
TESTS

Suspected infectious mononucleosis (Of individuals with EBV infectious mononucleosis, 95
percent will have a positive result, 86 percent in
the first week of illness.)
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. For screening tests,
the directions accompanying the test kit are
followed. For traditional tests, the sample should be
sent to the laboratory promptly.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report increased
heterophile titer or titers against EBV. Assess signs
and symptoms of infection such as fever, chills,
malaise, sore throat, anorexia, enlarged lymph
nodes, and fatigue. Provide rest, adequate nutritional and fluid intake, and activities that do not
cause fatigue or stress.

HEPATITIS TESTS
Hepatitis tests include measurements of serologic
markers that appear during the course of the disease
caused by the hepatitis A virus (HAV), hepatitis B
virus (HBV), hepatitis C virus (HCV), hepatitis D
virus (HDV), and hepatitis E virus. Laboratory
methods used in the detection of specific antigens or
antibodies include radioimmunoassay (RIA) and
enzyme immunoassay (EIA).
Hepatitis A is a self-limiting disease that does not
usually cause liver damage or a chronic infectious
state. It occurs as the result of oral ingestion of the
virus and is characterized by malaise, anorexia, fever,
and nausea. The virus is present in the feces, but

and Immunologic Testing

diagnosis is based on serologic markers (anti-HAV,
IgM, IgG) identified in the laboratory. The diagnosis
is made for hepatitis A if anti-HAV antibodies can
be demonstrated in the early acute stage of the
disease or if there is a high level of IgM anti-HAV
compared to the level of the IgG antibody to HAV.
IgM antibodies appear in the early stages, and IgG
antibodies indicate past infection and immunity to
reinfection.
Hepatitis B, also known as the Australian antigen,
is a more serious, prolonged disease that can result
in liver damage and chronic active hepatitis. HBV
can be found in the blood, feces, saliva, semen, sweat,
urine, or any body fluid of infected individuals and
can be transmitted by exposure to blood products or
parenteral contact with articles contaminated with
material containing the virus. Diagnosis is made by
identification of the hepatitis B surface antigen
(HBsAg) circulating in the blood before and during
the acute early stage before enzyme elevations or in
chronic carriers after an acute illness. It is the first
indicator of acute hepatitis infection. The recovery
from and immunity to HBV as late as 6 to 10 months
after an active infection are identified by the detection of anti-HBs. The presence of hepatitis B antibody (anti-HBe, HBeAb) indicates the resolution of
acute infection or, along with positive HBsAg, indicates an asymptomatic, healthy carrier. The presence
of hepatitis B e antigen (HBeAg) is an early indicator of hepatitis B infection. If HBeAg persists for
more than 3 months, it is indicative of chronic infection. Delta hepatitis coinfects with HBV, and diagnosis is made by detection of the antibodies (anti-D)
in the blood.
Hepatitis C is a parenterally acquired disease
usually caused by blood transfusion but also by IV
drug abuse. The disease can lead to chronic hepatitis
and cirrhosis of the liver. The test is performed to
detect the antibodies to HCV in the blood of those
at risk for the infection and transmission of the virus
as a blood donor. Antibody formation can take as
long as a year after exposure to the virus.
Hepatitis D is caused by a “defective” virus that
can produce infection only when HBV is present.
HDV antigens do not circulate and are found only in
hepatocytes. Hepatitis D occurs with HBV and can
result in more serious disease in individuals with
chronic HBV infection. Hepatitis D is also known as
delta agent hepatitis.
Hepatitis E is similar in presentation and disease
course to hepatitis A. It occurs primarily in Asia,
Africa, and South America.32
INTERFERING FACTORS

The administration of radionuclides within 1

SECTION I—Laboratory

Tests

body fluids, personal contact through sexual
activity, or presence of pregnancy (the infection
could be transmitted to the infant).33

Reference Values
Hepatitis A
Anti-HAV

Negative

THE PROCEDURE

IgM

Negative

IgG

Negative

A venipuncture is performed and the sample
collected in a red-topped tube. For screening tests,
the directions accompanying the test kit are
followed. For traditional testing, the sample should
be sent to the laboratory promptly, with the test
performed within 7 days or frozen for future analysis.

Hepatitis B
Surface antigen (HBsAg)

Negative

Surface antibody (HBsAb)

Negative

B antigen (HBeAg)

Negative

B antibody (HBeAb)

Negative

Core antibody (anti-HBcAb)

Negative

Hepatitis C
C antibody (anti-HCV)

Negative

Hepatitis D
Delta antibody (anti-HDV)

Negative

week of testing using the RIA technique can cause
inaccurate results.
Rheumatoid factor and competing IgG-specific
antibody can cause inaccurate positive and negative results.
INDICATIONS FOR HEPATITIS TESTS

Detection of the presence of antigen or antibody
to a specific type of hepatitis depending on symptoms and stage of the disease in the diagnosis of
the condition
Determination of possible hepatitis carrier status
Determination of past exposure or immunity
status in those with a history of hepatitis
Screening of pretransfusion donors for a history
or presence of hepatitis, especially if asymptomatic and information source questionable
Determination of progression to chronic hepatitis
or persistent signs and symptoms of liver dysfunction
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Obtain a thorough history regarding possible
ingestion of contaminated water or foods, environmental sanitation factors conducive to occurrence, recent blood transfusion, parenteral
exposure to materials contaminated by blood or

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report presence of
antigen or antibody to a specific type of hepatitis.
Provide rest and energy-saving assistance as
needed, skin care for jaundice and pruritus, and
adequate nutritional and fluid intake.
Disease transmission: Note and report type of
hepatitis. If hepatitis A, place client on enteric
precautions. If hepatitis B, C, or D, observe standard precautions for blood-borne pathogens (see
Appendix III for hand protection, personal
protection, and needles and sharps), and instruct
in precautions against transmission via sharing of
needles by IV drug abusers and sexual contact.
Disease prevention: Hepatitis A and B vaccines
for active immunity. Instruct client to avoid
donating blood for 6 months if a transfusion has
been received and to never donate blood if diagnosis of hepatitis B has been made.

ACQUIRED IMMUNODEFICIENCY
SYNDROME TESTS
AIDS and the early stages of HIV infection are
diseases of the immune system caused by the human
immunodeficiency virus or HIV-2. This virus is
responsible for infecting and destroying the T-helper
lymphocytes (CD4 cells). This destruction, in turn,
affects the ability of the body to produce antibodies
and suppresses cellular immune responses, leading
to disorders and infections by many opportunistic
infectious agents. The average time from HIV infection to development of full-blown AIDS is approximately 10 years. The clinical manifestations of the
infection also can vary from an initially mild illness
to an acute state. Those at high risk for the disease
include male homosexuals, hemophiliacs, recipients
of blood or blood products before 1985, and IV drug

CHAPTER 3—Immunology

users who share needles. Heterosexual transmission
of the virus is on the rise.34
After the virus has been acquired, antigens are
detectable in the blood serum as early as 2 weeks,
and they remain for 2 to 4 months. At this time, antibodies appear. Late in the disease, antigens reappear
and antibodies decrease, indicating a poor prognosis. The most common tests to screen for HIV-1
virus antibodies are the EIA, also known as the
enzyme-linked immunosorbent assay (ELISA), and
the immunofluorescence assay. The test is repeated if
the results are positive or borderline. Repeat testing
after a positive value requires confirmation by the
Western immunoblot (WIB) assay, which has the
ability to identify antibodies to at least nine different
epitopes of HIV-1. Antigen testing in the early stages
of HIV-1 infections before antibodies are detected
can be undertaken to monitor clients for progression of the disease and response to therapy. It is also
useful to diagnose HIV-1 infection in infants when
maternal antibodies are passively transferred and
diagnosis based on serologic testing is difficult.35
Reference Values
Negative for HIV antigen by antigen capture
assay during initial infectious state and in
advanced state of the disease
Negative for HIV antibodies by antibody detection methods, EIA, and immunofluorescence
assay
Negative for confirmation test for HIV antibodies by WIB

and Immunologic Testing

INDICATIONS FOR ACQUIRED
IMMUNODEFICIENCY SYNDROME TESTS

Detection of the core p24 protein and antibodies
to the identified protein in the diagnosis and staging or progression of infections in AIDS
Confirmation of positive test results obtained by
EIA to ensure accurate results
Determination of the extent of CD4 (T-helper
lymphocytes) cell decreases in relation to normal
or increased levels of CD8 (T-suppressor) cells to
predict immunodeficiency state
Prediction of exacerbation of the disease by
increased protein 2-microglobulin, indicating
destruction of lymphocytes and macrophages
Assistance in the diagnosis of AIDS in the presence of opportunistic infections determined by
culture and microorganism identification
Screening of those in high-risk groups for the
development of AIDS
Screening of blood donors by blood banks before
obtaining blood donations
Screening of blood before using for transfusion or
preparation of blood products
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Obtain a history regarding possible contact with
the virus such as sexual practices, drug abuse with
needle sharing, transfusion with contaminated
blood products, or presence of pregnancy (virus
could be transmitted to the infant). Inform the
client of confidentiality and legal requirements
regarding the test performance and test results.

INTERFERING FACTORS

Negative results can occur in infected individuals
because of lack of antibody formation early in the
disease and in late stages because of loss of ability
to produce antibodies.
Inaccurate results can occur with the use of test
kits that contain proteins if an individual has been
exposed to the media used in the kits.
Cross-reactive antibodies directed to antigenic
determinants found in nonpathogenic retroviruses can result in inaccurate positive results.36
Children who become infected before birth
through an infected mother can have inaccurate
negative results.
Corticosteroids can affect lymphocyte subset test
results.
Protease inhibitors can inhibit replication of
infected cells and cell-to-cell spread of HIV.

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped (antigen or antibody) or
lavender-topped (lymphocyte or microglobulin)
tube, depending on the tests to be performed.
Appropriate apparel (gloves and mask) and precautions for blood-borne pathogens are carried out
when obtaining and caring for the blood samples
(see Appendix III).
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report positive test
results. Inform client of the most current information regarding medications, economic and

SECTION I—Laboratory

Tests

social assistance, and possible psychological counseling services. Instruct client in adequate nutritional and fluid intake. Provide a sensitive,
nonjudgmental, and caring environment for the
client.
Disease transmission: Instruct client in precautions to take during sexual activity; advise to avoid
sharing needles during drug use and to avoid
donating blood. Provide care using standard
precautions and observing transmission-based
isolation procedures for blood-borne pathogens.
Medicolegal aspects: Observe regulations for
confidentiality in reporting test results, such as
use of computer or telephone. Maintain confidentiality of records containing test results. Carry out
state regulation regarding the reporting of positive results. Provide a form for physician to sign
regarding any risks associated with testing and
obtain a signed informed permission request
before the test. Contact Centers for Disease
Control and Prevention (CDC) for the latest
guidelines on reporting HIV status and appropriate follow-up and counseling.

IMMUNOLOGIC TESTS
RELATED TO CANCER
Tumor markers are defined as substances produced
by malignant or benign cells in response to the presence of cancer. They are detected by the examination
of body fluids and tissue specimens. Their use
includes tumor prediction, detection, and identification; monitoring of the course and prognosis; and
evaluation of therapy protocols. The most desirable
markers are those that can detect malignancy in a
remote area by the analysis of body fluids (serum,
urine, fluid from effusion, and CSF) rather than by
invasive procedures to obtain a tissue sample. The
markers are classified as endocrine (hormones),
metabolic consequences associated with tumor
(albumin, blood cells, lipids), enzymes and
isozymes, oncofetal antigens or glycoproteins, and
gene alteration or oncogenes. Current tumor markers and some clinical associations in use at this time
are listed in Table 3–14.37,38 Panels of tumor markers
to assist in the identification or confirmation of a
malignancy in relation to tissue site and to assist in
monitoring the course and prognosis of the malignancy are also performed.
Malignancies or cancer can invade organ tissues,
access vascular channels, and metastasize to other
body sites. They are characterized by an abnormal
number of cells that grow without the normal
control and immune abilities of the body. There is
no single molecular or morphologic characteristic

specific to malignancies.39 This allows for the presence of abnormal reference values associated with
benign cells and conditions other than cancer.
Complete specific test information regarding the
blood cells, enzyme, hormone, endocrine, and metabolic markers listed in Table 3–14 is included in the
respective chapters. These tests are commonly
performed to obtain information about many other
disorders, and differentiation is made when analyzing the results in the diagnosis of malignancy.
Antigens and globulins, used in the diagnosis and
treatment of cancer and commonly found in fetal
life, are considered individually in this section. These
substances are considered abnormal in adults if
present in excessive amounts.

SERUM -FETOPROTEIN TEST
During the first 10 weeks of life, the major serum
protein is not albumin, but -fetoprotein (AFP).
Fetal liver synthesizes huge quantities of AFP until
about the 32nd week of gestation. Thereafter,
synthesis declines until, at 1 year of age, the serum
normally contains no more than 30 ng/mL.
Resting liver cells (hepatocytes) normally manufacture very little AFP, but rapidly multiplying hepatocytes resume synthesis of large amounts.40 Thus,
the test’s greatest usefulness is in monitoring for
recurrence of hepatic carcinoma or metastatic
lesions involving the liver. Note that 30 to 50 percent
of Americans with liver cancer do not have elevated
AFP levels. More consistent elevations are seen in
those Asian and African populations with a very
high incidence of hepatocellular carcinoma.41
Measurement of AFP levels in maternal blood and
amniotic fluid is used to detect certain fetal abnormalities, especially neural tube defects such as anencephaly, spina bifida, and myelomeningocele (see
Chapter 10). Routine prenatal screening includes
determination of the mother’s serum AFP level at 13
to16 weeks of pregnancy. If maternal blood levels are
elevated on two samples obtained 1 week apart, an
ultrasound may be performed, and AFP levels in
amniotic fluid may be analyzed. Other possible
causes of elevated AFP levels during pregnancy
include multiple pregnancy and fetal demise.
INDICATIONS FOR SERUM -FETOPROTEIN TEST

Monitoring for hepatic carcinoma or metastatic
lesions involving the liver, as indicated by highly
elevated levels (e.g., 10,000 to 100,000 ng/mL)
Monitoring for response to treatment for hepatic
carcinoma, with successful treatment indicated by
an immediate drop in levels
Monitoring for recurrence of hepatic carcinoma,

CHAPTER 3—Immunology

TABLE 3–14

•

and Immunologic Testing

Cancer Tests and Tumor Markers

Marker

Clinical Association

Alkaline phosphatase (ALP) (enzyme isozyme)

Osteogenic sarcoma, osteoblastic carcinoma
metastasis

-Fetoprotein (AFP) (oncofetal antigen)

Testicular, hepatic carcinoma

CA 15-3 antigen (oncofetal antigen)

Breast malignancy

CA 19-9 antigen (oncofetal antigen)

Stomach, colon, pancreatic carcinoma

CA 50 antigen (oncofetal antigen)

Stomach, colon, pancreatic carcinoma

CA 125 antigen (oncofetal antigen)

Ovarian, fallopian tube carcinoma

Calcitonin (polypeptide hormone)

Thyroid medullary carcinoma

Carcinoembryonic antigen (CEA) (oncofetal antigen)

Breast, colon, lung carcinoma

Catecholamines (vanillylmandelic acid metabolite)

Neuroblastoma and pheochromocytoma

Creatine kinase isoenzyme (CK-BB) (enzyme isoenzyme)

Breast, pulmonary carcinoma

DU-PAN-2 (glycoprotein antigen)

Pancreatic carcinoma

Galactosyltransferase (GT II) (enzyme isoenzyme)

Pancreatic carcinoma

Genetic mutation (DNA, oncogenes)

Predisposition to development of carcinoma,
leukemia, lymphoma

Human chorionic gonadotropin (hCG) (glycoprotein
hormone)

Testicular carcinoma

5-Hydroxyindoleacetic acid (5-HIAA) (serotonin
metabolite)

Carcinoid tumor

Immunoglobulins produced by B lymphocytes

Multiple myeloma, lymphomas

Lactate dehydrogenase (LD) (enzyme isoenzyme
LD1)

Renal carcinoma, leukemia, lymphoma

Lymphocyte B- and T-cell surface antigens (blood
cell)

Lymphomas, lymphoblastic leukemia

Neuron-specific enolase (NSE) (enolase isoenzyme)

Neuroblastoma, lung carcinoma

Prostate-specific antigen (PSA) (serine protease)

Prostatic carcinoma

Prostatic acid phosphatase (PAP) (enzyme isozyme)

Prostatic carcinoma

Tissue polypeptide antigen (TPA) (oncofetal antigen)

Breast, lung, liver, pancreas, colorectal, stomach,
ovary, prostate, bladder, head and neck, thyroid
carcinoma

Squamous cell carcinoma (SCC) antigen (protein
antigen)

Cervical, lung, esophageal, head and neck carcinoma

Vasoactive intestinal peptide (VIP)

Intestinal tumor

Reference Values

Neonates
1 yr old to adults

Conventional Units

SI Units

600,000 ng/mL

600,000 g/L

30 ng/mL

30 g/L

SECTION I—Laboratory

Tests

with elevated levels occurring 1 to 6 months
before the client becomes symptomatic
Suspected hepatitis or cirrhosis, as indicated by
slightly to moderately elevated levels (e.g., 500
ng/mL)
Routine prenatal screening for fetal neural tube
defects and other disorders, as indicated by
elevated levels
Suspected intrauterine fetal death, as indicated by
elevated levels
Support for diagnosing embryonal gonadal teratoblastoma, hepatoblastoma, and ataxia-telangiectasia

diseases and in smokers (Table 3–15). Although the
test is not diagnostic for any specific disease, it is
used primarily when various types of carcinomas are
suspected.
Reference Values
Less than 2.5 ng/mL

INTERFERING FACTORS

Levels may be elevated in smokers who do not
have malignancies.

NURSING CARE BEFORE THE PROCEDURE

For serum studies, client preparation is the same as
that for any study involving the collection of a
peripheral blood sample (see Appendix I).
For amniotic fluid studies, the client is prepared
for amniocentesis, as described in Chapter 10.
THE PROCEDURE

For serum studies, a venipuncture is performed and
the sample collected in a red-topped tube. The
sample must be handled gently to avoid hemolysis
and transported promptly to the laboratory. For
amniotic fluid studies, amniocentesis is performed
(see Chapter 10).
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedures are the
same as for any study involving collection of a
peripheral blood sample or amniocentesis (see
Chapter 10).
Abnormal adult values: Note and report
increased levels and relate to tissue healing or
regeneration. Assess history for presence or treatment of malignancy; assist in coping with need
for additional treatments.
Abnormal fetal values: Note and report increased
levels in amniotic fluid analysis results or pregnant woman’s serum test results. Assess for fear
and anxiety levels while waiting for test results.
Provide information about genetic counseling,
termination of pregnancy, or both.

CARCINOEMBRYONIC ANTIGEN TEST
Carcinoembryonic antigen (CEA) is a glycoprotein
normally produced only during early fetal life and
during rapid multiplication of epithelial cells, especially those of the digestive system. Elevations of
CEA occur with many cancers, primary and recurrent, as well as with a number of nonmalignant

INDICATIONS FOR CARCINOEMBRYONIC
ANTIGEN TEST

Monitoring of clients with inflammatory intestinal disorders with a high risk of malignancy
Suspected carcinoma of the colon, pancreas, or
lung, because these cancers produce the highest
CEA levels
Monitoring of response to therapy for cancer,
with effective treatment indicated by normal
levels within 4 to 6 weeks
Monitoring for recurrence of carcinoma, with
elevated levels occurring several months before
the client becomes symptomatic
Suspected leukemia, gammopathy, or other disorder associated with elevated CEA levels (see Table
3–15)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Abnormal values: Note and report increased
values or return of increased values. Assess history
for presence of malignancy and site or treatment
of malignancy. Assist client and family in coping
with need for additional treatments or poor prognosis.

CHAPTER 3—Immunology

TABLE 3–15

•

and Immunologic Testing

Causes of Alterations in CEA Levels
Percentage with CEA Levels, ng/mL

2.5

2.6–5

5.1–10

Nonsmokers

Smokers

Ex-smokers

Colorectal

Pulmonary

Gastric

Breast

Head/neck

Cause of Alteration

Carcinomas

Pancreatic

Other

Leukemias

Lymphoma

Sarcoma

Benign tumors

Benign breast disease

Pulmonary emphysema

Alcoholic cirrhosis

Ulcerative colitis

Regional ileitis

Gastric ulcer

Colorectal polyps

Diverticulitis

CA 15-3, CA 19-9, CA 50, AND CA 125
ANTIGEN TESTS
Cancer antigens are substances detected in serum or
tissue and are defined by one or two monoclonal
antibodies. Immunologic methods are used to detect
the substances in serum and immunohistochemical
methods in tissue. Assay kits for these markers are
available to ensure consistent values among agencies
performing the tests. These tumor markers are not
used for screening malignancy in asymptomatic
populations.
CA 15-3 is a serum antigen defined by two monoclonal antibodies found in breast cancer and breast

cancer metastasis to the liver as well as in benign
diseases of the breast. CA 19-9 is a serum antigen
defined by a monoclonal antibody found in malignancies of the pancreas, gallbladder, salivary glands,
and endocervix as well as in benign disorders such
as acute pancreatitis, inflammatory bowel disease,
and hepatobiliary disease. The test is commonly
performed to monitor the course of a malignancy
that is known to produce the antigen. CA 50 is a
serum antigen defined by a monoclonal antibody
found in pancreatic, colorectal, and gastrointestinal
malignancies. Besides its diagnostic value, CA 50 is
used to monitor the course of a tumor that produces
the antigen.

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

CA 15-3

35 U/ml

35 kU/L

CA 19-9

37 U/ml

37 kU/L

CA 50

37 U/ml

37 kU/L

CA 125

35 U/ml

35 kU/L

CA 125 is a serum antigen defined by a monoclonal antibody found in ovarian and pelvic organ
malignancies as well as in breast and pancreatic
malignancies. Nonmalignant conditions such as
ascites of benign cause, pregnancy, menstruation,
endometriosis, and pelvic inflammatory disease also
cause increases in this antigen. The test is undertaken to monitor surgical removal of malignant
ovarian tumor for recurrence and metastasis.
Another test, tissue polypeptide antigen (TPA), is a
marker identified in serum and tissue in those with
a variety of malignancies in relation to the extent of
the disease and subsequent recurrence or regression
after surgical removal of the tumor.42
INTERFERING FACTORS

Chemotherapeutic agents administered to treat
tumor.
Levels can be increased in the absence of disease
or in benign disorders and can affect diagnostic
findings for malignancy.
INDICATIONS FOR CA 15-3, CA 19-9, CA 50,
AND CA 125 ANTIGEN TESTS

Diagnosis and confirmation of presence of local
and metastatic malignancy, suggested by an
increased level or a gradual rise in levels of the
specific cancer antigen
Determination of residual tumor after surgical
intervention to remove the malignancy
Monitoring of course of the malignancy and
effectiveness of therapeutic regimen to determine
progression, prognosis, or recurrence
Differentiation between malignant and benign
disorders of specific organ tissues
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Obtain a history regarding the presence of other
acute or chronic diseases and the assessment data
that support the diagnoses.

Ensure that neoplastic medication protocols are
administered.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be transported promptly to the laboratory for analysis by immunoassay methods.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report increased
values or return of increased values. Assess for
presence of malignancy site or metastasis or both,
past or ongoing treatments, and procedures for
malignancy. Assist client and family to reduce
anxiety and to cope with need for additional
treatments or poor prognosis.
REFERENCES
1. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 63.
2. Winkelstein, A, et al: White Cell Manual, ed 5. FA Davis,
Philadelphia, 1998, p 61.
3. Ibid, pp 61–62.
4. Ibid, p 63.
5. Ibid, pp 63–64.
6. Ibid, pp 68–71.
7. Ibid, p 74.
8. Sacher and McPherson, op cit, pp 242–243.
9. Ibid, p 244.
10. Winkelstein et al, op cit, p 69.
11. Ibid, p 69.
12. Ibid, pp 69–73.
13. Ibid, pp 72–73.
14. Ibid, p 74.
15. Ibid, p 65.
16. Sacher and McPherson, op cit, p 256.
17. Ibid, p 256.
18. Ibid, pp 252–253.
19. Ibid, pp 252–254.
20. Winkelstein et al, op cit, pp 83–84.
21. Sacher and McPherson, op cit, p 253.
22. Ibid, p 246.
23. Ibid, p 246.
24. Ibid, pp 254–255.
25. Ibid, p 255.
26. Ibid, p 262.

CHAPTER 3—Immunology

27.
28.
29.
30.
31.
32.
33.
34.
35.
36.

Ibid, pp 531–532.
Ibid, p 531.
Ibid, p 531.
Ibid, p 532.
Ibid, p 542.
Centers for Disease Control and Prevention, Hepatitis Branch:
Epidemiology and prevention of viral hepatitis A to E: An
overview. CDC, Atlanta, Ga, 1998.
Sacher and McPherson, op cit, pp 441–442.
Ray, CG, and Minnich, LL: Viruses, rickettsia, and chlamydia. In
James, JB: Clinical Diagnosis and Management by Laboratory
Methods, ed 18. WB Saunders, Philadelphia, 1991, p 1249.
Ibid, pp 1249–1250.
Stevens, RW, and McQuillan, GM: Serodiagnosis of human

37.

38.
39.
40.
41.
42.

and Immunologic Testing

immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections. In James, JB: Clinical Diagnosis and Management by
Laboratory Methods, ed 18. WB Saunders, Philadelphia, 1991, pp
913–914.
Rooney, MT, and Henry, JB: Molecular markers of malignant
neoplasms. In James, JB: Clinical Diagnosis and Management by
Laboratory Methods, ed 18. WB Saunders, Philadelphia, 1991, pp
285–286.
Sacher and McPherson, op cit, p 779.
Rooney and Henry, op cit, p 286.
Sacher and McPherson, op cit, pp 437–438.
Ibid, p 438.
Rooney and Henry, op cit, pp 297–298.

CHAPTER

Immunohematology
and Blood Banking
TESTS COVERED
ABO Blood Typing, 96
Rh Typing, 98
Direct Antiglobulin Test, 99

Indirect Antiglobulin Test, 100
Human Leukocyte Antigen Test, 101

INTRODUCTION

Immunohematology is the study of the antigens present on blood cell
membranes and the antibodies stimulated by their presence. For red cells, more than 300 antigenic configurations have been discovered and classified. A specific biologic role has been identified for only a few of these (e.g., ABO and Rh typing for blood transfusions). One
commonality is that blood cell antigens are inherited, and the genes that determine them follow
the laws of mendelian genetics.1 Thus, the greatest usefulness for many of the blood cell antigens that have been identified to date is in genetic studies.
The focus of this chapter is on tests of blood cell antigens and related antibodies that are used
in determining the compatibility of blood and blood products for transfusions.

ABO BLOOD TYPING
The major antigens in the ABO system are A and B.
An individual with A antigens has type A blood; an
individual with B antigens has type B blood. A
person with both A and B antigens has type AB
blood, and one having neither A nor B antigens has
type O blood. The genes determining the presence
or absence of A or B antigens reside on chromosome
number 9.2 Immunologically competent individuals
more than 6 months of age have serum antibodies
that react with the A and B antigens absent from
their own red cells (Table 4–1). Thus, a person with
type A blood has anti-B antibodies, whereas one
with type B blood has anti-A antibodies.
Individuals with type AB blood have neither of
these antibodies, whereas those with type O blood
96

have both. These antibodies are not inherited, but
develop after exposure to environmental antigens
that are chemically similar to red cell antigens (e.g.,
pollens and bacteria). Individuals do not, however,
develop antibodies to their own red cell antigens.3,4
Anti-A and anti-B antibodies are strong agglutinins and cause rapid, complement-mediated
destruction (see Chapter 3) of any incompatible
cells encountered. Although most of the anti-A and
anti-B activity resides in the IgM class of
immunoglobulins (see Chapter 3), some activity
rests with IgG. Anti-A and anti-B antibodies of the
IgG class coat the red cells without immediately
affecting their viability and can readily cross the
placenta, resulting in hemolytic disease of the
newborn. Persons with type O blood frequently
have more IgG anti-A and anti-B antibodies than do

CHAPTER 4—Immunohematology

TABLE 4–1

•

and Blood Banking

Antigens and Antibodies in ABO Blood Groups
Frequency, % in US Populations

Blood
Group

Antigens on
Red Cells

Antibodies
in Serum

Whites

American
Blacks

Native
Americans

Asians

Anti-B

Anti-A

Neither

Anti-A

A and B

Neither

Anti-B

From Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA Davis,
Philadelphia, 2000, p. 268, with permission.

individuals with type A or B blood. Thus, ABO
hemolytic disease of the newborn (erythroblastosis
fetalis) affects infants of type O mothers almost
exclusively.5
When blood transfusions are required, the client
is normally given blood of his or her own type to
prevent adverse antigen-antibody reactions. In
emergency situations, however, some individuals
may be given blood of other ABO types. For example, because type O blood has neither A nor B antigens, it may be given to individuals with types A, B,
and AB blood. Thus, a person with type O blood is
called a universal donor. With the advent of colloid
expanders (e.g., dextran), untyped blood is not given
even in cases of hemorrhage. Further, because
persons with type O blood have both anti-A and
anti-B antibodies, they can receive only type O
blood.
The situation is reversed for those with type AB
blood. Because these individuals lack anti-A and
anti-B antibodies, they may receive transfusions of
types A, B, and O blood in emergencies when type
AB blood is not available. Thus, a person with type
AB blood is called a universal recipient.
ABO blood typing is an agglutination test in
which the client’s red cells are mixed with anti-A and
anti-B sera, a process known as forward grouping.
The procedure is then reversed, and the person’s
serum is mixed with known type A and type B cells
(i.e., reverse grouping). When a transfusion is to be
administered, cross-matching of blood from the
donor and the recipient is performed along with
typing. Cross-matching detects antibodies in the
sera of the donor and the recipient that could lead to
a transfusion reaction as a result of red cell destruction.
Other pretransfusion or post-transfusion tests
can be performed to determine the cause of transfusion reactions. The leukoagglutinins are antibodies
in the donor blood that react with white blood cells

in the recipient’s blood, producing fever, cough,
dyspnea, and other lung complications, depending
on the severity of the reaction after the transfusion.
Such a reaction requires that leukocyte-poor blood
be used to transfuse these clients. Platelet antibody
tests are performed to detect specific antibodies that
cause post-transfusion purpuric reactions. Assays as
well as platelet typing can be performed to support a
diagnosis of post-transfusion purpura and thrombocytopenic purpura.6
Reference Values
The normal distribution of the four ABO blood
groups in the United States is shown in Table
4–1. Discrepancies in the results of forward and
reverse grouping may occur in infants, elderly
persons, and persons who are immunosuppressed or who have a variety of immunologic
disorders.7
INDICATIONS FOR ABO BLOOD TYPING

Identification of the client’s ABO blood type,
especially before surgery or other procedures in
which blood loss is a threat or for which replacement may be needed, or both
Identification of donor ABO blood type for stored
blood
Determination of ABO compatibility of donor’s
and recipient’s blood types
Identification of maternal and infant ABO blood
types to predict potential hemolytic disease of the
newborn
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Immunosuppressive drugs taken by the client or

SECTION I—Laboratory

Tests

the presence of an immunologic disorder should
be noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or other type of blood
collection tube, depending on laboratory preference.
The sample must be handled gently to avoid hemolysis and sent promptly to the laboratory.
Although correct client identification is important for all laboratory and diagnostic procedures, it
is crucial when blood is collected for ABO typing.
One of the most common sources of error in ABO
typing is incorrect identification of the client and the
specimens.8
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
The client should be informed of his or her blood
type, and the information should be recorded on
a card or other document (e.g., driver’s license)
that the client normally carries in the event of an
emergency requiring a blood transfusion.
Circulatory overload: Report increased blood
pressure; bounding pulse; and signs of pulmonary
edema such as dyspnea, rapid and labored breathing, cough producing blood-stained sputum, and
cyanosis.
Blood transfusion reaction: Note and report
reduced blood pressure, elevated temperature,
chills, palpitations, substernal or flank pain,
warmth at the infusion site, or anxiety. Discontinue transfusion and infuse saline. Send the leftover unit of blood and a blood and urine
specimen to the laboratory.
Critical values: Notify physician immediately if
an incompatible cross-match occurs.

Rh TYPING
After the ABO system, the Rh system is the group of
red cell antigens with the greatest importance.9 The
antigen was called the Rh factor because it was
produced by immunizing guinea pigs and rabbits
with red cells of rhesus monkeys. Researchers found
that the serum from the immunized animals agglutinated not only the rhesus monkey red cells but also
the red cells of approximately 85 percent of humans.
Thus, human red cells could be classified into two
new blood types: Rh-positive and Rh-negative. This
discovery was a great breakthrough in explaining
transfusion reactions to blood that had been tested
for ABO compatibility as well as in explaining

hemolytic disease of the newborn not caused by
ABO incompatibility between mother and fetus.10
We now know that the Rh system includes many
different antigens. The major antigen is termed Rho
or D. Persons whose red cells possess D are called
Rh-positive; those who lack D are called Rh-negative, no matter what other Rh antigens are present,
because the D antigen is more likely to provoke an
antibody response than any other red cell antigen,
including those of the ABO system. The other major
antigens of the Rh system are C, E, c, and e.11 Among
blacks, there are many quantitative and qualitative
variants of the Rh antigens that do not always fit into
the generally accepted classifications.12
Rh-negative individuals may produce anti-D
antibodies if exposed to Rh-positive cells through
either blood transfusions or pregnancy. Although 50
to 70 percent of Rh-negative individuals develop
antibodies if transfused with Rh-positive blood, only
20 percent of Rh-negative mothers develop anti-D
antibodies after carrying an Rh-positive fetus. This
difference occurs because a greater number of cells
are involved in a blood transfusion than are involved
in pregnancy.
When Rh antibodies develop, they are predominantly IgG. Thus, they coat the red cells and set them
up for destruction in the reticuloendothelial system.
The antibodies seldom activate the complement
system (see Chapter 3). Anti-D antibodies readily
cross the placenta from mother to fetus and are the
most common cause of severe hemolytic disease of
the newborn. Immunosuppressive therapy (e.g.,
with Rho[D] immune globulin [RhoGAM]) successfully prevents antibody formation when given to an
unimmunized Rh-negative mother just after delivery or abortion of an Rh-positive fetus.13
Rh typing involves an agglutination test in which
the client’s red cells are mixed with serum containing anti-D antibodies. Agglutination indicates that
the D antigen is present, and the person is termed
Rh-positive.
Reference Values
The D antigen is present on the red cells of 85
percent of whites and a higher percentage of
blacks, Native-Americans, and Asians.

INDICATIONS FOR RH TYPING

Identification of the client’s Rh type, especially
before surgery or other procedures in which
blood loss is a threat or for which replacement
may be needed, or for both

CHAPTER 4—Immunohematology

Identification of donor Rh type for stored
blood
Determination of Rh compatibility of donor’s and
recipient’s blood
Identification of maternal and infant Rh types to
predict potential hemolytic disease of the
newborn
Determination of anti-D antibody titer after
sensitization by pregnancy with an Rh-positive
fetus
Determination of the need for immunosuppressive therapy (e.g., with RhoGAM) when an Rhnegative woman has delivered or aborted an
Rh-positive fetus
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as that for any study involving the collection of
a peripheral blood sample.
As with ABO typing, the client should be
informed of his or her Rh type.
Women of childbearing age who are Rh-negative
should be informed of the need for follow-up
should pregnancy occur.
Rh incompatibility: Note and report Rh
factors of mother and father, number of pregnancies, and past transfusions of Rh-positive
blood given to an Rh-negative mother.
Communicate incompatible test results to
the physician. Inform client and prepare client
for administration of Rh immunoglobulins
(RhoGAM).

ANTIGLOBULIN TESTS
(COOMBS’ TESTS)
Antiglobulin (Coombs’) tests are used to detect
nonagglutinating antibodies or complement molecules on red cell surfaces. They are used most
commonly in immunohematology laboratories and

and Blood Banking

blood banks for routine cross-matching, antibody
screening tests, and preliminary investigations of
hemolytic anemias.14,15
The tests are based on the principle that
immunoglobulins (i.e., antibodies) act as antigens
when injected into a nonhuman host. This principle
was originally published by Moreschi in 1908, but
his findings drew little notice. In 1945, Coombs
independently rediscovered the principle when he
prepared antihuman serum by injecting human
serum into rabbits. The rabbit antibody produced
against the human globulin was then collected and
purified. This antihuman globulin was used to
demonstrate incomplete human antibodies that
were adsorbed to red cells and did not cause visually
apparent agglutination unless Coombs’ rabbit serum
was used. The two applications of the test currently
used are (1) the direct antiglobulin test (direct
Coombs’) and (2) the indirect antiglobulin test
(indirect Coombs’).16

DIRECT ANTIGLOBULIN TEST
It is never normal for circulating red cells to be
coated with antibody. The direct antiglobulin test
(DAT, direct Coombs’) is used to detect abnormal in
vivo coating of red cells with antibody globulin
(IgG) or complement, or both.
When this test is performed, the red cells are taken
directly from the sample, washed with saline (to
remove residual globulins left in the client’s serum
surrounding the red cells but not actually attached
to them), and mixed with antihuman globulin
(AHG). If the AHG causes agglutination of the
client’s red cells, specific antiglobulins can be used to
determine if the red cells are coated with IgG,
complement, or both.
The most common cause of a positive DAT is
autoimmune hemolytic anemia, in which affected
individuals have antibodies against their own red
cells. Other causes of positive results include
hemolytic disease of the newborn, transfusion of
incompatible blood, and red cell–sensitizing reactions caused by drugs. In the latter, the red cells may
be coated with the drug or with immune complexes
composed of drugs and antibodies that activate the
complement system.17,18 Drugs associated with such
reactions are listed in Table 4–2. Positive DAT results
may also be seen in individuals with Mycoplasma
pneumonia, leukemias, lymphomas, infectious
mononucleosis, lupus erythematosus and other
immune disorders of connective tissue, and metastatic carcinoma. Other conditions, such as the aftermath of cardiac vascular surgery, are associated with
production of autoantibodies.

100

SECTION I—Laboratory

Tests

•

Drugs That May Cause
Positive Results in Direct
Antiglobulin Tests

TABLE 4–2

Cephaloridine
(Loridine)

Penicillin

Cephalothin (Keflin)

Phenytoin (Dilantin)

Chlorpromazine
(Thorazine)

Procainamide
(Pronestyl)

Hydralazine
(Apresoline)

Quinidine

Isoniazid

Rifampin

Levodopa

Streptomycin

Melphalan (Alkeran)

Sulfonamides

Methyldopa (Aldomet)

Tetracycline

Reference Values
Negative (no agglutination)

INTERFERING FACTORS

Many drugs may cause positive reactions (see
Table 4–2).
INDICATIONS FOR DIRECT ANTIGLOBULIN TEST

Suspected hemolytic anemia or hemolytic disease
of the newborn as indicated by a positive reaction
Suspected transfusion reaction as indicated by a
positive result
Suspected drug sensitivity reaction as indicated by
a positive result
NURSING CARE BEFORE THE PROCEDURE

For samples collected by venipuncture, client preparation is the same as that for any study involving the
collection of a peripheral or cord blood sample (see
Appendix I).
Drugs currently taken by the client should be
noted.
If the test is to be performed on the newborn, the
parent(s) should be informed that a sample of
umbilical cord blood will be obtained at delivery
and will not result in blood loss to the infant.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or other type of
blood collection tube, depending on laboratory
preference. For cord blood, the sample is collected in
a red- or lavender-topped tube (depending on the

laboratory) from the maternal segment of the cord
after it has been cut and before the placenta has been
delivered.
NURSING CARE AFTER THE PROCEDURE

For venipunctures, care and assessment after the
procedure are the same as for any study involving
the collection of a peripheral blood sample.
Complications and precautions: Note and report
a positive value in cord blood of a neonate with
possible erythroblastosis fetalis for direct
Coombs’ because this test result indicates that
antibodies are attached to the circulating erythrocytes. Assess associated bilirubin and hemoglobin
levels. Prepare the infant for exchange transfusion
of fresh whole blood that has been typed and
cross-matched with the mother’s serum.

INDIRECT ANTIGLOBULIN TEST
The indirect antiglobulin test (IAT, indirect
Coombs’, antibody screening test) is used primarily
to screen blood samples for unexpected circulating
antibodies that may be reactive against transfused
red blood cells.
In this test, the client’s serum serves as the source
of antibody, and the red cells to be transfused serve
as the antigen. The test is performed by incubating
the serum and red cells in the laboratory (in vitro) to
allow any antibodies that are present every opportunity to attach to the red cells. The cells are then
washed with saline to remove any unattached serum
globulins, and AHG is added. If the client’s serum
contains an antibody that reacts with and attaches to
the donor red cells, the AHG will cause the antibody-coated cells to agglutinate.
If no agglutination occurs after addition of AHG,
then no antigen-antibody reaction has occurred.
The serum may contain an antibody, but the red
cells against which it is tested do not have the relevant antigen. Thus, the reaction is negative.19
Reference Values
Negative (no agglutination)
INTERFERING FACTORS

Recent administration of dextran, whole blood or
fractions, or intravenous contrast media may
result in a false-positive reaction.
Drugs that may cause false-positive reactions are
cephalosporins, insulin, isoniazid, levodopa,
mefenamic acid, methyldopa, methyldopa hydrochloride, penicillins, procainamide hydrochloride,

CHAPTER 4—Immunohematology

quinidine, rifampin, sulfonamides, and tetracyclines.
INDICATIONS FOR INDIRECT ANTIGLOBULIN TEST

Antibody screening and cross-matching before
blood transfusions, especially to detect antibodies
whose presence may not be elicited by other
methods such as ABO and Rh typing
Determination of antibody titers in Rh-negative
women sensitized by an Rh-positive fetus
Testing for the weak Rh variant antigen D
Detection of other antibodies in maternal blood
that may be potentially harmful to the fetus
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Exposure to substances that may cause false-positive reactions should be noted. The medication
history should also be noted.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube or other blood collection tube, depending on laboratory preference. The
sample must be handled gently to avoid hemolysis
and sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Note and report
a positive value for antibody detection, especially
in a pregnant woman. Inform the client that
further testing will be undertaken to identify the
antibodies.

HUMAN LEUKOCYTE ANTIGEN
TEST
All nucleated cells have human leukocyte antigens
(HLA) on their surface membranes. Although sometimes described as “white cell antigens,” HLA characterize virtually all cell types except red blood cells.
HLA consist of a glycoprotein chain and a globulin
chain. They are classified into five series designated
A, B, C, D, and DR (D-related), each series containing 10 to 20 distinct antigens. A, B, C, and D antigens
characterize the membranes of virtually all cells
except mature red blood cells; DR antigens seem to
reside only on B lymphocytes and macrophages (see
Chapter 3).
Some antigens have been identified with specific

and Blood Banking

101

• Diseases Associated with
Human Leukocyte Antigens

TABLE 4–3

Disease

Associated
Antigen

Ankylosing
spondylitis

B27

Reiter’s syndrome

B27

Diabetes mellitus
(juvenile, or
insulin-dependent)
Multiple sclerosis

B8, Bw15
A3, B7, B18

Acute anterior
uveitis

B27

Graves’ disease

Juvenile rheumatoid
arthritis

B27

Celiac disease

Psoriasis vulgaris

B13, Bw17

Myasthenia gravis

Dermatitis herpetiformis

Autoimmune chronic
active hepatitis

diseases (Table 4–3). Arthritic disorders, for example, have been closely linked to HLA-B27. In addition, HLA typing is valuable in determining
parentage. If the HLA phenotypes of a child and one
parent are known, it is possible to assess fairly accurately whether a given individual is the other
parent.20
Reference Values
HLA combinations vary according to certain
races and populations. The most common B
antigens in American whites, for example, are
B7, B8, and B12. In American blacks, the most
common of the B series are Bw17, Bw35, and a
specificity characterized as 1AG. This combination is in contrast to that of African blacks,
whose most common B antigens are B7, Bw17,
and 1AG. Similar variations among the A antigens also have been found among various races
and populations.
INDICATIONS FOR HUMAN LEUKOCYTE
ANTIGEN TESTS

Determination of donor and recipient compatibility for tissue transplantation, especially when
they are blood relatives21

102

SECTION I—Laboratory

Tests

Determination of compatibility of donor platelets
in individuals who will receive multiple transfusions over a long period of time
Support for diagnosing HLA-associated diseases
(see Table 4–3), especially when signs and symptoms are inconclusive
Determination of biologic parentage
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube or other blood
collection device, depending on laboratory preference. The sample is sent promptly to the laboratory
performing the test (not all laboratories are
equipped to do so).
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Medicolegal implications: HLA testing results for
biologic parentage exclusion are not allowed as
evidence in all jurisdictions.
REFERENCES
1. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 265.
2. Ibid, p 266.
3. Harmening, D: Modern Blood Banking and Transfusion Practices,
ed 4. FA Davis, Philadelphia, 2001, p 79.
4. Sacher and McPherson, op cit, pp 268–269.
5. Ibid, p 269.
6. Fischbach, FT: A Manual of Laboratory and Diagnostic Tests, ed 4.
JB Lippincott, Philadelphia, 1992, pp 556–558.
7. Harmening, op cit, p 89.
8. Ibid, p 80.
9. Sacher and McPherson, op cit, p 269.
10. Harmening, op cit, p 105.
11. Sacher and McPherson, op cit, p 271.
12. Harmening, op cit, p 110.
13. Sacher and McPherson, op cit, pp 272–273.
14. Ibid, p 275.
15. Harmening, op cit, pp 65–66.
16. Ibid, pp 65–66.
17. Ibid, p 66.
18. Sacher and McPherson, op cit, p 276.
19. Ibid, p 279.
20. Harmening, op cit, p 374.
21. Ibid, p 369.

CHAPTER

Blood Chemistry
TESTS COVERED
Blood Glucose (Serum Glucose, Plasma
Glucose), 105
Two-Hour Postprandial Blood Glucose
(Postprandial Blood Sugar), 108
Oral Glucose Tolerance Test, 109
Intravenous Glucose Tolerance Test, 111
Cortisone Glucose Tolerance Test, 111
Glycosylated Hemoglobin, 112
Tolbutamide Tolerance Test, 113
Serum Proteins, 114
1-Antitrypsin Test, 116
Haptoglobin, 118
Ceruloplasmin, 119
Urea Nitrogen, 120
Serum Creatinine, 122
Ammonia, 123
Serum Creatine, 123
Uric Acid, 124
Free Fatty Acids, 127
Triglycerides, 128
Total Cholesterol, 130
Phospholipids, 131
Lipoprotein and Cholesterol Fractionation,
133
Lipoprotein Phenotyping, 135
Bilirubin, 137
Alanine Aminotransferase, 140
Aspartate Aminotransferase, 141
Alkaline Phosphatase, 142
5′-Nucleotidase, 144
Leucine Aminopeptidase, 144
-Glutamyl Transpeptidase, 145
Isocitrate Dehydrogenase, 146
Ornithine Carbamoyltransferase, 146
Serum Amylase, 147
Serum Lipase, 148

Acid Phosphatase, 149
Prostate-Specific Antigen, 150
Aldolase, 150
Creatine Phosphokinase and Isoenzymes,
151
Troponin Levels, 154
Lactic Dehydrogenase and Isoenzymes,
155
Hexosaminidase, 156
-Hydroxybutyric Dehydrogenase, 157
Cholinesterases, 157
Renin, 158
Growth Hormone, 161
Growth Hormone Stimulation Tests, 162
Growth Hormone Suppression Test, 163
Prolactin, 163
Adrenocorticotropic Hormone, 164
Thyroid-Stimulating Hormone, 165
TSH Stimulation Test, 166
FSH/LH Challenge Tests, 168
Luteinizing Hormone, 169
Antidiuretic Hormone, 170
Thyroxine, 172
Triiodothyronine, 173
T3 Uptake, 174
Thyroxine-Binding Globulin, 175
Thyroid-Stimulating Immunoglobulins, 175
Calcitonin, 176
Parathyroid Hormone, 176
Cortisol/ACTH Challenge Tests, 178
Aldosterone Challenge Tests, 180
Catecholamines, 181
Estrogens, 182
Progesterone, 183
Testosterone, 184
Human Chorionic Gonadotropin, 185

103

104

SECTION I—Laboratory

Tests

Human Placental Lactogen, 186
Insulin, 188
C-Peptide, 189
Glucagon, 189
Gastrin, 190
Serum Sodium, 191
Serum Potassium, 192
Serum Chloride, 196
Serum Bicarbonate, 198
Serum Calcium, 200

Serum Phosphorus/Phosphate, 202
Serum Magnesium, 204
Serum Osmolality, 206
Arterial Blood Gases, 207
Vitamin A, 210
Vitamin C, 211
Vitamin D, 212
Trace Minerals, 212
Drugs and Toxic Substances, 213

INTRODUCTION

The blood transports innumerable substances that participate in and
reflect ongoing metabolic processes. Relatively few of these substances are routinely measured.
Some materials are analyzed to provide information about specific organs and processes; other
substances reflect the summed effects of numerous metabolic events.1 “Chemistry” includes the
measurement of glucose, proteins, lipids, enzymes, electrolytes, hormones, vitamins, toxins,
and other substances that may indicate derangement of normal physiological processes. In
recent years, the diagnosis of many disorders associated with abnormal blood chemistries has
become more rapid and accurate with the use of automated analyzers that can measure multiple chemistry components in a single blood sample.

CARBOHYDRATES
The body acquires most of its energy from the
oxidative metabolism of glucose. Glucose, a simple
six-carbon sugar, enters the diet as part of the sugars
called sucrose, lactose, and maltose and as the major
constituent of the complex polysaccharides called
dietary starch. Complete oxidation of glucose yields
carbon dioxide (CO2), water, and energy that is
stored as adenosine triphosphate (ATP).
If glucose is not immediately metabolized, it can
be stored in the liver or muscle as glycogen. Unused
glucose can also be converted by the liver into fatty
acids, which are stored as triglycerides, or into
amino acids, which can be used for protein synthesis. The liver is pivotal in distributing glucose as
needed for immediate fuel or as indicated for storage
or for structural purposes. If available glucose or
glycogen is insufficient for energy needs, the liver
can synthesize glucose from fatty acids or even from
protein-derived amino acids.2
Glucose fuels most cell and tissue functions. Thus,
adequate glucose is a critical requirement for homeostasis. Many cells can derive some energy from
burning fatty acids, but this energy pathway is less
efficient than burning glucose and generates acid
metabolites (e.g., ketones) that are harmful if they
accumulate in the body. Many hormones (Table
5–1) participate in maintaining blood glucose levels

in steady-state conditions or in response to stress.
Measures of blood glucose indicate whether the
regulation is successful. Pronounced departure from
normal, either too high or too low, indicates abnormal homeostasis and should initiate a search for the
etiology.3 The causes of abnormal blood glucose
levels are summarized in Table 5–2.
Two major methods are used to measure blood
glucose: chemical and enzymatic. Chemical methods
use the nonspecific reducing properties of the
glucose molecule. In enzymatic methods, glucose
oxidase reacts with its specific substrate, glucose,
liberating hydrogen peroxide, the effects of which
are then measured. Values are 5 to 15 mg/dL higher
for the reducing (chemical) methods than for enzymatic techniques because blood contains other
reducing substances in addition to glucose. Urea, for
example, can contribute up to 10 mg/dL in normal
serum and even more when uremia exists. Several
different indicator systems are used for automated
enzymatic methods, yielding somewhat different
normal values.4
Note also that, in the past, blood glucose values
were given in terms of whole blood. Today, most
laboratories measure serum or plasma glucose
levels. Because of its higher water content, serum
contains more dissolved glucose, and the resultant
values are 1.15 times higher than are those for
whole blood. Serum or plasma should be separated

CHAPTER 5—Blood

TABLE 5–1

Hormone
Insulin

•

Chemistry

105

Hormones That Influence Blood Glucose Levels

Tissue of Origin
Pancreatic cells

Metabolic Effect
1. Enhances entry of glucose into cells

Effect on
Blood
Glucose
Lowers

2. Enhances storage of glucose as glycogen, or
conversion to fatty acids
3. Enhances synthesis of proteins and fatty
acids
4. Suppresses breakdown of protein into amino
acids; of adipose tissue, into free fatty acids
Somatostatin

Pancreatic D cells

1. Suppresses glucagon release from cells
(acts locally)

Lowers

2. Suppresses release of insulin, pituitary tropic
hormones, gastrin, and secretin
Glucagon

Pancreatic cells

1. Enhances release of glucose from glycogen

Raises

2. Enhances synthesis of glucose from amino
acids or fatty acids
Epinephrine

Adrenal medulla

1. Enhances release of glucose from glycogen

Raises

2. Enhances release of fatty acids from adipose
tissue
Cortisol

Adrenal cortex

1. Enhances synthesis of glucose from amino
acids or fatty acids

Raises

2. Antagonizes insulin
Adrenocorticotropic
hormone (ACTH)

Anterior pituitary

1. Enhances release of cortisol

Raises

2. Enhances release of fatty acids from adipose
tissue
Growth hormone

Anterior pituitary

1. Antagonizes insulin

Raises

Thyroxine

Thyroid

1. Enhances release of glucose from glycogen

Raises

2. Enhances absorption of sugars from
intestine
From Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA Davis,
Philadelphia, 2000, p. 448, with permission.

promptly because red and white blood cells continue
to metabolize glucose. In blood with very high white
blood cell levels, excessive glycolysis may actually
lower glucose results. Arterial, capillary, and venous
blood samples have comparable glucose levels in a
fasting individual. After meals, venous levels are
lower than those in arterial or capillary blood.5

Blood Glucose (Serum Glucose,
Plasma Glucose)
Blood glucose (serum glucose, plasma glucose) is
measured in a variety of situations. In the fasting

state, the serum glucose level gives the best indication of overall glucose homeostasis.6
Blood glucose levels also can be measured at regular intervals throughout the day to monitor
responses to diet and medications in persons with a
diagnosis of abnormalities of glucose metabolism.
Such monitoring may take place in a hospital setting
or in the home with kits specially designed for selfmonitoring of blood glucose. Serial blood glucose
levels also are used to determine insulin requirements in clients with uncontrolled diabetes mellitus
and for individuals receiving total parenteral or
enteral nutritional support.

106

SECTION I—Laboratory

Tests

TABLE 5–2

•

Causes of Altered Blood Glucose Levels

Hyperglycemia

Hypoglycemia
PERSISTENT CAUSES

Diabetes mellitus

Insulinoma

Hemochromatosis

Addison’s disease

Cushing’s syndrome

Hypopituitarism

Hyperthyroidism

Galactosemia

Acromegaly, gigantism

Ectopic insulin production from tumors (adrenal
carcinoma, retroperitoneal sarcomas, pleural
fibrous mesotheliomas)

Obesity
Chronic pancreatitis
Pancreatic adenoma

Starvation
TRANSIENT CAUSES

Pheochromocytoma

Acute alcohol ingestion

Pregnancy (gestational diabetes)

Severe liver disease

Severe glycogen storage diseases

Acute stress reaction

Stress-related catecholamine excess (“functional”
hypoglycemia)

Shock, trauma
Convulsions, eclampsia

Hereditary fructose intolerance

Malabsorption syndrome

Myxedema

Postgastrectomy “dumping syndrome”
DRUGS

Glucagon

Clonidine

Adrenocorticosteroids

Dextrothyroxine

Oral contraceptives

Niacin

Estrogens

Salicylates

Thyroid hormones

Antituberculosis agents

Anabolic steroids

Sulfonylureas

Thiazide diuretics

Sulfonamides

Loop diuretics

Insulin

Propranolol

Ethanol

Antipsychotic drugs

Clofibrate

Hydantoins

MAO inhibitors

In addition to situations characterized by actual
or potential elevations in blood sugar, glucose levels
are evaluated in individuals suspected or known to
have hypoglycemia.

INTERFERING FACTORS

Elevated urea levels and uremia may lead to falsely
elevated levels.

CHAPTER 5—Blood

Chemistry

107

Reference Values
Newborns
Conventional
Units

Children

Adults

SI
Units

Conventional
Units

SI
Units

Conventional
Units

SI
Units

Whole
blood

25–51
mg/dL

1.4–2.8
mmol/L

50–90
mg/dL

2.8–5.0
mmol/L

60–100
mg/dL

3.3–5.6
mmol/L

Serum/
plasma

30–60
mg/dL

1.7–3.3
mmol/L

60–105
mg/dL

3.3–5.8
mmol/L

70–110
mg/dL

3.9–6.1
mmol/L

Critical
values

30 mg/dL
or 300
mg/dL

1.6
mmol/L
or 16.5
mmol/L

40 mg/dL
or 700
mg/dL

2.2
mmol/L
or 38.6
mmol/L

40 mg/dL
or 700
mg/dL

2.2
mmol/L
or 38.6
mmol/L

Note: Values may vary depending on the laboratory method used.

Extremely elevated white blood cell counts may
lead to falsely decreased values.
Failure to follow dietary restrictions before a fasting blood glucose may lead to falsely elevated
values.
Administration of insulin or oral hypoglycemic
agents within 8 hours of a fasting blood glucose
may lead to falsely decreased values.
INDICATIONS FOR BLOOD GLUCOSE TEST

Routine screening for diabetes mellitus:
Fasting blood glucose levels greater than 126
mg/dL on two or more occasions may be
considered diagnostic of diabetes mellitus if
other possible causes of hyperglycemia are
eliminated as sources of elevation (see Table
5–2).
Random (nonfasting) blood glucose levels of
greater than 200 mg/dL may be pathognomonic of diabetes mellitus.7
Clinical symptoms of hypoglycemia or hyperglycemia
Known or suspected disorder associated with
abnormal glucose metabolism (see Table 5–2)
Identification of abnormal hypoglycemia as indicated by a fasting blood sugar as low as 50 mg/dL
in men or 35 mg/dL in women8
Monitoring of response to therapy for abnormal
glucose metabolism
Determination of insulin requirements (i.e.,
“insulin coverage”)
Monitoring of metabolic response to drugs
known to alter blood glucose levels (see Table
5–2)
Monitoring of metabolic response to parenteral
or enteral nutritional support to determine
insulin requirements

NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
If a fasting sample is to be drawn, food and insulin
or any oral hypoglycemic agent should be withheld for approximately 8 hours before the test
(i.e., the client usually takes only water from
midnight until the sample is drawn in the morning).
For home glucose monitoring, the client should
be instructed in the correct use of the testing
equipment and in the method used to obtain the
blood sample.
THE PROCEDURE

A venipuncture is performed and the sample is
obtained in either a gray- or a red-topped tube,
depending on the laboratory performing the test.
The sample should be handled gently to avoid
hemolysis and transported promptly to the laboratory.
A capillary sample may be obtained in infants and
children as well as in adults for whom venipuncture
may not be feasible. Capillary samples also are used
for self-monitoring of blood glucose.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Resume food and medications withheld before
the test after the sample is drawn.
Abnormal values: Note and report increased
levels. Assess for symptoms associated with hyperglycemia such as polyuria and possible dehydra-

108

SECTION I—Laboratory

Tests

Reference Values
Children

Adults

Elderly Persons

Conventional
Units

SI
Units

Conventional
Units

SI
Units

Conventional
Units

SI
Units

Blood

120 mg/dL

6.6 mmol/L

120 mg/dL

6.6 mmol/L

140 mg/dL

7.7 mmol/L

Serum/
plasma

150 mg/dL

8.3 mmol/L

140 mg/dL

7.7 mmol/L

160 mg/dL

8.8 mmol/L

Note: Values may vary, depending on the laboratory method used.

tion, polydipsia, or weight loss. Prepare for additional glucose tests for diabetes mellitus. Monitor
intake and output (I&O). Prepare to administer
ordered medications (insulin or oral hypoglycemic) to treat known diabetic condition.
Instruct client on diabetic diet in relation to
medications, activities, and blood and urine test
results. Note and report decreased levels. Assess
for symptoms associated with hypoglycemia such
as weakness, sweating, nervousness, hunger,
confusion, or palpitations. Prepare to administer
sucrose or glucose orally or intravenously (IV).
Instruct client to keep readily absorbed carbohydrates on hand. Instruct client on diet and its relation to medications, activities, and blood and
urine test results.
Critical values: Notify the physician immediately of a blood glucose level of less than 30
mg/dL in infants or less than 40 mg/dL in adults
or a blood glucose level of greater than 300
mg/dL in infants or greater than 700 mg/dL in
adults.

Two-Hour Postprandial Blood
Glucose (Postprandial Blood
Sugar)
The 2-hour postprandial blood glucose (postprandial blood sugar, PPBS) test reflects the metabolic
response to a carbohydrate challenge.9 In normal
individuals, the blood sugar returns to the fasting
level within 2 hours.
In contrast, postprandial hypoglycemia appears
to result from delayed or exaggerated response to the
insulin secreted in relation to dietary blood sugar
rise. It may occur as an early event in individuals
with non-insulin-dependent diabetes mellitus
(NIDDM, type II diabetes mellitus) or in individuals
with gastrointestinal malfunction. Frequently, no
cause is demonstrated and the hypoglycemia is
considered “functional.” Postprandial hypoglycemia
differs from fasting hypoglycemia (i.e., hypoglycemia that occurs after 10 or more hours without
food) in that the latter nearly always has pathologi-

cal significance. It results from either overproduction of insulin or undermobilization of glucose and
is most commonly seen in clients with tumors of the
pancreatic cells (insulinoma), liver disease, and
chronic alcohol ingestion.10
With advancing age, the speed of glucose clearance declines. Two-hour levels in persons who do
not have diabetes and in those with negative family
histories may increase an average of 6 mg/dL for
each decade over age 30 years.11
INTERFERING FACTORS

Failing to follow dietary instructions may alter
test results.
Smoking and drinking coffee during the 2-hour
test period may lead to falsely elevated values.
Strenuous exercising during the 2-hour test
period may lead to falsely decreased values.
INDICATIONS FOR 2-HOUR POSTPRANDIAL
BLOOD GLUCOSE (POSTPRANDIAL BLOOD
SUGAR) TEST

Abnormal fasting blood sugar
Routine screening for diabetes mellitus, as indicated by a blood glucose level greater than the
fasting level and especially by a 2-hour level
greater than 200 mg/mL
Identification of postprandial hypoglycemia and
differentiation of this state from fasting hypoglycemia, with fasting hypoglycemia almost
always indicative of a pathological state
Known or suspected disorder associated with
abnormal glucose metabolism (see Table 5–2)
Monitoring of metabolic response to drugs
known to alter blood glucose levels (see Table
5–2)
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
test involving collection of a peripheral blood
sample.
Specific preparation includes ingesting a meal
(usually breakfast) containing at least 100 g of
carbohydrate 2 hours before the test.

CHAPTER 5—Blood

The American Diabetes Association recommends
a 300-g carbohydrate diet for 2 to 3 days before
the test, but this recommendation is not universally followed.
The time of the last meal before the test should be
noted.
The client should then fast from food and avoid
coffee, smoking, and strenuous exercise until the
sample is obtained.
Although medications are not withheld for this
test, those taken should be noted.
THE PROCEDURE

Two hours after the carbohydrate challenge is
ingested, a venipuncture is performed and the
sample is collected in either a gray- or a red-topped
tube, depending on the laboratory performing the
test. A capillary sample may be obtained in children
and in adults for whom venipuncture may not be
feasible. Capillary samples are also used when the
test is performed for mass screenings. Note that in
some instances a fasting blood sugar level may be
obtained before the carbohydrate challenge.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample. Resume usual diet and
activities.
Complications and precautions: Abnormal
increased or decreased values are treated in the
same way as for blood glucose testing. If the
glucose level does not return to a fasting state
in 2 hours, an additional glucose tolerance test
is required, and there are no critical values to
report.

Glucose Tolerance Tests
Glucose tolerance tests (GTTs) are used to evaluate
the response to a carbohydrate challenge throughout
a 3- to 5-hour period. When a glucose load is
presented, the normal individual’s blood insulin
level rises in response to it, with peak levels occurring 30 to 60 minutes after the carbohydrate challenge. Blood glucose levels, although elevated
immediately after the carbohydrate challenge, return
to normal fasting levels 2 to 3 hours later. For individuals in whom abnormal hypoglycemia or
gastrointestinal malabsorption is suspected, the test
may be extended to a 5-hour period.12–14
Several methods can be used to perform a glucose
tolerance test. The oral, IV, and cortisone glucose
tolerance tests are discussed in this section.
Tolerance tests also may be performed for pentose,
lactose, galactose, and D-xylose.

Chemistry

109

ORAL GLUCOSE TOLERANCE TEST
The oral glucose tolerance test (OGTT) is used for
individuals who are able to eat and who are not
known to have problems with gastrointestinal
malabsorption. The client should be in a normal
nutritional state and should be capable of normal
physical activity (i.e., not immobilized or on bed
rest), because carbohydrate depletion and inactivity
may impair glucose tolerance. In addition, drugs
that affect blood glucose levels (see Table 5–2)
should not be taken for several days before the test.
Because oral glucose tolerance testing is affected by
so many variables, the results are subject to many
diagnostic interpretations.15
The OGTT may be performed using blood
samples only or using urine samples as well. The
urine is normally negative for sugar throughout the
test; that is, because the average renal threshold for
glucose is 180 mg/dL, the plasma glucose level must
be approximately 180 mg/dL before sugar appears in
the urine. Renal threshold levels vary, however, and
urine testing during an OGTT may show how much
glucose the individual spills, if any, at various blood
glucose levels. As long as the renal threshold is not
surpassed by the blood glucose levels, all of the
glucose presented to the kidneys is reabsorbed from
the glomerular filtrate by the renal tubules, provided
that renal function is normal.
INTERFERING FACTORS

Failure to ingest a diet with sufficient carbohydrate content (e.g., 150 g/day) for at least 3 days
before the test may result in falsely decreased
values.
Impaired physical activity may lead to falsely
increased values.
Excessive physical activity before or during the
test may lead to falsely decreased values.
Smoking before or during the test may lead to
falsely increased values.
Ingestion of drugs known to alter blood glucose
levels may lead to falsely increased or decreased
values (see Table 5–2).
INDICATIONS FOR ORAL GLUCOSE TOLERANCE
TEST

Abnormal fasting or postprandial blood glucose
levels that are not clearly indicative of diabetes
mellitus
Identification of impaired glucose metabolism
without overt diabetes mellitus, which is characterized by a modest elevation in blood glucose
after 2 hours and a normal level after 3 hours
Evaluation of glucose metabolism in women of
childbearing age, especially those who are preg-

110

SECTION I—Laboratory

Tests

Reference Values
Time After Carbohydrate Challenge
1 Hr
2 Hr

30 min
Conventional Units

SI
Units

Conventional Units

SI
Units

Conventional Units

SI
Units

3 Hr
ConvenSI
tional Units Units

Whole
blood
glucose

150
mg/dL

8.3
160
mmol/L
mg/dL

8.8
115
mmol/L
mg/dL

Same as
6.6
fastmmol/L
ing

Same as
fasting

Serum/
plasma

160
mg/dL

8.8
170
mmol/L
mg/dL

9.4
125
mmol/L
mg/dL

Same as
7.1
fastmmol/L
ing

Same as
fasting

Urine
Negative throughout test
glucose
Note: Values for children over age 6 years are the same as those for adults. Values for elderly individuals are 10 to 30 mg/dL higher
at each interval because of the age-related decline in glucose clearance.

nant and have a history of previous fetal loss,
birth of babies weighing 9 pounds or more, or
positive family history for diabetes mellitus
Support for diagnosing hyperthyroidism and
alcoholic liver disease, which are characterized by
a sharp rise in blood glucose followed by a decline
to subnormal levels
Identification of true postprandial hypoglycemia
(5-hour GTT) caused by excessive insulin
response to a glucose load
Support for diagnosing gastrointestinal malabsorption, which is characterized by peak glucose
levels lower than that normally expected and
hypoglycemia in the latter hours of the test (5hour GTT)
Identification of abnormal renal tubular function,
if glycosuria occurs without hyperglycemia

Nursing Alert

Individuals with fasting blood sugars of
greater than 150 mg/dL or postprandial blood
glucose levels greater than 200 mg/dL should
not receive the glucose load required for this
test.
If the client vomits the oral glucose preparation, notify the laboratory and physician
immediately, and implement any treatment
ordered.
If signs and symptoms of hypoglycemia are
observed or reported, obtain a blood sugar
immediately and administer orange juice with
1 tsp of sugar or other beverage containing
sugar; notify the physician that the test has
been terminated.

NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
The general procedure for the test, including the
administration of glucose and the frequency of
collection of blood and urine samples
The importance of eating a diet containing at least
150 g carbohydrate per day for 3 days before the
test (Provide sample menus or lists of foods that
demonstrate how this may be accomplished.)
Which medications, if any, are to be withheld
before the test
That no food may be eaten after midnight before
the test but that water is not restricted
The importance of not smoking or performing
strenuous exercise after midnight before the test
and until the test is completed
The symptoms of hypoglycemia and the necessity
of reporting such symptoms immediately

Provide containers for collection of urine
samples.
THE PROCEDURE

A venipuncture is performed and a sample is
obtained for a fasting blood sugar. At the same time,
a second voided (double-voided) urine sample is
collected and tested for glucose. To collect a secondvoided specimen, have the client void 30 minutes
before the required specimen is due. Discard this
urine, then collect the second voided specimen at the
designated time.
The glucose load is administered orally. This is a
calculated dose, either 1.75 g/kg body weight or 50
g/m2 body surface. Several commercial preparations
are available that are flavored for palatability. Blood

CHAPTER 5—Blood

and urine samples are obtained at 1/2-hour, 1-hour,
2-hour, and 3-hour intervals. The second voided
urine specimen is necessary only at the beginning
of the test. The client should drink one glass of
water each time a urine sample is collected to
ensure adequate urinary output for remaining
specimens. If the test is extended to 5 hours, additional samples are collected at 4- and 5-hour intervals.
The test may be performed with blood samples
only, depending on the desired information to be
obtained from the test.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as those for any test involving the
collection of peripheral blood samples.
Resume food and medications withheld before
the test, as well as usual activities.
Complications and precautions: Same as for
blood glucose. Closely monitor those clients
whose pretest levels are greater than 200 mg/dL
for possible reactions to the additional glucose
intake required for the test.

INTRAVENOUS GLUCOSE TOLERANCE
TEST
The intravenous glucose tolerance test (IVGTT) is
essentially the same as the OGTT, except that the
carbohydrate challenge is administered IV instead of
orally. Because the results are somewhat difficult to
interpret, the IVGTT is used only in certain clinical
situations or for research purposes.
Reference Values
The reference values are the same as those for
the OGTT, except that the blood glucose level at
the 1/2-hour interval may be 300 to 400 mg/dL
because of the direct IV administration of the
glucose load.
INTERFERING FACTORS

Those factors that may alter the results of an
OGTT may also alter the results of an IVGTT.
Infusions of total parenteral nutrition (TPN,
hyperalimentation) during the test may lead to
falsely elevated values; alternative solutions with
less glucose should be infused for at least 3 hours
before and during the test.
INDICATIONS FOR INTRAVENOUS GLUCOSE
TOLERANCE TEST

Inability to take or tolerate oral glucose preparations used for the OGTT

Chemistry

111

Suspected gastrointestinal malabsorption problems that interfere with accurate performance of
the OGTT
Evaluation of blood glucose control without the
effects of gastrin, secretin, cholecystokinin, and
gastric inhibitory peptide, all of which stimulate
insulin production after oral ingestion of glucose
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
the OGTT.
If the person is receiving TPN, an alternative solution with less glucose should be prescribed and
infused for at least 3 hours before and during the
test.
THE PROCEDURE

The procedure is essentially the same as that for the
OGTT except that an intermittent venous access
device (e.g., heparin lock) may be inserted to administer the glucose load and to obtain blood samples.
Existing IV lines also may be used to administer the
carbohydrate challenge, which is usually 50 percent
glucose, with the amount to be given determined by
the client’s weight or body surface.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as those for the OGTT.
If an intermittent venous access device was
inserted for the procedure, remove it after
completion of the test and apply a pressure bandage to the site.
Resume food and medications withheld before
the test, as well as usual activities.
Resume infusions of TPN as ordered.

CORTISONE GLUCOSE TOLERANCE
TEST
The cortisone glucose tolerance test (cortisone
GTT) combines administration of a carbohydrate
challenge with a cortisone challenge. Cortisone
enhances the synthesis of glucose from amino acids
and fatty acids (gluconeogenesis) and, when administered with a glucose load, may produce an abnormal GTT that would not otherwise be evident. The
cortisone GTT is used only in certain clinical situations and for research purposes.
Reference Values
The reference values are similar to those for the
OGTT except that the blood glucose level at the
2-hour interval may be 20 mg/dL higher than
the client’s fasting level.

112

SECTION I—Laboratory

Tests

INTERFERING FACTORS

Those factors that may alter the results of an
OGTT may also alter the results of a cortisone
GTT.
Failure to administer or take the oral cortisone as
prescribed for the test will alter results.
INDICATIONS FOR CORTISONE GLUCOSE
TOLERANCE TEST

Inconclusive results of OGTT when prediabetes
or “borderline” diabetes is suspected, with a 2hour level of greater than 165 mg/dL considered
indicative of diabetes
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
the OGTT.
In addition, the client should be instructed on the
purpose and administration of the oral cortisone
acetate.
THE PROCEDURE

The procedure is the same as that for the OGTT
except that cortisone acetate is administered orally 8
hours and again 2 hours before the standard GTT is
begun.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for the OGTT.

Glycosylated Hemoglobin
Throughout the red blood cell’s life span, the hemoglobin molecule incorporates glucose onto its
chain. Glycosylation is irreversible and occurs at a
stable rate. The amount of glucose permanently
bound to hemoglobin depends on the blood sugar
level. Thus, the level of glycosylated hemoglobin,
designated Hgb A1c, reflects the average blood sugar
over a period of several weeks.
The test is used to evaluate the overall adequacy of
diabetic control and provides information that may
be missed by individual blood and urine glucose
tests. Insulin-dependent diabetics, for example, may
have undetected periods of hyperglycemia alternating with postinsulin periods of normoglycemia or
even hypoglycemia. High Hgb A1c levels reflect inadequate diabetic control in the preceding 3 to 5 weeks.
In addition to providing a more accurate assessment of overall blood glucose control, the test is
more convenient for diabetic clients because it is
performed only every 5 to 6 weeks and because there
are no dietary or medication restrictions before the
test.

Reference Values
Hgb A1c is 3 to 6 percent of hemoglobin.
Hgb A1c is 7 to 11 percent in diabetes under
control.
INTERFERING FACTORS

Individuals with hemolytic anemia and high
levels of young red blood cells may have spuriously low levels.
Individuals with elevated hemoglobin levels or on
heparin therapy may have falsely elevated levels.
INDICATIONS FOR GLYCOSYLATED
HEMOGLOBIN TEST

Monitoring overall blood glucose control in
clients with known diabetes, because the test aids
in assessing blood glucose levels over a period of
several weeks and provides data that may be
missed by random blood or urine glucose tests:
With prolonged hyperglycemia, levels of Hgb
A1c may rise to as high as 18 to 20 percent.
After normoglycemic levels are stabilized, Hgb
A1c levels return to normal in about 3 weeks.16
Monitoring adequacy of insulin dosage for blood
glucose control, especially that administered by
automatic insulin pumps
Evaluating the diabetic client’s degree of compliance with the prescribed therapeutic regimen,
because fasting or adjusting medications shortly
before the test will not significantly alter results
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
The client should be informed that fasting or
adjusting medications for diabetes shortly before
the test will not significantly alter results.
THE PROCEDURE

A venipuncture is performed and the sample
obtained in a lavender-topped tube. The sample
must be mixed adequately with the anticoagulant
contained in the tube and transported promptly to
the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Complications and precautions: A value of
greater than 15 percent of total Hgb A1c indicates
that the diabetes is out of control. Notify the
physician at once.

CHAPTER 5—Blood

Chemistry

113

Tolbutamide Tolerance Test

NURSING CARE BEFORE THE PROCEDURE

Tolbutamide (Orinase) is a hypoglycemic agent that
produces hypoglycemia by stimulating the cells of
the pancreas to secrete and release insulin. An IV
infusion of tolbutamide raises the serum insulin and
causes a rapid decrease in the blood glucose level.
Thus, the test demonstrates the pancreatic -cell
response to drug-induced stimulation. Note that the
test can be performed with glucagon or leucine
instead of tolbutamide for clients who are sensitive
to sulfonylureas or sulfonamides.

Client preparation is essentially the same as that for
an OGTT.
The individual should be informed that venous
access will be established with either a continuous
infusion or an intermittent device and that a
medication that lowers blood sugar will be
administered.
The client should be questioned regarding allergies to sulfonylureas or sulfonamides.
Clients with a history of abnormal hypoglycemia
will need reassurance that they will be monitored
closely during the test.

Reference Values
A decrease in serum glucose levels is evident
within 5 to 10 minutes of administration of the
drug. The lowest glucose levels occur in about 20
to 30 minutes and are generally about half of the
client’s usual fasting level. The glucose level
returns to pretest values in 1 to 3 hours.
INTERFERING FACTORS

The factors that may alter the results of an OGTT
may also alter the results of a tolbutamide tolerance test.
INDICATIONS FOR TOLBUTAMIDE TOLERANCE
TEST

Evaluation of fasting or postprandial hypoglycemia by assessing the degree of pancreatic cell response to drug-induced stimulation
Suspected insulinoma (insulin-producing tumor
of the pancreatic cells) as indicated by glucose
levels that drop markedly in response to tolbutamide and take 3 or more hours to return to
normal levels
Suspected prediabetic state that may be characterized by excessive insulin release, as indicated by
glucose levels that are lower than expected but
that follow the overall pattern of a normal
response to the test
Nursing Alert

Because of the expected drop in blood sugar
levels, the test should be performed with
extreme caution, if at all, on individuals with
fasting blood sugars of 50 mg/dL or less.
If the client is allergic to sulfonylureas or
sulfonamides, the test should be performed
using glucagon or leucine instead of tolbutamide.

THE PROCEDURE

Venous access is established and a sample is obtained
for a fasting blood sugar (FBS). The IV catheter is
then connected to an intermittent device (e.g.,
heparin lock) or to a continuous IV infusion of
normal saline at a keep-vein-open (KVO) rate.
Tolbutamide 1.0 g mixed in 20 mL sterile water is
administered IV. Blood glucose samples are obtained
via the IV catheter at 15-minute intervals for the first
hour and then at 11/2-, 2-, and 3-hour intervals.
Observe the client closely for signs and symptoms of
hypoglycemia. If hypoglycemia occurs, obtain a stat
FBS, notify the physician, and initiate an IV infusion
of 5 percent glucose and water, if ordered.
Note any signs or symptoms of sensitivity reaction to tolbutamide. If a reaction occurs, notify the
physician and administer drugs as ordered. Maintain
an open IV line until there is no further danger of
adverse drug reaction.
NURSING CARE AFTER THE PROCEDURE

The venous access device is left in place until any
danger of hypoglycemia is past. It is then removed
and a pressure bandage applied to the site. Food
and medications withheld before the test, as well
as usual activities, should be resumed on its completion.
Continue to observe for signs and symptoms of
hypoglycemia for 2 hours or more, depending on
results of the 3-hour interval blood sugar.
Assess the venipuncture site for signs of
hematoma or phlebitis.
Observe for adequate intake when foods are
resumed.

PROTEINS
Proteins, also called polypeptides, consist of amino
acids linked by peptide bonds. Although all human
proteins are constructed from a mere 20 amino
acids, variations in chain length, amino acid

114

SECTION I—Laboratory

Tests

sequence, and incorporated constituents combine to
make possible an almost infinite number of protein
molecules. All cells manufacture proteins, with
different proteins characterizing different cell types.
The amino acids needed for these processes enter the
body from dietary sources. These amino acids are
rapidly distributed to tissue cells, which promptly
incorporate them into proteins.
Three-fourths of the body’s solid matter is protein
and, except for hemoglobin, relatively little circulates
in whole blood. The major plasma proteins are albumin, the globulins, and fibrinogen. Fibrinogen
evolves into insoluble fibrin when blood coagulates.
The fluid that remains after coagulation is called
serum. Serum and plasma have the same protein
composition except that serum lacks fibrinogen and
several other coagulation factors (prothrombin,
factor VIII, factor V, and factor XIII).
The proteins in circulating blood transport amino
acids from one site to another, providing raw materials for synthesis, degradation, and metabolic interconversion. Circulating proteins also function as
buffers in acid–base balance, contribute to the maintenance of colloidal osmotic pressure, and aid in
transporting lipids, enzymes, hormones, vitamins,
and certain minerals.
Most plasma proteins originate in the liver.
Hepatocytes synthesize fibrinogen, albumin, and
TABLE 5–3

•

60 to 80 percent of the globulins. The remaining
globulins are immunoglobulins (antibodies), which
are manufactured by the lymphoreticular system.
Immunoglobulins are studied as part of the immune
system (see Chapter 3), whereas fibrinogen is
usually studied as part of a coagulation workup
(see Chapter 2). The focus of this section is on the
major serum proteins (albumin and nonantibody
globulins), binding proteins, and protein metabolites.17

Serum Proteins
General assessment of the serum proteins includes
measurement of total protein, albumin, globulin,
and the albumin-to-globulin (A-G) ratio. Although
these tests are being replaced by serum protein electrophoresis (see Chapter 3), they may still be ordered
for screening purposes or as components of multitest chemistry profiles, because they provide an
overall picture of protein homeostasis.
Several disorders can cause alterations in serum
proteins. Those affecting total protein levels are
listed in Table 5–3. Albumin levels show less variation. Except for dehydration, exercise, and effects
of certain drugs (e.g., gallamine triethiodide
[Flaxedil]), elevated albumin levels do not occur.
Albumin may be decreased in a number of situations

Causes of Altered Total Serum Proteins

Increased Levels

Decreased Levels

Kala-azar

Renal disease

Dehydration

Ulcerative colitis

Macroglobulinemias

Water intoxication

Sarcoidosis

Cirrhosis
Severe burns

Drugs

Scleroderma

Adrenocorticotropic hormone, corticosteroids

Malnutrition

Clofibrate

Hodgkin’s disease

Dextran

Hemorrhage

Growth hormone
Heparin

Drugs

Insulin

Ammonium ion

Sulfobromophthalein (Bromsulphalein, BSP)

Dextran

Thyroid preparations

Oral contraceptives

Tolbutamide

Pyrazinamide

X-ray contrast media

Salicylates

CHAPTER 5—Blood

caused, in general, by (1) decreased hepatic synthesis, (2) excessive renal excretion, (3) increased metabolic degradation, and (4) complex combined
disorders. Specific problems associated with hypoalbuminemia are listed in Table 5–4.
Globulin levels show more variation than do
albumin levels, probably because of the multiple
production sites for this protein. Causes of altered
globulin levels are listed in Table 5–5 according to
the type of globulin affected.
The A-G ratio indicates the balance between total
albumin and total globulin and is usually evaluated
in relation to the total protein level. A low protein
level and a reversed A-G ratio (i.e., decreased albumin and elevated globulins) suggest chronic liver
disease. A normal total protein level with a reversed
A-G ratio suggests myeloproliferative disease (e.g.,
leukemia, Hodgkin’s disease) or certain chronic
infectious diseases (e.g., tuberculosis, chronic hepatitis).
INTERFERING FACTORS

High serum lipid levels may interfere with accurate testing.
Numerous drugs may alter protein levels (see
Tables 5–3 and 5–4).
INDICATIONS FOR SERUM PROTEINS TEST

Routine screening as part of a complete physical
examination, with normal results indicating satisfactory overall protein homeostasis
Clinical signs of diseases associated with altered
serum proteins (see Tables 5–3, 5–4, and 5–5)
Monitoring of response to therapy with drugs
that may alter serum protein levels

Chemistry

• Causes of
Hypoalbuminemia

TABLE 5–4

Decreased Synthesis of Albumin
Malnutrition (starvation, malabsorption iron
deficiency)
Chronic diseases (tuberculosis)
Acute infections (hepatitis, brucellosis)
Chronic liver disease
Collagen disorders (scleroderma, systemic lupus
erythematosus)
Drugs
Acetaminophen (Tylenol)
Azathioprine (Imuran)
Conjugated estrogens (Premarin)
Cyclophosphamide (Cytoxan)
Dextran
Ethinyl estradiol (Estinyl)
Heroin
Mestranol/norethynodrel (Enovid)
Niacin
Nicotinyl alcohol (Roniacol)
Increased Loss of Albumin
Ascites
Burns (severe)
Nephrotic syndrome
Chronic renal failure

NURSING CARE BEFORE THE PROCEDURE

Increased Catabolism of Albumin

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
Some laboratories require an 8-hour fast before
the test, as well as a low-fat diet for several days
before the test, because high serum lipid levels
may interfere with accurate testing.

Malignancies (leukemias, advanced tumors)

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently and sent promptly to the laboratory.

Trauma
Multifactorial Causes
Cirrhosis
Congestive heart failure
Pregnancy
Toxemia of pregnancy
Diabetes mellitus
Myxedema
Rheumatic fever

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a

115

Rheumatoid arthritis
Hypocalcemia

116

SECTION I—Laboratory

TABLE 5–5
Globulin
1

Tests

•

Causes of Altered Serum Globulin Levels
Increased Levels

Decreased Levels

Pregnancy

Genetic deficiency of
1-antitrypsin

Malignancies
Acute infections
Tissue necrosis
2

Acute infections

Hemolytic anemia

Trauma, burns

Severe liver disease

Advanced malignancies
Rheumatic fever
Rheumatoid arthritis
Acute myocardial infarction
Nephrotic syndrome

Hypothyroidism

Hypocholesterolemia

Biliary cirrhosis
Nephrotic syndrome
Diabetes mellitus
Cushing’s syndrome
Malignant hypertension

Connective tissue diseases (such
as systemic lupus erythematosus
and rheumatoid arthritis)

Nephrotic syndrome

Hodgkin’s disease

Lymphosarcoma

Chronic active liver disease

Drugs

Lymphocytic leukemia

Bacille Calmetté-Guérin
vaccine

Tolazamide (Tolinase)
Tubocurarine

Methotrexate

Anticonvulsants

peripheral blood sample. Resume any foods withheld before the test.
Abnormal values: Note and report increased
levels. Assess for symptoms of dehydration that
can cause hyperproteinemia such as thirst, dry
skin and mucous membranes, or poor skin turgor.
Assess fluid loss resulting from vomiting, diarrhea, or renal dysfunction. Note and report
decreased levels. Assess in relation to hypoalbuminuria and for edema in serum albumin levels as
low as 2.0 to 2.5 g/dL. Assess for causes of hypoalbuminemia such as acute or chronic liver disease
or renal dysfunction. Assess for stress, injury, or
infection that requires increased protein intake.
Prepare for IV administration of albumin replace-

ment in severe conditions. Monitor I&O.
Encourage and instruct in increased dietary
protein intake.

1-Antitrypsin Test
1-Antitrypsin (1-AT) is an 1-globulin produced
by the liver. Its function is inhibition of the proteolytic enzymes trypsin and plasmin, which are
released by alveolar macrophages and by bacteria in
the lungs. As with many other proteins, the 1-AT
molecule has several structural variants. Some of
these variant molecules have different electrophoretic mobility and reduced ability to inhibit
proteolytic enzymes.

CHAPTER 5—Blood

Chemistry

117

Reference Values
The reference values for total protein, albumin, and globulin vary slightly across the life cycle and are listed
accordingly. Values for -globulins are provided for comparison purposes.
Total Protein

Albumin

-Globulins

Globulins

Conventional Units

SI
Units

Conventional Units

SI
Units

Newborns

5.0–7.1
g/dL

50–70 g/L

2.5–5.0
g/dL

25–50 g/L

1.2–4.0
g/dL

12–40
g/dL

0.7–0.9
g/dL

7–9 g/L

3 mo

4.7–7.4
g/dL

47–74 g/L

3.0–4.2
g/dL

30–42 g/L

1.0–3.3
g/dL

10–33
g/L

0.1–0.5
g/dL

1–5 g/L

1 yr

5.0–7.5
g/dL

50–75 g/L

2.7–5.0
g/dL

27–50 g/L

2.0–3.8
g/dL

20–38
g/L

0.4–1.2
g/dL

4–12 g/L

15 yr

6.5–8.6
g/dL

65–86 g/L

3.2–5.0
g/dL

32–50 g/L

2.0–4.0
g/dL

20–40
g/L

0.6–1.2
g/dL

6–12 g/L

Adults

6.6–7.9
g/dL

66–79 g/L

3.3–4.5
g/dL

33–45 g/L

2.0–4.2
g/dL

20–42
g/L

0.5–1.6
g/dL

5–16 g/L

Age

ConvenSI
Conventional Units Units tional Units

SI
Units

A-G ratio 1.5:1–2.5:1
Although discussed in Chapter 3, the normal values for serum protein electrophoresis are repeated next
for reference purposes. Values are reported as percentage of total proteins.
Total Globulins
Conventional
Units
52–68

SI
Units
0.520–

Albumin
Conventional
Units
32–48

0.680

SI
Units
0.320–
0.480

Conventional
Units
10.7–
21.0

2
SI
Units

0.107–
0.210

Inherited deficiencies in normal 1-AT activity
are associated with the development, early in life, of
lung and liver disorders in which functional tissue is
destroyed and replaced with excessive connective
tissue; that is, emphysema and cirrhosis may develop
in children and young adults who are deficient in 1AT, without the usual predisposing factors associated
with onset of these disorders. Such deficiencies are
seen on serum protein electrophoresis as a flat area
where the normal 1-globulin hump should be.
More detailed physiochemical analysis can demonstrate which variant form is present. Decreased levels
of 1-AT also are seen in nephrotic syndrome and
malnutrition.
Reference Values
80 to 213 mg/dL
INTERFERING FACTORS

Pregnancy

Conventional
Units
8.5–

SI
Units

0.085–

14.5

0.145

Conventional
Units
6.6–
13.5

SI
Units

0.066–

Conventional
Units
2.4–5.3

0.135

SI
Units
0.024–
0.053

Oral contraceptive and steroid administration
Extreme physical stress caused by trauma or
surgery
INDICATIONS FOR 1-ANTITRYPSIN TEST

Genetic absence or deficiency of 1-AT, indicated
by decreased levels of the protease
Suspected inflammation, infection, and necrosis
processes, indicated by increased levels of the
protease
Family history of 1-AT deficiency
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
The client should fast for 8 hours before the test.
Water is not restricted.
Oral contraceptives and steroids should be withheld 24 hours before the study, although this practice should be confirmed with the person
ordering the test.

118

SECTION I—Laboratory

Tests

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and frozen if
not tested immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume meals or medications withheld before the
test.
Abnormal values: Note and report decreased
levels. Assess for pulmonary or liver disorders and
associated signs and symptoms, smoking history,
and pollution in the home or work environment.
Inform client of stop-smoking clinics and
resources for genetic counseling. Instruct client in
ways to protect pulmonary system from irritants.
Inform client of the importance of medical
follow-up. Suggest ongoing support resources to
assist client in coping with illness and possible
early death.

Binding Proteins
HAPTOGLOBIN
Haptoglobin, an 2-globulin produced in the liver,
binds free hemoglobin released by the hemolysis
of red blood cells in the bloodstream. Most red
blood cells are normally removed in the reticuloendothelial system (e.g., liver, spleen) by a process
known as extravascular destruction. Approximately
10 percent of red blood cells are, however, broken
down in the circulation (intravascular destruction).
This percentage may increase in situations caused by
excessive red blood cell hemolysis (e.g., transfusion
reaction, hemolytic anemia).
The free hemoglobin released from intravascular
red blood cell destruction is unstable in plasma and
dissociates into components (- dimers) that are
quickly bound to haptoglobin. Formation of the
haptoglobin–hemoglobin complex prevents the
renal excretion of plasma hemoglobin and stabilizes
the heme-globin bond. The haptoglobin–hemoglobin complex is removed from the circulation by the
liver.
There is a limit to the capacity of the haptoglobinbinding mechanism, and a sudden intravascular
release of several grams of hemoglobin can exceed
binding capacity. Furthermore, because haptoglobin
itself is removed from the circulation as a haptoglobin–hemoglobin complex and is catabolized by the

liver, a decrease in or absence of haptoglobin may be
used to indicate increased intravascular red blood
cell hemolysis.
Because haptoglobin is formed in the liver,
chronic liver disease with impaired protein synthesis
also may result in decreased haptoglobin levels.
Although haptoglobin is absent in most newborns,
congenital absence of haptoglobin (congenital ahaptoglobinemia) can occur in a very small percentage
of the population.
If haptoglobin is deficient or its binding capacity
overwhelmed, unbound hemoglobin dimers are free
to be filtered by the renal glomerulus, after which
they are reabsorbed by the renal tubules and
converted into hemosiderin (a storage form of iron).
If renal tubular uptake capacity is exceeded, either
free hemoglobin or methemoglobin (a type of
hemoglobin with iron in the ferric, instead of the
ferrous, form) is excreted in the urine. Note that
reabsorption of free hemoglobin may damage the
renal tubules because of excessive deposition of
hemosiderin.18
Elevated haptoglobin levels are seen in inflammatory diseases (e.g., ulcerative colitis, arthritis,
pyelonephritis) and in disorders involving tissue
destruction (e.g., malignancies, burns, acute
myocardial infarction). Steroid therapy may also
elevate haptoglobin levels. Elevated levels are not of
major clinical significance except to indicate that
additional testing may be necessary to determine the
source of the elevation.
Reference Values
Conventional Units

SI Units

Newborns

0–10 mg/dL

0–0.1 g/L

Adults

30–160 mg/dL

0.3–1.6 g/L

INTERFERING FACTORS

Steroid therapy may result in elevated levels.
INDICATIONS FOR HAPTOGLOBIN TEST

Known or suspected disorder characterized by
excessive red blood cell hemolysis, as indicated by
decreased levels
Known or suspected chronic liver disease, as indicated by decreased levels
Suspected congenital ahaptoglobinemia, as indicated by decreased levels
Known or suspected disorders involving a diffuse
inflammatory process or tissue destruction, as
indicated by elevated levels

CHAPTER 5—Blood

TABLE 5–6

•

Chemistry

119

Causes of Altered Levels of Ceruloplasmin

Increased Levels
Acute infections

Decreased Levels
Wilson’s disease

Hepatitis

Malabsorption syndromes

Hodgkin’s disease

Long-term total parenteral nutrition

Hyperthyroidism

Menkes’ kinky hair syndrome

Pregnancy

Nephrosis

Malignancies of bone, lung, stomach

Severe liver disease

Myocardial infarction

Early infancy

Rheumatoid arthritis
Drugs
Oral contraceptives
Estrogens
Methadone
Phenytoin (Dilantin)

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. Some laboratories
require that the sample be placed in ice immediately
upon collection. The sample should be handled
gently to avoid hemolysis, which may alter test
results, and sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

CERULOPLASMIN
Ceruloplasmin (Cp) is an 2-globulin that binds
copper for transport within the circulation after it is
absorbed from the gastrointestinal tract. Among the
disorders associated with abnormal ceruloplasmin
levels is Wilson’s disease (hepatolenticular degeneration), an inherited disorder characterized by excessive absorption of copper from the gastrointestinal
tract, decreased ceruloplasmin, and deposition of
copper in the liver, brain, corneas (Kayser-Fleischer
rings), and kidneys. In addition to low ceruloplasmin levels, serum copper levels are decreased

because of excessive excretion of unbound copper in
the kidneys and deposition of copper in the body
tissues. The disorder manifests during the first three
decades of life and is fatal unless treatment is instituted.
Other causes of abnormal ceruloplasmin levels
are listed in Table 5–6.
Reference Values
Conventional Units

SI Units

Newborns

2–13 mg/dL

20–130 mol/L

Adults

23–50 mg/dL

230–500 mol/L

INDICATIONS FOR CERULOPLASMIN TEST

Family history of Wilson’s disease (hepatolenticular degeneration)
Signs of liver disease combined with neurological
changes, especially in a young person, with
Wilson’s disease indicated by decreased levels
Monitoring of ceruloplasmin levels in disorders
associated with abnormal values (see Table 5–6)
Monitoring of response to TPN (hyperalimentation), which may lead to decreased levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).

120

SECTION I—Laboratory

Tests

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. Some laboratories
require that the sample be placed in ice immediately
on collection. The sample should be handled gently
to avoid hemolysis and sent promptly to the laboratory.

nitrogen; the result is expressed as urea nitrogen.
Nitrogen contributes 46.7 percent of the total weight
of urea. The concentration of urea can be calculated
by multiplying the urea nitrogen result by 2.14.19
INTERFERING FACTORS

Therapy with drugs known to alter urea nitrogen
levels (see Table 5–7)

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal values: Note and report decreased
levels. Assess for hepatic or neurological or
psychiatric manifestations of Wilson’s disease.
Assess for history of ceruloplasmin deficiency by
Kayser-Fleischer rings determined by slit-lamp
examination. Inform of need for follow-up
medical care and genetic counseling.

INDICATIONS FOR UREA NITROGEN TEST

Known or suspected disorder associated with
impaired renal function, as indicated by increased
levels:
Obstructive, inflammatory, or toxic damage to
the kidneys, nephron loss caused by aging, or
extrarenal conditions that reduce the glomerular filtration rate (GFR) increase retention of
urea.
Monitoring for the effects of disorders associated
with altered fluid balance:
Dehydration or hypovolemia caused by vomiting, diarrhea, hemorrhage, or inadequate fluid
intake raises the urea nitrogen.
Fluid overload decreases the urea nitrogen if
renal function is adequate.
Known or suspected liver disease as indicated by
decreased levels caused by the liver’s inability to
convert ammonia to urea (80 percent of liver
function may be lost before this is evident)
Monitoring for effects of drugs known to be
nephrotoxic or hepatotoxic
Monitoring of response to various disorders
known to result in altered urea nitrogen levels (see
Table 5–7)

Protein Metabolites
Most nitrogen in the blood resides in proteins, and
the amount of nitrogen contained in proteins is high
in relation to amino acid content. When proteins are
metabolized, the nitrogen-containing components
are removed from the amino acids, a process known
as deamination. The resulting protein metabolites
include urea, creatinine, ammonia, creatine, and uric
acid. Levels of these nonprotein nitrogenous
compounds reflect various aspects of protein
balance and metabolism.

UREA NITROGEN
Urea is a nonprotein nitrogenous compound that is
formed in the liver from ammonia. Although urea
diffuses freely into both extracellular and intracellular fluid, it is ultimately excreted by the kidneys.
Blood urea levels reflect the balance between
production and excretion of urea. Changes in
protein intake, fluid balance, liver function, and
renal excretion affect blood urea levels. Specific
causes of alterations are listed in Table 5–7.
Blood urea analysis involves measurement of

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
Some laboratories require an 8-hour fast before
the test.
THE PROCEDURE

A venipuncture is performed and the sample is
obtained in either a gray-topped or red-topped tube,

Reference Values
Conventional Units [Urea Nitrogen]

SI Units [Urea]

Newborns

4–18 mg/dL

1.4–6.4 mmol/L

Children

7–18 mg/dL

2.5–6.4 mmol/L

Adults

5–20 mg/dL

1.8–7.1 mmol/L

Critical values

100 mg/dL

35.7 mmol/L

CHAPTER 5—Blood

TABLE 5–7

•

Chemistry

Causes of Altered Urea Levels

Increased Levels

Decreased Levels

Congestive heart failure

Inadequate dietary protein

Shock

Severe liver disease

Hypovolemia

Water overload

Urinary tract obstruction

Nephrotic syndrome

Renal diseases

Pregnancy

Starvation

Amyloidosis

Infection

Malabsorption syndromes

Myocardial infarction

Drugs

Diabetes mellitus

IV dextrose

Burns

Phenothiazines

Gastrointestinal bleeding

Thymol

Advanced pregnancy
Nephrotoxic agents
Excessive protein ingestion
Malignancies
Addison’s disease
Gout
Pancreatitis
Tissue necrosis
Advanced age
Drugs
Aspirin
Acetaminophen
Cancer chemotherapeutic agents
Antibiotics (amphotericin B, cephalosporins, aminoglycosides)
Thiazide diuretics
Indomethacin (Indocin)
Morphine
Codeine
Sulfonamides
Methyldopa (Aldomet)
Propranolol (Inderal)
Guanethidine (Ismelin)
Pargyline (Eutonyl)
Lithium carbonate
Dextran
Sulfonylureas

121

122

SECTION I—Laboratory

Tests

depending on the laboratory performing the test.
The sample should be handled gently to avoid
hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
If the client’s diet was restricted before the test, the
usual diet may be resumed.
Abnormal levels: Note and report decreased
levels. Assess hydration status for overhydration,
I&O, osmolality, and sodium levels. Note and
report increased levels and assess in relation to
creatinine level. Assess electrolyte panel and for
signs and symptoms of anemia, gastrointestinal
bleeding, oliguria, confusion, and level of
consciousness if urea nitrogen rises to greater
than 20 to 50 mg/dL. Monitor urinary output
every hour. Provide safety measures if consciousness is altered. Instruct as to restriction in fluid
and dietary intake of protein (meat, fish, poultry).

Daily generation of creatinine remains fairly
constant unless crushing injury or degenerative
diseases cause massive muscle damage. The kidneys
excrete creatinine very efficiently. Levels of blood
and urine flow affect creatinine excretion much less
than they influence urea excretion because temporary alterations in renal blood flow and glomerular
function can be compensated by increased tubular
secretion of creatinine. Thus, serum creatinine is a
more sensitive indicator of renal function than is
urea nitrogen.20
INDICATIONS FOR SERUM CREATININE TEST

Critical values: Notify the physician immediately if levels are greater than 100 mg/dL.

SERUM CREATININE
Creatinine is the end product of creatine metabolism. Creatine, although synthesized largely in the
liver, resides almost exclusively in skeletal muscle,
where it reversibly combines with phosphate to form
the energy storage compound phosphocreatine. This
reaction (creatine
phosphate ←
→ phosphocreatine) repeats as energy is released and regenerated,
but in the process small amounts of creatine are irreversibly converted to creatinine, which serves no
useful function and circulates only for transportation to the kidneys. The amount of creatinine generated in an individual is proportional to the mass of
skeletal muscle present; level of muscular activity is
not a critical determinant.

Known or suspected impairment of renal
function, including therapy with nephrotoxic
drugs:
In the absence of disorders affecting muscle
mass, elevated creatinine levels indicate
decreased renal function.
Creatinine levels may be normal in situations
in which a slow decline in renal function occurs
simultaneously with a slow decline in muscle
mass, as may occur in elderly individuals (in
such situations, a 24-hour urine collection
yields lower than normal excretion levels).
Along with a urea nitrogen, to provide additional
client information:
An elevated urea nitrogen with a normal creatinine usually indicates a nonrenal cause for the
excessive urea.
The urea nitrogen rises more steeply than creatinine as renal function declines, and it falls
more rapidly with dialysis.
With severe, permanent renal impairment, urea
levels continue to climb, but creatinine values
tend to plateau (at very high circulating creatinine levels, some is excreted through the
gastrointestinal tract).
Known or suspected disorder involving muscles,
including crushing injury to muscles:
In the absence of renal disease, elevated serum
creatinine levels are associated with trauma or

Reference Values
Conventional Units

SI Units

Children 6 yr

0.3–0.6 mg/dL

24–54 mol/L

Children 6–18 yr

0.4–1.2 mg/dL

36–106 mol/L

Men

0.6–1.3 mg/dL

53–115 mol/L

Women

0.5–1.0 mg/dL

44–88 mol/L

Critical values

10 mg/dL

880 mol/L

Adults

CHAPTER 5—Blood

disorders causing excessive muscle mass
(gigantism, acromegaly).
Decreased levels are associated with muscular
dystrophy.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
Some laboratories require an 8-hour fast before
the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Increased levels
should be assessed in relation to the urea nitrogen;
notify the physician immediately if levels are greater than 10 mg/dL unless the client is on dialysis.

AMMONIA
Blood ammonia comes from two sources: (1) deamination of amino acids during protein metabolism
and (2) degradation of proteins by colon bacteria.
The liver converts ammonia to urea, generating glutamine as an intermediary. The kidneys then use
glutamine as a source for synthesizing ammonia for
renal regulation of electrolyte and acid–base
balance. Serum ammonia levels have little effect on
renal excretion of ammonia.
Circulating blood normally contains very little
ammonia because the liver converts ammonia in the
portal blood to urea. When liver function is severely
compromised, especially in situations when
decreased hepatocellular function is combined with
impaired portal blood flow, ammonia levels rise.
Both elevated serum ammonia and abnormal glutamine metabolism have been implicated as etiologic
factors in hepatic encephalopathy (hepatic coma).21
Additional causes of altered serum ammonia levels
are listed in Table 5–8.
Reference Values
Conventional Units

Chemistry

123

INDICATIONS FOR SERUM AMMONIA TEST

Evaluation of advanced liver disease or other
disorders associated with altered serum ammonia
levels (see Table 5–8)
Identification of impending hepatic encephalopathy in clients with known liver diseases (e.g., after
bleeding from esophageal varices or other
gastrointestinal sources, or after excessive ingestion of protein) as indicated by rising levels
Monitoring for the effectiveness of treatment for
hepatic encephalopathy as indicated by declining
levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I). An 8-hour fast from
food is required before the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube. Some laboratories
require that the sample be placed in ice immediately
on collection. The sample should be handled gently
to avoid hemolysis and sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample. Resume foods withheld
before the test.

SERUM CREATINE
Creatine is a nitrogen-containing compound found
largely in skeletal muscle, where it functions as an
energy source. Its use by muscles results in loss
proportionate to the muscle mass and level of
muscular activity. Measurement of serum creatine
reflects this loss, which is fairly constant under
normal conditions.
Reference Values
Conventional Units

SI Units

Men

0.1–0.4 mg/dL

9–35 mol/L

Women

0.2–0.7 mg/dL

18–62 mol/L

SI Units

Newborns

90–150 g/dL

64–107 mol/L

Children

40–80 g/dL

23–47 mol/L

Adults

15–45 g/dL

11–32 mol/L

INTERFERING FACTORS

Failure to follow dietary restrictions and vigorous
exercise within 8 hours of the test may alter
results.

124

SECTION I—Laboratory

TABLE 5–8

Tests

•

Causes of Altered Blood Ammonia Levels

Increased Levels

Decreased Levels

Liver failure, late cirrhosis

Renal failure

GI hemorrhage

Hypertension

Late congestive heart failure
Drugs
Azotemia

Arginine (R-Gene)

Hemolytic disease of the newborn

Benadryl

Chronic obstructive pulmonary disease

Sodium salts

Leukemias

Glutamic acid (Acidulin)

Reye’s syndrome

MAO inhibitors

Inborn enzyme deficiency

Antibiotics (tetracycline [Achromycin],
kanamycin [Kantrex], neomycin)

Excessive protein ingestion

Potassium salts

Alkalosis
Drugs
Acetazolamide (Diamox)
Ammonium salts
Barbiturates
Colistin (Coly-Mycin S)
Diuretics
Ethanol
Heparin
Isoniazid
Methicillin
Morphine
Tetracycline

INDICATIONS FOR SERUM CREATINE TEST

Signs and symptoms of muscular disease (e.g.,
muscle injury, muscular dystrophies, dermatomyositis), as indicated by elevated levels
Monitoring for the progression of muscle-wasting
diseases with serial measurements indicating the
rate of muscle deterioration
Evaluation of the effects of hyperthyroidism and
rheumatoid arthritis on muscle tissue
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
Food, fluids, and vigorous exercise are not permitted for at least 8 hours before the test.

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and sent
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Resume foods and fluids withheld before the test,
as well as usual activities.

URIC ACID
Uric acid (urate) is the end product of purine
metabolism. Purines are important constituents of

CHAPTER 5—Blood

Chemistry

125

Reference Values
Conventional Units

SI Units

Children

2.5–5.5 mg/dL

0.15–0.33 mmol/L

Men

4.0–8.5 mg/dL

0.24–0.51 mmol/L

Women

2.7–7.3 mg/dL

0.16–0.43 mmol/L

Critical values

12 mg/dL

0.71 mmol/L

nucleic acids; purine turnover occurs continuously
in the body, producing substantial amounts of uric
acid even in the absence of dietary purine (e.g.,
meats, legumes, yeasts) intake. Most uric acid is
synthesized in the liver and excreted by the kidneys.
Serum urate levels are affected by the amount of uric
acid produced as well as by the efficiency of renal
excretion.
Both gout and urate renal calculi (kidney stones)
are associated with elevated uric acid levels. Other
disorders and drugs associated with altered uric acid
levels are listed in Table 5–9.
INTERFERING FACTORS

Therapy with drugs known to alter uric acid levels
(see Table 5–9), unless the test is being conducted
to monitor such drug effects
INDICATIONS FOR URIC ACID TEST

Family history of gout (autosomal dominant
genetic disorder) or signs and symptoms of gout,
or both, with the disorder indicated by elevated
levels
Known or suspected renal calculi, to determine
the cause
Signs and symptoms of disorders associated with
altered uric acid levels (see Table 5–9)
Monitoring for the effects of drugs known to alter
uric acid levels (see Table 5–9), either as a side
effect or as a therapeutic effect
Evaluation of the extent of tissue destruction in
infection, starvation, excessive exercise, malignancies, chemotherapy, or radiation therapy
Evaluation of possible liver damage in eclampsia,
as indicated by elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Some laboratories require an 8-hour fast from
food before the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should

be handled gently to avoid hemolysis and sent
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods withheld before the test.
Abnormal values: Note and report increased
level. Assess for symptoms associated with renal
stones and joint pain. Prepare to administer
ordered medications (allopurinol, probenecid,
nonsteroidal anti-inflammatory analgesics).
Increase fluid intake. Instruct client to avoid highpurine fluids and foods (sardines, organ meats,
legumes, alcohol, caffeine-containing beverages).
Critical values: Notify the physician immediately if levels are greater than 12 mg/dL.

LIPIDS
Lipids are carbon- and hydrogen-containing
compounds that are insoluble in water but soluble in
organic solvents. Biologically important categories
of lipids are the neutral fats (e.g., triglycerides), the
conjugated lipids (e.g., phospholipids), and the
sterols (e.g., cholesterol). Lipids function in the body
as sources of energy for various metabolic processes.
Other functions include contributing to the formation of cell membranes, bile acids, and various
hormones.
Lipids are derived from both dietary sources and
internal body processes. Almost the entire fat
portion of the diet consists of triglycerides, which
are combinations of three fatty acids and one glycerol molecule. Triglycerides are found in foods of
both animal and plant origin. The usual diet also
includes small quantities of phospholipids, cholesterol, and cholesterol esters. Phospholipids and
cholesterol esters contain fatty acids. In contrast,
cholesterol does not contain fatty acids, but its sterol
nucleus is synthesized from their degradation products. Because cholesterol has many of the physical
and chemical properties of other lipids, it is included
as a dietary fat. Note that cholesterol occurs only in
foods of animal origin, including eggs and cheese.

126

SECTION I—Laboratory

Tests

TABLE 5–9

•

Causes of Altered Uric Acid Levels

Increased Levels

Decreased Levels

Excessive dietary purines

Fanconi’s syndrome

Polycythemia

Wilson’s disease

Gout

Yellow atrophy of the liver

Psoriasis

Drugs

Type III hyperlipidemia

Probenecid

Chemotherapy, radiation therapy for malignancies

Sulfinpyrazone

von Gierke’s disease

Aspirin (4 g/day)

Sickle cell anemia

Adrenocorticotropic hormone,
corticosteroids

Pernicious anemia

Coumarin

Acute tissue destruction (infection, starvation, exercise)

Estrogens

Eclampsia, hypertension

Allopurinol

Hyperparathyroidism

Acetohexamide (Dymelor)

Decreased excretion from lactic acidosis, ketoacidosis, renal
failure, congestive heart failure

Azathioprine (Imuran)

Drugs

Clofibrate

Alcohol

2-Phenylcinchoninic acid (Cinchophen)

Aspirin (2 g/day)

Chlorprothixene (Taractan)

Thiazide diuretics

Mannitol

Diazoxide (Hyperstat)

Marijuana

Epinephrine
Ethacrynic acid (Edecrin)
Furosemide
Phenothiazines
Dextran
Methyldopa
Ascorbic acid
Aminophylline
Antibiotics (gentamicin)
Griseofulvin
Rifampin
Triamterene (Dyrenium)

Nearly all dietary fats are absorbed into the
lymph. Ingested triglycerides are emulsified by bile
and then broken down into fatty acids and glycerol
by pancreatic and enteric lipases. The fatty acids and
glycerol then pass through the intestinal mucosa and
are resynthesized into triglycerides that aggregate
and enter the lymph as minute droplets called

chylomicrons. Although chylomicrons are
composed primarily of triglycerides, cholesterol and
phospholipids absorbed from the gastrointestinal
tract also contribute to their composition (Table
5–10).
In addition to dietary sources of lipids, the body
itself is able to produce various fats. Unused glucose

CHAPTER 5—Blood

TABLE 5–10
Triglyceride
%

•

Chemistry

127

Lipoprotein Composition

Cholesterol Phospholipid
%
%

Protein
%

Electrophoretic
Mobility

Chylomicrons

85–95

3–5

5–10

1–2

Remain at origin

Very-low-density
lipoproteins

60–70

10–15

2-Lipoprotein, pre--lipoprotein

Low-density
lipoproteins

5–10

20–30

15–25

-Lipoprotein

High-density
lipoproteins

Very little

1-Lipoprotein

From Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA Davis,
Philadelphia, 2000, p. 473, with permission.

and amino acids, for example, may be converted into
fatty acids by the liver. Similarly, nearly all body cells
are capable of forming phospholipids and cholesterol, although most of the endogenous production
of these lipids occurs in the liver or intestinal
mucosa.
Because lipids are insoluble in water, special
transport mechanisms are required for circulation in
the blood. Free fatty acids travel through blood
combined with albumin and in this form are called
nonesterified fatty acids. Very little free fatty acid is
normally present in the blood; therefore, the major
lipid components found in serum are triglycerides,
cholesterol, and phospholipids. These lipids exist in
blood as macromolecules complexed with specialized proteins (apoproteins) to form lipoproteins.
Lipoproteins are classified according to their
density, which results from the amounts of the various lipids they contain (see Table 5–10). The least
dense lipoproteins are those with the highest triglyceride levels. Lipoprotein densities also are reflected
in the electrophoretic mobility of the various types.
As with the formation of other endogenous lipids,
most lipoproteins are formed in the liver.22,23

FREE FATTY ACIDS
Free fatty acids (FFA) travel through the blood
combined with albumin and in this form are called
nonesterified fatty acids (NEFA). Normally, approximately three fatty acid molecules are combined with
each molecule of albumin. If, however, the need for
fatty acid transport is great (e.g., when needed
carbohydrates are not available or cannot be used for
energy), as many as 30 fatty acids can combine with
one albumin molecule. Thus, although blood levels
of FFA are never very high, they rise impressively
after stimuli to release fat. The same stimuli that
elevate FFA will, in most cases, also elevate serum
triglycerides and may produce alterations in
lipoprotein levels. Specific causes of both elevated

and decreased FFA, including drugs, are listed in
Table 5–11.
Reference Values
Conventional Units
Free fatty
acids

8–25 mg/dL

SI Units

0.30–0.90 mmol/L

INTERFERING FACTORS

Ingestion of alcohol within 24 hours before the
test may result in falsely elevated values.
Failure to follow dietary restrictions before the
test may alter values.
Drugs known to alter FFA levels should not be
ingested unless the test is being performed to evaluate such effects (see Table 5–11).
INDICATIONS FOR FREE FATTY ACIDS TEST

Support for diagnosing uncontrolled or untreated
diabetes mellitus, as indicated by elevated levels
Evaluation of response to treatment for diabetes,
as indicated by declining levels
Suspected malnutrition, as indicated by elevated
levels
Known or suspected disorder associated with
excessive hormone production (see Table 5–11),
as indicated by elevated levels
Evaluation of response to therapy with drugs
known to alter FFA levels (see Table 5–11)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
The client should abstain from alcohol for 24
hours and from food for at least 8 hours before
the test.
Water is not restricted.

128

SECTION I—Laboratory

Tests

•

Factors Associated
with Altered Free Fatty
Acid Levels

TABLE 5–11

Increased Levels

Decreased Levels

Diabetes mellitus

Drugs

Starvation

Aspirin

Pheochromocytoma

Clofibrate

Acute alcohol intoxication

Glucose

Chronic hepatitis

Insulin

Acute renal failure

Neomycin

Glycogen storage disease

Streptozocin

Hypoglycemia
Hypothermia
Hormones
Adrenocorticotropic hormone
Cortisone
Epinephrine, norepinephrine
Growth hormone
Thyroid-stimulating hormone
Thyroxine
Drugs

Abnormal values: Note and report any increased
level. Assess in relation to glucose and ketone and
to lipid and lipoprotein electrophoresis levels.
Assess for recent weight gain or loss. Instruct in
appropriate fat and carbohydrate intake in the
diet.

TRIGLYCERIDES
Triglycerides, which are combinations of three fatty
acids and one glycerol molecule, are used in the body
to provide energy for various metabolic processes,
with excess amounts stored in adipose tissue. Fatty
acids readily enter and leave the triglycerides of
adipose tissue, providing raw materials needed for
conversion to glucose (gluconeogenesis) or for
direct combustion as an energy source. Although
fatty acids originate in the diet, many also derive
from unused glucose and amino acids that the liver
and, to a smaller extent, the adipose tissue convert
into storage energy.
Altered triglyceride levels are associated with a
variety of disorders and also are affected by
hormones and certain drugs, including alcohol
(Table 5–12). Diets high in calories, fats, or carbohydrates will elevate serum triglyceride levels, which is
considered a risk factor for atherosclerotic cardiovascular disease.
Reference Values

Amphetamines
Caffeine

Conventional Units

SI Units

Chlorpromazine

2 yr

5–40 mg/dL

0.06–0.45 mmol/L

Isoproterenol

2–20 yr

10–140 mg/dL

0.11–1.58 mmol/L

Nicotine

20–40 yr
Men

10–140 mg/dL

0.11–1.58 mmol/L

Women

10–150 mg/dL

0.11–1.68 mmol/L

Men

10–180 mg/dL

0.11–2.01 mmol/L

Women

10–190 mg/dL

0.11–2.21 mmol/L

Reserpine
Tolbutamide

40–60 yr
Drugs known to affect FFA levels (see Table 5–11)
may be withheld before the test, although this may
not always be done if the therapeutic effect on
FFA levels is being evaluated.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent immediately to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods and any drugs withheld before
the test.

Note: Values for serum triglycerides may vary according to
the laboratory performing the test. In addition, values
have been found to vary in relation to race, income level,
level of physical activity, dietary habits, and geographic
location as well as in relation to age and gender, as shown
here.
INTERFERING FACTORS

Failure to follow the usual diet for 2 weeks before
the test may yield results that do not accurately
reflect client status.
Ingestion of alcohol 24 hours before and food 12
hours before the test may falsely elevate levels.

CHAPTER 5—Blood

TABLE 5–12

•

Chemistry

129

Disorders and Drugs Associated with Altered
Triglyceride Levels

Elevated Levels

Decreased Levels
DISORDERS

Primary hyperlipoproteinemia

Acanthocytosis

Atherosclerosis

Cirrhosis

Hypertension

Inadequate dietary protein

Myocardial infarction

Hyperthyroidism

Diabetes mellitus

Hyperparathyroidism

Obstructive jaundice
Hypothyroidism (primary)
Hypoparathyroidism
Nephrotic syndrome
Chronic obstructive pulmonary disease
Down syndrome
von Gierke’s disease
DRUGS

Alcohol

Clofibrate

Cholestyramine

Dextrothyroxine

Corticosteroids

Heparin

Colestipol

Menotropins (Pergonal)

Oral contraceptives

Sulfonylureas

Thyroid preparations

Norethindrone

Estrogen

Androgens

Furosemide

Niacin

Miconazole

Anabolic steroids
Ascorbic acid

Drugs known to alter triglyceride levels should
not be ingested within 24 hours before the test
unless the test is being conducted to evaluate such
effects (see Table 5–12).
INDICATIONS FOR SERUM TRIGLYCERIDES TEST

As a component of a complete physical examination, especially for individuals over age 40 years
or who are obese, or both, to estimate the
degree of risk for atherosclerotic cardiovascular
disease
Family history of hyperlipoproteinemia (hyperlipidemia)
Known or suspected disorders associated with
altered triglyceride levels (see Table 5–12)

Monitoring of response to drugs known to alter
triglyceride levels or lipid-lowering agents
NURSING CARE BEFORE THE PROCEDURE

130

SECTION I—Laboratory

Tests

the test, although this practice should be
confirmed with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent promptly to the laboratory.

INTERFERING FACTORS

Ingestion of alcohol 24 hours before and food 12
hours before the test may falsely elevate levels.
Ingestion of drugs known to alter cholesterol
levels within 12 hours of the test may alter results,
unless the test is being conducted to evaluate such
effects (see Table 5–13).

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods and any drugs withheld before the
test.
Abnormal values: Note and report increased
level. Assess in relation to cholesterol and lipoprotein electrophoresis. Instruct in low-fat diet and
weight reduction caloric intake as appropriate.

TOTAL CHOLESTEROL
Cholesterol is necessary for the formation of cell
membranes and is a component of the materials that
render the skin waterproof. Cholesterol also
contributes to the formation of bile salts, adrenocorticosteroids, estrogens, and androgens.
Cholesterol has two sources: (1) that obtained
from the diet (exogenous cholesterol) and (2) that
which is synthesized in the body (endogenous
cholesterol). Although most body cells can form
some cholesterol, most is produced by the liver and
the intestinal mucosa. Because cholesterol is continuously synthesized, degraded, and recycled, it is
probable that very little dietary cholesterol enters
directly into metabolic reactions. Altered cholesterol
levels are associated with a variety of disorders and
also are affected by hormones and certain drugs
(Table 5–13).
Reference Values

INDICATIONS FOR TOTAL CHOLESTEROL TEST

As a component of a complete physical examination, especially for individuals over age 40 years or
those who are obese, or both, to estimate the
degree of risk for atherosclerotic cardiovascular
disease:
In general, the desirable blood cholesterol level
is less than 200 mg/dL.
Cholesterol levels of 200 to 240 mg/dL are
considered borderline, and the person is
considered at high risk if other factors such as
obesity and smoking are present; for the latter
individuals, additional tests such as lipoprotein
and cholesterol fractionation should be
performed.
Cholesterol levels of greater than 250 mg/dL
place the person at definite high risk for cardiovascular disease and require treatment; additional tests such as lipoprotein and cholesterol
fractionation should be performed.
Family history of hypercholesterolemia or cardiovascular disease or both
Known or suspected disorders associated with
altered cholesterol levels (see Table 5–13)
Monitoring of response to dietary treatment of
hypercholesterolemia and support for decisions
regarding need for drug therapy (Cholesterol
levels may fall with diet modification alone over a
period of 6 months, only to return gradually to
previous levels.)
Monitoring for response to drugs known to alter
cholesterol levels (see Table 5–13) or lipid-lowering agents

Conventional Units

SI Units

25 yr

125–200 mg/dL

3.27–5.20 mmol/L

NURSING CARE BEFORE THE PROCEDURE

25–40 yr

140–225 mg/dL

3.69–5.85 mmol/L

40–50 yr

160–245 mg/dL

4.37–6.35 mmol/L

50–65 yr

170–265 mg/dL

4.71–6.85 mmol/L

65 yr

175–265 mg/dL

4.71–6.85 mmol/L

General client preparation is the same as that for any
procedure involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should abstain from alcohol for 24 hours and from food for 12 hours
before the study.
Water is not restricted.
It also is recommended that drugs that may alter
cholesterol levels be withheld for 12 hours before
the test, although this practice should be
confirmed with the person ordering the study.

Note: Values for total cholesterol may vary according to the
laboratory performing the test. In addition, values have
been found to vary according to gender, race, income
level, level of physical activity, dietary habits, and
geographic location as well as in relation to age, as shown
here.

CHAPTER 5—Blood

TABLE 5–13

•

Chemistry

131

Disorders and Drugs Associated with Altered
Cholesterol Levels

Elevated Levels

Decreased Levels
DISORDERS

Familial hyperlipoproteinemia

Malabsorption syndromes

Atherosclerosis

Liver disease

Hypertension

Hyperthyroidism

Myocardial infarction

Cushing’s syndrome

Obstructive jaundice

Pernicious anemia

Hypothyroidism (primary)

Carcinomatosis

Nephrosis
Xanthomatosis
Pregnancy
Oophorectomy
DRUGS

Adrenocorticotropic hormone

Antidiabetic agents

Androgens

Cholestyramine

Bile salts

Clofibrate

Catecholamines

Colchicine

Corticosteroids

Colestipol

Oral contraceptives

Dextrothyroxine

Phenothiazines

Estrogen

Salicylates

Glucagon

Thiouracils

Haloperidol (Haldol)

Vitamins A and D (excessive)

Heparin
Kanamycin
Neomycin
Nitrates, nitrites
Para-aminosalicylate
Phenytoin (Dilantin)

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Resume food and any drugs withheld before the
test.

PHOSPHOLIPIDS
Phospholipids consist of one or more fatty acid
molecules and one phosphoric acid radical, and they
usually have a nitrogenous base. The three major
types of body phospholipids are the lecithins, the

132

SECTION I—Laboratory

Tests

cephalins, and the sphingomyelins. In addition to
diet as a source of phospholipids, nearly all body
cells are capable of forming these lipids. Most
endogenous phospholipids are formed, however, in
the liver and intestinal mucosa. The phospholipids
are transported together in circulating blood in the
form of lipoproteins.
Phospholipids are important for the formation of
cell membranes and for the transportation of fatty
acids through the intestinal mucosa into lymph.
Phospholipids also serve as donors of phosphate
groups for intracellular metabolic processes and may
act as carriers in active transport systems. Saturated
lecithins are essential for pulmonary gas exchange,
whereas the cephalins are major constituents of
thromboplastin, which is necessary to initiate the
clotting process. Sphingomyelin is present in large
quantities in the nervous system and acts as an insulator around nerve fibers.24
Phospholipids may be measured as part of an
overall lipid evaluation, but the significance of
altered levels is not completely understood. A direct
relationship between elevated phospholipids and
atherosclerotic cardiovascular disease has not been
demonstrated.
Alterations in phospholipid levels may be seen in
situations similar to those in which serum triglycerides and cholesterol also are abnormal. For example, elevated levels are associated with diabetes
mellitus, nephrotic syndrome, chronic pancreatitis,
obstructive jaundice, and early starvation. Decreased
levels are seen in clients with primary hypolipoproteinemia, severe malnutrition and malabsorption
syndromes, and cirrhosis. Antilipemic drugs (e.g.,
clofibrate) may lower phospholipid levels, and
epinephrine, estrogens, and chlorpromazine tend to
elevate them.
Another clinical application of phospholipid data
is the use of the lecithin:sphingomyelin (L:S) ratio in
estimating fetal lung maturity, with adequate lung
maturity indicated by lecithin levels greater than
those for sphingomyelin by a ratio of 2:1 or greater
(see Chapter 10).
Reference Values
Conventional Units

SI Units

Infants

100–275 mg/dL

1.00–2.75 g/L

Children

180–295 mg/dL

1.80–2.95 g/L

Adults

150–380 mg/dL

1.50–3.80 g/L

Note: Values may vary, depending on the laboratory
performing the test and the age of the client.

INTERFERING FACTORS

Ingestion of alcohol 24 hours before and food
12 hours before the test may falsely elevate
levels.
Ingestion of drugs known to alter phospholipid
levels within 12 hours before the test may alter
results unless the test is being conducted to evaluate such effects.
Antilipemic drugs (e.g., clofibrate) may lower
phospholipid levels.
Epinephrine, estrogens, and chlorpromazine tend
to elevate phospholipid levels.
INDICATIONS FOR SERUM PHOSPHOLIPIDS TEST

Known or suspected disorders that cause or are
associated with altered lipid metabolism:
Altered phospholipid levels are seen in situations similar to those in which serum triglycerides and cholesterol also are altered (see
Tables 5–12 and 5–13).
Elevated levels are associated with diabetes
mellitus, nephrotic syndrome, chronic pancreatitis, obstructive jaundice, and early starvation.
Decreased levels are seen in primary
hypolipoproteinemia, severe malnutrition,
malabsorption syndromes, and cirrhosis.
Support for identifying problems related to fat
metabolism and transport:
Phospholipid formation parallels deposition
of triglycerides in the liver, and severely
decreased levels result in low levels of lipoproteins that are essential for fat transport.
Abnormal bleeding of unknown origin, with
decreased cephalin (a type of phospholipid), a
possible contributor to low levels of thromboplastin
Suspected neurological disorder, which may be
associated with decreased levels of sphingomyelin
(a type of phospholipid)
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
procedure involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should abstain from alcohol for 24 hours and from food for 12 hours
before the study.
Water is not restricted.
It also is recommended that drugs that may
alter phospholipid levels be withheld for 12
hours before the test, although this practice
should be confirmed with the person ordering
the study.

CHAPTER 5—Blood

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods and any drugs withheld before the
test.

LIPOPROTEIN AND CHOLESTEROL
FRACTIONATION
Lipids are transported in the blood as lipoproteins—
complex molecules consisting of triglycerides,
cholesterol, phospholipids, and proteins. Lipoproteins exist in several forms that reflect the different concentrations of their constituents. These
forms, or fractions, are classified according to either
their densities or their electrophoretic mobility.
The lipoprotein fractions in relation to density are
(1) chylomicrons, (2) very-low-density lipoproteins
(VLDL), (3) low-density lipoproteins (LDL), and (4)
high-density lipoproteins (HDL). The least dense
lipoproteins—chylomicrons and VLDL—contain
the highest levels of triglycerides and lower amounts
of cholesterol and protein. LDL and HDL contain

Chemistry

133

the lowest amounts of triglycerides and relatively
higher amounts of cholesterol and protein (see Table
5–10).
Lipoprotein densities correspond to the electrophoretic mobility patterns of the several lipoprotein fractions. The two main fractions of
lipoproteins, as identified by electrophoresis, are
and . -Lipoproteins, which approximate the HDL
(1), migrate with the -globulins. The -lipoproteins, which reflect the VLDL (pre-) and the LDL
(), migrate with the -globulins. Chylomicrons
remain at the origin.
The cholesterol content of the HDL and LDL
fractions also can be determined by measuring total
cholesterol remaining after one fraction has been
removed. Note, however, that HDL cholesterol does
not correlate well with the total cholesterol concentration, is higher in women than in men, and tends
to be inversely proportional to triglyceride levels.
High HDL cholesterol and low LDL cholesterol
levels are predictive of a reduced risk of cardiovascular disease, whereas high LDL cholesterol and low
HDL cholesterol levels are considered risk factors for
atherosclerotic cardiovascular disease. Further, many
health-care providers believe that an adequate lipid
assessment need include only (1) total cholesterol,
(2) HDL cholesterol, (3) serum triglycerides, and (4)
estimate of chylomicron concentration.
Specific conditions associated with altered levels
of lipoprotein fractions are listed in Table 5–14.

Reference Values
Conventional Units

SI Units

Total lipoproteins

400–800 mg/dL

—

Chylomicrons

—

VLDL or pre-

3–32 mg/dL

—

LDL or

38–40 mg/dL

0.98–1.04 mmol/L

HDL or 1

20–48 mg/dL

0.51–1.24 mmol/L

LDL Cholesterol
Age

HDL Cholesterol

Conventional Units

SI Units

Conventional Units

SI Units

25 yr

73–138 mg/dL

1.87–3.53 mmol/L

32–57 mg/dL

0.82–1.46 mmol/L

25–40 yr

90–180 mg/dL

2.30–4.60 mmol/L

32–60 mg/dL

0.82–1.54 mmol/L

40–50 yr

100–185 mg/dL

2.56–4.74 mmol/L

33–60 mg/dL

0.84–1.54 mmol/L

50–65 yr

105–190 mg/dL

2.69–4.96 mmol/L

34–70 mg/dL

0.87–1.79 mmol/L

65 yr

105–200 mg/dL

2.69–5.12 mmol/L

35–75 mg/dL

0.90–1.92 mmol/L

Note: HDL cholesterol values are normally lower in men than in women, with an average range of 22 to 68 mg/dL.

134

SECTION I—Laboratory

TABLE 5–14

•

Lipoprotein
Chylomicrons

Tests

Conditions Associated with Altered Levels of Lipoprotein
Fractions
Increased Level

Decreased Level

Ingested fat

Not applicable—normal value is zero

Ingested alcohol
Types I and V hyperlipoproteinemia
VLDL

Ingested fat

Abetalipoproteinemia

Ingested carbohydrate

Cirrhosis

Ingested alcohol

Hypobetalipoproteinemia

All types of hyperlipoproteinemia
Exogenous estrogens
Diabetes mellitus
Hypothyroidism (primary)
Nephrotic syndrome
Alcoholism
Pancreatitis
Pregnancy
LDL cholesterol

Ingested cholesterol

Types I and V hyperlipoproteinemia

Ingested saturated fatty acids

Hypobetalipoproteinemia

Types II and III hyperlipoproteinemia

Abetalipoproteinemia

Hypothyroidism (primary)

Hyperthyroidism

Biliary obstruction

Cirrhosis

Nephrotic syndrome
HDL cholesterol

Ingested alcohol (moderate amounts)

All types of hyperlipoproteinemia

Chronic hepatitis

Exogenous estrogens

Hypothyroidism (primary)

Hyperthyroidism

Early biliary cirrhosis

Cirrhosis

Biliary obstruction

Tangier disease

INTERFERING FACTORS

Failure to follow usual diet for 2 weeks before the
test may yield results that do not accurately reflect
client status.
Ingestion of alcohol 24 hours before and food 12
hours before the test may alter results.
Excessive exercise 12 hours before the test may
alter results (regular exercise has been found to
lower HDL cholesterol levels).
Numerous drugs may alter results, including
those that are known to alter lipoprotein components (see Tables 5–12 and 5–13).

INDICATIONS FOR LIPOPROTEIN AND
CHOLESTEROL FRACTIONATION

Serum cholesterol levels of greater than 250
mg/dL, which indicate high risk for cardiovascular disease and the need for further evaluation and
possible treatment
Estimation of the degree of risk for cardiovascular
disease:
Individuals with LDL cholesterol levels greater
than 160 mg/dL are considered to be at high
risk.
Individuals at or above the upper reference

CHAPTER 5—Blood

range for HDL cholesterol have half the average
risk, whereas those at or near the bottom have
two, three, or more times the average risk.
Known or suspected disorders associated with
altered lipoprotein levels (see Table 5–14)
Evaluation of response to treatment for altered
levels and support for decisions regarding the
need for drug therapy (LDL cholesterol levels may
decrease with dietary modification alone; if not,
drug treatment is recommended.)
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
procedure involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should ingest a normal
diet, such that no weight gain or loss will occur for
2 weeks before the study, and should abstain from
alcohol for 24 hours and from food for 12 hours
before the test.
Water is not restricted.
The client also should avoid excessive exercise for
at least 12 hours before the test.
It also is recommended that drugs that may alter
lipoprotein components be withheld for 24 to 48
hours before the test (see Tables 5–12 and 5–13),
although this practice should be confirmed with
the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume food and any drugs withheld before the
test, as well as usual activities.
Abnormal values: Note and report increased or
decreased levels indicating atherosclerosis and
high risk for heart disease. Administer ordered
medications. Provide information about a lowfat, low-cholesterol, and low-calorie diet, if
needed.

LIPOPROTEIN PHENOTYPING
Lipoprotein phenotyping is an extension of the
information obtained through lipoprotein fractionation and provides another approach to correlating
laboratory findings with disease.
Six different lipoprotein distribution patterns
(phenotypes) are seen in serums with high levels of

Chemistry

135

cholesterol or triglycerides or both. These phenotypes, which are referred to by their assigned
numbers, have been correlated with genetically
determined abnormalities (familial or primary
hyperlipoproteinemias) and with a variety of
acquired conditions (secondary hyperlipoproteinemias).
Phenotype descriptions have proved useful in
classifying diagnoses and in evaluating treatment
and preventive regimens. Most hyperlipemic serums
can be categorized into lipoprotein phenotypes
without performing electrophoresis if the following
are known: (1) chylomicron status, (2) serum
triglyceride level, (3) total cholesterol, and (4) HDL
cholesterol.
Table 5–15 shows the clinical significance of each
of the lipoprotein phenotypes as primary familial
syndromes and as secondary occurrences caused by
disorders that alter lipid metabolism.
INTERFERING FACTORS

Failure to follow usual diet for 2 weeks before the
test may yield results that do not accurately reflect
client status.
Ingestion of alcohol 24 hours before and food 12
hours before the test may alter results.
Excessive exercise 12 hours before the test may
alter results.
Numerous drugs, including those that are known
to alter lipoprotein components (see Tables 5–12,
5–13, and 5–15) may alter results.
INDICATIONS FOR LIPOPROTEIN PHENOTYPING

Further evaluation of elevated serum cholesterol
levels and results of lipoprotein and cholesterol
fractionation
Family history of primary hyperlipoproteinemia
(hyperlipidemia)
Identification of the client’s specific lipoprotein
phenotype
Known or suspected disorders associated with the
several lipoprotein phenotypes (see Table 5–15)
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should ingest a normal
diet, so that no weight gain or loss will occur for 2
weeks before the study, and should abstain from
alcohol for 24 hours and from food for 12 hours
before the test.
Water is not restricted.
The client also should avoid excessive exercise for
at least 12 hours before the test.

136

SECTION I—Laboratory

TABLE 5–15
Phenotype
I

•

Tests

Clinicopathological Significance of Lipoprotein Phenotypes
May Occur
Secondary to

Familial Syndrome
Abdominal pain

Insulin-dependent diabetes

Eruptive xanthomas

Lupus erythematosus

Lipemia retinalis

Dysglobulinemias

Early vascular disease absent

Pancreatitis

Early, severe vascular disease

High-cholesterol diet

Prominent xanthomas

Nephrotic syndrome
Porphyria

Remarks
Lipoprotein lipase is
deficient.

Familial trait is autosomal
dominant; homozygotes
are especially severely
affected.

Hypothyroidism
Dysglobulinemias
Obstructive liver diseases
III

Accelerated vascular disease,
onset in adulthood

Hypothyroidism

Xanthomas, palmar yellowing

Dysglobulinemias

Abnormal glucose tolerance

Uncontrolled diabetes

Diet, lipid-lowering drugs
are very effective.

Hyperuricemia
IV

Accelerated vascular disease,
onset in adulthood

Obesity

Weight loss lowers VLDL.

Abnormal glucose tolerance

High alcohol intake

High-fat diet may convert
to type V.

Hyperuricemia

Oral contraceptives
Diabetes
Nephrotic syndrome
Glycogen storage disease

Abdominal pain

High alcohol intake

Pancreatitis

Diabetes

Eruptive xanthomas

Nephrotic syndrome

Abnormal glucose tolerance

Pancreatitis

Vascular disease not associated

Hypercalcemia

Weight loss does not
lower VLDL.

From Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA Davis,
Philadelphia, 2000, p. 477, with permission.

It also is recommended that drugs that may alter
lipoprotein components be withheld for 24 to
48 hours or longer before the test (see Tables
5–12, 5–13, and 5–15), although this practice
should be confirmed with the person ordering the
study.
THE PROCEDURE

A venipuncture is performed and the sample

collected in either a red- or lavender-topped tube,
depending on the laboratory’s procedure for determining lipoprotein phenotypes. The sample should
be sent to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

CHAPTER 5—Blood

Chemistry

137

Reference Values
Phenotype
I

IIa

IIb

III

Frequency

Very
rare

Common

Uncommon

Very
common

Rare

Chylomicrons

↑↑↑

Normal

Normal or ↑

Normal

↑↑

Pre--lipoproteins
(approximates
VLDL)

↑

↑↑

↑

(these two
bands merge)

↑↑↑

↑↑

-Lipoproteins
(approximates
LDL)

↓

↑↑

Normal
or ↑

Normal
or ↓

1-Lipoproteins
(approximates
HDL)

↓

Normal

Normal
or ↓

Total cholesterol

Normal
or ↑

↑↑

Normal
or ↑

↑↑

Total triglycerides

↑↑↑

Normal

↑

↑↑ or ↑↑↑

↑↑↑

Refrigerated serum
or plasma

“Cream”/
clear or
turbid

Clear

or
turbid

turbid

“Cream”/
turbid

From Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 476, with permission.

Resume food and any drugs withheld before the
test, as well as usual activities.

BILIRUBIN
Bilirubin is a degradation product of the pigmented
heme portion of hemoglobin. Old, damaged, and
abnormal erythrocytes are removed from the circulation by the spleen and to some extent by the liver
and bone marrow. The heme component of the red
blood cells is oxidized to bilirubin by the reticuloendothelial cells and released into the blood.
In the blood, the fat-soluble bilirubin binds to
albumin as unconjugated (prehepatic) bilirubin for
transport to the liver. In the liver, hepatocytes detach
bilirubin from albumin and conjugate it with
glucuronic acid, which renders the bilirubin water
soluble. Most of the conjugated (posthepatic) bilirubin is excreted into the hepatic ducts and then into
bile. Only small amounts of conjugated bilirubin
diffuse from the liver back into the blood. Thus,
most circulating bilirubin is normally in the unconjugated form.

Bilirubin is an excretory product that serves no
physiological function in bile or blood. Once the
conjugated bilirubin in bile enters the intestine,
most is converted to a series of urobilinogen
compounds and excreted into the stool as stercobilinogen after oxidation. A lesser amount is recycled
to the liver and either returned to bile or excreted in
urine as urobilinogen, which is oxidized to urobilin.
Bilirubin and its degradation products are
pigments and provide the yellow tinge in normal
serum, the yellow-green hue in bile, the brown in
stools, and the yellow in urine. Abnormally elevated
serum bilirubin levels produce jaundice; obstruction
to biliary excretion of bilirubin may produce lightcolored stools and dark urine.
The terms indirect and direct, which are used to
describe unconjugated (prehepatic) and conjugated
(posthepatic) bilirubin, respectively, derive from the
methods of testing for their presence in serum.
Conjugated bilirubin is described as direct (direct
reacting) because it is water soluble and can be
measured without modification. Unconjugated
bilirubin must be rendered soluble with alcohol or

138

SECTION I—Laboratory

TABLE 5–16

•

Tests

Causes of Elevations in Indirect and Direct Bilirubin Levels

Increased Indirect (Unconjugated) Bilirubin

Increased Direct (Conjugated) Bilirubin

Hemolysis: hemoglobinopathies, spherocytosis,
G-6-PD deficiency, autoimmunity, transfusion
reaction

Intrahepatic disruption: viral hepatitis, alcoholic
hepatitis, chlorpromazine, cirrhosis

Red blood cell degradation: hemorrhage into soft
tissues or body cavities, inefficient erythropoiesis, pernicious anemia

Extrahepatic bile duct obstruction: gallstones;
carcinoma of gallbladder, bile ducts, or head of
pancreas; bile duct stricture from inflammation
or surgical misadventure

Bile duct disease: biliary cirrhosis, cholangitis (idiopathic, infectious), biliary atresiaa

Defective hepatocellular uptake or conjugation:
viral hepatitis, hereditary enzyme deficiencies
(Gilbert, Crigler-Najjar syndromes), hepatic
immaturity in newborns

other solvents before the test can be performed and
is thus referred to as indirect (indirect reacting).
Impaired liver function causes dramatic increases
in serum bilirubin levels (hyperbilirubinemia).
Bilirubin must be in the conjugated form for normal
excretion via bile, stools, and urine. When the liver is
unable to conjugate bilirubin adequately, serum
levels of unconjugated bilirubin rise. Disorders in
which excessive hemolysis of red blood cells is
combined with impaired liver function also produce
hyperbilirubinemia. An example is physiological
jaundice of the newborn, in which the increased
destruction of red blood cells, common after birth, is
combined with the immature liver’s inability to
conjugate sufficient bilirubin. Kernicterus, a complication of newborn hyperbilirubinemia, occurs when
unconjugated bilirubin is deposited in brain tissue.
Impaired excretion of conjugated (posthepatic,
direct) bilirubin from the liver into the bile ducts or
from the biliary tract itself causes this form of bilirubin to be reabsorbed from the liver into the blood,

with resultant elevated serum levels. Because conjugated bilirubin is water soluble and readily crosses
the renal glomerulus, excessive amounts may be
excreted in the urine. The stools, however, are lighter
in color because of diminished amounts of conjugated bilirubin in the gut.
Serum bilirubin levels are measured as total
bilirubin, indirect bilirubin, and direct bilirubin.
Total bilirubin reflects the combination of unconjugated and conjugated bilirubin in the serum and can
be used to screen clients for possible disorders
involving bilirubin production and excretion. If total
bilirubin is normal, the levels of indirect (unconjugated) and direct (conjugated) bilirubin also are
assumed to be normal in most cases.
When total bilirubin levels are elevated, indirect
and direct bilirubin levels are measured to determine the source of the overall elevation. Specific
causes of elevations in indirect and direct bilirubin
are shown in Table 5–16. Numerous drugs also may
alter bilirubin levels.

Reference Values
Conventional Units

SI Units

Total bilirubin
Newborns

2.0–6.0 mg/dL

34.0–102.0 mol/L

48 hr

6.0–7.0 mg/dL

102.0–120.0 mol/L

5 day

4.0–12.0 mg/dL

68.0–205.0 mol/L

1 mo–adults

0.3–1.2 mg/dL

5.0–20.0 mol/L

Indirect bilirubin (unconjugated, prehepatic)
1 mo–adults

0.3–1.1 mg/dL

5.0–19.0 mol/L

0.1–0.4 mg/dL

1.7–6.8 mol/L

Direct bilirubin
1 mo–adults

CHAPTER 5—Blood

INTERFERING FACTORS

Prolonged exposure of the client, as well as of the
blood sample, to sunlight and ultraviolet light
reduces serum bilirubin levels.
Failure of the client to follow dietary restrictions
before the test.
Fasting normally lowers indirect bilirubin levels.
In Gilbert’s syndrome, a congenital defect in
bilirubin degradation, chronically elevated levels
of indirect bilirubin increase dramatically in the
fasting state.
Numerous drugs may elevate bilirubin levels (e.g.,
steroids, sulfonamides, sulfonylureas, barbiturates, antineoplastic agents, propylthiouracil,
allopurinol, antibiotics, gallbladder dyes, caffeine,
theophylline, indomethacin, and any drugs that
are considered hepatotoxic); it is recommended
that such drugs be withheld for 24 hours before
the test, if possible.
INDICATIONS FOR BILIRUBIN TEST

Known or suspected hemolytic disorders, including transfusion reactions, as indicated by elevated
total and indirect bilirubin levels (see also Table
5–16):
Hemolysis alone rarely causes indirect bilirubin
levels higher than 4 or 5 mg/dL.
If hemolysis is combined with impaired or
immature liver function, levels may rise more
dramatically.
Confirmation of observed jaundice:
Jaundice manifests when serum levels of indirect or direct bilirubin reach 2 to 4 mg/dL.
Determination of the cause of jaundice (e.g., liver
dysfunction, hepatitis, biliary obstruction, carcinoma)
Support for diagnosing liver dysfunction as
evidenced by elevated direct and total bilirubin
levels or by elevation of all three levels if bile duct
drainage also is impaired
Support for diagnosing biliary tract obstruction
as evidenced by elevated direct and total bilirubin
levels or by elevation of all three levels if liver
function is impaired25
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
For these tests, the client should fast from foods
for at least 4 hours before the test.
Water is not restricted.
Because many drugs may alter bilirubin levels (see
section titled “Interfering Factors”), a medication
history should be obtained.

Chemistry

139

It is recommended that those drugs that may alter
test results be withheld for 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
obtained in a red-topped tube. The sample should
be handled gently to avoid hemolysis and sent
immediately to the laboratory. The sample should
not be exposed for prolonged periods to sunlight
(i.e., more than 1 hour), ultraviolet light, or fluorescent lights. In infants, a capillary sample is obtained
by heelstick.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume food and any drugs withheld before the
test.
Abnormal values: Note and report increased
levels. Assess for associated signs and symptoms
of hyperbilirubinemia such as jaundice, pruritus,
pain caused by liver disease, biliary obstruction,
or food intolerances. Administer phenobarbital if
levels are greater than 12 mg/dL in newborns,
because this can lead to central nervous system
damage. Prepare for exchange transfusion if level
is greater than 15 mg/dL.

ENZYMES
Enzymes are catalysts that enhance reactions without directly participating in them. Individual
enzymes, each of which has its own substrate and
product specificity, exist for nearly all of the metabolic reactions that maintain body functions.
Enzymes are normally intracellular molecules.
Because certain metabolic reactions occur in many
tissues, the involved enzymes exist in many cell
types. Enzymes with more restricted metabolic
functions are found in only one of several specialized cell types. The presence of enzymes in circulating blood indicates cellular changes that have
permitted their escape into extracellular fluid. The
continuous synthesis and destruction of the cells of
the enzymes’ origins, for example, allow small
amounts of enzymes to appear in the blood. Cellular
disruption caused by damage by disease, toxins, or
trauma, as well as increased cell wall permeability,
also elevates serum enzyme levels. Additional causes
of elevated enzyme levels are an increase in the
number or activity of enzyme-containing cells and
decreases in normal excretory or degradation mechanisms.

140

SECTION I—Laboratory

Tests

Decreased serum enzyme levels rarely have diagnostic significance because so few enzymes are present in substantial quantity. Enzyme levels may
decline if the number of synthesizing cells declines,
if generalized or specific restriction in protein
synthesis occurs (enzymes are proteins), or if excretion or degradation increases.
Very few enzymes are studied routinely. Although
highly specialized enzyme analysis is applied to the
study of many genetically determined diseases, most
diagnostic enzyme studies involve only those
enzymes with changing values in serum, providing
inferential or confirmatory evidence of various
pathological processes. A major goal of enzyme
analysis is to localize disease processes to specific
organs, preferably to specific functional subdivisions
or even to specific cellular activities. Enzymes
unique to a single cell type or found in only a few
sites are particularly useful in this regard. The source
of elevations of those enzymes with widespread
distribution also can be determined by partitioning
total activity into isoenzyme fractions. Isoenzymes
are different forms of a single enzyme with
immunologic, physical, or chemical characteristics
distinctive for their tissue of origin.
Efforts to standardize the study of enzymes (enzymology) have led to new terminology for naming
and measuring enzymes. The Commission on
Enzymes of the International Union of Biochemistry
(IUB) has classified enzymes according to their
biochemical functions, assigning to each a numerical designation that embodies class, subclass, and
specification number. The IUB has also assigned
descriptive names according to the specific reaction
catalyzed and, in many cases, a practical name useful
for common reference. One result of this standardization is that enzymes that have been studied for
years have been renamed according to the new
terminology. For example, the liver enzyme that was
formerly called glutamic-oxaloacetic transaminase
(GOT) is now named aspartate aminotransferase
(AST).
Another attempt to standardize enzymology is the
introduction of international units (IU) for reporting enzyme activity. One IU of an enzyme is the
amount that catalyzes transformation of 1 mol of
substrate per minute under defined conditions. The
actual amounts vary among enzymes, and the IU is
not a single universally applicable value that can be
used to compare enzymes of different characteristics.26
In this section, enzymes associated with organs
and tissues such as the liver, pancreas, bone, heart,
and muscle are discussed. Enzymes specific to red
and white blood cells are included in Chapter 1.

Alanine Aminotransferase
Alanine aminotransferase (ALT), formerly known as
glutamic-pyruvic transaminase (GPT), catalyzes the
reversible transfer of an amino group between the
amino acid, alanine, and -ketoglutamic acid.
Hepatocytes are virtually the only cells with high
ALT concentrations, although the heart, kidneys,
and skeletal muscles contain moderate amounts.
Elevated serum ALT levels are considered a sensitive index of liver damage resulting from a variety of
disorders and numerous drugs, including alcohol.
Elevations also may be seen in nonhepatic disorders
such as muscular dystrophy, extensive muscular
trauma, myocardial infarction, congestive heart
failure (CHF), and renal failure, although the
increase in ALT produced by these disorders is not as
great as that produced by conditions affecting the
liver.
This test was formerly known as the serum
glutamic-pyruvic transaminase (SGPT) test.
Reference Values
Conventional Units

SI Units

10–30 U/L

0.17–0.51 kat/L

1–36 U/L

0.02–0.61 kat/L

5–35 U/L

0.08–0.60 kat/L

5–25 U/L

0.08–0.43 kat/L

8–50 U/L

0.14–0.85 kat/L

4–36 U/L

0.07–0.61 kat/L

Note: Reference values vary among laboratories and according to the method used for reporting results.

INTERFERING FACTORS

Numerous drugs, including alcohol, may falsely
elevate levels.
INDICATIONS FOR ALANINE AMINOTRANSFERASE
TEST

Known liver disease or liver damage caused by
hepatotoxic drugs:
Markedly elevated levels (sometimes as high as
20 times normal) are considered confirmatory
of liver disease.
A sudden drop in serum ALT levels in the presence of acute illness after extreme elevation of
blood levels (e.g., as seen in severe viral or toxic
hepatitis) is an ominous sign and indicates that
so many cells have been damaged that no additional source of enzyme remains.

CHAPTER 5—Blood

Monitoring for response to treatment for liver
disease, with tissue repair indicated by gradually
declining levels
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should abstain from alcohol for at least 24 hours before the study.
Because many drugs may alter ALT levels, a
medication history should be obtained. It is
recommended that drugs that may alter test
results be withheld for 12 hours before the test,
although this practice should be confirmed with
the person ordering the study.

Chemistry

141

hours, and lactic dehydrogenase, which begins rising
12 hours or more after infarction and remains
elevated for a week or more. Elevation of AST
cannot be used as the single enzyme indicator for
myocardial infarction, because it also rises in several
other conditions included in the differential diagnosis of heart attack. Other disorders associated with
elevated AST, and the magnitude of those elevations,
are listed in Table 5–17. Note also that numerous
drugs, especially those known to be hepatotoxic or
nephrotoxic, may elevate AST levels.27
The test for AST was formerly known as serum
glutamic-oxaloacetic transaminase (SGOT).
INTERFERING FACTORS

Numerous drugs may falsely elevate levels.

THE PROCEDURE

A venipuncture is performed and the sample is
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

TABLE 5–17 • Conditions Affecting
Serum Aspartate Aminotransferase
Levels

NURSING CARE AFTER THE PROCEDURE

Pronounced Elevation (5 or more times normal)

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test.
Abnormal levels: Note and report increased
levels. Assess symptoms of liver dysfunction associated with increases such as jaundice, anorexia,
and fatigue. Relate increases to other liver function tests. Provide rest and interventions to
conserve energy. Tell client which drugs to avoid
and encourage client to eat a healthy diet.

Aspartate Aminotransferase
Aspartate aminotransferase (AST), formerly known
as glutamic-oxaloacetic transaminase (GOT),
catalyzes the reversible transfer of an amino between
the amino acid, aspartate, and -ketoglutamic acid.
ALT exists in large amounts in both liver and
myocardial cells and in smaller but significant
amounts in skeletal muscles, kidneys, pancreas, and
brain.
Serum AST rises when cellular damage occurs to
the tissues in which the enzyme is found. When
heart muscle suffers ischemic damage, serum AST
rises within 6 to 8 hours; peak values occur at 24 to
48 hours and decline to normal within 72 to 96
hours. Elevation of AST occurs midway in the time
sequence between that of creatine phosphokinase
(CPK), which rises very early and falls within 48

Acute hepatocellular damage
Myocardial infarction
Shock
Acute pancreatitis
Infectious mononucleosis
Moderate Elevation (3–5 times normal)
Biliary tract obstruction
Cardiac arrhythmias
Congestive heart failure
Liver tumors
Chronic hepatitis
Muscular dystrophy
Dermatomyositis
Slight Elevation (up to 3 times normal)
Pericarditis
Cirrhosis, fatty liver
Pulmonary infarction
Delirium tremens
Cerebrovascular accident
Hemolytic anemia
Adapted from Sacher, RA, and McPherson, RA:
Widmann’s Clinical Interpretation of Laboratory
Tests, ed 11. FA Davis, Philadelphia, 2000, p. 415,
with permission.

142

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

Newborns

16–72 U/L

0.27–1.22 kat/L

6 mo

20–43 U/L

0.34–0.73 kat/L

1 yr

16–35 U/L

0.27–0.60 kat/L

5 yr

19–28 U/L

0.32–0.48 kat/L

Men

8–46 U/L

0.14–0.78 kat/L

Women

7–34 U/L

0.12–0.58 kat/L

Adults

INDICATIONS FOR ASPARTATE AMINOTRANSFERASE
TEST

Suspected disorders or injuries involving the liver,
myocardium, kidneys, pancreas, or brain, with
elevated levels indicating cellular damage to
tissues in which AST is normally found (see Table
5–17):
In myocardial infarction, AST rises within 6 to
8 hours, peaks at 24 to 48 hours, and declines to
normal within 72 to 96 hours.
Monitoring of response to therapy with potentially hepatotoxic or nephrotoxic drugs
Monitoring of response to treatment for various
disorders in which AST may be elevated, with
tissue repair indicated by declining levels
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
Because many drugs alter AST levels, a medication
history should be obtained. It is recommended
that any drugs that may alter test results be withheld for 12 hours before the test, although this
practice should be confirmed with the person
ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample is
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test, pending test results.

Complications and precautions: Increases in this
enzyme level in relation to ALT and other assessment data may indicate a cardiac disorder.
Monitor vital signs and cardiac activity by electrocardiogram (ECG).

Alkaline Phosphatase
Phosphatases are enzymes that cleave phosphate
from compounds with a single phosphate group.
Those that are optimally active at pH 9 are grouped
under the name alkaline phosphatase (ALP).
ALP is elaborated by a number of tissues. Liver,
bone, and intestine are the major isoenzyme sources.
During pregnancy, the placenta also is an abundant
source of ALP, and certain cancers elaborate small
amounts of a distinctive form of ALP called the
Regan enzyme. Additional sources of ALP are the
proximal tubules of the kidneys, the lactating
mammary glands, and the granulocytes of circulating blood (see Chapter 1 section titled “Leukocyte
Alkaline Phosphatase”).
Bone ALP predominates in normal serum, along
with a modest amount of hepatic isoenzyme, which
is believed to derive largely from the epithelium of
the intrahepatic biliary ducts rather than from the
hepatocytes themselves. Levels of intestinal ALP
vary; most people have relatively little, but isolated
elevations of this enzyme have been observed.
Intestinal ALP enters the blood very briefly while fats
are being digested and absorbed, but intestinal
disease rarely affects serum ALP levels.
Conditions associated with elevated serum ALP
levels, and the magnitude of those elevations, are
listed in Table 5–18.28 Numerous drugs also may
elevate serum ALP levels.
Decreased levels are seen in cretinism, secondary
growth retardation, scurvy, achondroplasia, and,
rarely, hypophosphatasia.

CHAPTER 5—Blood

Chemistry

143

Reference Values
General Reference
Levels

Bessey-Lowry
Method

Bodansky
Method

King-Armstrong
Method

Newborns

50–65 U/L

—

Children

20–150 U/L

3.4–9.0 U/L

5–14 U/L

15–30 U/L

Adults

20–90 U/L

0.8–2.3 U/L

1.5–4.5 U/L

4–13 U/L

INTERFERING FACTORS

Numerous drugs, including IV albumin, may
falsely elevate levels.

•

Conditions Associated
with Elevated Serum Alkaline
Phosphatase Levels

TABLE 5–18

Pronounced Elevation (5 or more times normal)
Advanced pregnancy
Biliary obstruction
Biliary atresia
Cirrhosis
Osteitis deformans
Osteogenic sarcoma
Hyperparathyroidism (primary, or secondary to
chronic renal disease)
Paget’s disease

Clofibrate, azathioprine (Imuran), and fluorides
may falsely decrease levels.
INDICATIONS FOR SERUM ALKALINE
PHOSPHATASE TEST

Signs and symptoms of disorders associated with
elevated ALP levels (e.g., biliary obstruction,
hepatobiliary disease, bone disease including
malignant processes) (see also Table 5–18)
Differentiation of obstructive biliary disorders
from hepatocellular disease, with greater elevations of ALP seen in obstructive biliary disorders
Known renal disease to determine effects on bone
metabolism
Signs of growth retardation in children
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter ALP levels, a
medication history should be obtained.

Infusion of albumin of placental origin

THE PROCEDURE

Moderate Elevation (3–5 times normal)

Infectious mononucleosis

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Metastatic tumors in bone

NURSING CARE AFTER THE PROCEDURE

Granulomatous or infiltrative liver diseases

Metabolic bone diseases (rickets, osteomalacia)
Extrahepatic duct obstruction
Mild Elevation (up to 3 times normal)
Viral hepatitis
Chronic active hepatitis
Cirrhosis (alcoholic)
Healing fractures
Early pregnancy
Growing children
Large doses of vitamin D
Congestive heart failure

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Abnormal levels: Note and report increased
levels. Correlate with serum calcium and phosphorus, serum bilirubin, and isoenzymes to determine reason for treatments, progress, and
prognosis in diseases of the bone or liver. Assess
for jaundice and pathological fracture. If client is
pregnant, handle extremities carefully and protect
from trauma. Administer ordered vitamin D.
Provide comfort measures (soothing bath for
pruritus, pain control, support for body image
changes) to treat jaundice, if it is present. Advise
client to restrict dietary fat.

144

SECTION I—Laboratory

Tests

Alkaline Phosphatase Isoenzymes

THE PROCEDURE

If serum alkaline phosphatase (ALP) levels are
elevated but the clinical picture does not provide
enough information to determine the origin of the
excess, ALP isoenzymes are evaluated. The major
ALP isoenzymes derive from liver, bone, intestine,
and placenta.
ALP isoenzymes may be partitioned by electrophoresis or by exploitation of differences in physical properties on optimal substrates. Electrophoresis has been applied with only modest success.
Hepatic and intestinal isoenzymes are easier to
differentiate with this method than are hepatic and
bone enzymes. Because hepatic ALP is more heat
resistant than bone ALP, the most common way to
differentiate between these two isoenzymes is by
heating the serum to 132.8 F (56 C).
Evaluation of ALP isoenzymes usually focuses on
measuring those of hepatic origin not affected by
bone growth or pregnancy. These are 5′-nucleotidase, leucine aminopeptidase, and -glutamyl
transpeptidase.

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

LEUCINE AMINOPEPTIDASE
Leucine aminopeptidase (LAP), an isoenzyme of
alkaline phosphatase, is widely distributed in body
tissues, with greatest concentrations found in hepatobiliary tissues, pancreas, and small intestine.
Elevated levels are associated with biliary obstruction resulting from gallstones and tumors, including
those of the head of the pancreas, strictures, and
atresia. Advanced pregnancy and therapy with drugs
containing estrogen and progesterone also may raise
LAP levels.

5′-NUCLEOTIDASE

Reference Values

5′-Nucleotidase (5′-N), an isoenzyme of ALP, is a
specific phosphomonoesterase formed in the hepatobiliary tissues. Elevated serum 5′-N levels are associated with biliary cirrhosis, carcinoma of the liver
and biliary structures, and choledocholithiasis or
other biliary obstruction.

Leucine Conventional Units

SI Units

Men

0.80–2.00 mg/dL

61.0–152.0 mol/L

Women

0.75–1.85 mg/dL

57.0–141.0 mol/L

Note: Values may vary depending on the units of measure
used by the laboratory performing the test.

Reference Values
Conventional Units
0–1.6 U

SI Units
27–233 nmol/s/L

0.3–3.2 U (Bodansky)

INDICATIONS FOR 5′-NUCLEOTIDASE TEST

Elevated alkaline phosphatase of uncertain etiology:
Elevated 5′-N levels support the diagnosis of
hepatobiliary disorders as the source of the
elevated alkaline phosphatase.
Normal levels support the diagnosis of bone
disease as the source of the elevated alkaline
phosphatase.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).

INTERFERING FACTORS

Advanced pregnancy and therapy with drugs
containing estrogen and progesterone may falsely
elevate levels.
INDICATIONS FOR LEUCINE AMINOPEPTIDASE
TEST

Elevated ALP of uncertain etiology:
Elevated levels support the diagnosis of hepatobiliary or pancreatic disease or both as the
source of the elevated ALP.
Normal levels support the diagnosis of bone
disease as the source of the elevated ALP.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
Some laboratories require the client to fast from
food for 8 hours before the test.

CHAPTER 5—Blood

THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any food withheld before the test.

-GLUTAMYL TRANSPEPTIDASE
-Glutamyl transpeptidase (GGT), an isoenzyme of
ALP, catalyzes the transfer of glutamyl groups
among peptides and amino acids. Hepatobiliary
tissues and renal tubular and pancreatic epithelia
contain large amounts of GGT. Other sources
include the prostate gland, brain, and heart.
Most GGT in serum derives from hepatobiliary
sources, and elevated levels point to hepatobiliary
disease.
INTERFERING FACTORS

Alcohol, barbiturates, and phenytoin may elevate
GGT levels.
Late pregnancy and oral contraceptives may
produce lower than normal values.
INDICATIONS FOR -GLUTAMYL TRANSPEPTIDASE
TEST

Elevated alkaline phosphatase of uncertain etiology:
Pronounced elevations are seen in clients with
obstructive disorders of the hepatobiliary tract
and hepatocellular carcinoma.

145

Modest elevations occur with hepatocellular
degeneration (e.g., cirrhosis) and with pancreatic or renal cell damage or neoplasms.
Other disorders associated with elevated GGT
levels include CHF, acute myocardial infarction
(after 4 to 10 days), hyperlipoproteinemia (type
IV), diabetes mellitus with hypertension, and
epilepsy.
Normal levels in the presence of elevated ALP
support the diagnosis of bone disease.
Known or suspected alcohol abuse, including
monitoring of individuals participating in alcohol
abstinence programs
About 60 to 80 percent of individuals considered to have alcohol abuse problems have
elevated GGT levels, whether or not other signs
of liver damage are present.
Moderate increases in GGT levels occur with
low alcohol intake.
A significant sustained rise occurs with ingestion of six or more drinks per day.
Normal levels return within 2 to 6 weeks of
abstinence from alcohol.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any test involving collection of a peripheral blood
sample (see Appendix I).
Some laboratories require the client to fast from
food for 8 hours before the test.
When the test is conducted to determine whether
the liver is the source of elevated ALP, the client
should abstain from alcohol for 2 to 3 weeks
before the test. This restriction may not apply
when the test is used to monitor compliance with
alcohol abstinence programs.
The client’s reported intake (or nonintake) of
alcohol should, however, be noted.

Reference Values
Conventional Units
Newborns

Chemistry

SI Units

5 times children’s (1–2 yr) values

Children
1–2 yr

3–30 U/L

0.05–0.51 kat/L

5–15 yr

5–27 U/L

0.08–0.46 kat/L

Men

6–37 U/L

0.10–0.63 kat/L

Women 45 yr

5–27 U/L

0.08–0.46 kat/L

Women 45 yr

6–37 U/L

0.10–0.63 kat/L

Adults

146

SECTION I—Laboratory

Tests

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any food withheld before the test.

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test, pending test results.

Isocitrate Dehydrogenase
Isocitrate dehydrogenase (ICD) catalyzes the decarboxylation of isocitrate in the Krebs cycle. This
enzyme is important in controlling the rate of the
cycle, which must be precisely adjusted to meet the
energy needs of cells. ICD is found in the liver, heart,
skeletal muscle, placenta, platelets, and erythrocytes.
Reference Values
Conventional Units

SI Units

Newborns

4.0–28.0 U/L

0.06–0.48 kat/L

Adults

1.27–7.0 U/L

0.02–0.12 kat/L

Ornithine Carbamoyltransferase
Ornithine carbamoyltransferase (OCT), formerly
known as ornithine transcarbamoylase, catalyzes
ornithine to citrulline in the urea cycle before its link
with the citric acid cycle. Its importance stems from
its role in the conversion of ammonia to urea by the
liver. Decreased levels may be seen in inherited
disorders associated with a partial block in the urea
cycle.
Reference Values
Conventional Units

SI Units

8–20 mIU/mL
INTERFERING FACTORS

Numerous drugs, including those that are hepatotoxic, may cause elevated levels.
INDICATIONS FOR ISOCITRATE DEHYDROGENASE
TEST

Elevated serum aspartate aminotransferase (ALT,
SGOT) or ALP of uncertain etiology, or both:
Elevated ICD levels are seen in early viral hepatitis, cancer of the liver, intrahepatic and extrahepatic obstruction, biliary atresia, cirrhosis,
and preeclampsia.
Therapy with potentially hepatotoxic drugs that
may lead to elevated ICD levels early in the course
of treatment
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter ICD levels, a
medication history should be obtained. It is
recommended that any drugs that may alter test
results be withheld for 24 hours before the test,
although this practice should be confirmed with
the person ordering the study.

8–20 U/L

0.02–0.34 kat/L

INTERFERING FACTORS

Hepatotoxic drugs and chemicals may produce
elevated levels.
INDICATIONS FOR ORNITHINE
CARBAMOYLTRANSFERASE TEST

Elevated serum ALP of uncertain etiology:
Elevated OCT levels are seen in viral hepatitis,
cholecystitis, cirrhosis, cancer of the liver, and
obstructive jaundice.
Therapy with hepatotoxic drugs or exposure to
hepatotoxic chemicals, with early effects indicated
by elevated OCT levels
Suspected mushroom poisoning as indicated by
elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter OCT levels, a
medication history should be obtained. It is
recommended that any drugs that may alter test

CHAPTER 5—Blood

results be withheld for 24 hours before the test,
although this practice should be confirmed with
the person ordering the study.

Chemistry

147

• Causes of Elevated
Serum Amylase

TABLE 5–19

THE PROCEDURE

Pronounced Elevation (5 or more times normal)

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Acute pancreatitis
Pancreatic pseudocyst
Morphine administration
Moderate Elevation (3–5 times normal)

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test, pending test results.

Advanced carcinoma of the pancreatic head
Mumps
Parotitis
Perforated peptic ulcer (sometimes)
Duodenal obstruction
Mild Elevation (up to 3 times normal)

Serum Amylase
Amylase is a digestive enzyme that splits starch into
disaccharides such as maltose. Although many cells
have amylase activity (e.g., liver, small intestine,
skeletal muscle, fallopian tubes), amylase circulating
in normal serum derives from the parotid glands
and the pancreas. Unlike many other enzymes,
amylase activity is primarily extracellular; it is
secreted into saliva and the duodenum, where it
splits large carbohydrate molecules into smaller
units for further digestive action by intestinal
enzymes.
Elevations in serum amylase are generally seen in
pancreatic inflammations, which cause disruption of
pancreatic cells and absorption of the extracellular
enzyme from the intestine and peritoneal lymphatics. Serum amylase levels also rise sharply after
administration of drugs that constrict pancreatic
duct sphincters. The most common offender is
morphine, and this drug is never indicated for individuals with abdominal pain that could be of
pancreatic or biliary tract origin. Other drugs that
may produce elevated serum amylase levels are
codeine, chlorothiazides, aspirin, pentazocine, corticosteroids, oral contraceptives, pancreozymin, and
secretin. Specific causes of elevated serum amylase,

Chronic pancreatitis (nonadvanced)
Renal failure
Common bile duct obstruction
Gastric resection
Adapted from Sacher, RA, and McPherson, RA:
Widmann’s Clinical Interpretation of Laboratory
Tests, ed 11. FA Davis, Philadelphia, 2000, p. 554,
with permission.

and the magnitude of the elevations produced, are
listed in Table 5–19.
INTERFERING FACTORS

A number of drugs may produce elevated levels
(e.g., morphine, codeine, chlorothiazides, aspirin,
pentazocine, corticosteroids, oral contraceptives,
pancreozymin, and secretin).
High blood glucose levels, which may be a result
of diabetes mellitus or IV glucose solutions, can
lead to decreased levels.
INDICATIONS FOR SERUM AMYLASE TEST

Diagnosis of early acute pancreatitis:
Serum amylase begins rising within 6 to 24

Reference Values
Conventional Units

SI Units

Children

60–160 U/dL

1.88–5.03 kat/L

Adults

80–180 U/dL (Somogyi)

1.36–3.0 kat/L

45–200 U/dL (dye)
Note: Values may vary according to the laboratory performing the test.

148

SECTION I—Laboratory

Tests

hours after onset and returns to normal in 2 to
7 days.
Urine amylase levels may remain elevated for
several days after serum amylase levels return
to normal.
Detection of blunt trauma or inadvertent surgical
trauma to the pancreas as indicated by elevated
levels
Diagnosis of macroamylasemia, a disorder seen in
alcoholism, malabsorption syndrome, and other
digestive problems with circulating complexes of
amylase and high-molecular-weight dextran
(findings include high serum amylase and negative urine amylase)
Support for diagnosing other disorders associated
with elevated serum amylase levels (see Table
5–19)
Support for diagnosing disorders associated with
decreased amylase levels, such as advanced
chronic pancreatitis, advanced cystic fibrosis, liver
disease, liver abscess, toxemia of pregnancy, severe
burns, and cholecystitis

fluids, nasogastric tube (NG) insertion, and bowel
decompression to decrease pancreatic stimulation. Instruct client to avoid alcohol intake and to
reduce carbohydrate intake if absorption problem
exists.

Serum Lipase
Lipases split triglycerides into fatty acids and glycerol. Different lipolytic enzymes have different
specific substrates, but overall activity is collectively
described as lipase. Serum lipase derives primarily
from pancreatic lipase, which is secreted into the
duodenum and participates in fat digestion.
Pancreatic lipase is quite distinct from lipoprotein
lipases, which clear the blood of chylomicrons after
fats are absorbed.
Viral hepatitis and disorders in which bile salts are
decreased may produce low serum lipase levels, as
will protamine and IV infusions of saline.
Reference Values

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum amylase
levels, a medication history should be obtained. It
is recommended that any drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test, pending test results.
Abnormal values: Note and report increased
levels. Correlate with urine amylase, hypocalcemia, hypokalemia, hyperglycemia, and bilirubin
in relation to pancreatic diseases. Assess for fluid
deficit if pancreatic hemorrhage is present, severity of abdominal pain if acute inflammation is
present, jaundice if common bile duct is
obstructed, and bowel sounds. Maintain nothing
by mouth (NPO) status and prepare client for IV

All groups

Conventional Units

SI Units

0–160 U/L

0–2.72 kat/L

INTERFERING FACTORS

Morphine, cholinergic drugs, and heparin may
lead to elevated levels.
Protamine and IV infusions of saline may lead to
decreased levels.
INDICATIONS FOR SERUM LIPASE TEST

Diagnosis of acute pancreatitis, especially if the
client has been ill for more than 3 days:
Serum amylase levels may return to normal
after 3 days, but serum lipase remains elevated
for approximately 10 days after onset.
Support for diagnosing pancreatic carcinoma,
especially if there is a sustained moderate elevation in serum lipase levels
Support for diagnosing other disorders associated with elevated serum lipase levels (e.g.,
peptic ulcer, acute cholecystitis, and early renal
failure)
Support for diagnosing disorders associated with
decreased serum lipase levels (e.g., advanced
chronic pancreatitis, cystic fibrosis, advanced
carcinoma of the pancreas, and viral hepatitis)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving collection of a peripheral blood sample
(see Appendix I).

CHAPTER 5—Blood

Chemistry

149

Reference Values
Conventional Units
Newborns

10.4–16.4 U/L

1 mo–13 yr

0.5–11.0 U/L (King-Armstrong)

Adults

SI Units

6.4–15.2 U/L

108.0–258.0 kat/L

0–0.8 U/L

0.0–14.0 kat/L

0.1–2.0 U/L (Gutman)
0.5–2.0 U/L (Bodansky)
0.1–5.0 U/L (King-Armstrong)
0.1–0.8 U/L (Bessey-Lowry)
0–0.56 U/L (Roy)
The client should fast from food for at least 8
hours before the test.
It is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume food and any drugs withheld before the
test.

Acid Phosphatase
Phosphatases are enzymes that cleave phosphate
from compounds with a single phosphate group.
Those that are optimally active at pH 5 are grouped
under the name acid phosphatase (ACP).
Many tissues (kidneys, spleen, liver, bone) contain
ACP, but the prostate gland, red blood cells (RBCs),
and platelets are especially rich in this activity. Two
isoenzymes, prostatic fraction and RBC/platelet
fraction, are diagnostically significant. These isoenzymes differ from one another in preferred substrate
and in the degree to which they are inhibited by various additives during laboratory testing. Normal
serum contains more RBC/platelet than prostatic
ACP, and small changes in prostatic fraction may be
difficult to detect. Tartaric acid inhibits prostatic

ACP. Thus, many laboratories report tartrateinhibitable ACP as well as total ACP in an effort to
focus more specifically on the prostatic fraction.
Decreased levels of prostatic ACP are seen after
estrogen therapy for prostatic carcinoma and in
clients with Down syndrome. Decreased levels are
associated with ingestion of alcohol, fluorides,
oxalates, and phosphates.
Administration of androgens in women and of
clofibrate in both genders produces elevated levels.
INTERFERING FACTORS

Prostatic massage or rectal examination within 48
hours of the test may cause elevated levels.
Administration of androgens in females and of
clofibrate in either gender may produce elevated
levels.
Ingestion of alcohol, fluorides, oxalates, and phosphates may result in decreased levels.
INDICATIONS FOR SERUM ACID PHOSPHATASE
TEST

Enlarged prostate gland, especially if prostatic
carcinoma is suspected:
Prostatic ACP is elevated in 50 to 75 percent of
individuals with prostatic carcinoma that has
extended beyond the gland.
Cancers that remain within the gland cause
ACP elevation in only 10 to 25 percent of those
affected.
Benign hyperplasia, inflammation, or ischemic
damage to the prostate rarely causes elevated
ACP levels.
Evaluation of the effectiveness of treatment of
prostatic carcinoma:
ACP levels fall to normal within 3 to 4 days of
successful estrogen therapy.

150

SECTION I—Laboratory

Tests

Recurrent elevation strongly suggests that bone
metastases are active.
Support for diagnosing other disorders associated
with elevated prostatic ACP levels (e.g., metastatic
bone cancer, Paget’s disease, osteogenesis imperfecta, hyperparathyroidism, and multiple
myeloma)
Known or suspected hematologic disorder:
Elevated RBC/platelet ACP is seen in hemolytic
anemia, sickle cell crisis, thrombocytosis, and
acute leukemia.
Support for diagnosing other disorders associated
with increased RBC/platelet ACP (e.g., renal
insufficiency, liver disease, Gaucher’s disease, and
Niemann-Pick disease)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
It is recommended that any drugs that may alter
test results be withheld for 12 to 24 hours before
the test, although this practice should be
confirmed with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory. If the test cannot
be performed within a few hours, the serum should
be frozen.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test.
Abnormal values: Note and report increased
levels or associated levels of prostate-specific antigen. Provide support in coping with a life-threatening disease, hormonal therapy, and possible
surgical procedure.

Prostate-Specific Antigen
Prostate-specific antigen (PSA) is a glycoprotein
found in the prostate tissues. Its presence is tested by
immunoassay techniques to assist in the detection of
prostatic carcinoma. It is considered to be a more
specific immunohistochemical marker for metastatic tumor of prostate origin than is ACP. ACP is a test
also performed to diagnose prostatic carcinoma, but
it is not entirely specific for this disease, because
increased values have been noted in bladder as well

as in prostatic carcinoma. Increased levels of PSA
correlate with the amount of prostatic tissue, both
malignant and benign.
Reference Values
Conventional Units

SI Units

Men 40 yr

2.0 ng/mL

2.0 g/L

Men 40 yr

2.8 ng/mL

2.8 g/L

INTERFERING FACTORS

Prostatic massage or rectal examination within 48
hours of the test can cause elevated levels.
INDICATIONS FOR PROSTATE-SPECIFIC ANTIGEN
TEST

Screening for early detection of prostate carcinoma and evaluating those who are at risk for this
disease, primarily men over 40 years of age
Diagnosing a malignant tumor of the prostate
gland, revealed by increased levels, depending on
the volume of the tumor
Determining chemotherapeutic regimen protocol
or radiation therapy and monitoring and evaluating the response to therapy, revealed by a decrease
in the PSA level
Evaluating progression or recurrence of the
tumor, revealed by a rise in the PSA level
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The age of the client
should be noted on the laboratory form. The sample
should be refrigerated if the test is not performed
within 24 hours.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Aldolase
Aldolase (ALS) is a glycolytic enzyme that catalyzes
the breakdown of 1,6-diphosphate into triose phosphate. It is found in many body tissues but is most
diagnostically significant in disorders of skeletal and
cardiac muscle, liver, and pancreas. Three isoen-

CHAPTER 5—Blood

Chemistry

151

Reference Values
Conventional Units

SI Units

Newborns

5.2–32.8 U/L (Sibley-Lehninger)

0.09–0.54 kat/L

Children

2.6–16.4 U/L (Sibley-Lehninger)

0.04–0.27 kat/L

Adults

1.3–8.2 U/L (Sibley-Lehninger)

0.02–0.14 kat/L

Men

3.1–7.5 U/L at 98.6 F (37 C)

0.05–0.13 kat/L

Women

2.7–5.3 U/L at 98.6 F (37 C)

0.04–0.09 kat/L

zymes have been identified: A, originating in skeletal
and cardiac muscle; B, originating in liver, kidneys,
and white blood cells; and C, originating in brain
tissue. Isoenzyme C probably lacks diagnostic capability because it does not cross the blood–brain
barrier.

involving collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.

INTERFERING FACTORS

THE PROCEDURE

Hepatotoxic drugs, insecticides, and anthelminthics may cause elevated levels.
Phenothiazines may cause decreased levels.
INDICATIONS FOR ALDOLASE TEST

Family history of Duchenne’s muscular dystrophy:
ALS levels rise before clinical signs appear, thus
permitting early diagnosis.
Signs and symptoms of neuromuscular disorders,
to differentiate muscular disorders from neurological disorders:
Pronounced elevations are seen in clients
having Duchenne’s muscular dystrophy,
polymyositis, dermatomyositis, trichinosis, and
severe crush injuries.
Decreased aldolase levels are seen in those with
late muscular dystrophy, because of loss of
muscle cells, or with use of phenothiazines.
ALS is not elevated in those with multiple sclerosis or myasthenia gravis, both of which are of
neural origin.
Support for diagnosing other disorders associated
with elevated ALS levels:
Moderate increases are associated with acute
hepatitis, neoplasms, and leukemia.
Mild elevations are seen in acute myocardial
infarction (peak elevation occurs in 24 hours,
with gradual return to normal within 1 week).
Evaluation of response to exposure to hepatotoxic
drugs or chemicals, with liver damage indicated
by elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test.
Abnormal values: Note and report increased
levels related to skeletal muscular disorders. Assess
for muscle fatigue and strength related to an acute
or chronic disorder. Provide energy-saving care to
conserve the client’s energy while still maintaining
as much independence as possible. Instruct in a
planned rest and exercise program.

Creatine Phosphokinase and
Isoenzymes
Creatine phosphokinase (CPK), also called creatine
kinase (CK), catalyzes the reversible exchange of
phosphate between creatine and adenotriphosphate
(ATP). Important in intracellular storage and release
of energy, CPK exists almost exclusively in skeletal
muscle, heart muscle, and, to a lesser extent, brain.
No CPK is found in the liver. Anything that damages
skeletal or cardiac muscle elevates serum CPK levels.
Brain injury affects serum CPK levels much less,
probably because relatively little enzyme crosses the
blood–brain barrier.
Spectacular CPK elevations occur in the early
phases of muscular dystrophy, but CPK elevation
diminishes as the disease progresses and muscle

152

SECTION I—Laboratory

Tests

•

Causes of Elevated
Creatine Phosphokinase

TABLE 5–20

Pronounced Elevation (5 or more times normal)
Early muscular dystrophy (CPK-MM, CPK3)
Acute myocardial infarction (CPK-MB, CPK2)
Severe angina (CPK-MB, CPK2)
Polymyositis (CPK-MM, CPK3)
Cardiac surgery
Moderate Elevation (2–4 times normal)
Vigorous exercise
Deep intramuscular injections
Surgical procedures affecting skeletal muscles
Delirium tremens
Convulsive seizures
Dermatomyositis
Alcoholic myopathy
Hypothyroidism
Pulmonary infarction
Acute agitated psychosis
Mild Elevation (up to 2 times normal)
Late pregnancy
Women heterozygous for the gene causing
Duchenne’s muscular dystrophy (CPK-MM, CPK3)
Brain injury (CPK-BB, CPK1)
Adapted from Sacher, RA, and McPherson, RA:
Widmann’s Clinical Interpretation of Laboratory
Tests, ed 11. FA Davis, Philadelphia, 2000, p. 536,
with permission.

mass decreases. Levels of CPK may be normal to low
in late, severe cases. Additional causes of elevated
CPK, and the magnitude of those elevations, are
listed in Table 5–20.
The CPK molecule consists of two parts, which
may be identical or dissimilar. These two constituent
chains are called M (muscle) and B (brain). Three
diagnostically significant isoenzymes have been
identified in relation to the two main components of
CPK. Brain CPK (CPK-BB, CPK1) is almost entirely
BB, cardiac CPK (CPK-MB, CPK2) contains 60
percent MM and 40 percent MB, and skeletal muscle
CPK (CPK-MM, CPK3) contains about 90 percent
MM and 10 percent MB. The isoenzyme normally
present in serum is almost entirely MM, and only
CPK-MM (CPK3) rises when skeletal muscle is

damaged. In contrast, serum CPK-MB (CPK2) rises
only when heart muscle is damaged.
Drugs that may produce elevated CPK levels
include anticoagulants, morphine, alcohol, salicylates in high doses, amphotericin-B, clofibrate, and
certain anesthetics. Any medication administered
intramuscularly (IM) also elevates CPK. In addition
to late muscular dystrophy, decreased levels are seen
in early pregnancy.
Myoglobin is an oxygen-carrying protein
normally found in cardiac and skeletal muscle. In
acute myocardial infarction (AMI), myoglobin levels
rise within 1 hour. Although myoglobin alone is not
particularly sensitive to cardiac damage, in conjunction with CPK-MB it has a diagnostic capability
approaching 100 percent in correctly identifying
AMI.29 See Table 5–21.
INTERFERING FACTORS

Vigorous exercise, deep intramuscular (IM) injections, delirium tremens, and surgical procedures
in which muscle is transected or compressed may
produce elevated levels.
Drugs that may produce elevated CPK levels
include anticoagulants, morphine, alcohol, salicylates in high doses, amphotericin-B, clofibrate,
and certain anesthetics.
Early pregnancy may produce decreased levels.
INDICATIONS FOR CREATINE PHOSPHOKINASE
AND ISOENZYMES TEST

Signs and symptoms of acute myocardial infarction:
Acute myocardial infarction releases CPK into
the serum within the first 48 hours, and values
return to normal in about 3 days.
CPK levels rise before aspartate aminotransferase and lactic dehydrogenase levels rise.
The isoenzyme CPK-MB (CPK2) rises only
when the heart muscle is damaged; it appears
in the first 6 to 24 hours and is usually gone in
72 hours.
Both total CPK and MB fraction may rise in
severe angina or extensive reversible ischemic
damage.30
Recurrent elevation of CPK suggests reinfarction or extension of ischemic damage.
An elevated CPK level helps to differentiate
myocardial infarction from CHF and conditions associated with liver damage.
Family history of Duchenne’s muscular dystrophy:
Spectacular CPK elevations occur in the early
phases of muscular dystrophy, even before clinical signs or symptoms appear.

CHAPTER 5—Blood

Chemistry

153

Reference Values
Conventional Units

SI Units

Total CPK
Newborns

30–100 U/L

0.51–1.70 kat/L

Children

15–50 U/L

0.26–0.85 kat/L

5–55 U/L

—

55–170 U/L

0.94–2.89 kat/L

5–35 g/mL

—

5–25 U/L

—

30–135 U/L

0.51–2.30 kat/L

5–25 g/mL

—

CPK-BB (CPK1)

0% of total CK

—

CPK-MB (CPK2)

0–7% of total CK

—

CPK-MM (CPK3)

5–70% of total CK

—

Myoglobin

100 ng/mL

100 nmol/L

Adults
Men

Women

Isoenzymes

Image/Text rights unavailable

154

SECTION I—Laboratory

Tests

Image/Text rights unavailable
CPK elevation diminishes as the disease
progresses and muscle mass decreases.
Signs and symptoms of other disorders associated
with elevated CPK levels (see Table 5–20)
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Troponin Levels
Differential diagnosis of chest pain remains problematic. It is estimated that 12 percent of patients
with AMI are sent home from the emergency
department.31 Traditional measures to diagnose
AMI include an ECG and measurement of cardiac
enzymes, particularly creatine kinase CK-MB.32 In
recent years, troponin levels have been studied to
determine the efficacy of this laboratory test in diagnosis of AMI. Troponin is a protein found in striated
muscle. There are three specific types: troponin-C
(TnC), troponin-I (TnI), and troponin-T (TnT).
TnT and TnI are specific for cardiac disease, and
several studies have concluded that elevated levels of
these enzymes result in greater sensitivity in diagnosing AMI and determining comprehensive risk
stratification of patients with unstable angina.31,33,34
TnT and TnI will be elevated within 4 hours after
myocardial damage and remain elevated for 10 to 14
days.
Reference Values

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as those for any study involving the collection
of a peripheral blood sample.
Resume any drugs withheld before the test, as well
as usual activities.
Abnormal values: Note and report increased
levels of CPK, CPK-MB, lactic dehydrogenase (in
relation to myocardial infarction), and CPK-MM
(in relation to muscular dystrophy). Monitor vital
signs. Monitor ECG for dysrhythmias. Monitor
for fluid overload (distended neck veins, dyspnea,
crackles on auscultation). Repeat ordered CPK
and lactic dehydrogenase enzyme and isoenzyme
tests.

Presence of cardiac enzyme marker
INTERFERING FACTORS

TnT may be present in renal failure.
INDICATIONS FOR TROPONIN LEVELS TEST

Diagnosis and risk stratification for unstable
angina
Diagnosis of AMI
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).

CHAPTER 5—Blood

Chemistry

155

Reference Values
Conventional Units
Total LDH

SI Units

80–120 U (Wacker) @ 636 F (300 C)
150–450 U (Wroblewski)

1.21–3.52 kat/L

71–207 U/L
LDH Isoenzymes

Percentage of Total

Fraction of Total

LDH1

29–37%

0.29–0.37

LDH2

42–48%

0.42–0.48

LDH3

16–20%

0.16–0.20

LDH4

2–4%

0.02–0.04

LDH5

0.5–1.5%

0.005–0.015

Note: Values may vary according to the laboratory performing the test.

THE PROCEDURE

A venipuncture is performed and the sample is
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and sent
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Lactic Dehydrogenase and
Isoenzymes
Lactic dehydrogenase (LDH) catalyzes the reversible
conversion of lactic acid to pyruvic acid within cells.
Because many tissues contain LDH, elevated total
LDH is considered a nonspecific indication of cellular damage unless other clinical data make the tissue
origin obvious. Pronounced elevations in total LDH
are seen in clients with megaloblastic anemia,
metastatic cancer (especially if the liver is involved),
shock, hypoxia, hepatitis, and renal infarction.
Moderate elevations occur in those with myocardial
and pulmonary infarctions, hemolytic conditions,
leukemias, infectious mononucleosis, delirium
tremens, and muscular dystrophy. Mild elevations
are associated with most liver diseases, nephrotic
syndrome, hypothyroidism, and cholangitis.
The most useful diagnostic information is
obtained by analyzing the five isoenzymes of LDH
through electrophoresis. These isoenzymes are
specific to certain tissues. The heart and erythrocytes
are rich sources of LDH1 and LDH2; however, the

brain is a source of LDH1, LDH2, and LDH3. The
kidneys contain LDH3 and LDH4; the liver and
skeletal muscle contain LDH4 and LDH5. Certain
glands (thyroid, adrenal, and thymus), pancreas,
spleen, lungs, lymph nodes, and white blood cells
contain LDH3, whereas the ileum is an additional
source of LDH5.
Situations in which isoenzyme analysis is most
useful include distinguishing myocardial infarction
from lung or liver problems, diagnosing myocardial
infarction in ambiguous settings such as the postoperative period or during severe shock and in hemolysis at a time of bone marrow hypoplasia.
Normally, serum contains more LDH2 than
LDH1. Damage to tissues rich in LDH1, however, will
cause this ratio to reverse. The reversed ratio (i.e.,
LDH2 greater than LDH2) is an important diagnostic finding that occurs whether or not total LDH is
elevated. The reversal is short lived. In myocardial
infarction, for example, the LDH1:LDH2 ratio
returns to normal within a week of the infarction
even though total LDH may remain elevated.35 The
tissue sources of LDH isoenzymes and common
causes of elevations are summarized in Table 5–21.
Numerous drugs may elevate LDH levels:
anabolic steroids, anesthetics, aspirin, alcohol, fluorides, narcotics, clofibrate, mithramycin, and
procainamide.
INTERFERING FACTORS

Numerous drugs may produce elevated LDH
levels (e.g., anabolic steroids, anesthetics, aspirin,
alcohol, fluorides, narcotics, clofibrate, mithramycin, and procainamide).

156

SECTION I—Laboratory

Tests

INDICATIONS FOR LACTIC DEHYDROGENASE
AND ISOENZYMES TEST

Confirmation of AMI or extension thereof, as
indicated by elevation (usually) of total LDH,
elevation of LDH1 and LDH2, and reversal of the
LDH1:LDH2 ratio within 48 hours of the infarction
Differentiation of acute myocardial infarction
from pulmonary infarction and liver problems,
which elevate LDH4 and LDH5
Confirmation of red blood cell hemolysis or renal
infarction, especially as indicated by reversal of
the LDH1:LDH2 ratio
Confirmation of chronicity in liver, lung, and
kidney disorders, as evidenced by LDH levels that
remain persistently high
Evaluation of the effectiveness of cancer
chemotherapy (LDH levels should fall with
successful treatment.)
Evaluation of the degree of muscle wasting in
muscular dystrophy (LDH levels rise early in this
disorder and approach normal as muscle mass is
reduced by atrophy.)
Signs and symptoms of other disorders associated
with elevation of the several LDH isoenzymes (see
Table 5–21)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.

mental and physical development of the infant, with
death resulting by the third or fourth year of life. The
deficiency of this enzyme is most common in families of Eastern-European Jewish and FrenchCanadian origin. Because of this deficiency,
gangliosides or complex sphingolipids are not
metabolized and accumulate in the brain, causing
the paralysis, blindness, dementia, and mental retardation that develop in the children who have this
disorder.36
Reference Values
56–80 percent of a total normal level
(10.4–23.8 U/L)
INTERFERING FACTORS

Pregnancy decreases the level of hexosaminidase
in relation to the total, resulting in an inaccurate
false positive.
Oral contraceptives can decrease the level.
INDICATIONS FOR HEXOSAMINIDASE TEST

Screening young adults for asymptomatic possession of this gene with or without a family history
of Tay-Sachs disease
Identifying carriers in high-risk clients during
prenatal examination, revealed by a lowered
enzyme activity
Diagnosing Tay-Sachs in infants, revealed by a
very low level or absence of enzyme activity
In utero prenatal diagnosis of amniotic fluid or
cells obtained from chorionic villi
NURSING CARE BEFORE THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
Food and fluids should be avoided for 8 hours
before the test, and oral contraceptives should be
withheld.

NURSING CARE AFTER THE PROCEDURE

THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test.

A venipuncture is performed and the sample
collected in a red-topped tube. Refer to the procedures to obtain prenatal samples via chorionic villus
biopsy or amniocentesis (see Chapters 10 and 14).

THE PROCEDURE

NURSING CARE AFTER THE PROCEDURE

Hexosaminidase
Hexosaminidase A is a test performed to determine
the presence of the lysosomal disease known as TaySachs, a genetic autosomal recessive condition characterized by early and progressive retardation in the

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any drugs withheld before the test.
Complications and precautions: Recommend

CHAPTER 5—Blood

special genetic counseling for those with a family
history of the disease or with abnormal test
results.

-Hydroxybutyric Dehydrogenase
-Hydroxybutyric dehydrogenase (-HBD, HBD) is
an enzyme similar to two isoenzymes of lactic dehydrogenase: LDH1 and LDH2. The -HBD test,
however, is cheaper and easier to perform than LDH
isoenzyme electrophoresis. Moreover, HBD levels
remain elevated for 18 days after acute myocardial
infarction, providing a diagnosis when the client has
delayed seeking treatment or has not had classic
signs and symptoms.
Reference Values
Conventional Units
70–300 U/L
140–350 U/L
Note: Values may vary according to the laboratory performing the test.
INDICATIONS FOR -HYDROXYBUTYRIC
DEHYDROGENASE TEST

Suspected “silent” myocardial infarction or otherwise atypical myocardial infarction in which the
client delayed seeking care:
HBD levels remain elevated for 18 days after
acute myocardial infarction (i.e., when other
cardiac enzymes have returned to normal
levels).
Support for diagnosing other disorders associated
with elevated HBD levels (e.g., megaloblastic and
hemolytic anemias, leukemias, lymphomas,
melanomas, muscular dystrophy, nephrotic
syndrome, and acute hepatocellular disease)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test

Chemistry

157

involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Cholinesterases
Cholinesterases hydrolyze concentrated acetylcholine and also cleave other choline esters. Two
types of cholinesterase are measured: (1) acetylcholinesterase (“true” cholinesterase) and (2)
pseudocholinesterase. Acetylcholinesterase (AcCHS)
is found at nerve endings and in erythrocytes; very
little is found in serum. Its substrate specificity is
limited to acetylcholine, and it is optimally active
against very low acetylcholine concentrations.
Pseudocholinesterase (PCE) derives from the liver
and is normally found in the serum in substantial
amounts. It is active against acetylcholine and other
choline esters. PCE is unusual in that the diagnostically significant change is depression, not elevation.
An important application of information about
PCE is in evaluating individuals for genetic variations of the enzyme before surgery in which
succinylcholine, an inhibitor of acetylcholine, is to
be used to induce anesthesia. Persons homozygous
for the abnormal form of PCE have depressed total
serum activity and their enzyme does not inactivate
succinylcholine; persons who receive the drug
during surgery may experience prolonged respiratory depression. Presence of the abnormal form of
PCE is determined by exposing the enzyme to dibucaine. Normal PCE is inhibited by dibucaine,

Reference Values
Conventional Units

SI Units

Acetylcholinesterase (AcCHS)

0.5–1.0 pH units

Pseudocholinesterase (PCE)

0.5–1.3 pH units

Men

274–532 IU/dL

2.74–5.32 kU/L

Women

204–500 IU/dL

2.04–5.00 kU/L

158

SECTION I—Laboratory

Tests

whereas abnormal PCE is found to be “dibucaine
resistant.”37
INTERFERING FACTORS

Numerous drugs may falsely decrease
cholinesterase levels (e.g., caffeine, theophylline,
quinidine, quinine, barbiturates, morphine,
codeine, atropine, epinephrine, phenothiazines,
folic acid, and vitamin K).
INDICATIONS FOR CHOLINESTERASE
DETERMINATIONS

collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.

Renin

Suspected exposure to organic phosphate insecticides:
Red blood cell AcCHS levels decline with severe
exposure; serum PCE decreases occur earlier.
When exposure ceases, serum PCE rises before
red blood cell AcCHS returns to normal.
Red blood cell AcCHS levels are more useful
than are serum PCE levels in determining prior
exposure.
Impending use of succinylcholine during anesthesia:
Persons homozygous for the abnormal form of
PCE have depressed total serum activity, and
their enzyme does not inactivate succinylcholine, with the abnormal PCE indicated as
“dibucaine resistant.”
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter cholinesterase
levels and activity, a medication history should be
obtained. It is recommended that those drugs that
may alter test results be withheld for 12 to 24
hours before the test, although this practice
should be confirmed with the person ordering the
study.

Renin is an enzyme released by the juxtaglomerular
apparatus of the kidney in response to decreased
extracellular fluid volume, serum sodium, and renal
perfusion pressure. It catalyzes the conversion of
angiotensinogen, produced by the liver, to angiotensin I. Angiotensin I is then converted to angiotensin II in the lungs. Angiotensin II elevates
systemic blood pressure by causing vasoconstriction
and by stimulating the release of aldosterone.
Renin released by the kidneys is found initially in
the renal veins. Thus, the output of renin by each
kidney may be determined by obtaining samples
directly from the right and left renal veins and
comparing the results with those obtained from an
inferior vena cava sample. This test is indicated
when renal artery stenosis is suspected, because the
kidney affected by decreased perfusion releases
higher amounts of renin. Renal vein assay for renin
is performed using fluoroscopy and involves cannulation of the femoral vein and injection of dye to aid
in visualizing the renal veins. Because this is an invasive procedure, a signed consent is required.
INTERFERING FACTORS

THE PROCEDURE

A venipuncture is performed and the sample

Failure to follow dietary restrictions, if ordered,
before the test may affect the test results.
Failure to take prescribed diuretics, if ordered,
before the test may affect the test results.
Failure to maintain required positioning (e.g.,
upright versus recumbent) for at least 2 hours
before the test may affect the test results.

Reference Values

Peripheral vein

Conventional Units

SI Units

0.4–4.5 (ng/hr)/mL (normal salt intake, standing position)

0.4–4.5 gh–1 L–1

1.5–1.6 (ng/hr)/mL or more (normal salt intake, supine position)

1.5–1.6 gh–1 L–1

Renal vein assay Difference between each renal sample and the vena cava sample should be 1.4–1.0
Note: Values for peripheral vein samples should be substantially higher (e.g., 2.9–24 [ng/hr]/mL) in clients who are sodium
depleted and in the upright position. These values also may vary according to the laboratory performing the test.

CHAPTER 5—Blood

High-dose adrenocorticosteroid therapy, excessive
salt intake, and excessive licorice ingestion may
produce decreased levels.
INDICATIONS FOR RENIN TEST

Assessment of renin production by the kidneys
when client has hypertension of unknown etiology or when other disorders associated with
altered renin levels are suspected:
Elevated renin levels are seen in renovascular
and malignant hypertension, adrenal hypofunction (Addison’s disease), salt-wasting
disorders, end-stage renal disease, reninproducing renal tumors, and secondary hyperaldosteronism.
Decreased levels are associated with primary
hyperaldosteronism, hypervolemia, excessive
salt ingestion or retention, excessive adrenocorticosteroid levels resulting from either disease
or drug therapy, and excessive licorice ingestion.
Renin levels may be high, low, or normal in
essential hypertension.
In primary hyperaldosteronism, plasma renin
levels are decreased, even with salt depletion
before the test (results should be evaluated in
relation to the serum aldosterone level, which is
elevated in primary hyperaldosteronism).
Suspected renal artery stenosis as the cause of
hypertension, as indicated by renal vein output
of renin by the affected kidney more than 1.4
times that of the vena cava sample
Nursing Alert

The renal vein assay for renin should be
performed with extreme caution, if at all, in
clients with allergies or previous exposure to
radiographic dyes.
NURSING CARE BEFORE THE PROCEDURE

Client preparation varies according to the method
for obtaining the sample and the factors to be
controlled (e.g., salt depletion).
1. Peripheral vein, normal salt intake. Client
preparation is essentially the same as that
for any test involving collection of a peripheral blood sample. The client should follow
a normal diet with adequate salt and potassium intake. Licorice intake and certain
medications may be restricted for 2 weeks or
more before the test, although this practice
should be confirmed with the person ordering
the study. The position relevant to the type of

Chemistry

159

sample (e.g., upright versus recumbent)
should be maintained for 2 hours before the
test.
2. Peripheral vein, sodium depleted. Client preparation is the same as just described, except that
a diuretic is administered for 3 days before the
study and dietary sodium is limited to “no
added salt” (approximately 3 g/day). Sample
menus should be provided. The purpose of the
diuretic therapy and sodium restriction should
be explained, and client understanding and
ability to follow pretest preparation should be
ascertained.
Explain to the client:
The purpose of the study
That a “no added salt” diet must be followed for
3 days before the study
That prescribed diuretics must be taken for 3 days
before the study
Other restrictions in diet (e.g., licorice) or drugs
necessary before the study
That the test will be performed in the radiology
department by a physician and will take about 30
minutes
The general procedure, including the sensations
to expect (momentary discomfort as the local
anesthetic is injected, sensation of warmth as the
dye is injected)
Whether premedications will be given
After-procedure assessment routines (e.g.,
frequent vital signs) and activity restrictions
Encourage questions and verbalization of concerns
appropriate to the client’s age and mental status.
Then:
Question the client about possible allergies to
radiographic dyes.
Ensure that signed consent has been obtained.
To the extent possible, ensure that the dietary and
medication regimens and restrictions are
followed.
Assist the client in maintaining the upright position (standing or sitting) for 2 hours before the
test, if ordered, to stimulate renin secretion.
Take and record vital signs and have the client
void; provide a hospital gown.
Administer premedication, if ordered.
Obtain a stretcher for client transport.
THE PROCEDURE

The procedure varies with the method for obtaining the sample.
1. Peripheral vein. A venipuncture is performed
and the sample collected in a chilled lavendertopped tube. The tube should be inverted
gently several times to promote adequate

160

SECTION I—Laboratory

Tests

mixing with the anticoagulant, placed in ice,
and sent to the laboratory immediately.
2. Renal vein. The client is assisted to the supine
position on the fluoroscopy table, and a site is
selected for femoral vein catheterization. The
skin may be shaved (if necessary), cleansed
with an antiseptic, draped with sterile covers,
and injected with a local anesthetic.
A catheter is inserted into the femoral vein and
advanced to the renal veins under fluoroscopic
observation. Radiographic dye may be injected into
the inferior vena cava at this point to aid in identification of the renal veins. A renal vein is entered and
a blood sample obtained. The other renal vein is
then entered and a second blood sample obtained.
The catheter is then retracted into the inferior vena
cava and a third sample obtained.
The samples are placed in chilled lavender-topped
tubes that are labeled to identify collection sites.
The tubes should be inverted gently several times
to promote adequate mixing with the anticoagulant, placed in ice, and sent to the laboratory immediately.
The femoral catheter is removed after the third
sample is obtained, and pressure is applied to the site
for 10 minutes. A pressure dressing is then applied.
NURSING CARE AFTER THE PROCEDURE

1. Peripheral vein. Care and assessment after the
procedure are the same as for any study involving the collection of a peripheral blood
sample. Pretest diet and medications, which
may have been modified or restricted before
the study, should be resumed.
2. Renal vein. Maintain the client on bed rest for
8 hours after the procedure. Monitor vital
signs and record according to the following
schedule: every 15 minutes for 1 hour, every 30
minutes for 1 hour, and every hour for 4 hours.
Monitor the catheterization site for bleeding or
hematoma each time vital signs are checked.
Resume previous diet and medications.
Abnormal values: Note and report results and
correlate with urinary sodium, serum, and
urinary aldosterone. Monitor blood pressure,
especially if antihypertensive medications have
been withheld. Monitor I&O for fluid deficit or
excess.
Allergic response (renal vein): Note and report
allergic response to dye injection and assess for
rash, urticaria, dyspnea, and tachycardia.
Administer ordered antihistamine or steroids and
oxygen. Have emergency equipment and supplies
on hand.
Vein thrombosis (renal vein): Note and report

any flank or back pain, hematuria, or abnormal
renal test results (blood urea nitrogen, creatinine).

HORMONES
Hormones are chemicals that control the activities
of responsive tissues. Some hormones exert their
effects in the vicinity of their release; others are
released into the extracellular fluids of the body and
affect distant tissues. Similarly, some hormones
affect only specific tissues (target tissues), whereas
others affect nearly all cells of the body. Chemically,
hormones are classified as polypeptides, amines, and
steroids.
Hormones act on responsive tissues by (1) altering the rate of synthesis and secretion of enzymes or
other hormones, (2) affecting the rate of enzymatic
catalysis, and (3) altering the permeability of cell
membranes. Once the hormone has accomplished
its function, its rate of secretion normally decreases.
This is known as negative feedback. After sufficient
reduction in hormonal effects, negative feedback
decreases, and the hormone is again secreted.

Hypophyseal Hormones
The hypophysis, also known as the pituitary gland,
lies at the base of the brain in the sella turcica and is
connected to the hypothalamus by the hypophyseal
stalk. The hypophysis has two distinct portions: (1)
the adenohypophysis (anterior pituitary) and (2) the
neurohypophysis (posterior pituitary). The adenohypophysis arises from upward growth of pharyngeal epithelium in the embryo, whereas the
neurohypophysis arises from the downward growth
of the hypothalamus in the embryo.
Almost all hormonal secretion from the hypophysis is controlled by the hypothalamus. Neurohypophyseal hormones are formed in the
hypothalamus and travel down nerve fibers to the
neurohypophysis, where they are stored and then
released into the circulation in response to feedback mechanisms. Adenohypophyseal hormone
secretion is controlled by releasing and inhibiting
factors that are secreted by the hypothalamus and
carried to the adenohypophysis by the hypothalamic–hypophyseal portal vessels. Hypothalamic
releasing and inhibiting factors identified thus far
include (1) thyrotropin-releasing hormone (TRH);
(2) corticotropin-releasing hormone (CRH); (3)
gonadotropin-releasing hormone (GnRH), also
known as luteinizing hormone–releasing hormone
(LHRH) and follicle-stimulating hormone–releasing factor; (4) growth hormone–releasing hormone
(GHRH); (5) growth hormone–inhibiting hormone

CHAPTER 5—Blood

(GHIH); and (6) prolactin inhibitory hormone
(PIH). A releasing factor for melanocyte-stimulating
hormone also is believed to exist. The releasing
factors either stimulate or inhibit the adenohypophysis in the release of its hormones.
The adenohypophysis consists of three major cell
types: (1) acidophils, (2) basophils, and (3) chromophobes. The acidophils secrete growth hormone
(GH), also called somatotropic hormone (STH, SH)
or somatotropin, and prolactin (HPRL), also known
as luteotropic hormone (LTH), lactogenic hormone,
or lactogen. The basophils secrete adrenocorticotropic hormone (ACTH), also known as adrenocorticotropin and corticotropin; thyroid-stimulating
hormone (TSH), also known as thyrotropin; folliclestimulating hormone (FSH); luteinizing hormone
(LH), also known as interstitial cell–stimulating
hormone (ICSH); and melanocyte-stimulating
hormone (MSH). The chromophobes, which constitute about half of the adenohypophyseal cells, are
resting cells capable of transformation to either
acidophils or basophils.
The hormones stored and released by the neurohypophysis include antidiuretic hormone (ADH),
also known as vasopressin, and oxytocin. Radioimmunoassays are used to determine the blood
levels of the hypophyseal hormones.

GROWTH HORMONE
Growth hormone (GH, STH, SH) is secreted in
episodic bursts, usually during early sleep. The
effects of GH occur throughout the body. GH
promotes skeletal growth by stimulating hepatic
production of proteins. It also affects lipid and
glucose metabolism. Under the influence of growth
hormone, free fatty acids enter the circulation for
use by muscle; hepatic glucose production (gluconeogenesis) also rises. Growth hormone also
increases blood flow to the renal cortex and the
glomerular filtration rate; the kidney excretes more
calcium and less phosphate than usual. GH is
believed to antagonize insulin.
Deficiencies in GH are apparent only in childhood. Children with GH deficiency have very small
statures but normal body proportions. The child
also may be deficient in other hypophyseal
hormones, and this disorder is known as pituitary
dwarfism.
Excessive levels of GH are apparent in all ages.
Excess GH in children causes the long bones of the
skeleton to enlarge and produces gigantism. In
adults, the bones of the skull, hands, and feet thicken
to produce the physical appearance of acromegaly.
In this disorder, the internal organs, skeletal muscle,

Chemistry

161

and heart muscle hypertrophy. Nerves and cartilage
also enlarge and may produce nerve compression
and joint disorders.
Reference Values
Conventional Units

SI Units

Newborns

15–40 ng/mL

15–40 g/L

Children

0–10 ng/mL

0–10 g/L

Adults

0–10 ng/mL

0–10 g/L

Note: Values may vary according to the laboratory
performing the test.

INTERFERING FACTORS

Hyperglycemia and therapy with drugs such as
adrenocorticosteroids and chlorpromazine may
cause falsely decreased levels.
Hypoglycemia, physical activity, stress, and a variety of drugs (e.g., amphetamines, arginine,
dopamine, levodopa, methyldopa, beta blockers,
histamine, nicotinic acid, estrogens) may cause
falsely elevated levels.38
INDICATIONS FOR GROWTH HORMONE TEST

Growth retardation in children with decreased
levels indicative of pituitary etiology
Monitoring for response to treatment of growth
retardation caused by GH deficiency
Suspected disorder associated with decreased GH
(e.g., pituitary tumors, craniopharyngiomas,
tuberculosis meningitis, and pituitary damage or
trauma)
Gigantism in children with increased levels
indicative of pituitary etiology
Support for diagnosing acromegaly in adults as
indicated by elevated levels; acidophil or chromophobe tumors of the adenohypophysis may
account for these elevated levels39
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
The client should be informed that the test will be
performed on 2 consecutive days, between the
hours of 6 and 8 AM.
The client should fast from food and avoid strenuous exercise for 12 hours before each sample is
drawn.
Additionally, it is recommended by some that the
client be maintained on bed rest for 1 hour before
each sample is obtained.

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Tests

Because many drugs may affect serum GH levels,
a medication history should be obtained. It is
recommended that those drugs that alter test
results be withheld for 12 hours before the study,
although this practice should be confirmed with
the person ordering the test.

Reference Values
Conventional Units

SI Units

Arginine
Men

10 ng/mL

10 g/L

THE PROCEDURE

Women

15 ng/mL

15 g/L

The test is performed on 2 consecutive days, between
the hours of 6 and 8 AM. A venipuncture is
performed and the sample collected in a red-topped
tube. The sample should be handled gently to avoid
hemolysis and sent immediately to the laboratory.

L-Dopa

7 ng/mL above
baseline level

7 g/L

NURSING CARE AFTER THE PROCEDURE

GROWTH HORMONE STIMULATION
TESTS
Baseline levels of GH are affected by many factors
and may be misleading at times. Stimulation tests
are performed to determine responsiveness to
substances that normally stimulate GH secretion,
such as arginine and L-dopa. Insulin also may be
given to induce hypoglycemia, which in turn stimulates GH secretion. It has been found that blood
sugar levels of less than 50 mg/dL cause GH levels to
rise 10 times or more in normal individuals.
Idiosyncratic responses to the different stimulants
may occur. Thus, it may be necessary to perform two
or three different stimulation tests before arriving at
diagnostic conclusions.40
INTERFERING FACTORS

Factors that may affect serum GH determinations
also may alter results of GH stimulation tests.
INDICATIONS FOR GROWTH HORMONE
STIMULATION TESTS

Low or undetectable serum GH levels, with
GH deficiency or adult panhypopituitarism

or insulin

confirmed by no increase after administration of
the stimulant
Confirmation of the diagnosis of acromegaly as
evidenced by reduced GH output after L-dopa is
administered as a stimulant (i.e., an idiosyncratic
response is seen in acromegaly)
Nursing Alert

If insulin is used as the stimulant, the client
should be observed carefully during and after
the test for signs and symptoms of extreme
hypoglycemia.
NURSING CARE BEFORE THE PROCEDURE

Initial client preparation is the same as that for
serum GH determinations.
The client should be weighed on the day of the
test because dosage of the stimulant is determined
by weight.
Because several blood samples will be obtained
and because certain of the stimulants (i.e., insulin
and arginine) are administered IV, the client
should be informed that an intermittent venous
access device (e.g., heparin lock) will be inserted.
THE PROCEDURE

An intermittent venous access device is inserted,
usually at about 8 AM, and a venous sample is
obtained and placed in a red-topped tube. The
sample is handled gently to avoid hemolysis and sent
to the laboratory immediately.
The stimulant is then administered. L-Dopa is
administered orally; arginine and insulin are administered IV in a saline infusion. If insulin is used to
lower blood sugar, an ampule of 50 percent glucose
should be on hand in the event that severe hypoglycemia occurs.
After the stimulant is administered, three blood
samples are obtained via the venous access device at
30-minute intervals. The samples are placed in redtopped tubes and sent to the laboratory immediately
upon collection.

CHAPTER 5—Blood

Chemistry

163

NURSING CARE AFTER THE PROCEDURE

THE PROCEDURE

Care and assessment after the procedure are essentially the same as for serum GH determinations.
If an intermittent venous access device was
inserted for the procedure, remove after completion of the test and apply a pressure bandage to
the site.
If insulin was used as the stimulant, resume
dietary intake as soon as possible after the test is
completed and observe for signs of hypoglycemia.
Complications and precautions: If insulin is
used, note and report signs and symptoms of
hypoglycemia such as sweating, tachycardia,
tremors, irritability, or confusion. Prepare client
for IV glucose administration.

A venipuncture is performed and a sample collected
in a red-topped tube. The sample is handled gently
to avoid hemolysis and sent to the laboratory immediately.
The glucose solution (usually 100 g) is administered orally. If the client is unable to drink or retain
the glucose solution, the physician is notified. IV
glucose may be administered, if necessary, to
perform the test.
After 1 to 2 hours, depending on laboratory
procedures, a second blood sample is collected in a
red-topped tube and sent to the laboratory immediately.

GROWTH HORMONE SUPPRESSION
TEST

Care and assessment after the procedure are the
same as for serum GH determinations.
Complications and precautions: Monitor for
hyperglycemia after ingestion of the glucose solution.

Hyperglycemia suppresses GH secretion in normal
individuals. This principle is used in evaluating individuals with abnormally elevated levels and those
who are believed to be hypersecreting GH but who
show normal levels on routine serum GH determinations. Administration of a glucose load that
produces hyperglycemia should decrease serum GH
levels within 1 to 2 hours. In individuals who are
hypersecreting GH, a decrease in serum GH will not
occur in response to hyperglycemia. Note that the
test may require repetition to confirm results.
Reference Values
Conventional Units
3 ng/dL

SI Units
3 g/L

INTERFERING FACTORS

Factors that may affect serum GH determinations
may also alter results of GH suppression tests.
INDICATIONS FOR GROWTH HORMONE
SUPPRESSION TEST

Elevated serum GH levels
Signs of GH hypersecretion with serum GH levels
within normal limits
Confirmation of GH hypersecretion as indicated
by decreased response to GH suppression
NURSING CARE BEFORE THE PROCEDURE

Initial client preparation is the same as that for
serum GH determinations.
The client should be informed that it will be
necessary to drink an oral glucose solution and
that two blood samples will be obtained.

NURSING CARE AFTER THE PROCEDURE

PROLACTIN
Prolactin (hPRL, LTH) is secreted by the acidophil
cells of the adenohypophysis. It is unique among
hormones in that it responds to inhibition via the
hypothalamus rather than to stimulation; that is,
prolactin is secreted except when influenced by the
hypothalamic inhibiting factor, which is believed to
be the neurotransmitter dopamine.
The only known function of hPRL is to induce
milk production in a female breast already stimulated by high estrogen levels. Once milk production
is established, lactation can continue without
elevated prolactin levels. Levels of hPRL rise late in
pregnancy, peak with the initiation of lactation, and
surge each time a woman breast-feeds. The function
of hPRL in men is not known.
Excessive circulating hPRL disturbs sexual function in both men and women. Women experience
amenorrhea and anovulation, and they may have
inappropriate milk secretion (galactorrhea). Men
experience impotence, which occurs even when
testosterone levels are normal, and sometimes
gynecomastia.41
INTERFERING FACTORS

Therapy with drugs such as estrogens, oral
contraceptives, reserpine, -methyldopa, phenothiazines, haloperidol, tricyclic antidepressants,
and procainamide derivatives may produce
elevated levels.
Episodic elevations may occur in response to
sleep, stress, exercise, and hypoglycemia.

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be handled gently to avoid hemolysis and transported promptly to the laboratory.

Reference Values
Conventional Units

SI Units

Children

1–20 ng/mL

1–20 g/L

Men

1–20 ng/mL

1–20 g/L

Nonlactating

1–25 ng/mL

1–25 g/L

Menopausal

1–20 ng/mL

1–20 g/L

Women

Therapy with dopamine, apomorphine, and ergot
alkaloids may produce decreased levels.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Assess for signs
and symptoms of pituitary conditions such as
mood changes; body image changes; sexual
dysfunction in men; and menstrual, milk secretion, and weight gain abnormalities in women.

ADRENOCORTICOTROPIC HORMONE

INDICATIONS FOR SERUM PROLACTIN TEST

Sexual dysfunction of unknown etiology in men
and women, because excessive circulating hPRL
may indicate the source of the problem (e.g.,
damage to the hypothalamus, pituitary adenoma)
Failure of lactation in the postpartum period or
suspected postpartum hypophyseal infarction
(Sheehan’s syndrome), or both, as indicated by
decreased levels
Suspected tumor involving the lungs or kidneys,
with elevated levels indicating ectopic hPRL
production
Support for diagnosing primary hypothyroidism
as indicated by elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum hPRL levels,
a medication history should be obtained. It is
recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should

Adrenocorticotropic hormone (ACTH) is secreted
by the basophils of the adenohypophysis. ACTH
stimulates the adrenal cortex to secrete (1) glucocorticoids, of which cortisol predominates; (2) adrenal
androgens, which are converted by the liver to
testosterone; and, to a lesser degree, (3) mineralocorticoids, of which aldosterone predominates.
ACTH secretion is closely linked to melanocytestimulating hormone; it also is thought to stimulate
pancreatic cells and the release of GH.
ACTH release, which is stimulated by its corresponding hypothalamic releasing factor, occurs
episodically in relation to decreased circulating
levels of glucocorticoid, increased stress, and hypoglycemia. ACTH levels also vary diurnally; the highest levels occur on awakening, decrease throughout
the day, and then begin to rise again a few hours
before awakening. Circulating aldosterone levels
may influence ACTH secretion to some extent;
however, androgens are believed to have no effect on
ACTH levels. ACTH assays are expensive to perform
and are not universally available.
INTERFERING FACTORS

ACTH levels vary diurnally; highest levels occur
upon awakening, decrease throughout the day,
and then begin to rise again a few hours before
awakening.

Reference Values
Conventional Units

SI Units

BioScience Laboratories

80 pg/mL at 8 AM

17.6 pmol/L

Mayo Clinic

120 pg/mL at 6 to 8 AM

26.4 pmol/L

Note: Normal values vary according to the laboratory performing the test. Results are
usually evaluated in relation to other tests of adrenal-hypophyseal function (e.g., plasma
cortisol).

CHAPTER 5—Blood

Numerous drugs may lead to decreased ACTH
levels (e.g., adrenocorticosteroids, estrogens,
calcium gluconate, amphetamines, spironolactone, and ethanol).
Stress, exercise, and blood glucose levels may
affect results.
INDICATIONS FOR PLASMA ADRENOCORTICOTROPIC
HORMONE TEST

Signs and symptoms of adrenocortical dysfunction:
Elevated ACTH levels with low cortisol levels
indicate adrenocortical hypoactivity (Addison’s
disease).
Low ACTH levels with high cortisol levels indicate adrenocortical hyperactivity (Cushing’s
syndrome) caused by benign or malignant
adrenal tumors.
High ACTH levels, without diurnal variation,
combined with high cortisol levels indicate
adrenocortical hyperfunction caused by excessive ACTH production (e.g., resulting from
pituitary adenoma and nonendocrine malignant tumors in which there is ectopic ACTH
production).
Decreased ACTH levels are associated with
panhypopituitarism, hypothalamic dysfunction, and long-term adrenocorticosteroid
therapy.
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving the collection of a peripheral blood
sample (see Appendix I).
For this test, the client should follow a low-carbohydrate diet for 48 hours and fast from food for 12
hours before the test.
In addition, strenuous exercise should be avoided
for 12 hours before the test, and 1 hour of bed rest
is necessary immediately before the test.
Medications that may alter test results should be
withheld for at least 24 to 48 hours or longer
before the study, although this practice should be
confirmed with the person ordering the test.
The client should be informed that it may be
necessary to obtain more than one sample and
that samples must be obtained at specific times to
detect peak and trough levels of ACTH.
THE PROCEDURE

Between 6 and 8 AM (peak ACTH secretion time), a
venipuncture is performed and the sample collected
in a green-topped tube. The sample must be placed
in a container of ice and sent to the laboratory
immediately. When ACTH hypersecretion is

Chemistry

165

suspected, a second sample may be obtained
between 8 and 10 PM to determine whether diurnal
variation in ACTH levels is occurring.
The ACTH stimulation test can be conducted by
the timed serial laboratory analysis of blood
plasma samples for cortisol levels after the administration of metyrapone. The ACTH suppression
test can be conducted by the laboratory analysis of
blood plasma samples for cortisol levels after the
administration of dexamethasone. The tests are
performed to assist in the diagnosis of Addison’s
disease or Cushing’s syndrome.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods and any medications withheld
before the test, as well as usual activities.
Complications and precautions: Note cortisol
level and its relation to increases in ACTH
production by the pituitary gland.

THYROID-STIMULATING HORMONE
Thyroid-stimulating hormone (TSH) is produced
by the basophil cells of the adenohypophysis in
response to stimulation by its hypothalamic releasing factor, thyrotropin-releasing hormone (TRH).
TRH responds to decreased circulating levels of
thyroid hormones, as well as to intense cold,
psychological tension, and increased metabolic
need, and it stimulates the adenohypophysis to
secrete TSH. TSH accelerates all aspects of hormone
production by the thyroid gland and enhances
hPRL release. Measuring TSH provides useful information about both hypophyseal and thyroid gland
function.
Hypersecretion of TSH by the adenohypophysis
(e.g., because of TSH-secreting pituitary tumors)
causes hyperthyroidism as a result of excessive stimulation of the thyroid gland. Elevated TSH levels are
also seen with prolonged emotional stress and are
more common in colder climates. Primary hypothyroidism (i.e., hypothyroidism caused by disorders
involving the thyroid gland itself) leads to elevated
TSH levels because of normal feedback mechanisms.
TSH levels are normally elevated at birth.
Note that increased TSH secretion is associated
with excess secretion of exophthalmos-producing
substance, which also originates in the adenohypophysis. This substance promotes water storage in
the retro-orbital fat pads and causes the eyes to
protrude, a common sign of hyperthyroidism.
Exophthalmos sometimes persists after the hyper-

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thyroidism is corrected and also may occur in
persons with normal thyroid function.
TSH levels are normal in situations in which the
functional ability of the thyroid gland is normal but
the thyroid hormone levels are low, a phenomenon
that is seen in clients with severe illnesses with
protein deficiency (thyroid hormones are proteins)
such as neoplastic disease, severe burns, trauma,
liver disease, renal failure, and cardiovascular problems. Deficiency of thyroid hormone produces a
hypometabolic state. Excess TSH production is not
stimulated, however, because circulating thyroid
levels are appropriate to the client’s metabolic needs
(i.e., the person is metabolically euthyroid). Treatment involves correcting the underlying causes. The
apparent hypothyroidism is not treated, however,
because such treatment could be devastating to a
severely debilitated person.
TSH is measured by radioimmunoassay.
Immunologic cross-reactivity occurs with glycoprotein hormones such as human chorionic gonadotropin (hCG), follicle-stimulating hormone
(FSH), and luteinizing hormone (LH).
Reference Values
Conventional Units
Newborns
Children and
adults

SI Units

25 IU/mL
by day 3

25 mU/L

10 IU/mL

10 mU/L

INTERFERING FACTORS

Aspirin, adrenocorticosteroids, and heparin may
produce decreased TSH levels.
Lithium carbonate and potassium iodide may
produce elevated TSH levels.
Falsely increased levels may occur in hydatidiform
mole, choriocarcinoma, embryonal carcinoma of
the testes, pregnancy, and postmenopausal states
characterized by high FSH and LH levels.42
INDICATIONS FOR THYROID-STIMULATING
HORMONE TEST

Signs and symptoms of hypothyroidism, hyperthyroidism, or suspected pituitary or hypothalamic dysfunction, or hypothyroidism or
hyperthyroidism combined with suspected pituitary or hypothalamic dysfunction:
Elevated levels are seen with primary hypothyroidism.
Decreased or undetectable levels are associated
with secondary hypothyroidism caused by
pituitary or hypothalamic hypofunction.

Decreased levels are seen with primary hyperthyroidism.
Elevated levels may indicate secondary hyperthyroidism resulting from pituitary hyperactivity (e.g., caused by tumor).
Differentiation of functional euthyroidism from
true hypothyroidism in debilitated individuals,
with the former indicated by normal levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs known to alter TSH
levels be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample is
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
The test for TSH is used on newborns to screen
for congenital hypothyroidism. It is performed by
obtaining a sample of blood from a heelstick and
saturating a spot on a special filter paper with the
blood. A kit is available for this test; it contains a
comparison chart to identify elevations.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Note the relation of TSH to levels of other thyroid tests indicating hypothyroidism as opposed to other
thyroid disorders.

TSH STIMULATION TEST
The TSH stimulation test is used to evaluate the
thyroid–pituitary–hypothalamic feedback loop. In
this test, a purified form of hypothalamic
thyrotropin-releasing hormone (TRH) is administered IV. Normally, TRH stimulates the adenohypophysis to release TSH, which, in turn, causes
hormonal release from the thyroid gland. A normal
response (e.g., elevated TSH levels) indicates that the
adenohypophysis is capable of responding to TRH
stimulation. If thyroid hormones also are measured
as part of the test, elevated levels indicate that the
thyroid gland is capable of responding to TSH stimulation.

CHAPTER 5—Blood

Reference Values
TSH levels rise within 15 to 30 minutes of TRH
administration, peak at 2.5 to 4 times normal,
and return to baseline levels within 2 to 4 hours.
Thyroid hormone secretion (e.g., T3 and T4),
which should be increased by 50 to 75 percent,
occurs in 1 to 4 hours.
INDICATIONS FOR TSH STIMULATION TEST

Low or undetectable serum TSH levels, hypothyroidism, or hyperthyroidism of unknown etiology
or type, or low serum TSH levels combined with
hypothyroidism or hyperthyroidism:
A normal or delayed TSH response in persons
with low baseline TSH levels and signs of
hypothyroidism indicates hypothalamic
dysfunction or disruption of the hypothalamic–hypophyseal portal circulation and
confirms the diagnosis of tertiary hypothyroidism.
A decreased or absent TSH response in persons
with low baseline TSH levels and signs of
hypothyroidism indicates hypopituitarism and
confirms the diagnosis of secondary hypothyroidism.
A normal or increased TSH response in clients
with elevated baseline TSH levels and signs of
hypothyroidism, with persistently decreased
thyroid gland hormone levels, confirms the
diagnosis of primary hypothyroidism.
A decreased or absent TSH response in persons
with low baseline TSH levels and signs of
hyperthyroidism, with persistently elevated
thyroid gland hormone levels, indicates that
thyroid hormone production is occurring
autonomously and confirms the diagnosis of
primary hyperthyroidism.
NURSING CARE BEFORE THE PROCEDURE

Initial client preparation is the same as that for
serum determinations of TSH.
Because several blood samples will be obtained
and because the TRH will be administered IV, the
client should be informed that an intermittent
venous access device (e.g., heparin lock) may be
inserted.
THE PROCEDURE

The procedure varies somewhat according to the
laboratory performing the test. One example of the
procedure is described subsequently.
An intermittent venous access device is inserted
and a venous sample is obtained and placed in a red-

Chemistry

167

topped tube. The sample is handled gently to avoid
hemolysis and sent promptly to the laboratory. The
sample should be labeled either with the time drawn
or as the baseline sample.
A bolus of TRH is then administered IV through
the access device. Additional blood samples are
obtained via the access device 1/2, 1, 2, 3, and 4 hours
after administration of the TRH. Each sample is
placed in a red-topped tube, labeled, and sent to the
laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are essentially the same as for serum TSH determinations.
If an intermittent venous access device was
inserted for the procedure, remove after completion of the test and apply a pressure bandage to
the site.
Complications and precautions: Note increased
levels in relation to other thyroid tests and prepare
client for a nuclear scan laboratory study using
the iodine 131 (131I) radionuclide (see Chapter
20).

FOLLICLE-STIMULATING HORMONE
Follicle-stimulating hormone (FSH) is secreted by
the basophil cells of the adenohypophysis in
response to stimulation by hypothalamic gonadotropin-releasing hormone (GnRH), which also is
called luteinizing hormone–releasing hormone
(LHRH) and follicle-stimulating hormone–releasing factor. FSH affects gonadal function in both men
and women. In women, FSH promotes maturation
of the graafian (germinal) follicle, causing estrogen
secretion and allowing the ovum to mature. In men,
FSH partially controls spermatogenesis, but the
presence of testosterone also is necessary. GnRH
secretion, which in turn stimulates FSH secretion, is
stimulated by decreased estrogen and testosterone
levels. Isolated FSH elevation also may occur when
there is failure to produce spermatozoa, even though
testosterone production is normal. FSH production
is inhibited by rising estrogen and testosterone
levels.
FSH levels are normally low during childhood
but begin to rise as puberty approaches. Surges of
FSH occur initially during sleep but, as puberty
advances, daytime levels also rise. During childbearing years, FSH levels in women vary according
to the menstrual cycle. Decreased FSH levels after
puberty are associated with male and female infertility. After the reproductive years, estrogen and testosterone levels decline, causing FSH levels to rise in
response to normal feedback mechanisms. A 24-

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hour urine specimen also can be collected and tested
for FSH.

FSH/LH CHALLENGE TESTS
The hypothalamic–hypophyseal–gonadal axis can be
evaluated by administering drugs and hormones
known to affect specific hormonal interactions.
These include clomiphene, GnRH, hCG, and progesterone.
Clomiphene, a drug used to treat infertility,
prevents the hypothalamus from recognizing
normally inhibitory levels of estrogen and testosterone. Consequently, the hypothalamus continues
to secrete GnRH, which, in turn, continues to stimulate the adenohypophysis to secrete FSH and LH.
After 5 days of clomiphene, both FSH and LH levels
rise, usually 50 to 100 percent above baseline levels.
In anovulatory women whose ovaries are normal,
clomiphene often enhances FSH and LH levels so
that ovulation is induced. If FSH and LH levels do
not rise with clomiphene administration, either
hypothalamic or hypophyseal dysfunction is indicated. The source of the dysfunction may be identified by administering purified GnRH. If FSH and
LH levels rise, the pituitary gland is normal but
hypothalamic function is impaired. FSH and LH
levels that do not rise indicate hypophyseal dysfunction.
Human chorionic gonadotropin (hCG), a placental hormone with effects similar to those of LH, is
used to evaluate testicular activity in men with low
testosterone levels. Elevated testosterone levels after
hCG administration indicate that testicular function
is normal but that hypothalamic–pituitary activity is
impaired. Failure of testosterone levels to rise
suggests primary testicular dysfunction.

Progesterone, a hormone secreted by the ovary, is
used to evaluate amenorrhea. In the normal
menstrual cycle, the progesterone surge that follows
ovulation inhibits GnRH secretion, and hormonal
levels decline. Menstrual bleeding, also called withdrawal bleeding, occurs when the estrogen-stimulated endometrium experiences a drop in hormonal
stimulation. This normal situation can be simulated
by administering oral or IM progesterone to amenorrheic women already exposed to adequate estrogen levels. If menstrual bleeding occurs, the
underlying cause of the amenorrhea is failure to
ovulate. Lack of bleeding in response to progesterone administration indicates (1) inadequate
estrogen production, resulting from either primary
ovarian failure or inadequate pituitary secretion of
FSH; (2) hypothalamic dysfunction with defective
GnRH secretion; (3) impaired hypophyseal response
to GnRH; or (4) abnormal uterine response to
hormonal stimulation. These possibilities can be
distinguished by administering estrogen to stimulate
the endometrium and then repeating the progesterone challenge. If bleeding occurs, then either
ovarian failure or inadequately responsive hypothalamic–hypophyseal activity is the underlying cause of
the amenorrhea. Measuring FSH, LH, and estrogen
levels helps further to diagnose the problem.43
INTERFERING FACTORS

In menstruating women, values vary in relation to
the phase of the menstrual cycle.
Values are higher in postmenopausal women.
Administration of the drug clomiphene may
result in elevated FSH levels.
Therapy with estrogens, progesterone, and
phenothiazines may result in decreased FSH
levels.44

Reference Values
Conventional Units

SI Units

Children

5–10 mIU/mL

5–10 IU/L

Men

10–15 mIU/mL

10–15 IU/L

Early in cycle

5–25 mIU/mL

5–25 IU/L

Midcycle

20–30 mIU/mL

20–30 IU/L

Luteal phase

5–25 mIU/mL

5–25 IU/L

Women (menopausal)

40–250 mIU/mL

40–250 IU/L

Women (menstruating)

Note: Results should be evaluated in relation to other tests of gonadal function.

CHAPTER 5—Blood

INDICATIONS FOR FOLLICLE-STIMULATING
HORMONE TEST

Evaluation of ambiguous sexual differentiation in
infants
Evaluation of early sexual development in girls
under age 9 years or boys under age 10 years, with
precocious puberty associated with elevated levels
Evaluation of failure of sexual maturation in
adolescence
Evaluation of sexual dysfunction or changes in
secondary sexual characteristics in men and
women:
Elevated levels are associated with ovarian or
testicular failure, with polycystic ovary disease,
after viral orchitis, and with Turner’s syndrome
in women and Klinefelter’s syndrome in men.
Decreased levels may be seen with neoplasms
of the testes, ovaries, and adrenal glands, resulting in excessive production of sex hormones.
Suspected pituitary or hypothalamic dysfunction:
Elevated levels may be seen in pituitary tumors.
Decreased levels are associated with hypothalamic lesions and panhypopituitarism.
Suspected early acromegaly as indicated by
elevated levels
Suspected disorders associated with decreased
FSH levels, such as anorexia nervosa and renal
disease
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs known to alter FSH
levels be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
In women, the phase of the menstrual cycle
should be ascertained, if possible.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Note levels in
relation to 24-hour urinary FSH and LH results.
Prepare client for serial samples for testing.

Chemistry

169

LUTEINIZING HORMONE
Luteinizing hormone is secreted by the basophil cells
of the adenohypophysis in response to stimulation
by GnRH, the same hypothalamic releasing factor
that stimulates FSH release. LH affects gonadal function in both men and women. In women, a surge of
LH occurs at the midpoint of the menstrual cycle
and is believed to be induced by high estrogen levels.
LH causes the ovum to be expelled from the ovary
and stimulates development of the corpus luteum
and production of progesterone. As progesterone
levels rise, LH production decreases. In men, LH
stimulates the interstitial Leydig cells, located in the
testes, to produce testosterone.
During childhood, LH levels decrease and are
lower than those of FSH. Similarly, LH levels rise
after those of FSH as puberty approaches. During the
childbearing years, LH levels in women vary according to the menstrual cycle but remain fairly constant
in men. Decreased LH levels after puberty are associated with male and female infertility. After the reproductive years, as gonadal hormones decline, LH
levels rise in response to normal feedback mechanisms. The rise in LH levels, however, is not as
marked as that for FSH levels. A 24-hour urine specimen also can be collected and tested for LH.
INTERFERING FACTORS

In menstruating women, values vary in relation to
the phase of the menstrual cycle.
Values are higher in postmenopausal women.
Drugs containing estrogen tend to cause elevated
LH levels.
Drugs containing progesterone and testosterone
may lead to decreased levels.
INDICATIONS FOR SERUM LUTEINIZING
HORMONE TEST

Evaluation of male and female infertility, as indicated by decreased levels
Support for diagnosing infertility caused by
anovulation as evidenced by lack of the midcycle
LH surge
Evaluation of response to therapy to induce
ovulation
Suspected pituitary or hypothalamic dysfunction:
Elevated levels may be seen in pituitary tumors.
Decreased levels are associated with hypothalamic lesions and panhypopituitarism.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

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Tests

Reference Values
Conventional Units

SI Units

Children

5–10 mIU/mL

5–10 IU/L

Men

5–20 mIU/mL

5–20 IU/L

Early in cycle

5–25 mIU/mL

5–25 IU/L

Midcycle

40–80 mIU/mL

40–80 IU/L

Luteal phase

5–25 mIU/mL

5–25 IU/L

Women (menopausal)

75 mIU/mL

75 IU/L

Women (menstruating)

Note: Results should be evaluated in relation to other tests of gonadal function.

It is recommended that any drugs known to alter
LH levels be withheld for 12 to 24 hours before
the test, although this practice should be
confirmed with the person ordering the study.
In women, the phase of the menstrual cycle
should be ascertained, if possible.
If the test is being performed to detect ovulation,
the client should be informed that it may be
necessary to obtain a series of samples over a
period of several days to detect peak LH levels.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Psychogenic stimuli (e.g., stress, pain, anxiety) also
may stimulate ADH release, but the mechanism by
which this occurs is unclear.
ADH acts on the epithelial cells of the distal
convoluted tubules and the collecting ducts of the
kidneys, making them permeable to water. Thus,
with ADH, more water is absorbed from the
glomerular filtrate into the bloodstream. Without
ADH, water remains in the filtrate and is excreted,
producing very dilute urine. In contrast, maximal
ADH secretion produces very concentrated urine.
ADH also is believed to stimulate mild contractions
in the pregnant uterus and to aid in promoting milk
ejection in lactation, functions similar to those of
oxytocin, which also is secreted by the hypothalamus
and released by the neurohypophysis.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Abnormal test results, complications, and
precautions: Respond as for FSH testing, because
LH is usually performed on the same blood
sample.

ANTIDIURETIC HORMONE
Antidiuretic hormone (ADH) is formed by the
hypothalamus but is stored in the neurohypophysis
(posterior pituitary gland). ADH is released in
response to increased serum osmolality or decreased
blood volume. Although as little as a 1 percent
change in serum osmolality will stimulate ADH
secretion, blood volume must decrease by approximately 10 percent for ADH secretion to be induced.

Reference Values
Conventional Units
2.3–3.1 pg/mL

SI Units
2.3–3.1 ng/L

INTERFERING FACTORS

Alcohol, phenytoin drugs, -adrenergic drugs,
and morphine antagonists may lead to decreased
ADH secretion.
Acetaminophen, barbiturates, cholinergic agents,
clofibrate, estrogens, nicotine, oral hypoglycemic
agents, cytotoxic agents (e.g., vincristine), tricyclic
antidepressants,
oxytocin,
carbamazepine
(Tegretol), and thiazide diuretics may lead to
increased ADH secretion.45
Pain, stress, and anxiety may lead to increased
ADH secretion.
Failure to follow dietary and exercise restrictions
before the test may alter results.

CHAPTER 5—Blood

INDICATIONS FOR SERUM ANTIDIURETIC
HORMONE TEST

Polyuria or altered serum osmolality of unknown
etiology, or both, to identify possible alterations in
ADH secretion as the cause
Central nervous system trauma, surgery, or
disease that may lead to impaired secretion of
ADH
Differentiation of neurogenic (central) diabetes
insipidus from nephrogenic diabetes insipidus:
Neurogenic diabetes insipidus is characterized
by decreased ADH levels.
ADH levels may be elevated in nephrogenic
diabetes insipidus if normal feedback mechanisms are intact.
Known or suspected malignancy associated with
syndrome of inappropriate ADH (SIADH) secretion (e.g., oat cell lung cancer, thymoma,
lymphoma, leukemia, and carcinoma of the
pancreas, prostate gland, and intestine), with the
disorder indicated by elevated ADH levels
Known or suspected pulmonary conditions associated with SIADH secretion (e.g., tuberculosis,
pneumonia, and positive pressure mechanical
ventilation), with the disorder indicated by
elevated ADH levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving collection of a peripheral blood
sample (see Appendix I).
The client should fast from food and avoid strenuous exercise for 12 hours before the sample is
obtained. It is recommended that drugs that may
alter ADH levels be withheld for 12 to 24 hours
before the study, although this practice should be
confirmed with the person ordering the test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a plastic red-topped tube. Plastic is used
because contact with glass causes degradation of
ADH. The sample should be handled gently to avoid
hemolysis and sent to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Resume food and any medications withheld
before the test, as well as usual activities.
Abnormal levels: Note and report increased levels
in relation to renin level. Assess for fluid volume
excess resulting from sodium and water retention.

Chemistry

171

Monitor I&O, weight gain, edema, and increases
in blood pressure. Instruct in diuretic therapy
regimen. Note and report decreased levels in relation to sodium level. Assess for fluid volume
deficit. Monitor I&O and weight loss. Instruct in
long-term fluid, sodium, and corticosteroid therapy regimen.

Thyroid and Parathyroid
Hormones
The thyroid gland synthesizes and releases thyroxine
(T4) and triiodothyronine (T3) in response to stimulation by TSH, which is secreted by the adenohypophysis. The thyroid gland synthesizes its
hormones from iodine and the essential amino acid
tyrosine. Most of the body’s iodine is ingested as
iodide through dietary intake and is absorbed into
the bloodstream from the gastrointestinal tract.
One-third of the absorbed iodide enters the thyroid
gland; the remaining two-thirds is excreted in the
urine. In the thyroid gland, enzymes oxidize iodide
to iodine.
The thyroid gland secretes a protein, thyroglobulin, into its follicles. Thyroglobulin has special properties that allow the tyrosine contained in its
molecules to react with iodine to form thyroid
hormones. The thyroid hormones thus formed are
stored in the follicles of the gland as the thyroglobulin–thyroid hormone complex called colloid.
When thyroid hormones are released into the
bloodstream, they are split from thyroglobulin as a
result of the action of proteases, which are secreted
by thyroid cells in response to stimulation by TSH.
Much more T4 than T3 is secreted into the bloodstream. Upon entering the bloodstream, both immediately combine with plasma proteins, mainly
thyroxine-binding globulin (TBG), but also with
albumin and prealbumin. Although more than 99
percent of both T4 and T3 are bound to TBG, physiological activity of both hormones results from only
the unbound (“free”) molecules. Note also that TBG
has greater affinity for T4 than for T3, which allows
for more rapid release of T3 from TBG for entry into
body cells. T3 is thought to exert at least 65 to 75
percent of thyroidal hormone effects, and it is
believed by some that T4 has no endocrine activity at
all until it is converted to T3, which occurs when one
iodine molecule is removed from T4.46
The main function of thyroid hormones is to
increase the metabolic activities of most tissues by
increasing the oxidative enzymes in the cells. This
increase, in turn, causes increased oxygen consumption and increased utilization of carbohydrates,

172

SECTION I—Laboratory

Tests

proteins, fats, and vitamins. Thyroid hormones also
mobilize electrolytes and are necessary for the
conversion of carotene to vitamin A. Although the
mechanism is not known, thyroid hormones are
essential for the development of the central nervous
system. Thyroid-deficient infants may suffer irreversible brain damage (cretinism). Thyroid deficiency in adults (myxedema) produces diffuse
psychomotor retardation, which is reversible with
hormone replacement. Thyroid hormones also are
thought to increase the rate of parathyroid hormone
secretion.
Alterations in thyroid hormone production may
be caused by disorders affecting the hypothalamus,
which secretes thyrotropin-releasing hormone in
response to circulating T4 and T3 levels; the pituitary
gland; or the thyroid gland itself. Such alterations
may affect all body systems. Hypothyroidism is the
general term for the hypometabolic state induced by
deficient thyroid hormone secretion, whereas hyperthyroidism indicates excessive production of thyroid
hormones.
An additional hormone produced by the thyroid
gland is calcitonin, which is secreted in response to
high serum calcium levels. Calcitonin causes an
increase in calcium reabsorption by bone, thus
lowering serum calcium.47
A number of tests pertaining to thyroid hormones
may be performed, some of which may be grouped
as a “thyroid screen” (e.g., T4, T3, and TSH). A “T7”
is sometimes ordered. This is interpreted as a T4 plus
a T3, because there is no such substance as T7. Before
it was possible to measure thyroid hormones
directly, serum iodine measurements (e.g., proteinbound iodine) were used as indicators of thyroid
function. These tests were severely affected by
organic and inorganic iodine contaminants and are
no longer used to any great extent. Similarly, measurement of thyroidal uptake of radioactive iodine
(131I) has been replaced by direct measurements of
T4 and TSH.48

THYROXINE
Thyroxine (T4) is measured by competitive protein
binding or by radioimmunoassay. In competitive
protein binding, the affinity between T4 and TBG is
exploited. Reagent TBG fully saturated with radiolabeled T4 is incubated with T4 extracted from the
client’s serum. TheT4 from the test serum displaces
the radiolabeled T4 in the amount present. This
procedure is known as T4 by displacement (T4 D), T4
by competitive binding (T4 CPB), and T4 MurphyPattee (T4 MP). T4 measured by radioimmunoassay
(T4 RIA) is the preferred method to measure T4

because it is not affected by circulating iodinated
substances.
Most T4 (99.97 percent) in the serum is bound to
TBG. The remainder circulates as unbound (“free”)
T4 (FT4) and is responsible for all of the physiological activity of thyroxine. Because FT4 is not dependent on normal levels of TBG, as is the case with total
serum thyroxine, FT4 levels are considered the most
accurate indicator of thyroxine and its thyrometabolic activity. It is difficult, however, to measure FT4
directly because quantities are so small and the
interference from bound T4 is great. Free hormone
levels are, therefore, usually calculated by multiplying the values for total T4 by the T3 uptake ratio. The
result is expressed as the free thyroxine index (FT4 I).
The free hormone index varies directly with the
amount of circulating hormone and inversely with
the amount of unsaturated TBG present in the
serum.49
Reference Values
Conventional Units

SI Units

T4 D
Newborns 11.0–23.0 g/dL

140–230 nmol/L

1–4 mo

7.5–16.5 g/dL

95–200 nmol/L

4–12 mo

5.5–14.5 g/dL

70–185 nmol/L

Children

5.0–13.5 g/dL

65–170 nmol/L

Adults

4.5–13.0 g/dL

60–165 nmol/L

T4 RIA

4.0–12.0 g/dL

50–150 nmol/L

FT4

0.9–2.3 ng/dL

10–30 nmol/L

Note: Values may vary according to the laboratory performing the test. Results should be evaluated in relation to
other tests of thyroid function.
INTERFERING FACTORS

Results of T4 D may be altered by circulating iodinated substances; T4 RIA is not similarly affected.
Pregnancy, estrogen therapy, or estrogen-secreting tumors may produce elevated T4 levels.
Ingestion of thyroxine will elevate T4 levels.
Heroin and methadone may produce elevated T4
levels.
Androgens, glucocorticoids, heparin, salicylates,
phenytoin anticonvulsants, sulfonamides, and
antithyroid drugs such as propylthiouracil may
lead to decreased T4 levels.
INDICATIONS FOR THYROXINE TEST

Signs of hypothyroidism, hyperthyroidism, or
neonatal screening for congenital hypothyroidism

CHAPTER 5—Blood

(required in many states), or hypothyroidism
or hyperthyroidism combined with neonatal
screening:
Decreased T4 and FT4 levels indicate hypothyroid states and also may be seen in early
thyroiditis.
Elevated T4 and FT4 levels indicate hyperthyroid states.
Normal T4 and FT4 levels in clients with signs
of hyperthyroidism may indicate T3 thyrotoxicosis.
Normal FT4 levels are seen in pregnancy,
whereas T4 and TBG are usually elevated.
Monitoring of response to therapy for hypothyroidism or hyperthyroidism:
Elevated T4 and FT4 levels indicate response to
treatment for hypothyroidism.
Decreased T4 and FT4 levels indicate response
to treatment for hyperthyroidism.
Evaluation of thyroid response to protein deficiency associated with severe illnesses (e.g.,
metastatic cancer, liver disease, renal disease,
diabetes mellitus, cardiovascular disorders, burns,
and trauma):
T4 is decreased in such disorders because of a
deficiency of TBG, a protein.
FT4 index is normal, if thyroid function is
normal, because FT4 index is not dependent on
TBG levels.

Chemistry

173

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels
and relation to other thyroid tests and procedures
performed. Assess for signs and symptoms of
hyperthyroidism such as tachycardia, increased
appetite, diaphoresis, elevated temperature,
exophthalmos, weight loss, insomnia, hyperactivity, or inability to handle stress. Prepare for possible radionuclide therapy or surgical intervention.
Administer ordered medications to reduce levels.
Instruct in adequate fluid and nutritional dietary
intake and eye care for exophthalmos. Instruct
client to avoid stressful situations.
Decreased levels: Note and report decreased
levels and relation to other thyroid tests and
proce-dures. Assess for cold intolerance, weight
gain, skin changes, constipation, lethargy, or
fatigue. Administer ordered replacement therapy.
Instruct client in appropriate fluid and low caloric
nutritional dietary intake, long-term thyroid
medication regimen, control of environment
for relaxation and warmth, and care of skin and
hair. Instruct client to avoid sedatives to promote
sleep.

NURSING CARE BEFORE THE PROCEDURE

TRIIODOTHYRONINE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
It is usually recommended that thyroid medications be withheld for 1 month before the test and
that other drugs that may alter thyroxine levels be
withheld for at least 24 hours before the study.
This practice should be confirmed, however, with
the person ordering the test.
For infants, explain to the parent(s) the purpose
of the test and that it may require repetition in 3
to 6 weeks because of normal changes in infant
thyroid hormone levels.

Although produced in smaller quantities than T4,
triiodothyronine (T3) is physiologically more significant. The competitive protein-binding techniques
that are useful in measuring T4 are not used to measure T3 because it is present in smaller amounts and
has less affinity for TBG than for T4. Thus, T3 is
measured only by radioimmunoassay (T3 RIA).
As with T4, most T3 (99.7 percent) in the serum is
bound to TBG. The remainder circulates as
unbound (“free”) T3 (FT3) and is responsible for all
of the physiological activity of T3. Because FT3 is not
dependent on normal levels of TBG, as is the case
with total T3, FT3 levels are the most accurate indicators of thyrometabolic activity. FT3 levels may be
calculated by multiplying total T3 levels by the T3
uptake ratio.

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
For neonatal screening, the sample is obtained by
heelstick. A multiple neonatal screening kit is
usually used; the directions provided with the kit
must be followed carefully.

INDICATIONS FOR TRIIODOTHYRONINE TEST

Support for diagnosing hyperthyroidism in
clients with normal T4 levels, with early hyperthyroidism and T3 thyrotoxicosis indicated by
elevated T3 levels in the presence of normal T4
levels

174

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

T3 RIA
Newborns

90–170 ng/dL

1.3–2.6 nmol/L

Adults

80–200 ng/dL

1.2–3.0 nmol/L

FT3

0.2–0.6 ng/dL

0.003–0.009 nmol/L

Reverse triiodothyronine (rT3)

38–44 ng/dL

0.58–0.67 nmol/L

Support for diagnosing “euthyroid sick”
syndrome in severely ill clients with protein deficiency, as indicated by low T3 levels, normal FT3
levels, and elevated rT3 levels50

the RT3 U level determined from a pool of normal
serum
Reference Values
Conventional Units

SI Units

T3 resin uptake

25–35%

0.25–0.35

T3 uptake ratio

0.1–1.35

0.1–0.35

NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving collection of a peripheral blood
sample (see Appendix I).
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

T3 UPTAKE
The T3 uptake (RT3 U) test evaluates the quantity of
TBG in the serum and the quantity of thyroxine (T4)
bound to it. In the T3 uptake procedure, a known
amount of resin containing radiolabeled T3 is added
to a sample of the client’s serum. Normally, TBG in
the serum is not fully saturated with thyroid
hormones; the saturation level varies in relation to
the amounts of TBG and thyroid hormones present.
In the T3 uptake test, the radiolabeled T3 binds with
available TBG sites. Results of the test are determined by measuring the percentage of labeled T3
that remains bound to the resin after all available
sites on TBG have been filled. Note that the percentage of T3 bound to the resin is inversely proportional
to the percentage of TBG saturation in the serum.
Results of the T3 uptake test are evaluated in relation to serum levels of total T4 and T3 and also are
used in calculating FT3 and FT4 indices. For these
calculations, the T3 uptake ratio (RT3 UR) is used, a
ratio obtained by dividing the client’s RT3 U level by

INTERFERING FACTORS

Drugs that alter TBG levels or that compete for
TBG-binding sites may affect test results.
Estrogens may lead to increased TBG levels.
Androgens and glucocorticoids may lead to
decreased TBG levels.
Salicylates and phenytoin anticonvulsants
compete with T4 for TBG-binding sites.
Results may vary during pregnancy when TBG
levels are usually elevated.
INDICATIONS FOR T3 UPTAKE TEST

Signs of hypothyroidism or hyperthyroidism:
Decreased levels (indicating a low percentage of
radiolabeled T3 remaining) indicate low serum
T4 levels and hypothyroidism.
Elevated levels (indicating a high percentage of
radiolabeled T3 remaining) indicate high
serum T4 levels and hyperthyroidism.
Known or suspected problems associated with
altered TBG levels (e.g., hereditary abnormality of
TBG synthesis, drug therapy, pregnancy, and
disorders associated with decreased serum
proteins):
Elevated levels may indicate low TBG levels.
Decreased levels may indicate elevated TBG
levels.
Monitoring for response to therapy with drugs
that compete with T4 for TBG-binding sites:
Elevated levels may indicate that TBG-binding
sites are saturated with competing drugs.
Calculation of free T3 and T4 indices

CHAPTER 5—Blood

NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
It is recommended that drugs that alter TBG
levels or compete for TBG-binding sites be withheld for 12 to 24 hours before the test, although
this practice should be confirmed with the person
ordering the study.
THE PROCEDURE

Chemistry

Diagnosis of hereditary abnormality of globulin
synthesis, indicated by decreased levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
It is recommended that drugs that may alter TBG
levels be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the
test.

NURSING CARE AFTER THE PROCEDURE

THYROXINE-BINDING GLOBULIN

THYROID-STIMULATING
IMMUNOGLOBULINS

Thyroxine-binding globulin (TBG) may be measured directly by radioimmunoassay. Estrogens
elevate serum TBG levels; thus, women who are
pregnant, who are receiving estrogen therapy or oral
contraceptives, or who have estrogen-secreting
tumors have higher TBG levels.
Reference Values
Conventional Units
16–32 g/dL

SI Units
120–180 mg/mL

INTERFERING FACTORS

Estrogens elevate serum TBG levels and, thus,
women who are pregnant, who are receiving
estrogen therapy or oral contraceptives, or who
have estrogen-secreting tumors have higher TBG
levels.
Androgens and corticosteriods decrease serum
TBG levels.
INDICATIONS FOR THYROXINE-BINDING
GLOBULIN TEST

Signs and symptoms of hypothyroidism or hyperthyroidism in conditions associated with altered
TBG levels (e.g., pregnancy), to differentiate true
thyroid disorders from problems related to altered
TBG levels

175

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Resume any medications withheld before the test.

The globulin formerly known as long-acting thyroid
stimulator (LATS) is one of the biologically unique
autoantibodies with the effect of stimulating the
target cell. Now called thyroid-stimulating
immunoglobulins (TSI, TSIg), these antibodies react
with the cell surface receptor that usually combines
with TSH. The TSI reacts with the receptors, activates intracellular enzymes, and promotes epithelial
cell activity that operates outside the feedback regulation for TSH.
Reference Values
TSI is not normally detected in the serum,
although it may be found in the serum of about
5 percent of people without apparent hyperthyroidism or exophthalmos.
INTERFERING FACTORS

Administration of radioactive iodine preparations
within 24 hours of the test may alter results.
INDICATIONS FOR THYROID-STIMULATING
IMMUNOGLOBULINS TEST

Known or suspected thyrotoxicosis with elevated
levels found in 50 to 80 percent of affected individuals

176

SECTION I—Laboratory

Tests

Determination of possible etiology of exophthalmos as indicated by elevated levels
Monitoring of response to treatment for thyrotoxicosis with possible relapse indicated by
elevated levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
The client should not have received any radioactive iodine preparations within 24 hours of the
test.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

CALCITONIN
Calcitonin, also called thyrocalcitonin, is secreted by
the parafollicular or C cells of the thyroid gland in
response to elevated serum calcium levels. Its role is
not completely understood, but the following functions are known: (1) It antagonizes the effects of
parathyroid hormone and vitamin D, (2) it inhibits
osteoclasts that reabsorb bone so that calcium
continues to be laid down and not reabsorbed into
the blood, and (3) it increases renal clearance of
magnesium and inhibits tubular reabsorption of
phosphates. The net result is that calcitonin
decreases serum calcium levels.

tonin levels, when serum calcium levels are
normal. (Further verification may require raising
the serum calcium level by IV infusion of calcium
or pentagastrin and measuring the level to which
plasma calcitonin rises in response; a rise of 0.105
to 0.11 ng/mL is to be expected.)
Altered serum calcium levels of unknown etiology
may be caused by a disorder associated with
altered calcitonin levels.
Elevated calcitonin levels are seen in cancers
involving the breast, lung, and pancreas as a result
of ectopic calcitonin production by tumor cells.
Elevated calcitonin levels also are seen in primary
hyperparathyroidism and in secondary hyperparathyroidism resulting from chronic renal failure.
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving the collection of a peripheral
blood sample (see Appendix I).
For this test, the client should fast from food for at
least 8 hours before collection of the sample.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a green-topped tube. The sample should
be handled gently to avoid hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving collection of a
peripheral blood sample.
Resume foods withheld before the test.
Complications and precautions: Note increased
levels. Assess in relation to calcium and parathyroid hormone levels. Prepare the client for subsequent treatment decisions (medication protocol,
surgery).

Reference Values
Conventional Units

SI Units

Men

0.155 ng/mL

0.155 g/L

Women

0.105 ng/mL

0.105 g/L

INTERFERING FACTORS

Failure to fast from food for 8 hours before the
test may alter results.
INDICATIONS FOR CALCITONIN TEST

Support for diagnosing medullary carcinoma of
the thyroid gland is indicated by elevated calci-

PARATHYROID HORMONE
Parathyroid hormone (PTH, parathormone) is
secreted by the parathyroid glands in response to
decreased levels of circulating calcium. Actions of
PTH include (1) mobilizing calcium from bone into
the bloodstream, along with phosphates and protein
matrix; (2) promoting renal tubular reabsorption of
calcium and depression of phosphate reabsorption,
thereby reducing calcium excretion and increasing
phosphate excretion by the kidneys; (3) decreasing
renal secretion of hydrogen ions, which leads to
increased renal excretion of bicarbonate and chloride; and (4) enhancing renal production of active

CHAPTER 5—Blood

Chemistry

177

vitamin D metabolites, causing increased calcium
absorption in the small intestine. The net result of
PTH action is maintenance of adequate serum
calcium levels.

calcium also may be obtained. The sample(s) should
be handled gently to avoid hemolysis and transported promptly to the laboratory.

Reference Values

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume foods withheld before the test.
Increased levels: Note and report increased levels
in relation to calcium and phosphate levels. Assess
for signs and symptoms of hypercalcemia (greater
than 10.5 mg/dL) leading to renal calculi formation, susceptibility to fractures, sluggishness,
lethargy, anorexia, and constipation. Instruct in
dietary restriction of calcium, medication regimen (corticosteroids, antineoplastics, phosphates), or signs and symptoms of hypophosphatemia (less than 3 mg/dL) such as irritability, confusion, and functional deficits.
Instruct in dietary intake of foods rich in phosphorus and medication replacement regimen.
Decreased levels: Note and report decreased levels
in relation to calcium levels. Assess for signs and
symptoms of hypocalcemia (less than 8.5 mg/dL),
such as muscle cramping and spasms of hands and
feet. In mild cases, instruct in dietary intake of
calcium and vitamin D supplements; in severe
states, prepare for IV administration of calcium.

Conventional Units
2.3–2.8 pmol/L

SI Units
23–28 g/mL

Note: PTH is measured by radioimmunoassay. Because the
antibody used for the assay directly affects the results,
values vary according to the laboratory performing the
test.

INTERFERING FACTORS

Failure to fast from food for 8 hours before the
test may alter results.
INDICATIONS FOR PARATHYROID HORMONE
TEST

Suspected hyperparathyroidism:
Elevated levels occur in primary hyperparathyroidism as a result of hyperplasia or tumor of
the parathyroid glands.
Elevated levels also may occur in secondary
hyperparathyroidism (usually as a result of
chronic renal failure, malignant tumors that
produce ectopic PTH, and malabsorption
syndromes).
Suspected surgical removal of the parathyroid
glands or incidental damage to them during
thyroid or neck surgery, as indicated by decreased
levels
Evaluation of parathyroid response to altered
serum calcium levels, with elevated serum
calcium levels, especially those resulting from
malignant processes, leading to decreased PTH
production
Evaluation of parathyroid response to other
disorders that may lead to decreased PTH
production (e.g., hypomagnesemia, autoimmune
destruction of the parathyroid glands)51
NURSING CARE BEFORE THE PROCEDURE

Client preparation is essentially the same as that for
any study involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast from food for at
least 8 hours before collection of the sample.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. A sample for serum

NURSING CARE AFTER THE PROCEDURE

Adrenal Hormones
Adrenal hormones are secreted by two functionally
and embryologically distinct portions of the adrenal
gland. The adrenal cortex, which is of mesodermal
origin, secretes three types of steroids: (1) glucocorticoids, which affect carbohydrate metabolism; (2)
mineralocorticoids, which promote potassium
excretion and sodium retention by the kidneys; and
(3) adrenal androgens, which the liver converts to
testosterone. Cortisol is the predominant glucocorticoid, whereas aldosterone is the predominant
mineralocorticoid. Production and secretion of
cortisol and adrenal androgens are stimulated by
ACTH. Although ACTH also may enhance aldosterone production, the usual stimulants are either
increased serum potassium or decreased serum
sodium.
The adrenal medulla, which constitutes only
about one-tenth of the volume of the adrenal glands,
derives from the ectoderm and physiologically
belongs to the sympathetic nervous system. The
hormones secreted by the adrenal medulla are
epinephrine and norepinephrine, which are collectively known as the catecholamines. Epinephrine is

178

SECTION I—Laboratory

Tests

secreted in response to sympathetic stimulation,
hypoglycemia, or hypotension. Most norepinephrine is manufactured by and secreted from sympathetic nerve endings; only a small amount is
normally secreted by the adrenal medulla.52

CORTISOL
Cortisol (hydrocortisone), the predominant glucocorticoid, is secreted in response to stimulation by
ACTH. Ninety percent of cortisol is bound to cortisol-binding globulin (CBG) and albumin; the free
portion is responsible for its physiological effects.
Cortisol stimulates gluconeogenesis, mobilizes fats
and proteins, antagonizes insulin, and suppresses
inflammation. Cortisol secretion varies diurnally,
with the highest levels seen upon awakening and the
lowest levels occurring late in the day. Bursts of
cortisol excretion also may occur at night.
Elevated cortisol levels occur in Cushing’s
syndrome, in which there is excessive production of
adrenocorticosteroids. Cushing’s syndrome may be
caused by pituitary adenoma, adrenal hyperplasia,
benign or malignant adrenal tumors, and nonendocrine malignant tumors that secrete ectopic
ACTH. Therapy with adrenocorticosteroids also
may produce cushingoid signs and symptoms.
Elevated cortisol levels are additionally associated
with stress, hyperthyroidism, obesity, and diabetic
ketoacidosis.
Decreased cortisol levels occur with Addison’s
disease, in which there is deficient production of
adrenocorticosteroids. Addison’s disease is usually
caused by idiopathic adrenal hypofunction,
although it may also be seen in pituitary hypofunction, hypothyroidism, tuberculosis, metastatic
cancer involving the adrenal glands, amyloidosis,
and hemochromatosis. Addison’s disease may occur
after withdrawal of corticosteroid therapy because of
drug-induced atrophy of the adrenal glands.

CORTISOL/ACTH CHALLENGE TESTS
A variety of tests that stimulate or suppress cortisol/ACTH levels can be used further to evaluate

individuals with signs and symptoms of adrenal
hypofunction or hyperfunction or abnormal cortisol
levels.
Dexamethasone is a potent glucocorticoid that
suppresses ACTH and cortisol production. In the
rapid dexamethasone test, 1 mg of oral dexamethasone is given at midnight; cortisol levels are then
measured at 8 AM. Normally, plasma cortisol should
be no more than 5 to 10 mg/dL after dexamethasone
administration. A 5-hour urine collection test for
17-hydroxycorticoids (17-OHCS), metabolites of
glucocorticoids, also may be collected as part of the
test. Elevated plasma cortisol levels in response to
dexamethasone administration are associated with
Cushing’s syndrome.
Metyrapone is a drug that inhibits certain
enzymes required to convert precursor substances
into cortisol. When the drug is administered, plasma
cortisol levels decrease and ACTH levels subsequently increase in response. The test involves
mainly measurement of urinary excretion of 17OHCS, which should rise if the adenohypophysis is
normally responsive to decreased cortisol levels.
Plasma cortisol levels are measured to ensure that
sufficient suppression has been induced by the
metyrapone such that test results will be valid.
Insulin-induced hypoglycemia (serum glucose of
50 mg/dL or less) also stimulates ACTH production.
Adenohypophyseal response to hypoglycemia is
usually measured indirectly by plasma cortisol levels
because the test is more universally available. A
normal response is an increase of 6 g/dL or more
over baseline cortisol levels. Lack of response to
hypoglycemic stimulation indicates either pituitary
or adrenal hypofunction. They can be differentiated
either by directly measuring plasma ACTH levels or
by administering ACTH preparations and observing
cortisol response.
Purified exogenous ACTH or synthetic ACTH
preparations (e.g., cosyntropin) may be used diagnostically to stimulate cortisol secretion. The usual
response is an increase in plasma cortisol levels of 7
to 18 g/dL over baseline levels within 1 hour of
ACTH administration. Lack of response indicates
adrenal insufficiency.53

Reference Values
8 AM
Conventional Units

4 PM
SI Units

Conventional Units

SI Units

Children

15–25 g /dL

410–690 nmol/L

5–10 g/dL

140–280 nmol/L

Adults

9–24 g /dL

250–690 nmol/L

3–12 g/dL

80–330 nmol/L

CHAPTER 5—Blood

INTERFERING FACTORS

The time of day when the test is performed may
alter results because cortisol levels vary diurnally,
with highest levels being seen on awakening and
lowest levels occurring late in the day.
Stress and excessive physical activity may produce
elevated levels.
Pregnancy, therapy with estrogen-containing
drugs, lithium carbonate, methadone, and ethyl
alcohol may lead to elevated cortisol levels.
Therapy with levodopa, barbiturates, phenytoin
(Dilantin), and androgens may produce decreased
levels.
Failure to follow dietary restrictions, if ordered,
may alter test results.
INDICATIONS FOR CORTISOL ASSAY

Suspected adrenal hyperfunction (Cushing’s
syndrome) from a variety of causes, as indicated
by elevated levels that do not vary diurnally
Evaluation of effects of disorders associated with
elevated cortisol levels (e.g., hyperthyroidism,
obesity, and diabetic ketoacidosis)
Suspected adrenal hypofunction (Addison’s
disease) from a variety of causes, as indicated by
decreased levels
Monitoring for response to therapy with adrenocorticosteroids:
Elevated levels are seen in clients receiving
adrenocorticosteroid therapy.
Decreased levels may occur for months after
therapy is discontinued, resulting from druginduced atrophy of the adrenal glands.
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
Some laboratories require an 8-hour fast and
activity restriction before the test. Medications
that may alter cortisol levels should be withheld
for 12 to 24 hours before the study, although this
practice should be confirmed with the person
ordering the test.
The client should be informed that it may be
necessary to obtain more than one sample and
that samples must be obtained at specific times to
detect peak and trough levels of cortisol.
THE PROCEDURE

At approximately 8 AM, a venipuncture is performed
and the sample is collected in a green-topped tube.
The sample should be handled gently to avoid
hemolysis and sent promptly to the laboratory. If
cortisol hypersecretion is suspected, then a second

Chemistry

179

sample may be obtained at approximately 4 PM to
determine whether diurnal variation in cortisol
levels is occurring.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume food and any medications withheld
before the test, as well as usual activities.
Increased levels: Note and report increased levels
in relation to urinary cortisol, serum glucose, and
calcium. Assess potential for infection, fluid
volume excess (weight gain, edema, increased
blood pressure), hyperglycemia (thirst, polyuria,
polydipsia), mood changes (euphoria, psychosis),
poor body image (moon face, buffalo hump on
the back, acne, hair growth in undesirable areas in
women, obese trunk, and thin extremities), and
bone or joint pain. Monitor I&O. Provide support
for psychophysiological changes. Help client to
develop coping skills. Instruct client to increase
dietary protein; decrease sodium, calories, and
carbohydrates; and avoid infections.
Decreased levels: Note and report decreased
levels in relation to electrolyte panel (hyponatremia, hyperkalemia) and serum glucose for
hypoglycemia. Assess for fluid volume deficit,
long-term administration of corticosteroid therapy, and changes in body image (pigmentation of
the skin, masculinization in women). Monitor
I&O. Administer ordered corticosteroid regimen.
Provide support for physical changes affecting
body image. Advise client to avoid situations that
cause stress or anxiety. Instruct client in longterm supplemental or replacement cortisone regimen.

ALDOSTERONE
Aldosterone, the predominant mineralocorticoid, is
secreted by the zona glomerulosa of the adrenal
cortex in response to decreased serum sodium,
decreased blood volume, and increased serum
potassium. It is thought that altered serum sodium
and potassium levels directly stimulate the adrenal
cortex to release aldosterone. In addition, decreased
blood volume and altered sodium and potassium
levels stimulate the juxtaglomerular apparatus of the
kidney to secrete renin. Renin is subsequently
converted to angiotensin II, which then stimulates
the adrenal cortex to secrete aldosterone. In normal
states, ACTH does not play a major role in aldosterone secretion. In disease or stress states, however,
ACTH may also enhance aldosterone secretion.

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Aldosterone increases sodium reabsorption in the
renal tubules, gastrointestinal tract, salivary glands,
and sweat glands. This subsequently results in
increased water retention, blood volume, and blood
pressure. Aldosterone also increases potassium
excretion by the kidneys in exchange for the sodium
ions that are retained.

ALDOSTERONE CHALLENGE TESTS
In normal individuals, increased serum sodium
levels and blood volume suppress aldosterone secretion. In primary aldosteronism, however, this
response is not seen. Serum sodium levels may be
elevated through ingestion of a high-sodium diet for
approximately 4 days or by infusing 2 L of normal
saline intravenously. If appropriate control of aldosterone levels is managed through negative feedback
systems and the renin–angiotensin system, plasma
aldosterone levels will be low normal or decreased in
response to the increased sodium load.
Fludrocortisone acetate (Florinef), a synthetic
mineralocorticoid, produces the same effect after 3
days of administration. Aldosterone challenges are
used to differentiate between primary and secondary
hyperaldosteronism.54
Reference Values
Conventional Units

SI Units

Supine

3–9 ng/dL

0.08–0.30 nmol/L

Standing

5–30 ng/dL

0.14–0.80 nmol/L

INTERFERING FACTORS

Upright body posture (see “Nursing Care Before
the Procedure” section), stress, and late pregnancy
may lead to increased levels.
Therapy with diuretics, hydralazine (Apresoline),
diazoxide (Hyperstat), and nitroprusside may lead
to elevated levels.
Excessive licorice ingestion may produce
decreased levels, as may therapy with propranolol
and fludrocortisone (Florinef).
Altered serum electrolyte levels affect aldosterone
secretion.
Decreased serum sodium and elevated serum
potassium increase aldosterone secretion.
Elevated serum sodium and decreased serum
potassium suppress aldosterone secretion.
INDICATIONS FOR PLASMA ALDOSTERONE TEST

Suspected hyperaldosteronism as indicated by
elevated levels:

Primary aldosteronism (e.g., resulting from
benign adenomas or bilateral hyperplasia of
the aldosterone-secreting zona glomerulosa
cells) is indicated by elevated aldosterone and
low plasma renin levels.
Secondary hyperaldosteronism (e.g., resulting
from changes in blood volume and serum
electrolytes, CHF, cirrhosis, nephrotic syndrome, chronic obstructive pulmonary disease
[COPD], and renal artery stenosis) is indicated
by elevated aldosterone and plasma renin levels.
Suspected hypoaldosteronism (e.g., as seen in
diabetes mellitus and toxemia of pregnancy) as
indicated by decreased levels
Evaluation of hypertension of unknown etiology
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving the collection of a peripheral blood
sample (see Appendix I).
The client should not have ingested licorice for 2
weeks before the test. Medications that alter
plasma aldosterone levels also may be withheld
for up to 2 weeks before the test, although this
practice should be confirmed with the person
ordering the study.
If hospitalized, the client should be told not to get
out of bed in the morning until the sample has
been obtained and that it may be necessary to
obtain a second sample after he or she has been up
for about 2 to 4 hours.
Nonhospitalized individuals should be instructed
on when to report to the laboratory in relation to
the length of time to be upright before the test.
THE PROCEDURE

A venipuncture is performed and the sample is
collected in a red-, green-, or lavender-topped tube,
depending on laboratory procedures. The client’s
position and length of time the position was held
should be noted on the laboratory request form. The
sample(s) should be handled gently to avoid hemolysis and sent to the laboratory immediately. A
sample for plasma renin also may be obtained in
conjunction with the test.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels
related to urinary aldosterone levels. Assess for
fluid volume excess caused by sodium and fluid
retention, and administer ordered diuretics.

CHAPTER 5—Blood

Chemistry

181

Reference Values
Conventional Units
Epinephrine and norepinephrine

SI Units

100–500 ng/L

Epinephrine
Supine

0–110 pg/mL

0–600 pmol/L

Standing

0–140 pg/mL

0–764 pmol/L

Supine

70–750 pg/mL

413–4432 pmol/L

Standing

200–1700 pg/mL

1,182–10,047 pmol/L

Norepinephrine

Note: Results are usually evaluated in relation to urinary measurements of catecholamine metabolites. Several
measurements of plasma levels may also be indicated.

Decreased levels: Note and report decreased
levels related to sodium levels. Assess for fluid
volume deficit. Instruct in sodium and corticosteroid replacement regimen.

CATECHOLAMINES
The adrenal medulla, a component of the sympathetic nervous system, secretes epinephrine and
norepinephrine, which are collectively known as the
catecholamines. A third catecholamine, dopamine, is
secreted in the brain, where it functions as a neurotransmitter.
Epinephrine (adrenalin) is secreted in response to
generalized sympathetic stimulation, hypoglycemia,
or arterial hypotension. It increases the metabolic
rate of all cells, heart rate, arterial blood pressure,
and levels of blood glucose and free fatty acids, and
it decreases peripheral resistance and blood flow to
the skin and kidneys.
Norepinephrine is secreted by sympathetic nerve
endings, as well as by the adrenal medulla, in
response to sympathetic stimulation and the presence of tyramine. It decreases the heart rate, while
increasing peripheral vascular resistance and arterial
blood pressure. Normally, norepinephrine is the
predominant catecholamine.
The only clinically significant disorder involving
the adrenal medulla is the catecholamine-secreting
tumor, pheochromocytoma. Catecholamineproducing tumors also can originate along sympathetic paraganglia; these tumors are known as
functional paragangliomas. Pheochromocytomas
may release catecholamines, primarily epinephrine,
continuously or intermittently. Because the most
common sign of pheochromocytoma is arterial
hypertension, measurement of plasma catecholamines (or the urinary metabolites thereof) is indicated in evaluating new-onset hypertension.55

INTERFERING FACTORS

Catecholamine levels vary diurnally and with
postural changes.
Shock, stress, hyperthyroidism, strenuous exercise, and smoking may produce elevated plasma
catecholamines.
Dopamine, norepinephrine (Levophed), sympathomimetic drugs, tricyclic antidepressants, methyldopa, hydralazine, quinidine, and
isoproterenol (Isuprel) may produce elevated
levels.
A diet high in amines (e.g., bananas, nuts, cereal
grains, tea, coffee, cocoa, aged cheese, beer, ale,
certain wines, avocados, and fava beans) may
produce elevated plasma catecholamine levels,
although this effect is more likely to be seen in
relation to certain urinary metabolites.
INDICATIONS FOR PLASMA CATECHOLAMINES
TEST

Hypertension of unknown etiology or suspected
pheochromocytoma or paragangliomas or both
Identification of pheochromocytoma as the cause
of hypertension as indicated by elevated combined catecholamine and epinephrine levels
Support for diagnosing paragangliomas as indicated by elevated combined catecholamine and
norepinephrine levels
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving the collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast for 12 hours
and abstain from smoking for 24 hours before the
test. Vigorous exercise should be avoided, with
provision made for rest in a recumbent position
for at least 1 hour before the study.

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Tests

Medications that may alter test results, especially
over-the-counter cold preparations containing
sympathomimetics, may be withheld for up to 2
weeks before the test, although this practice
should be confirmed with the person ordering the
study.
The need for dietary restriction of amine-rich
foods for 48 hours before the test should be
confirmed with the laboratory performing the test
or the person ordering it.
If samples are to be obtained via an intermittent
venous access device (e.g., heparin lock), the
client should be informed of its purpose and that
it may be inserted as long as 24 hours before the
test.

steroids, and their molecular structures and those of
the adrenocorticosteroids are quite similar.
Moreover, small amounts of the gonadal hormones
or precursors thereof are secreted by the adrenal
glands in both men and women.
Secretion of gonadal hormones is regulated via
the hypothalamic–hypophyseal system. When blood
levels of gonadal hormones decline, the hypothalamus is stimulated to release gonadotropin-releasing
hormone, which then stimulates the adenohypophysis to release its gonadotropic hormones. These
tropic hormones are called, in both men and
women, follicle-stimulating hormone and luteinizing hormone, even though the ovarian follicle and
corpus luteum are unique to women.

THE PROCEDURE

If more than one sample is to be obtained, a heparin
lock should be inserted 12 to 24 hours before the
test; the stress of repeated venipunctures could
falsely elevate levels.
For hospitalized individuals, a sample of venous
blood should be collected in a chilled lavendertopped tube between 6 and 8 AM. For nonhospitalized clients, the first sample should be obtained
after approximately 1 hour of rest in a recumbent
position. The sample is handled gently to avoid
hemolysis, packed in ice, and sent to the laboratory immediately.
The client should then be helped to stand for 10
minutes, after which a second sample is obtained.
The time(s) of collection and the position of the
client should be noted on the laboratory request
form.
NURSING CARE AFTER THE PROCEDURE

If an intermittent venous access device was inserted,
remove after completion of the test and apply a pressure bandage to the site.
Resume foods and any medications withheld
before the test, as well as usual activities.
Abnormal levels: Note increased levels in relation
to 24-hour urinary vanillylmandelic acid (VMA)
and metanephrine levels. Assess for pulse and
blood pressure increases, hyperglycemia, shakiness, and palpitations associated with increased
values.

Gonadal Hormones
The gonadal hormones, secreted primarily by the
ovaries and testes, include estrogens, progesterone,
and testosterone. These hormones are essential for
normal sexual development and reproductive function in men and women. All gonadal hormones are

ESTROGENS
Estrogens are secreted in large amounts by the
ovaries and, during pregnancy, by the placenta.
Minute amounts are secreted by the adrenal glands
and, possibly, by the testes. Estrogens induce and
maintain the female secondary sex characteristics,
promote growth and maturation of the female
reproductive organs, influence the pattern of fat
deposition that characterizes the female form, and
cause early epiphyseal closure. They also promote
retention of sodium and water by the kidneys and
sensitize the myometrium to oxytocin.
Elevated estrogen levels are associated with ovarian and adrenal tumors as well as estrogen-producing tumors of the testes. Decreased levels are
associated with primary and secondary ovarian failure, Turner’s syndrome, hypopituitarism,
adrenogenital syndrome, Stein-Leventhal syndrome,
anorexia nervosa, and menopause. Estrogen levels
vary in relation to the menstrual cycle.
Many different types of estrogens have been identified, but only three are present in the blood in
measurable amounts: estrone, estradiol, and estriol.
Estrone (E1) is the immediate precursor of estradiol
(E2), which is the most biologically potent of the
three. In addition to ovarian sources, estriol (E3) is
secreted in large amounts by the placenta during
pregnancy from precursors produced by the fetal
liver. Through radioimmunoassay, plasma levels of
E2 and E3 can be determined. Total plasma estrogen
levels are difficult to measure and are not routinely
performed.
INTERFERING FACTORS

In menstruating women, estrogen levels vary in
relation to the menstrual cycle.
Therapy with estrogen-containing drugs and

CHAPTER 5—Blood

Chemistry

183

Reference Values
Conventional Units

SI Units

Estradiol (E2)
Children under 6 yr

3–10 pg/mL

10–36 pmol/L

12–34 pg/mL

40–125 pmol/L

Early cycle

24–68 pg/mL

90–250 pmol/L

Midcycle

50–186 pg/mL

200–700 pmol/L

Late cycle

73–149 pg/mL

250–550 pmol/L

30–32

2–12 ng/mL

7–40 nmol/L

33–35

3–19 ng/mL

10–65 nmol/L

36–38

5–27 ng/mL

15–95 nmol/L

39–40

10–30 ng/mL

35–105 nmol/L

Adults
Men
Women (menstruating)

Estriol (E3)
Weeks of pregnancy

adrenocorticosteroids will elevate levels, whereas
clomiphene will decrease them.
INDICATIONS FOR ESTROGENS TEST

Infertility or amenorrhea of unknown etiology,
with primary or secondary ovarian failure indicated by low estradiol (E2) levels
Establishment of the time of ovulation
Evaluation of response to therapy for infertility
Suspected precocious puberty with the disorder
indicated by elevated estradiol (E2) levels
Suspected estrogen-producing tumors, as indicated by consistently high estradiol (E2) levels
without normal cyclic variations
High-risk pregnancy with suspicion of fetal
growth retardation, placental dysfunction, or
impending fetal jeopardy, as indicated by
decreased estriol (E3) levels relative to the stage of
pregnancy
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs known to alter
estrogen levels be withheld for 12 to 24 hours
before the test, although this practice should be
confirmed with the person ordering the study.
In menstruating women, the phase of the
menstrual cycle should be ascertained, if possible.

If the test is being conducted to detect ovulation,
the client should be informed that it may be
necessary to obtain a series of samples over a
period of several days to detect the normal variation in estrogen levels.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Assess increased
or decreased levels in relation to age, gender, pregnancy, and menopausal status and in relation to
associated levels of 24-hour urinary analysis and
serum estradiol and estriol levels.

PROGESTERONE
Progesterone is secreted in nonpregnant women
during the latter half of the menstrual cycle by the
corpus luteum and in large amounts by the placenta
during pregnancy. It also is secreted in minute
amounts by the adrenal cortex in both men and

184

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Tests

Reference Values
Conventional Units

SI Units

100 ng/dL

3 nmol/L

Follicular phase

150 ng/dL

5 nmol/L

Luteal phase

300–1200 ng/dL

10–40 nmol/L

First trimester

1500–5000 ng/dL

50–160 nmol/L

Second and third trimesters

8,000–20,000 ng/dL

250–650 nmol/L

Women (menopausal)

10–22 ng/dL

2 nmol/L

Men
Women (menstruating)

Women (pregnant)

women. Progesterone prepares the endometrium for
implantation of the fertilized ovum, decreases
myometrial excitability, stimulates proliferation of
the vaginal epithelium, and stimulates growth of the
breasts during pregnancy. Although progesterone
may promote sodium and water retention, its effect
is weaker than that of aldosterone, which it directly
antagonizes. The net effect is loss of sodium and
water from the body.
INTERFERING FACTORS

In menstruating women, progesterone levels vary
in relation to the menstrual cycle.
Therapy with estrogen, progesterone, or adrenocorticosteroids may produce elevated levels.
INDICATIONS FOR PLASMA PROGESTERONE TEST

Infertility of unknown etiology with failure to
ovulate, indicated by low levels throughout the
menstrual cycle
Evaluation of response to therapy for infertility
Support for diagnosing disorders associated with
elevated progesterone levels (e.g., precocious
puberty, ovarian tumors or cysts, and adrenocortical hyperplasia and tumors)
High-risk pregnancy with suspicion of placental
dysfunction, fetal abnormality, impending fetal
jeopardy, threatened abortion, or toxemia of pregnancy, as indicated by lower than expected levels
for the stage of pregnancy
Support for diagnosing disorders associated with
decreased progesterone levels (e.g., panhypopituitarism, Turner’s syndrome, adrenogenital
syndrome, and Stein-Leventhal syndrome)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

It is recommended that any drugs that may alter
progesterone levels be withheld for 12 to 24 hours
before the test, although this practice should be
confirmed with the person ordering the study.
In menstruating women, the phase of the
menstrual cycle should be ascertained, if possible.
If the test is being performed to detect ovulation,
the client should be informed that it may be
necessary to obtain a series of samples over a
period of several days to detect the normal variation in progesterone levels.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Assess increased
or decreased levels in relation to age, menstrual or
pregnancy status, and 24-hour urinary pregnanediol level.

TESTOSTERONE
Testosterone is produced in men by the Leydig cells
of the testes. Minute amounts also are secreted by
the adrenal glands in men and women and by the
ovaries in women. In the male fetus, testosterone is
secreted by the genital ridges and fetal testes.
Testosterone is produced in response to stimulation by luteinizing hormone, which is secreted by
the adenohypophysis in response to stimulation
by gonadotropin-releasing hormone. Testosterone

CHAPTER 5—Blood

Chemistry

185

Reference Values
Conventional Units

SI Units

0.12–0.16 ng/mL

0.41–0.55 nmol/L

60 yr

3.9–7.9 ng/mL

13.59–27.41 nmol/L

60 yr

1.5–3.1 ng/dL

5.20–10.75 nmol/L

Menstruating

0.25–0.67 ng/mL

0.87–2.32 nmol/L

Menopausal

0.21–0.37 ng/mL

0.72–1.28 nmol/L

Children
Men

Women

promotes development of the male sex organs and
testicular descent in the fetus, induces and maintains
secondary sexual characteristics in men, promotes
protein anabolism and bone growth, and enhances
sodium and water retention to some degree.
INTERFERING FACTORS

Testosterone levels vary diurnally, with highest
levels occurring in the early morning.
Administration of testosterone, thyroid and
growth hormones, clomiphene, and barbiturates
may lead to elevated levels.
Therapy with estrogens and spironolactone
(Aldactone) may produce decreased levels.
INDICATIONS FOR TESTOSTERONE TEST

In men, support for diagnosing precocious
puberty, testicular tumors, and benign prostatic
hypertrophy, as indicated by elevated levels
In women, support for diagnosing adrenogenital
syndrome, adrenal tumors or hyperplasia, SteinLeventhal syndrome, ovarian tumors or hyperplasia, and luteomas of pregnancy, as indicated by
elevated levels
In men and women, support for diagnosing
nonendocrine tumors that produce ACTH ectopically, as indicated by elevated levels without diurnal variation
In men, support for diagnosing infertility, with
testicular failure indicated by decreased levels
Support for diagnosing other disorders associated
with decreased testosterone levels (e.g., hypopituitarism, Klinefelter’s syndrome, cryptorchidism
[failure of testicular descent], and cirrhosis)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
It is recommended that drugs that may alter

testosterone levels be withheld for 12 to 24 hours
before the test, although this practice should be
confirmed with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample collected in either a red- or a green-topped tube, depending on the laboratory performing the test. The
sample should be handled gently to avoid hemolysis
and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Complications and precautions: Assess increased
or decreased levels in relation to age, gender,
menstrual or menopausal status, as well as possible sexual dysfunction and medicolegal aspects of
the abuse of anabolic steroids related to athletic
ability.

Placental Hormones
During pregnancy, the placenta secretes estrogens,
progesterone, human chorionic gonadotropin
(hCG), and human placental lactogen (hPL).
Estrogens and progesterone, which are not specific
to pregnancy, are discussed in the preceding
sections. In contrast, hCG and hPL are fairly specific
to pregnancy, but levels may also be altered in individuals with trophoblastic tumors (e.g., hydatidiform mole, choriocarcinoma) and tumors that
ectopically secrete placental hormones.

HUMAN CHORIONIC GONADOTROPIN
Human chorionic gonadotropin (hCG) is a glycoprotein that is unique to the developing placenta. Its

186

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Tests

presence in blood and urine has been used for
decades to detect pregnancy. Tests using rabbits,
frogs, and rats, however, have now been replaced by
immunologic tests that use antibodies to hCG.
Earlier immunologic tests were not always reliable,
because the antibody used could cross-react with
other glycoprotein hormones such as luteinizing
hormone. Furthermore, it was sometimes not possible to obtain reliable results until 4 to 8 weeks after
the first missed period. Currently, more sensitive and
specific tests use antibody that reacts only with the
subunit of hCG, not with other hormones. The most
sensitive of the radioimmunoassays for hCG can
detect elevated levels within 8 to 10 days after
conception, even before the first missed period.
Because hCG is associated with the developing
placenta, it is secreted at increasingly higher levels
during the first 2 months of pregnancy, declines
during the third and fourth months, and then
remains relatively stable until term. Levels return to
normal within 1 to 2 weeks of termination of pregnancy. Human chorionic gonadotropin prevents the
normal involution of the corpus luteum at the end
of the menstrual cycle and stimulates it to double in
size and produce large quantities of estrogen and
progesterone. It is also thought to stimulate the
testes of the male fetus to produce testosterone and
to induce descent of the testicles into the scrotum.
INDICATIONS FOR HUMAN CHORIONIC
GONADOTROPIN TEST

Suspected testicular tumor as indicated by
elevated levels
Support for diagnosing nonendocrine tumors
that produce hCG ectopically (e.g., carcinoma of
the stomach, liver, pancreas, and breast; multiple
myeloma; and malignant melanoma), as indicated
by elevated levels
Monitoring for the effectiveness of treatment for
malignancies associated with ectopic hCG
production, as indicated by decreasing levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and sent
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Complications and precautions: Relate age,
gender, and time of gestation to the test results.

HUMAN PLACENTAL LACTOGEN

Early detection of pregnancy (i.e., within 8 to 10
days of conception), especially in women with a
history of infertility or habitual abortion
Prediction of outcome in threatened abortion
(levels below 10,000 mIU/mL are highly predictive that abortion will occur)
Suspected intrauterine fetal demise or incomplete
abortion as indicated by decreased levels56
Suspected hydatidiform mole or choriocarcinoma
as indicated by elevated levels

Human placental lactogen (hPL), also known as
human chorionic somatotropin (hCS), is produced
by the placenta but exerts its known effect on the
mother. Human placental lactogen causes decreased
maternal sensitivity to insulin and causes utilization
of glucose, thus increasing the glucose available to
the fetus. It also promotes release of maternal free
fatty acids for utilization by the fetus. It is also
thought that hPL stimulates the action of growth
hormone in protein deposition, promotes breast

Reference Values
Conventional Units

SI Units

3 mIU/mL

3 IU/L

8–10 days

5–40 mIU/mL

5–40 IU/L

1 mo

100 mIU/mL

100 IU/L

2 mo

100,000 mIU/mL

100,000 IU/L

4 mo–term

50,000 mIU/mL

50,000 IU/L

Nonpregnant women
Pregnant women

CHAPTER 5—Blood

Chemistry

187

Reference Values
Conventional Units

SI Units

0.5 g/mL

Not detected

0.5 g/mL

Not detected

5–27 weeks

4.6 g/mL

4.6 mg/L

28–31 weeks

2.4–6.1 g/mL

2.4–6.1 mg/L

32–35 weeks

3.7–7.7 g/mL

3.7–7.7 mg/L

36 weeks–term

5.0–8.6 g/mL

5.0–8.6 mg/L

Diabetic at term

10–12 g/mL

10.0–12.0 mg/L

Men
Women
Nonpregnant
Pregnant

growth and preparation for lactation, and maintains
the pregnancy by altering the endometrium.
Human placental lactogen rises steadily through
pregnancy, maintaining a high plateau during the
last trimester. Blood levels of hPL correlate with
placental weight and tend to be high in diabetic
mothers. Levels also may be elevated in multiple
pregnancy and Rh isoimmunization, as well as in
nonendocrine tumors that secrete ectopic hPL.
During pregnancy, hPL levels vary greatly with
the individual as well as on a day-to-day basis. Thus,
serial determinations may be necessary with the
client serving as her own control.57
INTERFERING FACTORS

During pregnancy, hPL levels vary greatly with
the individual as well as on a day-to-day basis.
Levels tend to be higher in diabetic mothers,
multiple gestation, and Rh isoimmunization.
INDICATIONS FOR HUMAN PLACENTAL
LACTOGEN TEST

Detection of placental insufficiency as evidenced
by low hPL levels in relation to gestational age
Support for diagnosing intrauterine growth retardation caused by placental insufficiency, as indicated by hPL levels of less than 4 g/mL,
especially when blood estrogen levels are low
Prediction of outcome in threatened abortion as
indicated by lower than expected levels for the
stage of pregnancy
Support for diagnosing hydatidiform mole and
choriocarcinoma as indicated by decreased levels
Support for diagnosing malignancies associated
with elevated levels (e.g., nonendocrine tumors
that secrete ectopic hPL)

Monitoring for the effectiveness of treatment for
malignancies associated with ectopic hPL production as indicated by decreasing levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
The pregnant client should be informed that
several determinations may be necessary throughout the pregnancy.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.

Pancreatic Hormones
The islets of Langerhans, the endocrine cells of the
pancreas, produce at least three glucose-related
hormones: (1) insulin, which is produced by the beta
cells; (2) glucagon, which is produced by the alpha
cells; and (3) somatostatin, which is produced by the
delta cells.
The overall effect of insulin is to promote glucose
utilization and energy storage. It accomplishes this
by enhancing glucose and potassium entry into most
body cells, stimulating glycogen synthesis in liver
and muscle, promoting the conversion of glucose to

188

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

8.0–15.0 U/mL or 0.3–0.6 ng/mL

55–104 pmol/L

25–231 U/mL

173–1604 pmol/L

1 hr

18–276 U/mL

125–1916 pmol/L

2 hr

16–166 U/mL

111–1152 pmol/L

3 hr

4–38 U/mL

27–263 pmol/L

Insulin-to-glucose ratio

0.3:1

Fasting
After 100 g glucose
1

/2 hr

fatty acids and triglycerides, and enhancing protein
synthesis. It exerts its effects by interacting with cell
surface receptors.
In contrast to insulin, glucagon increases blood
glucose levels by stimulating the breakdown of
glycogen and the release of glucose stored in the
liver. Somatostatin inhibits secretion of both insulin
and glucagon. It also inhibits release of growth
hormone, thyroid-stimulating hormone, and
adrenocorticotropic hormone by the adenohypophysis and may decrease production of parathormone,
calcitonin, and renin. In addition, it is thought to
inhibit secretion of gastric acid and gastrin. The
exact physiological roles of glucagon and somatostatin are unknown.
Blood levels of insulin are measured by radioimmunoassay and can be determined in most laboratories. Samples for blood glucagon levels require
special handling, and tests for its presence may not
be routinely available in all laboratories.
Somatostatin may be measured but this test is not
routinely performed. C-peptide, a metabolically
inactive peptide chain formed during the conversion
of proinsulin to insulin, may be measured to provide
an index of -cell activity not affected by exogenous
insulin.

INSULIN
Insulin is secreted by the cells in response to
elevated blood glucose, certain amino acids, ketones,
fatty acids, cortisol, growth hormone, glucagon,
gastrin, secretin, cholecystokinin, gastric inhibitory
peptide, estrogen, and progesterone. Because of
normal feedback mechanisms, high insulin levels
inhibit secretion of insulin. Elevated blood levels of
somatostatin, epinephrine, and norepinephrine also
inhibit insulin secretion.
Abnormally elevated serum insulin levels are seen
with insulin- and proinsulin-secreting tumors

(insulinomas), with reactive hypoglycemia in developing diabetes mellitus, and with excessive administration of exogenous insulin.
A blood glucose level is usually obtained with the
serum insulin determination. Serum insulin levels
may also be measured when glucose tolerance tests
are performed.
INTERFERING FACTORS

Administration of insulin or oral hypoglycemic
agents within 8 hours of the test may lead to
falsely elevated levels.
Failure to follow dietary restrictions before the
test may lead to falsely elevated levels.
Therapy with drugs containing estrogen and
progesterone may produce elevated levels.
INDICATIONS FOR SERUM INSULIN TEST

Evaluation of postprandial (“reactive”) hypoglycemia of unknown etiology
Support for diagnosing early or developing noninsulin-dependent diabetes mellitus as indicated
by excessive production of insulin in relation to
blood glucose levels (best demonstrated with
glucose tolerance tests or 2-hour postprandial
tests)
Confirmation of functional hypoglycemia (i.e., no
known physiological cause for the hypoglycemia)
as indicated by circulating insulin levels appropriate to changing blood glucose levels
Evaluation of fasting hypoglycemia of unknown
etiology
Support for diagnosing insulinoma as indicated
by sustained high levels of insulin and absence of
blood glucose-related variations
Evaluation of uncontrolled insulin-dependent
diabetes mellitus
Differentiation between insulin-resistant diabetes,
in which insulin levels are high, and non-insulinresistant diabetes, in which insulin levels are low

CHAPTER 5—Blood

Support for diagnosing pheochromocytoma as
indicated by decreased levels
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for the related
blood glucose test (e.g., fasting blood glucose,
glucose tolerance test) with which the serum insulin
determination is performed.
THE PROCEDURE

The general procedure is the same as that for the
related blood glucose test. Blood samples for serum
insulin determinations are obtained in red-topped
tubes and then packed in ice. The samples should be
handled gently to avoid hemolysis and sent immediately to the laboratory.

Chemistry

189

INDICATIONS FOR C-PEPTIDE TEST

Suspected excessive insulin administration in
either diabetic or nondiabetic individuals, as indicated by low C-peptide and elevated serum
insulin levels
Determination of -cell function when insulin
antibodies preclude accurate measurement of
serum insulin production (Insulin antibodies
are most common in diabetic clients receiving exogenous insulin prepared from animal
extracts.)
Support for diagnosing insulinoma, especially
when the tumor secretes more proinsulin than
active hormone, because the normal correlation
between insulin and C-peptide will be altered

NURSING CARE AFTER THE PROCEDURE

NURSING CARE BEFORE THE PROCEDURE

Care and assessment after the procedure are the
same as for the related blood glucose test.
Assess the client for signs of hypoglycemia, which
may occur in response to fasting or excessive
blood glucose load.
Resume foods and any medications withheld
before the test.
Abnormal values: Note and report decreased or
increased levels and relation to type I or II
diabetes mellitus, respectively, and response to
glucose intake.

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
Some laboratories may require that the client fast
from food for 8 hours before the test.

Critical values: Notify the physician at once if
fasting level is greater than 30 U/mL. Prepare
client for glucose administration.

C-PEPTIDE
Measurement of C-peptide, which is accomplished
through radioimmunoassay techniques, provides an
index of -cell activity that is unaffected by the
administration of exogenous insulin. As the cells
release insulin, they also release equimolar amounts
of metabolically inactive C-peptide. Injectable
insulin preparations are purified to remove Cpeptide. Furthermore, injected insulin elevates
immunoreactive serum insulin levels and suppresses
pancreatic secretion of endogenous insulin and Cpeptide. That is, although exogenous insulin elevates
serum insulin levels, C-peptide levels are either
unaffected or decreased. C-peptide determinations
may be carried out to augment or confirm results of
serum insulin measurements.59

THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis and sent
promptly to the laboratory. The sample also can be
tested for insulin measurement.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume usual diet.

GLUCAGON
Glucagon is secreted by the cells of the islets of
Langerhans in response to decreased blood glucose
levels. Its actions are opposed by insulin. Elevated
glucagon levels are associated with conditions that
produce actual hypoglycemia or a physiological
need for greater blood glucose (e.g., trauma, infection, starvation, excessive exercise) and with insulin
lack. Thus, elevated glucagon levels may be found in
severe or uncontrolled diabetes mellitus, despite
hyperglycemia.
Reference Values

Reference Values
Conventional Units
0.9–4.2 ng/mL

SI Units
0.30–1.39 nmol/L

Conventional Units
50–200 pg/mL

SI Units
50–200 ng/L

190

SECTION I—Laboratory

Tests

INTERFERING FACTORS

Trauma, infection, starvation, and excessive exercise may lead to elevated levels, as will acute
pancreatitis, pheochromocytoma, uncontrolled
diabetes mellitus, and uremia.
Failure to follow dietary restrictions before the
test may lead to falsely decreased levels.
INDICATIONS FOR GLUCAGON DETERMINATION

Suspected glucagonoma as indicated by elevated
levels (as high as 1000 pg/mL) in the absence of
diabetic ketoacidosis, uremia, pheochromocytoma, or acute pancreatitis
Confirmation of glucagon deficiency related to
loss of pancreatic tissue as a result of chronic
pancreatitis, pancreatic neoplasm, or surgical
resection (Arginine infusion, which normally
leads to elevated glucagon levels, may be used for
further confirmation of the deficiency state.)
Suspected renal transplant rejection, as indicated
by rising plasma glucagon levels (Glucagon levels
may rise markedly several days before serum creatinine begins to rise.)
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
test involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast from foods for
8 hours before the study. Water is permitted.
THE PROCEDURE

A venipuncture is performed and the sample is
collected in either a green- or a lavender-topped
tube, depending on the laboratory performing the
test. The sample should be handled gently to avoid
hemolysis and sent to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Resume usual diet as soon as possible after the
sample has been obtained.
Complications and precautions: Assess the test
results in relation to insulin and glucose levels.

Gastric and Intestinal Hormones
The stomach and intestine secrete various enzymes
and hormones that aid in the digestive process. The
hormones secreted include gastrin, cholecystokinin,
secretin, and gastric inhibitory peptide (GIP). Of
these, only gastrin is currently of diagnostic significance.

Gastrin is secreted by the gastrin cells (G cells) of
the gastric antrum, the pylorus, and the proximal
duodenum in response to vagal stimulation and the
presence of food (especially protein) in the stomach.
Gastrin stimulates the secretion of acidic gastric
juice and pepsin and the release of pancreatic
enzymes. It also stimulates motor activities of the
stomach and intestine, increases pyloric relaxation,
constricts the gastroesophageal sphincter, and
promotes the release of insulin.
Cholecystokinin is secreted by the duodenal
mucosa in response to the presence of fats. It
opposes the actions of gastrin, stimulates contraction of the gallbladder, relaxes the sphincter of Oddi,
and with secretin, controls pancreatic secretions.
Secretin is secreted by the duodenal mucosa in
response to the presence of peptides and acids in the
duodenum. It also opposes the actions of gastrin,
and with cholecystokinin, controls pancreatic secretions. GIP inhibits gastric motility and secretion and
stimulates secretion of insulin.

GASTRIN
Measurement of serum gastrin levels, which is
accomplished through radioimmunoassay techniques, is indicated when disorders producing
elevated levels are suspected. Excessive gastrin secretion occurs because of normal feedback mechanisms
in disorders associated with decreased gastric acid
production as a result of cellular destruction or
atrophy (e.g., gastric carcinoma and age-related
changes in gastric acid secretion). Elevated levels
also may be seen in gastric and duodenal ulcers, in
which gastric acid secretion is actually normal or
low; pernicious anemia; uremia; and chronic gastritis. Decreased gastrin levels are associated with
true gastric hyperacidity as may occur with stress
ulcers.
Both protein ingestion and calcium infusions
elevate serum gastrin levels in certain situations.
Thus, these substances can be used to provoke
gastrin secretion when a single serum determination
is inconclusive. In the secretagogue provocation test,
a fasting serum gastrin sample is drawn and the
client is then given a high-protein test meal. A postprandial blood sample is then obtained. In individuals with duodenal or gastric ulcers, gastrin levels will
be markedly higher than in normal persons after
protein-stimulated gastrin secretion. Likewise, an
infusion of calcium gluconate produces elevated
serum gastrin levels in a person with gastrinoma
caused by gastrin production by tumor cells. This
effect is not seen in individuals with peptic ulcer
disease.

CHAPTER 5—Blood

Chemistry

191

ELECTROLYTES

Reference Values
Conventional Units

SI Units

Fasting

50–150 pg/mL

50–150 ng/L

Postprandial

80–170 pg/mL

80–170 ng/L

Note: Postprandial values may vary according to the test
method used.
INTERFERING FACTORS

Protein ingestion and calcium infusions will
elevate serum gastrin levels in some situations;
these substances may be used for “challenge tests”
of gastrin secretion.
INDICATIONS FOR SERUM GASTRIN TEST

Suspected
gastrinoma
(Zollinger-Ellison
syndrome) as indicated by markedly elevated
levels (e.g., greater than 1000 pg/mL) and by
marked response to calcium challenge
Support for diagnosing gastric carcinoma, pernicious anemia, or G-cell hyperplasia as indicated
by elevated levels
Differential diagnosis of peptic ulcer disease from
other disorders, because gastrin levels may be
normal but will rise in response to protein challenge
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
test involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast from food for
12 hours before the study. Water is not restricted.
It also is recommended that medications be withheld for 12 to 24 hours before the test, although
this practice should be confirmed with the person
ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be packed in ice, handled gently to avoid hemolysis,
and transported immediately to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Resume usual diet and medications.
Complications and precautions: Assess bowel
sounds if levels are increased to 100 to 500 pg/mL,
which indicates Zollinger-Ellison syndrome associated with peptic ulcer disease.

Electrolytes are substances that dissociate into electrically charged ions when dissolved. Cations carry
positive charges and anions carry negative charges.
Both affect the electrical and osmolal (i.e., the
number of particles dissolved in a fluid) functioning
of the body. Body fluids always contain equal
numbers of positive and negative charges, but the
nature of the ions, the number of charges present on
a single molecule, and the nature and mobility of the
charged molecules differ enormously among body
fluid compartments (e.g., intracellular versus extracellular).
Not all charged particles are ions. Proteins, for
example, carry a net negative charge. Whenever fluid
contains protein, there must be accompanying
cations. Similarly, not all solutes found in plasma are
ions. Urea and glucose, for example, do not dissociate; they do not contribute to electrical activity of
fluids and membranes, and they contribute only
moderately to plasma osmolality.
Electrolyte quantities and the balance among
them in the body fluid compartments are controlled
by (1) oxygen and carbon dioxide exchange in the
lungs; (2) absorption, secretion, and excretion of
many substances by the kidneys; and (3) secretion of
regulatory hormones by the endocrine glands.
Quantitatively, the most important body fluid
ions are sodium, potassium, chloride, and bicarbonate. These ions are measured in routine serum electrolyte determinations. Other serum ions that may
be measured include calcium, magnesium, and
phosphorus.60

SERUM SODIUM
Sodium (Na, Na ) is the most abundant cation in
extracellular fluid and, along with its accompanying
chloride and bicarbonate anions, accounts for 92
percent of serum osmolality. Sodium plays a major
role in maintaining homeostasis through a variety of
functions, which include (1) maintenance of
osmotic pressure of extracellular fluid, (2) regulation of renal retention and excretion of water, (3)
maintenance of acid–base balance, (4) regulation of
potassium and chloride levels, (5) stimulation of
neuromuscular reactions, and (6) maintenance of
systemic blood pressure. Serum sodium levels may
be affected by a variety of disorders and drugs (Table
5–22) and are evaluated in relation to other serum
electrolyte and blood chemistry results. Tests of
urinary sodium and osmolality also may be necessary for complete interpretation. Note that falsely
decreased serum sodium levels may occur with

192

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

Infants

134–150 mEq/L

134–150 mmol/L

Children

135–145 mEq/L

135–145 mmol/L

Adults

135–145 mEq/L

135–145 mmol/L

Critical values

120 mEq/L or 160 mEq/L

120 mmol/L or 160 mmol/L

elevated serum triglyceride levels and myeloma
proteins.
INTERFERING FACTORS

Elevated serum triglyceride levels and myeloma
proteins may lead to falsely decreased levels.
Adrenocorticosteroids, methyldopa, hydralazine,
reserpine, and cough medicines may lead to
increased levels.
Lithium, vasopressin, and diuretics may lead to
decreased levels.
INDICATIONS FOR SERUM SODIUM TEST

Routine electrolyte screening in acute and critical
illness
Determination of whole body stores of sodium,
because the ion is predominantly extracellular
Known or suspected disorder associated with
altered fluid and electrolyte balance (see Table
5–22)
Estimation of serum osmolality, which is
normally 285 to 310 mOsm/kg, by using the
following formula, where BUN stands for blood
urea nitrogen:
Serum osmolality

2(Na )

glucose
20

BUN
3

Note: If the value for serum osmolality is
greater than 2.0 to 2.3 times the value for serum
sodium, then hyperglycemia, uremia, or metabolic acidosis should be suspected.
Evaluation of the effects of drug therapy on serum
sodium levels (e.g., diuretic therapy)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum sodium
levels, a medication history should be obtained. It
is recommended that any drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.

THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels.
Assess for symptoms associated with hypernatremia, such as fluid deficit with thirst; dry
mucous membranes and skin; poor skin turgor;
or fluid excess with edema, weight gain, or
elevated blood pressure. Administer fluid replacement at an ordered rate and time if the client
is dehydrated or if diuretics are administered
for fluid excess. Instruct client in a low-sodium
diet.
Decreased levels: Note and report decreased
levels. Assess for symptoms associated with
hyponatremia, such as oliguria, rapid pulse,
abdominal cramping, fluid retention, weight gain,
edema, or elevated blood pressure. Administer
ordered sodium replacement via IV or dietary
intake. Instruct client in sodium intake (food, salt
tablets) to replace and maintain sodium, especially if this electrolyte is lost because of vomiting,
diarrhea, perspiration, or use of diuretics.
Critical values: Notify the physician at once of
levels less than 120 mEq/L or greater than 160
mEq/L.

SERUM POTASSIUM
Potassium (K, K ) is the most abundant intracellular cation; much smaller amounts are found in the
blood. Potassium is essential for the transmission of
electrical impulses in cardiac and skeletal muscle. In
addition, it helps to maintain the osmolality and
electroneutrality of cells, functions in enzyme reactions that transform glucose into energy and amino

CHAPTER 5—Blood

TABLE 5–22

•

Chemistry

193

Disorders and Drugs Associated with Altered Serum
Sodium and Extracellular Fluid Levels

Increased Serum Sodium (Hypernatremia)

Decreased Serum Sodium (Hyponatremia)

Total Body Sodium Normal, ECF Volume Low

Total Body Sodium and ECF Volume Low, but Total
Body Sodium Proportionately Lower

Hypovolemia

Addison’s disease

Dehydration

Salt-losing renal disorders

Fever

Gastrointestinal fluid loss (nasogastric suction, vomiting, diarrhea, fistula, paralytic ileus)

Thyrotoxicosis

Diaphoresis

Hyperglycemic hyperosmolar nonketotic
syndrome

Diuresis

Diabetes insipidus

Burns

Hyperventilation

Ascites

Mechanical ventilation without humidification

Massive pleural effusion
Diabetes ketoacidosis

Total Body Sodium Increased Proportionately
More Than ECF Volume

Total Body Sodium Normal and ECF Volume Normal
to High

Excessive salt ingestion

Acute water intoxication

Inappropriate or incorrect intravenous therapy
with fluids containing sodium

Syndrome of inappropriate antidiuretic hormone
secretion

Cushing’s syndrome

Glucocorticoid deficiency

Hyperaldosteronism

Severe total body potassium depletion

Total Body Sodium Low with ECF Volume
Proportionately Lower

Total Body Sodium and ECF Volume Increased, but
ECF Proportionately Greater

Gastroenteritis

Acute renal failure with water overload

Osmotic diuresis

Congestive heart failure

Diaphoresis

Cirrhosis
Nephrotic syndrome

Drugs

Adrenocorticosteroids

Lithium carbonate

Methyldopa (Aldomet)

Vasopressin

Hydralazine (Apresoline)

Diuretics (thiazides, mannitol, ethacrynic acid,
furosemide)

Reserpine (Serpasil)
Cough medicines
Adapted from Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11.
FA Davis, Philadelphia, 2000, p 401, with permission.

acids into proteins, and participates in the maintenance of acid–base balance.
Numerous disorders and drugs can affect serum
potassium levels. As shown in Table 5–23, the clinical problems associated with altered serum potas-

sium levels may be categorized as (1) inappropriate
cellular metabolism, (2) altered renal excretion, and
(3) altered potassium intake. False elevations in
serum potassium can occur with vigorous pumping
of the hand after tourniquet application for

194

SECTION I—Laboratory

Tests

venipuncture, in hemolyzed samples, or with high
platelet counts during clotting. Falsely decreased
levels are seen in anticoagulated samples left at room
temperature.
Altered serum potassium levels are of particular
concern because of their effects on cardiac impulse
conduction, especially when the client also is taking
medications that affect cardiac conduction. The
combination of low serum potassium (hypokalemia) and therapy with digitalis preparations, for
example, can produce serious consequences because
of increased ventricular irritability.
Note also that potassium is a very changeable ion,
moving easily between intracellular and extracellular

TABLE 5–23

•

fluids. An example is seen in states of acidosis and
alkalosis. In acidosis (decreased serum pH), potassium moves from the cells into the blood; in alkalosis (increased serum pH), the reverse occurs.
INTERFERING FACTORS

False elevations may occur with vigorous pumping of the hand after tourniquet application for
venipuncture, in hemolyzed samples, or with high
platelet counts during clotting.
Falsely decreased levels are seen in anticoagulated
samples left at room temperature.
Numerous drugs may produce elevated and
decreased levels (see Table 5–23).

Disorders and Drugs Associated with Altered Serum
Potassium Levels

Increased Serum Potassium (Hyperkalemia)

Decreased Serum Potassium (Hypokalemia)

Inappropriate Cellular Metabolism

Acidosis

Alkalosis

Insulin deficiency

Insulin excess

Hypoaldosteronism

Familial periodic paralysis

Cell necrosis (trauma, burns, hemolysis,
antineoplastic therapy)

Rapid cell generation (leukemia, treated
megaloblastic anemia)

Addison’s disease

Chronic excessive licorice ingestion

Decreased Renal Excretion

Increased Excretion

Acute renal failure

Gastrointestinal loss (vomiting, diarrhea,
nasogastric suction, fistula)

Chronic interstitial nephritis

Excessive diuresis

Tubular unresponsiveness to aldosterone

Hyperaldosteronism

Hypoaldosteronism

Laxative abuse
Hypomagnesemia
Renal tubular acidosis
Diaphoresis
Thyrotoxicosis
Cushing’s syndrome

Increased Potassium Intake

Decreased Potassium Intake

Salt substitutes

Anorexia nervosa

Potassium supplements (oral or IV)

Diet deficient in meat and vegetables

Potassium salts of antibiotics

Clay eating (binds potassium and prevents absorption)

Transfusion of old banked blood
IV therapy with inadequate potassium
supplementation

CHAPTER 5—Blood

TABLE 5–23

•

Chemistry

195

Disorders and Drugs Associated with Altered Serum
Potassium Levels

Increased Serum Potassium (Hyperkalemia)

Decreased Serum Potassium (Hypokalemia)

Drugs

Aldosterone antagonists

Furosemide

Potassium preparations of antibiotics

Ethacrynic acid

Amphotericin B

Thiazide diuretics

Tetracycline

Insulin

Heparin

Aspirin

Epinephrine

Prednisone

Marijuana

Cortisone

Isoniazid

Gentamicin
Polymyxin B
Lithium carbonate
Sodium polystyrene sulfonate (Kayexalate)
Ammonium chloride
Aldosterone
Laxatives

Adapted from Sacher, RA, and McPherson, RA: Widmann’s Clinical Interpretation of Laboratory Tests, ed 11. FA
Davis, Philadelphia, 2000, p. 402, with Permission.

Reference Values
Conventional Units

SI Units

Infants

4.1–5.3 mEq/L

4.1–5.3 mmol/L

Children

3.4–4.7 mEq/L

3.4–4.7 mmol/L

Adults

3.5–5.0 mEq/L

3.5–5.0 mmol/L

Critical values

2.5 mEq/L or 6.5 mEq/L

2.5 mmol/L or 6.5 mmol/L

INDICATIONS FOR SERUM POTASSIUM TEST

Routine electrolyte screening in acute and critical
illness
Known or suspected disorder associated with
altered fluid and electrolyte balance, especially
renal disease, disorders of glucose metabolism,
trauma, and burns (see Table 5–23)
Known or suspected acidosis of any etiology,
because potassium moves from the cells into the
blood in acidotic states
Evaluation of cardiac dysrhythmias to determine
whether altered serum potassium level is
contributing to the problem (e.g., the combination of low serum potassium and therapy with

digitalis preparations may lead to ventricular irritability)
Evaluation of the effects of drug therapy (e.g.,
diuretics) on serum potassium levels
Evaluation of response to treatment for abnormal
serum potassium levels
Nursing Alert

Because of the effects of serum potassium
levels on cardiac impulse conduction, abnormal values should be reported to the physician immediately so that treatment may be
instituted.

196

SECTION I—Laboratory

Tests

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum potassium
levels, a medication history should be obtained. It
is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. Vigorous pumping of
the hand after tourniquet application should be
avoided, because it may lead to falsely elevated
results. The sample should be handled gently to avoid
hemolysis, which may also falsely elevate results, and
transported immediately to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the
test.
Increased levels: Note and report increased levels.
Assess for symptoms associated with hyperkalemia such as oliguria, irritability, diarrhea, and
ECG tracings for peaked T waves. Assess results of
arterial blood gases (ABGs). Prepare client for IV
administration of medications (sodium bicarbonate for acidosis, calcium gluconate if calcium level
is low) or oral or enema administration of sodium
polystyrene sulfonate. Instruct client in low potassium dietary intake and food restrictions (citrus
juices, bananas, dried fruits, potatoes, and tomatoes).
Decreased levels: Note and report decreased
levels. Assess for symptoms of hypokalemia such
as thirst, vomiting, anorexia, weak pulse, decreased
blood pressure, ECG tracings for depressed T
waves, or prominent U waves. Administer oral or
IV potassium replacement. Instruct client in foods
high in potassium, as already listed.
Critical values: Notify the physician at once of
levels less than 2.5 mEq/L or greater than 6.5
mEq/L (greater than 8.1 mEq/L in infants).

SERUM CHLORIDE
Chloride (Cl, Cl2) is the most abundant anion in
extracellular fluid. It participates with sodium in
the maintenance of water balance and aids in the

regulation of osmotic pressure. It also contributes
to gastric acid (HCl) for digestion and for activation of enzymes. Its most important function is
in the maintenance of acid–base balance. In certain
forms of metabolic acidosis, for example, serum
chloride levels may rise in response to decreased
serum bicarbonate levels; this condition is known
as hyperchloremic acidosis. If bicarbonate levels
fall and serum chloride concentration remains
relatively normal, however, a gap between measured cations (i.e., sodium and potassium) and
measured anions (i.e., chloride and bicarbonate)
occurs. This condition often is called anion gap
acidosis (see also section titled “Anion Gap,” which
follows).
Chloride also helps to maintain acid–base balance
through the chloride-bicarbonate shift mechanism,
in which chloride ions enter red blood cells in
exchange for bicarbonate. Bicarbonate leaves the red
blood cells in response to carbon dioxide, which is
released from the tissues into venous blood and
absorbed into the red blood cells. The carbon dioxide is subsequently converted into carbonic acid,
which dissociates into bicarbonate and hydrogen
ions. When the bicarbonate concentration in the red
blood cells exceeds that of the plasma, bicarbonate
diffuses into the blood, and chloride enters the red
blood cells to supply the anions necessary for electroneutrality. For this reason, the chloride content of
red blood cells in venous blood is slightly higher
than that of arterial red blood cells.
Numerous disorders and drugs may alter serum
chloride levels (Table 5–24).
INTERFERING FACTORS

Drugs such as potassium chloride, ammonium
chloride, acetazolamide (Diamox), methyldopa
(Aldomet), diazoxide (Hyperstat), and guanethidine (Ismelin) may lead to elevated levels.
Drugs such as ethacrynic acid (Edecrin),
furosemide (Lasix), thiazide diuretics, and bicarbonate may lead to decreased levels.
INDICATIONS FOR SERUM CHLORIDE TEST

Routine electrolyte screening in acute and critical
illness
Known or suspected disorder associated with
altered acid–base or fluid and electrolyte balance,
or both conditions
Support for diagnosing disorders associated with
altered serum chloride levels (see Table 5–24)
Differentiation of the type of acidosis (hyperchloremic versus anion gap acidosis), with serum
chloride levels remaining relatively normal in
anion gap acidosis

CHAPTER 5—Blood

TABLE 5–24

•

Chemistry

197

Disorders and Drugs Associated with Altered Serum
Chloride Levels

Increased Serum Chloride (Hyperchloremia)

Decreased Serum Chloride (Hypochloremia)
DISORDERS

Acidosis

Alkalosis

Hyperkalemia

Hypokalemia

Hypernatremia

Hyponatremia

Dehydration

Gastrointestinal loss (vomiting, diarrhea, nasogastric
suction, fistula)

Eclampsia
Renal failure (severe)

Diuresis

Congestive heart failure

Hypoventilation (especially due to chronic obstructive
pulmonary disease)

Hyperventilation (especially due to
neurogenic hyperventilation related
to head injury)

Acute infections

Cushing’s syndrome

Burns

Hyperaldosteronism

Heat stroke

Anemia

Fever

Hypoproteinemia

Diabetic ketoacidosis

Serum sickness

Pyelonephritis

Hyperparathyroidism

Addisonian crisis

Excessive dietary salt

Starvation

Jejunoileal bypass

Inadequate chloride intake

Gastric carcinoma
DRUGS

Potassium chloride

Ethacrynic acid (Edecrin)

Ammonium chloride

Furosemide (Lasix)

Acetazolamide (Diamox)

Thiazide diuretics

Methyldopa (Aldomet)

Bicarbonate

Diazoxide (Hyperstat)
Guanethidine (Ismelin)

Reference Values
Conventional Units

SI Units

Newborns

94–112 mEq/L

94–112 mmol/L

Infants

95–110 mEq/L

95–110 mmol/L

Children

98–105 mEq/L

98–105 mmol/L

Adults

95–105 mEq/L

95–105 mmol/L

Critical values

80 mEq/L or 115 mEq/L 80 mmol/L or 115 mmol/L

198

SECTION I—Laboratory

Tests

Evaluation of the effects of drug therapy on serum
chloride levels (see Table 5–24)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum chloride
levels, a medication history should be obtained. It
is recommended that those drugs that may alter
test results be withheld for 12 to 24 hours before
the test, although this practice should be
confirmed with the person ordering the study.

kidneys regulate both the generation of bicarbonate
ions and their rate of urinary excretion. Bicarbonate
also participates with chloride in the bicarbonatechloride shift mechanism involving red blood cells.
Measurement of serum bicarbonate ion concentration may be made directly or indirectly by means
of total CO2 content, because more than 90 percent
of blood CO2 exists in the ionized bicarbonate form.
Bicarbonate also is measured as part of blood gas
determinations. Numerous disorders, especially
those involving acid–base imbalance, and drugs are
associated with altered serum bicarbonate levels
(Table 5–25).

THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels
(hyperchloremia) in relation to increased sodium
and decreased bicarbonate, and assess for changes
in chloride caused by or resulting in metabolic
acidosis.
Decreased levels: Note and report decreased
levels (hypochloremia). Assess for possible cause
(vomiting, gastric suction, diarrhea, diuretic
medication regimen, chronic lung disease,
increased bicarbonate and decreased potassium
resulting in metabolic alkalosis).
Critical values: Notify the physician at once of
levels less than 80 mEq/L or greater than 115
mEq/L.

SERUM BICARBONATE
Bicarbonate (HCO3, HCO3–) is the major extracellular buffer in the blood; it functions with carbonic
acid (H2CO3) in maintaining acid–base balance.
Normally, the ratio of bicarbonate to dissolved
carbon dioxide (CO2), which derives from H2CO3, is
20:1. If this ratio is altered, acid–base imbalance
occurs. Additional CO2, for example, causes
increased acidity (falling pH), whereas loss of CO2
produces alkalinity (rising pH). Similarly, additional
bicarbonate leads to alkalosis, whereas loss of bicarbonate produces acidosis.
The lungs control regulation of CO2 levels.
Bicarbonate levels are under renal control; the

ANION GAP
The results of serum levels of sodium, potassium,
chloride, and bicarbonate may be used to calculate
the anion gap. The anion gap refers to the normal
discrepancy between unmeasured (i.e., those not
routinely measured) cations and anions in the
blood. Unmeasured anions include the negative
charges contributed by serum proteins and those
of phosphates, sulfates, and other metabolites.
Unmeasured anions normally total about 24 mEq/L.
Cations not routinely measured include calcium and
magnesium, and together they account for about 7
mEq/L. Because there are normally more unmeasured anions than cations, the difference between
the two is called the anion gap. This is normally 12
to 18 mEq/L.
The anion gap can be determined by subtracting
the sum of routinely measured anions, chloride and
bicarbonate, from the sum of routinely measured
cations, sodium and potassium (i.e., [Na K] – [Cl
HCO3]). The concept of anion gap allows consideration of metabolic derangements without measuring specific metabolites. An increase in the anion gap
is seen in acidotic states in which there is no
compensatory rise in chloride levels. Examples of
anion gap acidosis include diabetic ketoacidosis,
lactic acidosis caused by either tissue hypoxia (type
A) or renal or hepatic metabolic defect (type B), and
excessive alcohol ingestion.61
INTERFERING FACTORS

Numerous drugs may alter serum bicarbonate
levels (see Table 5–25).
INDICATIONS FOR SERUM BICARBONATE TEST

Routine electrolyte screening in acute and critical
illness
Known or suspected disorder associated with
altered acid–base or fluid and electrolyte balance,
or both

CHAPTER 5—Blood

TABLE 5–25

•

Chemistry

199

Disorders and Drugs Associated with Altered Serum
Bicarbonate Levels

Increased Serum Bicarbonate

Decreased Serum Bicarbonate
DISORDERS

Metabolic alkalosis

Metabolic acidosis

Compensated metabolic alkalosis

Compensated metabolic acidosis

Respiratory acidosis (slightly elevated or normal)

Respiratory alkalosis (slightly low or normal)

Compensated respiratory acidosis

Compensated respiratory alkalosis

Hypoventilation

Hyperventilation

Chronic obstructive pulmonary disease

Diarrhea

Vomiting

Dehydration

Nasogastric suction

Severe malnutrition

Diuresis

Burns

Aldosteronism

Myocardial infarction

Congestive heart failure

Acute ethanol intoxication

Hypokalemia

Shock

Cushing’s syndrome

Renal disease

Pulmonary edema

Hyperthyroidism

Milk-alkali syndrome
DRUGS

Aldosterone

Triamterene (Dyrenium)

Adrenocorticotropic hormone

Acetazolamide (Diamox)

Sodium bicarbonate abuse

Calcium chloride

Adrenocorticosteroids

Ammonium chloride

Viomycin

Salicylate toxicity

Thiazide diuretics

Paraldehyde
Sodium citrate

Reference Values
Conventional Units

SI Units

Peripheral vein

19–25 mEq/L

19–25 mmol/L

Arterial sample

22–26 mEq/L

22–26 mmol/L

Critical values

15 mEq/L or 35 mEq/L

15 mmol/L or 35 mmol/L

Support for diagnosing disorders associated with
altered serum bicarbonate levels (see Table 5–25)
Determination of the degree of compensation in
acidotic and alkalotic states (Table 5–26)
Evaluation of the effects of drug therapy on serum
bicarbonate levels

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum bicarbonate

200

SECTION I—Laboratory

Tests

TABLE 5–26

•

Blood Gases in Acid–Base Imbalance
pH

pCO2

HCO3

Base Excess (BE)

↓

↑

Normal

Sl ↓ or normal

↑

Normal

↓

Normal

↓

Sl ↓ or normal

↓

↑

Normal

↑

Sl ↑ or normal

↑

↓

↑

↓

Respiratory acidosis with compensation

↑

Respiratory alkalosis with compensation

Sl ↑ or normal

↓
↓

↓

Metabolic acidosis with compensation

Metabolic alkalosis with compensation

Mixed respiratory and metabolic acidosis
Sl

slightly.

levels, a medication history should be obtained. It
is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels
or base excess in relation to hypokalemia and
hypochloremia. Assess for vomiting, presence of
gastric suctioning, diuretic therapy, or excessive
intake of oral bicarbonate (baking soda, antacids).
Assess for respiratory changes, tingling in fingers,
or more severe muscular irritability symptoms.
Assess for cardiac dysrhythmias if hypokalemia is
present. Administer ordered oral or IV electrolyte
replacement (potassium, chloride). Administer
fluids (juices, broth) to replace electrolytes if
decreases are not extreme.
Decreased levels: Note and report decreased
levels or base deficit in relation to other electrolytes. Assess gastrointestinal losses such as
vomiting leading to acidosis and diarrhea leading
to alkalosis, I&O, metabolic acidosis with change
in respirations (Kussmaul’s breathing), confusion,

or lethargy. Prepare for IV sodium bicarbonate.
Monitor I&O closely to prevent fluid and electrolyte imbalance.
Critical values: Notify the physician at once of
levels less than 15 mEq/L or greater than 35
mEq/L.

SERUM CALCIUM
Calcium (Ca, Ca ) is the most abundant cation in
the body and participates in virtually all vital
processes. About half the total amount of calcium
circulates as free ions that participate in blood coagulation, neuromuscular conduction, intracellular
regulation, glandular secretion, and control of skeletal and cardiac muscle contractility. The remaining
calcium is bound to circulating proteins and plays
no physiological role. Serum calcium measurement
includes both ionized and protein-bound calcium.
Calcium ions undergo continuous turnover, with
bone serving as the major reservoir. Serum contains
only a small amount at any one time, but the serum
level reflects overall calcium metabolism. Calcium
levels are largely regulated by the parathyroid glands
and vitamin D. Other substances affecting calcium
levels include estrogens and androgens, calcitonin,
and ingested carbohydrates. Increased or decreased
serum proteins also may affect levels of proteinbound calcium.62
Table 5–27 shows the various disorders and drugs
associated with altered calcium levels. Abnormal
serum calcium may produce cardiac dysrhythmias.
Furthermore, serum calcium levels have a reciprocal
relationship with serum phosphate levels; if one
rises, the other tends to fall.

CHAPTER 5—Blood

TABLE 5–27

•

Chemistry

201

Disorders and Drugs Associated with Altered Serum
Calcium Levels

Increased Levels (Hypercalcemia)

Decreased Levels (Hypocalcemia)
DISORDERS

Acidosis

Alkalosis

Hyperparathyroidism

Hypoparathyroidism

Cancers involving bone

Pseudohypoparathyroidism

Paget’s disease of bone

Inadequate dietary intake of calcium and/or vitamin D

Prolonged immobility

Vitamin D–resistant rickets

Leukemia

Malabsorption syndromes

Multiple myeloma

Hypoproteinemia

Lymphomas

Laxative abuse

Hyperproteinemia

Acute pancreatitis

Polycythemia vera

Burns

Bone growth or active bone formation

Osteomalacia

Vitamin D intoxication

Peritonitis

Hyperthyroidism (severe)

Pregnancy

Milk-alkali syndrome

Overwhelming infections
Hypomagnesemia
Renal failure
Phosphate excess
DRUGS

Thiazide diuretics

Barbiturates

Hormones (androgens, progestins, estrogens)

Anticonvulsants

Vitamin D

Acetazolamide (Diamox)

Calcium supplements

Adrenocorticosteroids
Cytotoxic drugs

INTERFERING FACTORS

Values are higher in children because of growth
and active bone formation.
Numerous drugs may alter serum calcium levels
(see Table 5–27).
Increased or decreased serum protein levels may
alter results.
INDICATIONS FOR SERUM CALCIUM TEST

Evaluation of the effects of various disorders on
overall calcium metabolism, especially diseases
involving bone (see Table 5–27)
Detection of parathyroid gland loss after thyroid

or other neck surgery, as indicated by decreased
levels
Monitoring of the effects of renal failure on
calcium levels, which are usually decreased in the
disorder
Evaluation of cardiac dysrhythmias to determine
whether altered serum calcium level is contributing to the problem
Evaluation of coagulation disorders to determine
whether altered serum calcium level is contributing to the problem
Monitoring for the effects of various drugs on
serum calcium levels (see Table 5–27)
Evaluation of the effectiveness of treatment for

202

SECTION I—Laboratory

Tests

Reference Values
Conventional Units
Newborns

SI Units

7.0–11.5 mg/dL

1.75–2.90 mmol/L

3.7–7.0 mEq/L
Infants

8.6–11.2 mg/dL

2.15–2.80 mmol/L

5.0–6.0 mEq/L
Children

12.0 mg/dL

3 mmol/L

6.0 mEq/L
Adults

9–11 mg/dL

2.25–2.75 mmol/L

4.5–5.5 mEq/L
Critical values

6 mg/dL or 13 mg/dL

abnormal calcium levels, especially in deficiency
states
Nursing Alert

Because altered serum calcium levels may
produce cardiac dysrhythmias, abnormal
values should be reported to the physician
immediately so that treatment may be instituted.

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum calcium
levels, a medication history should be obtained. It
is recommended that drugs that may alter test
results be withheld for 12 to 24 hours before the
test, although this practice should be confirmed
with the person ordering the study.
THE PROCEDURE

1.5 mmol/L or 3.25 mmol/L

nausea and vomiting, or increased intake of
dietary calcium. Encourage fluid intake. Instruct
client to restrict foods and medications high in
calcium (milk and other dairy foods, eggs, some
antacids).
Decreased levels: Note and report decreased
levels. Assess for symptoms associated with
hypocalcemia such as muscular irritability
(tingling in fingers and around mouth, muscle
cramping or twitching, facial spasm or Chvostek’s
sign, carpopedal spasm or Trousseau’s sign, and
tetany). Instruct client to eat foods and fluids high
in calcium. Administer oral calcium supplement
or replacement; prepare for IV calcium replacement in more severe cases.
Critical values: Notify the physician at once of
levels less than 6 mg/dL or greater than 13
mg/dL.

SERUM PHOSPHORUS/PHOSPHATE
Phosphorus (P), the dominant intracellular anion,
is measured in serum as phosphate (HPO4– –,
H2PO4–). Results are reported as inorganic phosphorus (Pi). Phosphates are vital constituents of
nucleic acids, intracellular energy storage compounds, intermediary compounds in carbohydrate
metabolism, and various regulatory compounds,
including that which modulates dissociation of
oxygen from hemoglobin. Phosphorus also aids in
regulation of calcium levels and functions as a buffer
in the maintenance of acid–base balance. It
contributes to the mineralization of bones and teeth,
promotes renal tubular reabsorption of glucose,
and, as a component of phospholipids, aids in fat
transport.
As with calcium, phosphorus ions undergo
continuous turnover, with bone serving as the major

CHAPTER 5—Blood

TABLE 5–28

•

Chemistry

203

Disorders and Drugs Associated with Altered Serum
Phosphorus/Phosphate

Increased Levels (Hyperphosphatemia)

Decreased Levels (Hypophosphatemia)
DISORDERS

Diabetic ketoacidosis

Recovery phase of diabetic ketoacidosis

Renal failure

Renal tubular acidosis

Vitamin D intoxication

Hypocalcemia

Hypercalcemia

Vitamin D deficiency

Prolonged immobilization

Hyperparathyroidism

Hypoparathyroidism

Carbohydrate ingestion

Pseudohypoparathyroidism

Malnutrition

Bone growth or active bone formation

Malabsorption syndromes

Hyperthyroidism

Hypothyroidism

Acromegaly

Hypopituitarism

Sarcoidosis

Alcoholism

Pyloric obstruction

Prolonged vomiting and diarrhea

Milk-alkali syndrome
DRUGS

Sodium phosphate

Acetazolamide (Diamox)

Heparin

Aluminum hydroxide

Phenytoin (Dilantin)

Insulin

Posterior pituitary injection (Pituitrin)

Epinephrine

Androgens

Reference Values
Conventional Units

SI Units

Infants

4.5–6.7 mg/dL

1.45–2.16 mmol/L

Children

4.5–5.5 mg/dL

1.45–1.78 mmol/L

Adults

2.4–4.7 mg/dL

0.78–1.50 mmol/L

Critical values

1 mg/dL

0.32 mmol/L

Note: Phosphorus is measured in terms of phosphate; the results cannot
be expressed in milliequivalents because different phosphate groups
have different valences.

reservoir. Serum contains a relatively small amount
of phosphorus at any given time. Phosphorus levels
are largely regulated by the parathyroid glands and
vitamin D, and they are normally reciprocal to those
of serum calcium. The equilibrium between serum
phosphate levels and intracellular stores is affected
by carbohydrate metabolism and blood pH. When
persons with diabetic ketoacidosis are treated with

insulin, for example, phosphate enters the cells along
with glucose and potassium. Phosphate excretion is
controlled by the kidneys. Disorders and drugs associated with altered phosphorus levels are listed in
Table 5–28. Note that several disorders associated
with decreased phosphorus levels are the same as
those causing elevated serum calcium levels (e.g.,
hyperparathyroidism).

204

SECTION I—Laboratory

Tests

INTERFERING FACTORS

Phosphate levels are higher in children because of
bone growth and active bone formation.
Values vary diurnally, being higher at night than
in the morning.
A number of drugs may alter serum phosphate
levels (see Table 5–28).
Hemolysis of the sample may cause falsely
elevated values resulting from release of phosphate from red blood cells.
INDICATIONS FOR SERUM
PHOSPHORUS/PHOSPHATE TEST

Support for diagnosing disorders associated with
altered phosphorus/phosphate levels, especially
bone disorders, parathyroid disorders, renal
disease, and alcoholism (see Table 5–28)
Monitoring of the effects of renal failure on phosphorus levels, which are usually increased in the
disorder
Support for identification of the cause of growth
abnormalities in children
Monitoring for the effects of various drugs on
serum phosphate levels (see Table 5–28)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Because many drugs may alter serum phosphorus/phosphate levels, a medication history should
be obtained. It is recommended that any drugs
that may alter test results be withheld for 12 to 24
hours before the test, although this practice should
be confirmed with the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis, which may
falsely elevate levels, and transported promptly to
the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels
(hyperphosphatemia) and associated calcium
levels. Instruct client to avoid foods high in phosphorus (milk and dairy products, poultry, fish,
grain cereals).
Decreased levels: Note and report decreased

levels (hypophosphatemia) in relation to calcium
levels. Instruct client to include foods and fluids
high in phosphorus, as already listed.
Critical values: Notify the physician at once of
levels less than 1 mg/dL.

SERUM MAGNESIUM
Magnesium (Mg, Mg ) is an essential nutrient
found in bone and muscle. In the blood, magnesium
is most abundant in the red blood cells, with relatively little found in the serum. Magnesium functions in (1) control of sodium, potassium, calcium,
and phosphorus; (2) utilization of carbohydrates,
lipids, and proteins; and (3) activation of enzyme
systems that enable B vitamins to function.
Magnesium also increases intestinal absorption of
calcium and is required for bone and cartilage
formation. It is essential for oxidative phosphorylation, nucleic acid synthesis, and blood clotting.
Magnesium is so abundant in foods that dietary
deficiency is rare. Decreased serum magnesium
levels are seen, however, in chronic alcoholism.
Elevated levels most commonly occur in renal failure. A variety of other disorders and drugs also are
associated with altered magnesium levels (Table
5–29). Altered magnesium levels are associated with
cardiac dysrhythmias, especially decreased levels,
which may lead to excessive ventricular irritability.
INTERFERING FACTORS

A number of drugs may alter serum magnesium
levels (see Table 5–29).
Because magnesium is found in red blood cells,
hemolysis of the sample may lead to falsely
elevated values.
INDICATIONS FOR SERUM MAGNESIUM TEST

Determination of magnesium balance in renal
failure and chronic alcoholism
Evaluation of known or suspected disorders associated with altered magnesium levels (see Table
5–29)
Evaluation of cardiac dysrhythmias to determine
whether altered serum magnesium level is
contributing to the problem (i.e., decreased
magnesium levels may lead to excessive ventricular irritability)
Monitoring of the effects of various drugs on
serum magnesium levels (see Table 5–29)
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).

CHAPTER 5—Blood

TABLE 5–29

•

Chemistry

Disorders and Drugs Associated with Altered Serum
Magnesium Levels

Increased Levels (Hypermagnesemia)

Decreased Levels (Hypomagnesemia)
DISORDERS

Addison’s disease

Hyperaldosteronism

Adrenalectomy

Hypokalemia

Renal failure

Hypocalcemia

Diabetic ketoacidosis

Diabetic ketoacidosis (resolving)

Dehydration

Alcoholism, cirrhosis

Hypothyroidism

Hyperthyroidism

Hyperparathyroidism

Hypoparathyroidism
Acute pancreatitis
Gastrointestinal loss (vomiting, diarrhea,
nasogastric suction, fistula)
Malabsorption syndromes
Malnutrition
Nephrotic syndrome
Toxemia of pregnancy
High-phosphate diet
DRUGS

Antacids and laxatives containing magnesium

Thiazide diuretics

Salicylates

Ethacrynic acid (Edecrin)

Lithium carbonate

Calcium gluconate
Amphotericin B
Neomycin
Insulin
Aldosterone
Ethanol

Reference Values
Conventional Units

SI Units

Newborns

1.4–2.9 mEq/L

0.58–1.19 mmol/L

Children

1.6–2.6 mEq/L

0.65–1.07 mmol/L

Adults

1.5–2.5 mEq/L

0.61–1.03 mmol/L

1.8–3.0 mg/dL

0.74–1.23 mmol/L

1 mg/dL or 4.9 mg/dL

0.41 or 2.02 mmol/L

Critical values

205

206

SECTION I—Laboratory

Tests

Because many drugs may alter serum magnesium
levels, a medication history should be obtained. It
is recommended that those drugs that may alter
test results be withheld for 12 to 24 hours before
the test, although this practice should be
confirmed with the person ordering the study.
THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels.
Assess for symptoms associated with hypermagnesemia, such as a decrease in muscle activity,
which can affect respiration and lead to respiratory arrest and coma. Instruct client to avoid
foods high in magnesium (meats, fish, whole
grains, green vegetables) and medications
containing magnesium (antacids or laxatives).
Decreased levels: Note and report decreased
levels. Assess for symptoms of hypomagnesemia,
such as weakness, tremors, paresthesia, and tetany,
which can lead to convulsions. Assess for decreases
in potassium, sodium, and calcium. Administer
ordered magnesium replacement. Instruct client
to eat foods high in magnesium, as already listed.
Critical values: Notify the physician at once of
levels less than 1.0 mg/dL or greater than 4.9
mg/dL.

SERUM OSMOLALITY
Osmolality refers to the concentration of solutes in
plasma or serum (particle number) or in urine
(number of particles). Osmolality affects the movement of fluids across body membranes and the
kidney’s ability to concentrate or dilute the urine.

Dehydration causes an increase in osmolality, and
overhydration causes a decrease. Increased osmolality causes an increase in antidiuretic hormone
(ADH) secretion, which results in increased reabsorption of water by the kidneys, increased concentration in urine, and decreased concentration in
serum. This lower concentration in serum osmolality normally reduces ADH secretion, which then
decreases water reabsorption by the kidneys and
excretion of diluted urine. Urine is normally more
concentrated than plasma; the ratio of urine to
serum osmolality ranges from 1:1 to 3:1 in normal
states. A decrease in the 1:1 ratio is seen in fluid overload or in diabetes insipidus, and a ratio that does
not rise above 1.2:1.0 indicates a loss of renal
concentration function.63
Serum osmolality is mostly used to monitor fluid
and electrolyte balance; urine osmolality is used to
monitor the concentrating ability of the kidneys and
fluid and electrolyte balance. Decreased levels in
serum osmolality are seen in fluid excess or overhydration, hyponatremia, and syndrome of inappropriate ADH (SIADH) secretion. Decreased levels in
urine osmolality are seen in diabetes insipidus, excess
fluid intake or overhydration, hypokalemia, hypercalcemia, and severe renal disease. Increased levels in
serum osmolality are seen in dehydration, hypercalcemia, hypernatremia, hyperglycemia, diabetes
insipidus, ketosis, severe renal disease, alcohol ingestion, and mannitol therapy. Increased levels in urine
osmolality are seen in Addison’s disease, SIADH,
hypernatremia, shock or acidotic states, and CHF.
INTERFERING FACTORS

A delay of longer than 10 hours in testing the
specimen can affect test results.
Osmotic diuretics and mineralocorticoids can
affect test results.
Improper technique such as tourniquet in place
for an extended time can cause hemostasis.
INDICATIONS FOR SERUM OSMOLALITY TEST

Screening for alcohol ingestion revealed by
increase in osmolality level as the alcohol level in
the blood is increased

Reference Values
Conventional Units

SI Units

Children

270–290 mOsm/kg

270–290 mmol/kg

Adults

280–300 mOsm/kg

280–300 mmol/kg

Critical values

240 mOsm or 360 mOsm

240 or 360 mmol/kg

CHAPTER 5—Blood

Monitoring fluid and electrolyte balance (especially sodium) and determining a state of dehydration or overhydration
Evaluating ADH secretion or suppression
Monitoring IV fluid replacement therapy to
prevent fluid excess or overload
Evaluating the effect of renal dialysis therapy and
course of renal failure
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood sample
(see Appendix I).
Obtain a history of conditions affecting renal
function, a medication regimen, and the results of
an electrolyte panel. Any medications that may
affect test results should be withheld, although
this practice should be confirmed with the person
ordering the study.
Inform the client that a urine specimen can be
collected, tested, and compared with the results of
the blood test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be handled gently to avoid hemolysis or hemostasis
and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume any medications withheld before the test.
Increased levels: Note and report increased levels.
Assess for symptoms associated with dehydration,
such as thirst, dry skin and mucous membranes,
and poor skin turgor. Assess relationship to urine
osmolality and electrolyte panel. Prepare to
increase fluid intake orally or IV.
Decreased levels: Note and report decreased levels.
Assess for symptoms associated with overhydration such as edema, weight gain, dyspnea, cough,
and venous distention. Assess relationship to urine
osmolality and electrolyte panel. Administer
ordered medications such as diuretic therapy.
Critical values: Notify physician at once of
levels less than 240 mOsm or greater than 360
mOsm.

ARTERIAL BLOOD GASES
Arterial blood gas (ABG) determinations are made
not only to determine levels of actual blood gases
(i.e., oxygen and carbon dioxide) but also to assess

Chemistry

207

the client’s overall acid–base balance. Thus, ABG
levels may indicate hypoxia, hypercapnia or
hypocapnia, acidosis, alkalosis, and physiological
compensation for acid–base imbalance. The components of an ABG determination are as follows:
1. pH reflects the number of hydrogen ions in the
body and is influenced primarily by the ratio
of bicarbonate ions (HCO3–) to carbonic acid
(H2CO3), which is essentially carbon dioxide
(CO2), in the blood. The normal HCO3–-toCO2 ratio is 20:1. When the hydrogen ion
concentration increases (acidosis), the pH
falls; when the hydrogen ion concentration
decreases (alkalosis), the pH rises. Bicarbonate
levels are regulated by the kidneys, whereas
carbon dioxide levels are controlled by the
lungs. Both the lungs and the kidneys respond
to alterations in pH levels by either retaining or
excreting carbon dioxide and bicarbonate,
respectively.
2. pO2 indicates the partial pressure of oxygen in
the blood. When oxygen levels are lower than
normal, the client is hypoxic. Hypoxemia may
be caused by either low cardiac output or
impaired lung function.
3. pCO2 indicates the partial pressure of carbon
dioxide in the blood, which is regulated by the
lungs. Except in cases of compensation for
metabolic acid–base imbalances, elevated
levels (hypercapnia, hypercarbia) indicate
impaired gas exchange in the lungs so that
excess CO2 is not eliminated. Decreased levels
(hypocapnia, hypocarbia) indicate increased
loss of CO2 through the lungs (hyperventilation).
4. HCO3– indicates the bicarbonate ion concentration in the blood, which is regulated by the
kidneys. Altered levels are associated with
metabolic acid–base imbalances or reflect
response to respiratory alterations in CO2
levels.
5. O2 saturation (O2 Sat, SaO2) indicates the
oxygen content of the blood expressed as
percent of oxygen capacity (the amount of
oxygen the blood could carry if all of the
hemoglobin were fully saturated with oxygen).
If the blood is 50 percent saturated, for example, the oxygen content is one-half of the
oxygen capacity.
6. Base excess (BE) usually indicates the difference between the normal serum bicarbonate
(HCO3–) level and the client’s bicarbonate
level. Positive values indicate excess bicarbonate relative to normal values, whereas negative
values indicate decreased HCO3– levels.

208

SECTION I—Laboratory

Tests

Reference Values
Conventional Units

SI Units

pH
Newborns

7.32–7.49

Adults

7.35–7.45

pO2
Newborns

60–70 mm Hg

Adults

75–100 mm Hg

pCO2

35–45 mm Hg

HCO3

–

Newborns

20–26 mEq/L

20–26 mmol/L

Adults

22–26 mEq/L

22–26 mmol/L

O2 saturation

96–100%

Base excess
Critical values
pH
pO2
Infants
Adults
pCO2
HCO3–
O2 saturation

1 to –2
7.2 or 7.6
37 mm Hg or 92 mm Hg
40 mm Hg
20 mm Hg or 70 mm Hg
10 mEq/L or 40 mEq/L
60%

INTERFERING FACTORS

Fever may falsely elevate pO2 and pCO2;
hypothermia may lower them.
Suctioning of respiratory passages within 20 to 30
minutes of the test may alter results. Excessive
heparin in the sample will lower pH and pCO2.
Exposure of the sample to atmospheric air (e.g.,
air bubbles in the sample) may alter results.
Exposure of the sample to room temperature for
more than 2 minutes may alter test results.
INDICATIONS FOR ARTERIAL BLOOD GASES TEST

Evaluation of the effectiveness of pulmonary
ventilation in maintaining adequate oxygenation
and in removing carbon dioxide, especially in
disorders such as chronic pulmonary disease,
neurological insults, and drug intoxication
Evaluation of the effectiveness of cardiac output
in maintaining adequate oxygenation, especially
in shock and acute myocardial infarction
Determination of the need for oxygen therapy
(Oxygen is generally indicated if the pO2 is 70 mm
Hg or less, except in pulmonary disorders charac-

10 mmol or 40 mmol/L

terized by chronic hypoxemia in which lower
oxygen levels may be tolerated by the client without supplemental oxygen.)
Determination of respiratory failure, which is
defined as a pO2 of 50 mm Hg or less with a pCO2
of 50 mm Hg or more
Determination of acid–base balance, type of
imbalance, and degree of compensation (see Table
5–26)
Determination of need for mechanical ventilation
(For example, elevated or rising pCO2 levels may
indicate the need for mechanical ventilation,
especially when pO2 is decreased.)
Evaluation of effectiveness of mechanical ventilation and indication for modification of ventilator
settings
Evaluation of response to weaning from mechanical ventilation
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That repeat determinations may be necessary
until cardiopulmonary function or acid–base
balance, or both, are stabilized

CHAPTER 5—Blood

The method and site for obtaining the sample
(e.g., arterial puncture or arterial line sample)
Any anticipated discomforts (Arterial punctures
cause a brief, sharp pain unless a local anesthetic
is used.)
That if an arterial puncture is performed, it will be
necessary to maintain digital pressure on the
puncture site for 5 minutes or more, after which a
pressure dressing will be applied
Prepare the client for the procedure:
Take the client’s temperature. Fever may falsely
elevate pO2 and pCO2; hypothermia may lower
them.
The client should not have had a respiratory therapy treatment, been suctioned, or had ventilator
settings changed less than 20 to 30 minutes before
the sample is obtained.
If the test is being conducted to determine the
need for oxygen therapy or response to weaning
from mechanical ventilation, the client should be
off oxygen, off mechanical ventilation, or on a
weaning mode for a preset time, which is specified
by the person ordering the test.
If the sample is to be obtained by radial artery
puncture, the Allen test should be performed to
assess patency of the ulnar artery; in the event that
thrombosis involving the radial artery occurs after
the puncture:
Extend the client’s wrist over a rolled towel or
similar support.
Ask the client to clench the fist; if the client
cannot clench the fist, elevate the hand above
heart level.
Apply digital pressure over both radial and
ulnar arteries.
Ask the client to unclench the fist while pressure is maintained on the arteries.
Observe the palm for blanching, which is the
expected response.
Release pressure on the ulnar artery while
continuing to maintain pressure on the radial
artery.
Observe the palm for returning pinkness,
which is a positive result.
If the palm remains blanched or if return of
pinkness takes longer than approximately 5
seconds (a negative result), do not use the wrist
for arterial punctures.
Inform the client’s physician of a negative
response to the Allen test.
THE PROCEDURE

The procedure varies slightly with the method for
obtaining the sample.

Chemistry

209

Arterial Puncture. A blood gas collection kit is
obtained. If prepackaged kits are not available,
obtain a 3-mL syringe, heparin (usually in the
concentration of 100 U/mL), 20-gauge or 21-gauge
needles, povidone-iodine or alcohol swabs or
sponges, gauze pads, and tape. Fill a plastic or paper
cup or a small plastic bag about halfway with ice.
If the syringe is not preheparinized, draw approximately 1 mL of heparin into the syringe, pull the
plunger back to about the 3-mL line, and rotate the
barrel. Then expel all except approximately 0.1 mL
of heparin and change the needle. Excess heparin in
the syringe will lower the pH and pCO2 of the
sample.
Palpate the artery to be used. The radial artery is
usually the most accessible, but the brachial or the
femoral artery also may be used. If the radial artery
is to be used, extend the client’s wrist over a rolled
towel or similar support.
Cleanse the site with povidone-iodine and allow
to dry. It is recommended by some that the iodine
solution be removed with an alcohol swab before
arterial puncture. If the client is allergic to iodine,
use only alcohol to prepare the site. Some authorities also advocate anesthetizing the puncture site
with a small amount of 1 percent lidocaine (Xylocaine).
Using the heparinized syringe with needle
attached, puncture the artery. A 45-degree angle is
used for radial artery punctures; a 60- to 90-degree
angle is used for brachial arteries. A 90-degree angle
is generally used for femoral artery punctures.
Advance the needle until blood begins to enter the
syringe; it should not be necessary to pull back on
the plunger. After 2 to 3 mL of blood have been
obtained, withdraw the needle and immediately
apply firm pressure to the puncture site with a sterile gauze pad. Inform the client that the discomfort
felt after the puncture will disappear in a few
minutes.
Meanwhile, expel any air or air bubbles from the
syringe, because mixing with atmospheric air may
alter test results. The needle may be plugged by
inserting it into a rubber cap, or it may be removed
and the rubber cap supplied in the blood gas collection kit placed on the hub of the syringe. The sample
is then placed in ice to inhibit metabolic blood activity; failure to do this within 2 minutes of collecting
the sample will alter test results.
The sample is sent immediately for analysis.
On the ABG request form or sample label, note
the time the sample was collected, the client’s
temperature, and whether the client was breathing
room air, receiving oxygen, or using mechanical
ventilation.

210

SECTION I—Laboratory

Tests

Arterial Line Sample. See Appendix I, the section
titled “Indwelling Devices and Atrial Venous
Catheters.”
NURSING CARE AFTER THE PROCEDURE

For arterial punctures, maintain digital pressure
on the site for 5 minutes and then apply a sterile
pressure dressing. If the client is receiving anticoagulants or has bleeding tendencies, apply digital
pressure for 10 to 15 minutes.
Observe the arterial puncture site for bleeding or
hematoma formation every 5 to 10 minutes for
one-half hour after the pressure dressing is
applied.
Check for presence of pulses distal to the site
when performing site observations, if the brachial
or the femoral artery was used.
Check for signs of nerve impairment distal to the
site.
Provide support when test findings are revealed
and if repeated or serial testing is necessary in
acute conditions.
Evaluate the results of pH with electrolytes
(particularly hypokalemia or hyperkalemia) and
oxygen, carbon dioxide, and bicarbonate associated with respiratory or metabolic acidosis or
alkalosis.
Assess respiratory pattern, level of consciousness,
neuromuscular irritability, fluid and electrolyte
imbalances, and symptoms of impaired tissue
perfusion as a result of hypoxia, any of which can
be associated with abnormal ABGs.
Notify physician at once of critical lab values.

VITAMINS AND TRACE
MINERALS
Vitamins are essential organic substances that
perform various metabolic functions. Vitamins
cannot be synthesized in adequate amounts by the
body and, therefore, inadequate dietary intake
causes deficiency diseases. Vitamins are classified as
fat soluble and water soluble. The fat-soluble vitamins are vitamins A, D, E, and K. Because they are
stored in the body, excessive ingestion of exogenous
fat-soluble vitamins may cause abnormally elevated
levels. Vitamin C and the B-complex vitamins are
water soluble and are not stored in the body. The Bcomplex vitamins include B1 (thiamine), which is
involved in carbohydrate metabolism; B2 (riboflavin), which is involved in the transport of
oxidative metabolism and fatty acids; B3 (niacin),
which is involved in the transport of cellular respiration; and B6 (pyridoxine), which is involved as a
cofactor of enzymes and in the conversion of trypto-

phan to nicotinic acid. A vitamin B6 deficiency
causes beriberi, and a vitamin B3 deficiency causes
pellagra.
For diagnostic purposes, blood levels of vitamins
A and C and a metabolite of vitamin D are measured. Vitamin B12 and folic acid also are measured in
studies pertaining to hematologic function (see
Chapter 1).

VITAMIN A
Vitamin A is obtained from foods of animal origin,
such as eggs, milk, butter, and liver. Its precursor,
carotene, a yellowish pigment, is obtained from
yellow or orange vegetables and fruits and from leafy
green vegetables.
Vitamin A promotes normal vision by permitting
visual adaptation to light and dark, and it prevents
night blindness (xerophthalmia). It also contributes
to the growth of bone, teeth, and soft tissues;
supports the formation of thyroxine; maintains
epithelial cellular membranes; aids in spermatogenesis; and maintains the integrity of skin and mucous
membranes as barriers to infection.
Reference Values
Conventional Units
Vitamin A 65–275 IU/dL

SI Units
—

0.15–0.60 mg/mL 0.52–2.09 mol/L
Carotene
Infants

0–40 g/dL

0–0.7 mol/L

Children

40–130 g/dL

0.7–2.4 mol/L

Adults

50–300 g/dL

0.9–5.5 mol/L

INTERFERING FACTORS

Pregnancy and oral contraceptive use can lead to
falsely elevated levels, as can hyperlipidemia,
hypercholesterolemia of diabetes, myxedema, and
nephritis.
Excessive ingestion of mineral oil, low-fat diets,
and liver disease may lead to decreased levels.
Failure to follow dietary and drug restrictions
before the test may alter results.
Excessive exposure of the sample to light may alter
results.
INDICATIONS FOR VITAMIN A AND CAROTENE
TEST

Evaluation of skin disorders, with vitamin A deficiency a possible cause

CHAPTER 5—Blood

Support for diagnosing xerophthalmia (night
blindness) as indicated by decreased levels
Suspected vitamin A deficiency caused by fat
malabsorption or biliary tract disease
Support for diagnosing excessive vitamin A or
carotene ingestion, or both, as indicated by
elevated blood levels
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast for 8 hours
before the study. Water is not restricted.
Vitamin supplements containing vitamin A
should be withheld for at least 24 hours before the
test.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should
be covered to protect it from light, which may alter
test results; handled gently to avoid hemolysis; and
sent promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Resume usual diet.
Vitamin supplements may be resumed pending
test results.
Decreased level: Note and report symptoms of
deficiency or decreased level. Administer ordered
vitamin A supplement orally, and instruct client
to eat foods high in vitamin A to correct deficiency.
Increased level: Note and report symptoms of
excesses or increased level. Discontinue the oral or
topical medication administered for acne or other
skin conditions.

VITAMIN C
Vitamin C (ascorbic acid) functions in many metabolic processes, especially in those related to collagen
formation and the stress response. In addition, vitamin C helps to maintain capillary strength, facilitates the release of iron from ferritin for hemoglobin
formation and red blood cell maturation, and may
maintain the integrity of the amniotic sac.
Elevated vitamin C levels are associated with
excessive intake of the vitamin within 24 hours of
the test. Decreased intake produces scurvy with low
vitamin C levels.

Chemistry

211

Reference Values
Conventional Units

SI Units

Children

0.6–1.6 mg/dL

34–91 mol/L

Adults

0.2–2.0 mg/dL

11–113 mol/L

INTERFERING FACTORS

Excessive intake of vitamin C within 24 hours of
the test will produce elevated levels.
Failure to follow dietary restrictions before the
test may alter results.
INDICATIONS FOR VITAMIN C TEST

Evaluation of the effects of major stressors (e.g.,
pregnancy, major surgery, burns, infections,
malignancies) on vitamin C levels
Evaluation of the effects of malabsorption
syndromes on vitamin C levels
Evaluation of the effectiveness of therapy with
vitamin C in treating deficiency states
NURSING CARE BEFORE THE PROCEDURE

General client preparation is the same as that for any
study involving collection of a peripheral blood
sample (see Appendix I).
For this test, the client should fast from food for 8
hours beforehand.
Vitamin C preparations also should be withheld
for 24 hours before the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a black-topped tube. The sample is
handled gently to avoid hemolysis and transported
promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Resume usual diet.
Vitamin C preparations may be resumed pending
test results.
Decreased level: Note and report symptoms of
deficiency or decreased level such as bleeding and
poor wound healing. Instruct client to eat foods
high in vitamin C to correct deficiency.
Administer oral vitamin C supplement in ordered
dosage.
Increased level: Note and report symptoms of
excesses or increased level. Discontinue the oral
intake to prevent overdose; high doses taken as a
preventive treatment can cause renal calculi.

212

SECTION I—Laboratory

Tests

VITAMIN D
The form of vitamin D most easily and accurately
measured is 25-hydroxy-cholecalciferol [vitamin D3,
25(OH)D3, cholecalciferol], a monohydroxylated
form that leaves the liver for subsequent dihydroxylation by the kidney. Indirect measurement of vitamin D by serum alkaline phosphatase, calcium, and
phosphorus determinations preceded 25(OH)D3
assays and may still be used in the diagnosis of disorders of calcium metabolism.
Vitamin D aids in the maintenance of
calcium–phosphorus balance and in the deposition
of calcium and phosphorus in the bone. It also facilitates absorption of calcium and phosphorus from
the small intestine and aids in the renal excretion of
phosphorus.
Reference Values
Conventional Units

SI Units

25(OH)D3

0.7–3.3 IU/mL

10–55 ng/mL

25–100 pmol/L

INTERFERING FACTORS

Excessive ingestion of vitamin D leads to elevated
levels.
Therapy with anticonvulsants and glucocorticoids
may produce decreased levels.
INDICATIONS FOR VITAMIN D TEST

Differential diagnosis of hypercalcemia caused by
parathyroid adenoma or vitamin D toxicity
Confirmation of vitamin D deficiency as the cause
of bone disease
Confirmation of vitamin D deficiency caused by
malabsorption syndromes, hepatobiliary disease,
and chronic renal failure
Evidence of interference with vitamin D levels as
a result of anticonvulsant or steroid therapy
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any study
involving the collection of a peripheral blood
sample.
It is recommended that anticonvulsant and
steroid medications be withheld for 24 hours
before the test, although this practice should be
confirmed by the person ordering the study.
THE PROCEDURE

A venipuncture is performed and the sample
collected in a red-topped tube. The sample should

be handled gently to avoid hemolysis and transported promptly to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any study involving the collection of a
peripheral blood sample.
Resume medications withheld before the test.
Decreased level: Note and report symptoms of
deficiency or decreased level such as bone deformities. Instruct client to eat foods that are
enriched with vitamin D. Administer ordered oral
supplement.
Increased level: Note and report symptoms of
excesses or increased levels taken in medications
or vitamin supplements, or both (intoxication,
renal calculi, gastrointestinal intolerance).
Discontinue the oral intake of vitamin D, and
instruct client to avoid foods high in vitamin D.

TRACE MINERALS
Seven trace minerals are known to be essential to
human function even though they are present in
minute quantities in the body. These essential
minerals are cobalt, copper, iodine, iron, manganese,
molybdenum, and zinc.
Cobalt is a constituent of vitamin B12 and is
essential to the formation of red blood cells.
Copper participates in cytochrome oxidation of
tissue cells for energy production, promotes
absorption of iron from the intestines and transfer
from tissues to plasma, and is essential to hemoglobin formation. It also promotes bone and brain
tissue formation and supports the maintenance of
myelin. Iodine is an essential component for the
synthesis of thyroid hormones. Iron, which is
discussed in Chapter 1, is an essential component of
hemoglobin.
Manganese functions as a coenzyme in urea
formation and in the metabolism of proteins, fats,
and carbohydrates. Molybdenum facilitates the
enzymatic action of xanthine oxidase and liver aldehyde oxidase in purine catabolism and functions in
the formation of carboxylic acid. Zinc is an essential
component of cellular enzymes such as alkaline
phosphatase, carbonic anhydrase, lactic dehydrogenase, and carboxypeptidase, which function in
protein and carbohydrate metabolism. It also aids in
the storage of insulin, functions in deoxyribonucleic
acid (DNA) replication, assists in carbon dioxide
exchange, promotes body growth and sexual maturation, and may affect lymphocyte formation and
cellular immunity.
Other trace minerals are found in the body, but

CHAPTER 5—Blood

Chemistry

213

Reference Values
Conventional Units

SI Units

Cobalt

1 g/dL

1.7 nmol/L

Copper

130–230 g/dL

20.41–36.11 mol/L

Iodine (protein-bound)

4–8 g/dL

Manganese

4–20 mg/dL

Zinc

50–150 g/dL

7.6–23.0 mol/L

Chromium

0.3–0.85 g/L

5.7–16.3 nmol/L

their functions remain unclear. These minerals
include chromium, fluorine, lithium, arsenic,
cadmium, nickel, silicon, tin, and vanadium.
Deficiencies of trace minerals are likely only in
individuals dependent on parenteral nutrition,
because the normal diet provides adequate intake.
Elevated blood levels are usually caused by environmental contamination, either in industrial settings
or through water pollution.
INDICATIONS FOR TRACE MINERALS TEST

Monitoring of response to parenteral nutrition,
which may lead to deficiencies of trace minerals
Suspected exposure to environmental toxins,
which may be indicated by elevated levels of trace
minerals
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).
THE PROCEDURE

A venipuncture is performed and the sample
collected in a metal-free tube. The sample is handled
gently to avoid hemolysis and transported immediately to the laboratory.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
Abnormal values: Note and report deficiency or
decreased levels associated with anemia, poor
wound healing, reduced sexual maturation,
growth retardation, and the administration of
total parenteral nutrition that can eliminate some
trace minerals. Instruct client to eat foods high in
trace minerals. Administer oral supplements as
ordered.

DRUGS AND TOXIC SUBSTANCES
Blood levels of drugs are used to monitor attainment
of therapeutic drug levels, compliance with therapeutic regimens, and potential excess dosing. They
are also used in situations when accidental or deliberate drug overdose is suspected. In therapeutic situations, serial samples may be drawn to determine
peak (highest) and trough (lowest) blood levels of
drugs. Samples for peak drug levels are generally
drawn within 30 to 60 minutes of drug administration. Trough levels are drawn immediately before the
next dose of the drug is to be given. It is necessary to
know as exactly as possible the time the drug was
administered or ingested for accurate interpretation
of test results.
Many potential toxins are present in the household and in industrial settings. Data regarding circulating levels of toxic substances may be used to
diagnose either acute or chronic poisoning with
metals or common commercial substances.
Reference Values
Therapeutic and toxic levels of various drugs are
shown in Table 5–30. Toxic doses and effects of
industrial and household toxins are listed in
Table 5–31. For child values, refer to agency
laboratory information.
INDICATIONS FOR BLOOD LEVELS OF DRUGS
AND TOXIC SUBSTANCES TEST

Determination of therapeutic levels of prescribed
drugs, especially those with narrow therapeutic
ranges or serious toxic effects, or both
Evaluation of the degree of compliance with the
therapeutic regimen
Known or suspected drug overdose
Known or suspected exposure to environmental
toxins

214

SECTION I—Laboratory

Tests
TABLE 5–30

Drug

Peak Time

•

Blood Levels of Drugs
Duration
of Action

Therapeutic
Level

Toxic Level

2 days

20–25 g/mL

35 g/mL

34–43 mol/L

60 mol/L

4–8 g/mL

12 g/mL

8.4–16.8 mol/L

25.1 mol/L
35 g/mL

Antibiotics
Amikacin

IM: 1/2 hr
IV: 15 min

SI units
Gentamicin

IM: /2 hr

2 days

IV: 15 min
SI units
Kanamycin

1/2 hr

2 days

20–25 g/mL
42–52 mol/L

73 mol/L

/2–11/2 hr

5 days

25–30 g/mL

30 g/mL

IV: 15 min

2 days

2–8 g/mL

12 g/mL

4–17 mol/L

25 mol/L

SI units
Streptomycin
SI units
Tobramycin
SI units
Anticonvulsants
Barbiturates and barbiturate-related
Amobarbital

IV: 30 sec

10–20 hr

7 g/mL

30 g/mL

30 mol/L

132 mol/L

IV: 30 sec

15 hr

4 g/mL

15 g/mL

18 mol/L

66 mol/L
55 g/mL

SI units
Pentobarbital
SI units
Phenobarbital

15 min

80 hr

10 g/mL
43 mol/L

230 mol/L

PO: 3 hr

7–14 hr

1 g/mL

10 g/mL

4 mol/L

45 mol/L

SI units
Primidone
SI units
Benzodiazepines
Clonazepam (Klonopin)

1–4 hr

60 hr

SI units
Diazepam (Valium)

1–4 hr

1–2 days

SI units

5–70 ng/ml

70 ng/mL

55–222 mol/L

222 mol/L

5–70 ng/mL

70 ng/mL

0.01–0.25 mol/L

0.25 mol/L

10–20 g/mL

20 g/mL

40–80 mol/L

80 mol/L

Hydantoins
Phenytoin (Dilantin)

3–12 hr

7–42 hr

SI units
Succinimides
Ethosuximide (Zarontin)
SI units

1 hr

8 days

40–80 g/mL

100 g/mL

283–566 mol/L

708 mol/L

CHAPTER 5—Blood

TABLE 5–30
Drug

•

Duration
Peak Time

Chemistry

215

Blood Levels of Drugs
Therapeutic
of Action

Level

Toxic Level

Miscellaneous
Carbamazepine (Tegretol)

4 hr

2 days

SI units
Valproic acid (Depakene)

1–4 hr

2–10 g/mL

12 g/mL

8–42 mol/L

50 mol/L

50–100 g/mL

100 g/mL

350–700 mol/L

700 mol/L

8–9 hr

10–18 g/mL

20 g/mL

25–30 hr

2–4.5 g/mL

9 g/mL

5.9–13 mol/L

26 mol/L

2.4–5 g/mL

6 g/mL

7–15 mol/L

18 mol/L

4–8 g/mL

12 g/mL

17–35 mol/L

50 mol/L

2–8 g/mL

30 g/mL

24 hr

SI units
Bronchodilators
Aminophylline/theophylline

PO: 2 hr
IV: 15 min

Cardiac Drugs
Disopyramide (Norpace)

PO: 2 hr

SI units
Quinidine

PO: 1 hr

20–30 hr

IV: immediate
SI units
Procainamide (Pronestyl)

PO: 1 hr

10–20 hr

IV: /2 hr
SI units
NAPA (N-acetyl
procainamide,
a procainamide
metabolite)

—

IV: immediate

5–10 hr

7–29 mol/L

108 mol/L

2–6 g/mL

9 g/mL

8–25 mol/L

38 mol/L

6–8 hr

5–10 g/kg

30 g/kg

5–10 g/kg

15 g/kg

SI units
Lidocaine
SI units
Bretylium
Verapamil

15–30 min
PO: 5 hr

8–10 hr

IV: 3–5 min

IV: 1/2–1 hr

Diltiazem

PO: 2–3 hr

3–4 hr

50–200 ng/mL

200 ng/mL

Nifedipine

1–3 hr

3–4 hr

5–10 mg

90 mg

Digitoxin

4 hr

30 days

10–25 ng/mL

30 ng/mL

13–33 nmol/L

39 nmol/L

0.5–2 ng/mL

2.5 ng/mL

0.6–2.5 nmol/L

3.0 nmol/L

10–18 g/mL

20 g/mL

40–71 mol/L

80 mol/L

2.3–5 g/mL

5 g/mL

7–15 mol/L

15 mol/L

SI units
Digoxin

2 hr

7 days

SI units
Phenytoin (Dilantin)

PO: 2 hr

96 hr

SI units
Quinidine

IV: 1 hr
—

SI units

—

(Continued on the following page)

216

SECTION I—Laboratory

Tests

Evaluation of chronic exposure to industrial
products known to be toxic
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a peripheral blood sample
(see Appendix I).

TABLE 5–30
Drug

•

THE PROCEDURE

Blood Levels of Drugs (Continued)

Duration
Peak Time

Therapeutic
of Action

Level

Toxic Level

Salicylates
2–20 mg/dL

30 mg/dL

SI units

0.1–1.4 mmol/L

2.1 mmol/L

2–30 mg/dL

40 mg/dL

SI units

0.1–2.1 mmol/L

2.8 mmol/L

0.005 mg/dL

Aspirin

15 min

12–30 hr

Narcotics
Codeine

—

17 nmol/L

SI units
Hydromorphone (Dilaudid)

0.1 mg/dL
350 nmol/L

SI units
Methadone

—

0.2 mg/dL
6.46 mol/L

SI units
Meperidine (Demerol)

0.5 mg/dL
20 mol/L

SI units
Morphine

—

0.005 mg/dL

—

10 g/mL

55 g/mL

43 mol/L

230 mol/L
30 g/mL

Barbiturates
Phenobarbital
SI units
Amobarbital

—

7 g/mL
30 mol/L

130 mol/L

—

4 g/mL

15 g/mL

17 mol/L

66 mol/L

3 g/mL

10 g/mL

12 mol/L

42 mol/L

0.1 g/dL

100 mg/dL

SI units
Pentobarbital
SI units
Secobarbital

—

SI units
Alcohols
Ethanol

—

(legal level for
intoxication)
Methanol

—

20 mg/dL

CHAPTER 5—Blood

TABLE 5–30
Drug

•

Chemistry

217

Blood Levels of Drugs

Duration
Peak Time

Therapeutic
of Action

—

Level

Toxic Level

Psychiatric Drugs
Amitriptyline (Elavil)
SI units
Imipramine (Tofranil)

—

SI units
Lithium (Lithonate)

1–4 hr

—

SI units

100–250 ng/mL

300 ng/mL

361–902 nmol/L

1083 nmol/L

100–250 ng/mL

300 ng/mL

357–898 nmol/L

1071 nmol/L

0.8–1.4 mEq/L

1.5 mEq/L

0.8–1.4 mol/L

1.5 mol/L

0–25 g/mL

150 g/mL

0–170 mol/L

1000 mol/L
4 hr after
ingestion

Miscellaneous
Acetaminophen

—

SI units

Prochlorperazine

—

0.5 g/mL

1.0 g/mL

Bromides

—

75–150 mg/dL

150 mg/dL

7–15 mmol/L

15 mmol/L

SI units

administered or ingested should be noted on the
laboratory request form.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a
peripheral blood sample.
It may be necessary to withhold subsequent doses
of drugs administered for therapeutic reasons
until test results are available, but this practice
should be confirmed with the person prescribing
the medication.
Abnormal values: Note and report both therapeutic and toxic values for the drug test
performed. Notify the physician at once if any
value is at a critical level. Prepare for immediate
interventions to prevent cardiac arrest or other
manifestations of toxicity, such as ECG monitor-

ing, oxygen, or intubation and ventilation.
Administer ordered antidote or other medications.
Long-term drug therapy: Support client and
instruct in long-term medication regimen, which
symptoms to note and report, and when to
discontinue the medication.
Medicolegal aspects: Collection, delivery, possession, and transportation of the specimen should
be witnessed by a legally responsible person, and
the possession of it must remain unbroken from
the time of collection to the completion of any
legal court action (chain of evidence). Seal specimen to prevent tampering and label “Medicolegal
Case.” In some cases a number is used instead of a
name for identification. Toxicology tests to determine abuse, suicide, intentional overdose, or
suspected murder or attempted murder require
these considerations.

218

SECTION I—Laboratory

TABLE 5–31

•

Tests

Toxic Doses and Effects of Industrial and Household Toxins

Substance

Toxic Dose

Toxic Effects

Aniline

50 mg/kg

Methemoglobinemia, hepatotoxicity,
nephrotoxicity

Arsenic/antimony

5 mg/kg

Gastric hemorrhage, shock

Barium salts

—

Bloody diarrhea, cardiac depression,
muscle spasms, respiratory failure, renal
failure

Benzene products

50 mg/kg

CNS depression, respiratory failure, cardiac
arrest, bone marrow depression, liver
damage

Bismuth

0.1–3.5 g/L

Weakness, fever, anorexia, black gum line,
renal damage

Cadmium

41 ng/mL

Severe gastroenteritis, liver damage, acute
renal failure; if inhaled as dust or fumes,
pulmonary edema

Carbon tetrachloride

5–10 mL (total)

CNS depression, liver and kidney failure

Chlorate or bromate salts

50 mg/kg

Methemoglobinemia, intravascular hemolysis, acute renal failure

Cobalt

0.11–0.45 g/L

Nerve damage, thyroid dysfunction

Copper salts

50 mg/kg

Generalized capillary damage, kidney and
liver damage

Cyanide

5 mg total (0.5 mg/100
mL of blood)

Confusion, dyspnea, convulsions, death
from respiratory failure

DDT

50 mg/kg

Fatigue, confusion, ataxia, convulsions,
death from respiratory failure

2.4-D

—

Lethargy, diarrhea, cardiac arrest, hyperpyrexia, convulsion, coma

Ergot

5 mg/kg

Gastrointestinal inflammation, renal
damage, gangrene of fingers and toes
caused by persistent peripheral vascoconstriction

Ethylene glycol

5 mg/kg

CNS depression, death from renal failure or
respiratory paralysis

Iron salts

500 mg/kg

Bloody diarrhea, shock, liver damage

Fluoride

50 mg/kg (0.2–0.3 mg/dL of
blood)

Hemorrhagic gastroenteritis, tremors,
hypocalcemia, shock

Formaldehyde

500 mg/kg

Hemorrhagic gastroenteritis, renal failure,
circulatory collapse

Hydrogen sulfide

0.1–0.2% in air

Death from respiratory paralysis

Sodium hypochlorite

Several ounces of household bleach

Edema of pharynx, glottis, larynx; perforation of esophagus or stomach, pulmonary
edema from fumes

Iodine

5 mg/kg

Bloody diarrhea, renal damage, death from
asphyxia or circulatory collapse

CHAPTER 5—Blood

TABLE 5–31

•

Chemistry

219

Toxic Doses and Effects of Industrial and Household Toxins

Substance

Toxic Dose

Toxic Effects

Ipecac, syrup or fluid
extract

1–2 oz fluid extract (14
times more concentrated
than syrup)

Shock caused by intractable vomiting and
diarrhea, death from cardiac depression

Isopropyl alcohol

500 mg/kg

Severe CNS depression, death from respiratory failure or circulatory collapse

Kerosene

500 mg/kg if swallowed;
few mL lethal if aspirated

Severe chemical pneumonitis, coma

Lead

30 g/kg (120 g/L blood
level)

Gastrointestinal inflammation, liver and
kidney damage, encephalopathy in children, paralysis of extremities, death from
encephalopathy or peripheral vascular
collapse

Lye, sodium and potassium hydroxide

10 g total dose may be
fatal

Laryngeal or glottic edema, perforation of
esophagus or stomach, severe diarrhea,
shock, death

Mercury salts

5 mg/kg

Acute: Death from acute renal failure or
peripheral vascular collapse
Chronic: Progressive peripheral neuritis,
death from renal failure

Naphthalene (mothballs)

5 g/kg

CNS excitement or depression, acute
hemolytic anemia, convulsions

Nicotine

5 mg/kg

CNS stimulation followed by depression;
vomiting, diarrhea, dyspnea, death from
respiratory paralysis

Oxalic acid

50 mg/kg

Shock caused by severe gastroenteritis,
hypocalcemia, convulsions, renal
damage, coma, death

Parathion/organophosphorus insecticides

5 mg/kg

Vomiting, diarrhea, generalized muscle
weakness, convulsions, coma, death, all
caused by inhibition of acetylcholinesterase and accumulation of
cholinesterase at myoneural junctions

Phosphorus

5 mg/kg

Penetrating burns; liver, kidney, and cardiac
damage

Quaternary ammonium
germicides

5 mg/kg

CNS depression, dyspnea, death from
asphyxia

Rotenone

50 mg/kg

Severe hypoglycemia, tremors, convulsions, respiratory stimulation followed by
depression, death from respiratory arrest

Selenium

58–234 g/L

Metallic taste, nausea, vomiting, headache,
pulmonary disorders

Silver salts

3.5–35 g total dose

Bloody diarrhea, severe corrosion of the
gastrointestinal tract, coma, convulsions,
death
(Continued on the following page)

220

SECTION I—Laboratory

TABLE 5–31

Substance

•

Tests

Toxic Doses and Effects of Industrial and Household
Toxins (Continued)
Toxic Dose

Toxic Effects

Strychnine

5 mg/kg

Stimulation of spinal cord, tetanic convulsions, death in 1–3 hr (with the face fixed
in a grin and the body arched in hyperextension) from anoxia

Thallium salts

5 mg/kg (50 g/L blood
level)

Hemorrhagic gastroenteritis, encephalopathy (delirium, convulsions, coma), death

Turpentine

500 mg/kg

Aspiration pneumonitis, vomiting, diarrhea,
CNS excitement (delirium), stupor,
convulsions, coma, death from respiratory failure

Zinc

70–50 g/L

Hypertension, tachycardia nausea, vomiting, diarrhea, cough, metallic taste

REFERENCES
1. Sacher, RA, and McPherson, RA: Widmann’s Clinical Inter-pretation of Laboratory Tests, ed 11. FA Davis, Philadelphia, 2000, p 321.
2. Ibid, pp 322–323.
3. Ibid, p 323.
4. Ibid, p 324.
5. Ibid, p 323.
6. Ibid, p 325.
7. Ibid, p 605.
8. Ibid, p 611.
9. Ibid, p 326.
10. Ibid, pp 610–611.
11. Ibid, p 606.
12. Ibid, p 326.
13. Springhouse Corporation: Nurse’s Reference Library, Diagnostics,
ed 2. Springhouse, Springhouse, PA, 1986, p 242.
14. Fischbach, FT: A Manual of Laboratory Diagnostic Tests, ed 4. JB
Lippincott, Philadelphia, 1992, p 303.
15. Sacher and McPherson, op cit, p 606.
16. Ibid, p 607.
17. Ibid, p 433.
18. Hillman, RS, and Finch, CA: Red Cell Manual, ed 7. FA Davis,
Philadelphia, 1996, p 23.
19. Sacher and McPherson, op cit, p 328.
20. Ibid, p 329.
21. Ibid, pp 433–434.
22. Ibid, p 338.
23. Guyton, AC: Textbook of Medical Physiology, ed 6. WB Saunders,
Philadelphia, 1981, pp 849–850.
24. Ibid, pp 856–857.
25. Sacher and McPherson, op cit, pp 332, 425.
26. Ibid, pp 397–398.
27. Ibid, pp 402–403.
28. Ibid, pp 400–401, 427–428.
29. Kontos, MC, et al: Use of the combination of myoglobin and CKMB mass for rapid diagnosis of acute myocardial infarction. Am J
Emerg Med, 15(1):14–19, 1997.
30. Sacher and McPherson, op cit, pp 406–409.
31. Collinson, PO: Troponin T or troponin I or CK-MB (or none?).
Eur Heart J, 19(Suppl N):N16–24, 1998.

32. Sommers, M, and Johnson, S: Davis’s Manual of Nursing
Therapeutics for Diseases and Disorders. FA Davis, Philadelphia,
1997.
33. Kost, GJ, Kirk, JD, and Omand, K: A strategy for the use of cardiac
injury markers (troponin I and T, creatine kinase-MB mass and
isoforms, and myoglobin) in the diagnosis of acute myocardial
infarction. Arch Pathol Lab Med, 122(3):245–251, 1998.
34. Lindahl, B, Venge, P, and Wallentin, L: The FRISC experience with
troponin T. Use as decision tool and comparison with other prognostic markers. Eur Heart J, 19(Suppl N):N51–58, 1998.
35. Sacher and MacPherson, op cit, pp 411–412.
36. Berkow, R (ed): The Merck Manual, ed 16. Merck Research
Laboratories, Rahway, NJ, 1992, p 1839.
37. Sacher and McPherson, op cit, pp 405–406.
38. Ibid, pp 555–556.
39. Ibid.
40. Ibid, p 557.
41. Ibid, pp 557, 634.
42. Ibid, pp 583, 587, 590–591.
43. Ibid, pp 621–623.
44. Ibid, pp 617–627.
45. Ibid, pp 559–562.
46. Ibid, pp 582–583.
47. Guyton, op cit, pp 931–937, 984.
48. Sacher and McPherson, op cit, pp 585–586, 588.
49. Ibid, pp 586–587.
50. Ibid, pp 582–583, 590–592.
51. Ibid, pp 594, 598–601.
52. Ibid, pp 562, 577.
53. Ibid, pp 565–568.
54. Ibid, pp 572–573.
55. Ibid, pp 577–579.
56. Ibid, pp 631–632.
57. Ibid, pp 633–634.
58. Ibid, pp 603–604.
59. Ibid, pp 604, 611.
60. Ibid, pp 367–368.
61. Ibid, pp 379, 383.
62. Ibid, pp 357, 596.
63. Ibid, pp 380–381.

CHAPTER

Studies of Urine
TESTS COVERED
Routine Urinalysis, 222
Clearance Tests and Creatinine Clearance,
239
Tubular Function Tests and
Phenolsulfonphthalein Test, 240
Concentration Tests and Dilution Tests,
241
Electrolytes, 244

Pigments, 247
Enzymes, 250
Hormones and Their Metabolites, 252
Proteins and Their Metabolites, 261
Vitamins and Minerals, 263
Microbiologic Examination of Urine, 264
Cytologic Examination of Urine, 265
Drug Screening Tests of Urine, 265

OVERVIEW OF URINE FORMATION AND ANALYSIS Because urine results from
filtration of blood, many of the substances carried in the blood are also found in the urine. The
nature and amount of the substances present in urine reflect ongoing physiological processes
in health and disease states. The comparative ease of obtaining urine samples ensures the
continued use of urine studies as an aid to diagnosis.1
Urine is an ultrafiltrate of plasma from which substances essential to the body are reabsorbed
and through which substances that are not needed are excreted. Normally, 25 percent of the
cardiac output perfuses the kidneys each minute. This perfusion results in the production of
180 L of glomerular filtrate per day, 90 percent of which is reabsorbed. In addition to water,
substances reabsorbed include glucose, amino acids, and electrolytes. Substances excreted from
the body include urea, uric acid, creatinine, and ammonia. The major electrolytes lost are chloride, sodium, and potassium. Other substances found in urine include pigments, enzymes,
hormones and their metabolites, vitamins, minerals, and drugs. Red blood cells, white blood
cells, epithelial cells, crystals, mucus, and bacteria may also be found in urine.2,3
In general, the concentration of most substances normally found in the urine reflects the
plasma levels of the substances. If the plasma concentration of a substance is high, more of it is
lost in the urine in the presence of normal renal function. Conversely, if the plasma concentration is abnormally low, the substance is reabsorbed. The concentration of substances found in
the urine is also affected by factors such as dietary intake, body metabolism, endocrine function, physical activity, body position, and time of day.4 For these reasons, results of urine tests
must be evaluated in relation to the client’s history and current health status. For some studies,
urine specimens are collected at certain times of day or over 24-hour periods. Dietary intake
may also be modified for certain studies.
Commercially prepared reagent dipsticks are available to perform simple and quick testing
in hospitals, clinics, physicians’ offices, and homes. They are used for routine screening of single
or multiple urinary evaluations of protein, glucose, ketones, hemoglobin, urobilinogen, and
nitrites as well as pH. The strips contain reagents that react with specific substances by changing color. Color change is observed and compared to a color chart for the presence of abnor221

222

SECTION I—Laboratory

Tests

mal levels of substances. Special care in their use is required to prevent inaccurate results, and
confirmation of quantitative tests is appropriate if results from the dipstick testing reveal
abnormalities.
Urine samples for more exhaustive laboratory testing may be obtained through a variety of
methods. These are described in Appendix II. Urine studies include routine urinalysis, clearance tests, tubular function tests, concentration tests, and analyses for specific substances such
as electrolytes, pigments, enzymes, hormones and their metabolites, proteins, and vitamins and
minerals. Microbiologic and cytologic examination of urine may also be performed.

ROUTINE URINALYSIS
A routine urinalysis (UA) has two major components: (1) macroscopic analysis and (2) microscopic
analysis. Macroscopic analysis includes examining
the urine for overall physical and chemical characteristics. The microscopic component of a UA
involves examining the sample for formed elements,
also termed urinary sediment.
Urine samples for routine analysis are best
collected first thing in the morning. Urine that has
accumulated in the bladder overnight is more
concentrated, thus allowing detection of substances
that may not be present in more dilute random
samples.5 The sample should be examined within 1
hour of collection. If this is not possible, the sample
may be refrigerated until it can be examined. Failure
to observe these precautions may lead to invalid
results. If, for example, the sample is allowed to stand
for long periods without refrigeration, the glucose
level may drop and the ketones may dissipate. The
color of the urine may also deepen. Similarly,
urinary sediment begins deteriorating within 2
hours of sample collection. If bacteria are present,
they may multiply if the sample is neither examined
promptly nor refrigerated. Also, the pH of the
sample may be altered, rendering it more alkaline. If
the sample is exposed to light for long periods of
time, bilirubin and urobilinogen may be oxidized.6

MACROSCOPIC ANALYSIS
COLOR

The color of urine is mainly a result of the presence
of the pigment urochrome, which is produced
through endogenous metabolic processes. Because
urochrome is normally produced at a fairly constant
rate, the intensity of the yellow color may indirectly
indicate urine concentration and the client’s state of
hydration.7,8 Pale urine with a low specific gravity
may occur, for example, in a normal person after
high fluid intake. Note, however, that an individual
with uncontrolled or untreated diabetes may also

produce pale urine. The pale urine in this case is
caused by osmotic diuresis resulting from the excessive glucose load. The client actually may be dehydrated. Further, the specific gravity of the urine from
such an individual could be high because of the
presence of excessive glucose.9 Similarly, deeper
colored urine may not always indicate concentrated
urine. The presence of bilirubin may produce darker
urine in normally hydrated individuals.
Urine color may be described as pale yellow,
straw, light yellow, yellow, dark yellow, and amber.
For the most accurate appraisal of urine color, the
sample should be examined in good light against a
white background. If the sample is allowed to stand
at room temperature for any length of time, the
urochrome will increase and the color of the sample
may deepen.10
Numerous factors that affect the color of urine are
listed in Table 6–1.
APPEARANCE (CLARITY)

The term appearance generally refers to the clarity of
the urine sample. Urine is normally clear or slightly
cloudy. In alkaline urine, cloudiness may be caused
by precipitation of phosphates and carbonates. In
acidic urine, cloudiness may be caused by precipitation of urates, uric acid, or calcium oxalate. The
accumulation of uroerythrin, a pink pigment
normally present in urine, may produce a pinkish or
reddish haze in acidic urine.
The most common substances that may cause
cloudy urine are white blood cells, red blood cells,
bacteria, and epithelial cells. Presence of these
substances may indicate inflammation or infection
of the urinary and genital tracts and must be
confirmed through microscopic examination. Other
substances that may produce cloudy urine are
mucus, yeasts, sperm, prostatic fluid, menstrual and
vaginal discharges, fecal material, and external
substances such as talcum powder and antiseptics.11
Proper client instruction and specimen collection
may aid in reducing the presence of such substances
in the urine.

CHAPTER 6—Studies

•

TABLE 6–1
Urine Color
Very pale yellow

Factors Affecting the Color of Urine

Cause
Excessive fluid intake

Urine Color
Green

Diabetes insipidus

Vitamins

Nephrotic syndrome

Psychoactive drugs

Alcohol

Proprietary diuretics
Blue

Nitrofurans

Anxiety

Proprietary diuretics

Underhydration

Methylene blue
Brown

Acid hematin

Urobilin

Myoglobin

Carrots

Bile pigments

Phenacetin

Levodopa

Cascara

Nitrofurans

Nitrofurantoin

Some sulfa drugs

Chlorpromazine
Quinacrine
Riboflavin
Sulfasalazine
Bilirubin
Phenazopyridine
(Pyridium)

Red

Biliverdin
Pseudomonas

Bilirubin

Orange

Cause

Diabetes mellitus

Diuretics

Dark yellow, amber

of Urine

Rhubarb
Black, brownish
black

Melanin
Homogentisic acid
Indicans
Urobilin

Azo drugs

Red blood cells
oxidized to
methemoglobin

Phenothiazine

Levodopa

Oral anticoagulants

Cascara

Red blood cells

Iron complexes

Hemoglobin

Phenols

Myoglobin
Porphyrins
Porphobilinogen
Many drugs and dyes
Rifampin
Phenolsulfonphthalein
Fuscin
Beets
Rhubarb
Senna

223

224

SECTION I—Laboratory

Tests

Lymph and fat globules in urine can also yield
cloudy specimens. The presence of lymph in the
urine is most often associated with obstruction of
abdominal lymph flow and rupture of lymphatic
vessels into portions of the urinary tract. Fat globules in the urine are most commonly associated with
nephrotic syndrome but may also be seen in clients
with fractures of the long bones or pelvis.12
ODOR

Normally, a fresh urine specimen has a faintly
aromatic odor. As the specimen stands, the odor of
ammonia predominates because of the breakdown
of urea. Ingestion of certain foods and drugs impart
characteristic odors to urine; this is especially true of
asparagus.
Some unusual odors are indicative of certain
disease states. Urine with a fruity odor, for example,
may indicate ketonuria resulting from uncontrolled
diabetes mellitus or starvation. Other abnormal
odors are associated with amino acid disorders.
Urine with a “mousy” smell is associated with
phenylketonuria (PKU), whereas urine that smells
like maple syrup is associated with maple syrup
urine disease. Urine with a “fishy” or fetid odor is
generally associated with bacterial infection. This
odor is especially noticeable when urine is allowed to
stand for some time. Occasionally, urine may lack an
odor. This characteristic is seen in acute renal failure
because of acute tubular necrosis and failure of
normal mechanisms of ammonium secretion.13,14
SPECIFIC GRAVITY

The specific gravity of urine is an indication of the
kidney’s ability to reabsorb water and chemicals
from the glomerular filtrate. It also aids in evaluating hydration status and in detecting problems
related to secretion of antidiuretic hormone. By definition, specific gravity is the density of a liquid
compared with that of a similar volume of distilled
water when both solutions are at the same or similar
temperatures. The normal specific gravity of
distilled water is 1.000. The specific gravity of urine
is greater than 1.000 and reflects the density of the
substances dissolved in the urine. Both the number
of particles present and their size influence the
specific gravity of urine. Large urea molecules, for
example, influence the specific gravity more than do
small sodium and chloride molecules. Similarly, if
large amounts of glucose or protein are present in
the sample, the specific gravity will be higher.15
The specific gravity of the glomerular filtrate is
normally 1.010 as it enters Bowman’s capsule. A
consistent urinary specific gravity of 1.010 usually
indicates damage to the renal tubules such that

concentrating ability is lost. Urine with a low specific
gravity may be seen in clients with overhydration
and diabetes insipidus. Urine with a high specific
gravity is associated with dehydration, uncontrolled
diabetes mellitus, and nephrosis. High specific gravities may also be seen in clients who are receiving
intravenous (IV) solutions of dextran or other highmolecular-weight fluids and in those who have
received radiologic contrast media.
The specific gravity of urine provides preliminary
information. For a more thorough evaluation of
renal concentrating ability, urine osmolality may be
determined, and concentration tests may be
performed.16
PH

The pH of urine reflects the kidney’s ability to regulate the acid–base balance of the body. In general,
when too much acid is present in the body (i.e.,
respiratory or metabolic acidosis), acidic urine (low
pH) is excreted. Conversely, alkaline urine (high pH)
is excreted in states of respiratory or metabolic alkalosis. Various foods and drugs also affect urinary pH.
The kidney controls the acid–base balance of the
body through regulation of hydrogen ion excretion.
Various acids are excreted via the glomerulus along
with sodium ions. In the renal tubules, bicarbonate
ions are reabsorbed and hydrogen ions are secreted
in exchange for sodium ions. Additional hydrogen
ions are excreted as ammonium.
Disorders involving the renal tubules affect regulation of pH. In renal tubular acidosis, for example,
the ability of the distal tubules to secrete hydrogen
ions and form ammonia is impaired. Metabolic
acidosis results. Similarly, in proximal tubular acidosis, bicarbonate is wasted.
As noted previously, the acidity or alkalinity of
the urine generally reflects that of the body. A paradoxic situation can occur, however, in clients with
hypokalemic alkalosis, which can occur with
prolonged vomiting or excessive use of diuretics. In
this situation, an acidic urine may be produced
when hydrogen ions are secreted instead of potassium ions (which are deficient) to maintain electrochemical neutrality in the renal tubules.17
The pH or urine samples must be evaluated in
relation to the client’s dietary and drug intake. A diet
high in meat and certain fruits such as cranberries
produces acidic urine. A diet high in vegetables and
citrus fruits produces an alkaline urine. Drugs such
as ammonium chloride and methenamine mandelate produce an acid urine, whereas sodium bicarbonate, potassium citrate, and acetazolamide result
in alkaline urine.
The changes in urinary pH that occur in relation

CHAPTER 6—Studies

to ingestion of certain foods and drugs are applied to
the treatment of certain urinary tract disorders.
Maintenance of an acidic urine may be used in the
treatment of urinary tract infections (UTIs) because
urea-splitting organisms do not multiply as rapidly
in an acidic environment. These same organisms
cause the pH of a urine specimen to rise if it is
allowed to stand for a period of time.18 Acidic urine
also helps to prevent the formation of ammonium
magnesium kidney stones, which are more likely to
form in alkaline urine. Other types of kidney stones
are more likely to be prevented if the urine is alkaline. The induction of alkaline urine may also be
used in the treatment of UTIs with drugs such as
kanamycin, in sulfonamide therapy, and in the treatment of salicylate poisoning.19
Urine is generally less acidic after a meal (the
“alkaline tide”) because of secretion of acids into the
stomach. Urine tends to be more acidic in the morning as a result of the mild respiratory acidosis that
normally occurs during sleep.20 Thus, the time of
day at which the sample is collected may influence
evaluation of urinary pH.
PROTEIN

Urine normally contains only a scant amount of
protein, which derives from both the blood and the
urinary tract itself. The proteins normally filtered
through the glomerulus include small amounts of
low-molecular-weight serum proteins such as albumin. Most of these filtered proteins are reabsorbed
by the proximal renal tubules. The distal renal
tubules secrete a protein (Tamm-Horsfall mucoprotein) into the urine. Other normal proteins in urine
include microglobulin, immunoglobulin light
chains, enzymes and proteins from tubular epithelial
cells, leukocytes, and other cells shed by the urinary
tract. More than 200 urinary proteins have been
identified.21
Normal protein excretion must be differentiated
from that which is caused by disease states. Persons
who do not have renal disease may have proteinuria
after strenuous exercise or during dehydration.
Functional (nonrenal) proteinuria may also be seen
in congestive heart failure (CHF), cold exposure,
and fever.22
Postural (orthostatic) proteinuria may also occur
in a small percentage of normal individuals. In this
situation, the client spills protein while in an upright
posture but not when recumbent. Postural proteinuria is evaluated by having the client collect a urine
sample on first arising and then approximately 2
hours later after having been up and about. The
second sample should be positive for protein; the
first should be negative. Orthostatic proteinuria is

of Urine

225

generally a benign condition, although the client
should be reevaluated periodically for persistent,
nonpostural proteinuria.
Persistent proteinuria is generally indicative of
renal disease or of systemic disorders leading to
increased serum levels of low-molecular-weight
proteins. Renal disease resulting in proteinuria may
be a result of damage to the glomerulus or to the
renal tubules. When the glomerular membrane is
damaged, greater amounts of albumin pass into the
glomerular filtrate. If damage is more extensive,
large globulin molecules are also excreted. Nephrotic
syndrome is an example of renal disease primarily
associated with glomerular damage. In this disorder
there is heavy proteinuria accompanied by decreased
serum albumin. In contrast, renal disease resulting
from tubular damage is characterized by loss of
proteins that are normally reabsorbed by the tubules
(i.e., low-molecular-weight proteins). An example of
renal disease primarily associated with tubular
damage is pyelonephritis. The proteinuria that
occurs in disorders involving the renal tubules is
generally not as profound as that associated with
glomerular damage.23,24
Systemic disorders that result in excessive production or release of hemoglobin, myoglobin, or
immunoglobulins may lead to proteinuria and may,
in addition, lead to actual renal disease.
Myoglobinemia, for example, which may occur with
extensive destruction of muscle fibers, leads to
excretion of myoglobin in the urine and may lead to
acute renal tubular necrosis.25 Multiple myeloma, a
neoplastic disorder of plasma cells, is another example of a systemic disorder that may cause proteinuria. In this disorder, the blood contains excessive
levels of monoclonal immunoglobulin light chains
(Bence Jones protein).26 This protein overflows
through the glomerulus in quantities greater than
the renal tubules can absorb. Thus, large amounts of
Bence Jones protein appear in the urine. As with
myoglobinuria, the excessive amounts of protein can
ultimately damage the kidney itself.
Because proteinuria may indicate serious renal or
systemic disease, its detection on UA must always be
further evaluated for possible cause. Proteinuria
occurring in the latter months of pregnancy also
must be carefully evaluated because it may indicate
serious complications of pregnancy.
GLUCOSE

Normally, glucose is virtually absent from the urine.
Although nearly all glucose passes into the glomerular filtrate, most of it is reabsorbed by the proximal
renal tubules through active transport mechanisms.
In active transport, carrier molecules attach to mole-

226

SECTION I—Laboratory

Tests

cules of other substances (e.g., glucose) and transport them across cell membranes. Usually there are
enough carrier molecules to transport all of the
glucose from the renal tubules back to the blood. If
plasma glucose levels are very high, however, such
that carrier mechanisms are overwhelmed, glucose
will appear in the urine. The point at which a
substance appears in the urine is called its renal
threshold.27 The renal threshold for glucose ranges
from 160 to 200 mg/dL, depending on the individual. That is, the blood sugar must rise to its renal
threshold level before glucose appears in the urine.
The most common cause of glycosuria is uncontrolled diabetes mellitus. Because even a normal
person may have elevated blood glucose levels
immediately after a meal, urine samples for glucose
are best collected immediately before meals, when
the blood sugar should be at its lowest point.
Similarly, urine that has been accumulating in the
bladder overnight may contain excessive amounts of
glucose resulting from increased concentration of
urine and perhaps also from something eaten the
previous evening. Because a negative test result for
urinary sugar may not necessarily indicate a normal
blood sugar level and because there is a great deal of
variation in individual renal thresholds for glucose,
recent trends for diabetes control have moved away
from urinary glucose monitoring to blood glucose
monitoring. Evaluation of glucose in routine urine
specimens, however, remains a useful screening
technique.
In addition to diabetes mellitus, many other
disorders can result in glycosuria. In general, these
disorders fall into two general categories: (1) those
in which the blood sugar is elevated and (2) those in
which the blood sugar is not elevated but in which
renal tubular absorption of glucose is impaired.
Disorders that may lead to elevated blood glucose
levels and, thus, to glycosuria are listed in Table 6–2.
In addition, several drugs are known to elevate the
blood sugar enough to produce glycosuria. These
also are listed in Table 6–2.
When renal tubular reabsorption of glucose is
impaired, glucose may appear in the urine without
actual hyperglycemia. In disorders involving the
renal tubules, glycosuria is one of many abnormal
findings. Reabsorption of amino acids, bicarbonate,
phosphate, sodium, and water may also be impaired.
Disorders associated with altered renal tubular function and glycosuria are listed in Table 6–2.
Pregnancy represents a special case in which glycosuria may be present without hyperglycemia.
During pregnancy, the glomerular filtration rate
(GFR) is increased so that it may not be possible for
the renal tubules to reabsorb all of the glucose
presented. Glucose may appear in the urine even

though blood glucose levels are within normal
limits. This situation must be distinguished from
actual diabetes with elevated blood sugar levels, a
serious complication of pregnancy.28
Certain drugs are known to produce false-positive
results when testing for glucose in urine, especially
when copper sulfate reduction testing methods (e.g.,
Clinitest tablets, Benedict’s solution) are used. These
drugs are listed in Table 6–3. Allowing urine specimens to remain at room temperature for long periods may produce false-positive results.
The presence of nonglucose sugars in the urine
may also produce false-positive results in tests for
glycosuria. These sugars include lactose, fructose,
galactose, pentose, and sucrose. Lactose may appear
in the urine during normal pregnancy and lactation,
in lactase deficiency states, and in certain disorders
affecting the intestines (e.g., celiac disease, tropical
sprue, and kwashiorkor). Fructose may appear in the
urine after parenteral feedings with fructose and in
clients with inherited enzyme deficiencies, which are
generally benign in nature. Galactose in the urine
also is associated with certain inherited enzyme deficiencies. Pentose may appear in the urine after ingestion of excessive amounts of fruits. Similarly, sucrose
may be found if large amounts of sucrose are
ingested, but it may also be found in clients with
intestinal disorders associated with sucrase deficiency (e.g., sprue).29
Glycosuria may, therefore, indicate a number of
pathological states or may result from drug and food
ingestion. A thorough history and further evaluation
through additional laboratory tests are indicated
whenever glycosuria occurs.
KETONES

The term ketones refers to three intermediate products of fat metabolism: acetone, acetoacetic acid, and
-hydroxybutyric acid. Measurable amounts of
ketones are not normally present in urine. With
excessive fat metabolism, however, ketones may be
found. Excessive fat metabolism can occur in several
situations: (1) impaired ability to metabolize carbohydrates, (2) inadequate carbohydrate intake, (3)
excessive carbohydrate loss, and (4) increased metabolic demand.30 The disorder most commonly associated with impaired ability to metabolize
carbohydrates is diabetes mellitus. Because carbohydrates cannot be used to meet the body’s energy
needs, fats are burned, leading to the presence of
ketones in the urine. A similar situation occurs when
carbohydrate intake is inadequate to the body’s
needs. This is seen in weight-reduction diets and
starvation. Excessive loss of carbohydrates (e.g.,
caused by vomiting and diarrhea) and increased
metabolic demand (e.g., acute febrile conditions and

CHAPTER 6—Studies

TABLE 6–2

•

of Urine

Disorders and Drugs That May Result in Glycosuria

Glycosuria with High Blood Sugar
Diabetes mellitus

Glucosuria without High Blood Sugar
Renal tubular dysfunction

Gestational diabetes

Fanconi’s syndrome

Acromegaly

Galactosemia

Cushing’s syndrome

Cystinosis

Hyperthyroidism

Lead poisoning

Pheochromocytoma

Multiple myeloma

Advanced cystic fibrosis

Pregnancy (must be distinguished from gestational diabetes)

Hemochromatosis
Severe chronic pancreatitis
Carcinoma of the pancreas
Hypothalamic dysfunction
Brain tumor or hemorrhage
Massive metabolic derangement
Severe burns
Uremia
Advanced liver disease
Sepsis
Cardiogenic shock
Glycogen storage disease
Obesity
Medication-induced hyperglycemia
Adrenal corticosteroids
Adrenocorticotropic hormone
Thiazides
Oral contraceptives
Excessive IV glucose
Dextrothyroxine

TABLE 6–3

227

•

Drugs That May Produce False-Positive Glycosuria Results

Ascorbic acid

Oxytetracycline (Terramycin)

Cephalosporins

Para-aminobenzoic acid (PABA)

Chloral hydrate

Paraldehyde

Levodopa

Penicillins

Metaxalone (Skelaxin)

Salicylates

Morphine

Streptomycin

Nalidixic acid (NegGram)

Radiographic contrast media

228

SECTION I—Laboratory

Tests

toxic states, especially in infants and children) can
also produce ketonuria. Other disorders in which
ketones may be found in the urine include lactic
acidosis and salicylate toxicity. Ketonuria also has
been found after anesthesia and is believed to be a
result of both decreased food intake before surgery
and increased metabolic demand in relation to physiological stressors.
As with glucose, ketones in the urine are associated with elevated blood ketone levels. Because
ketone bodies are acids, ketonuria may indicate
systemic acidosis. Ketones in urine are measured
most frequently in clients with diabetes mellitus and
in those on weight-reduction diets. The finding of
ketones on UA requires further follow-up through
history and laboratory tests to determine the source.
Individuals receiving levodopa, paraldehyde,
phenazopyridine (Pyridium), and phthalein
compounds may produce false-positive results when
tested for ketonuria.
BLOOD

Blood can be present in the urine as either red blood
cells or hemoglobin. If enough blood is present, the
color of the sample can range from pink-tinged to
red to brownish-black. Very small amounts of blood,
although clinically significant, may not be detected
unless the sample is tested with reagent strips
(“dipsticks”) or by microscopic examination. The
dipstick approach for macroscopic UA provides a
useful screening approach. Positive results require
further evaluation to determine the nature and
source of the blood.31,32
The presence of red blood cells in urine (hematuria) is relatively common, whereas the presence of
hemoglobin in urine (hemoglobinuria) is seen
much less frequently. Hematuria is usually associated with disease of or damage to the genitourinary
tract. When hematuria is accompanied by significant
proteinuria, kidney disease is generally indicated
(e.g., acute glomerulonephritis). In contrast, hematuria with only small amounts of protein is associated with inflammation and bleeding of the lower
urinary tract (e.g., cystitis).33 Other disorders
commonly associated with hematuria include
pyelonephritis, tumors of the genitourinary tract,
kidney stones, lupus nephritis, and trauma to the
genitourinary tract. Nonrenal causes of hematuria
include bleeding disorders and anticoagulant therapy. Hematuria may also occur in healthy individuals after excessive strenuous exercise because of
damage to the mucosa of the urinary bladder.34
Free hemoglobin is not normally found in the
urine. Instead, any hemoglobin that could be

presented to the glomerulus combines with haptoglobin. The resultant hemoglobin–haptoglobin
complex is too large to pass through the glomerular
membrane. If the amount of free hemoglobin
exceeds the amount of haptoglobin, however, the
hemoglobin will pass through the glomerulus and
ultimately be excreted into the urine.35 Any disorder
associated with hemolysis of red blood cells and
resultant release of hemoglobin can lead to the
appearance of hemoglobin in the urine. Common
causes of hemoglobinuria include hemolytic
anemias, transfusion reactions, trauma to red blood
cells by prosthetic cardiac valves, extensive burns,
trauma to muscles and blood vessels, and severe
infections. Hemoglobinuria may also occur in
healthy individuals and is thought to be caused by
trauma to small blood vessels.36
Note that hemoglobin is broken down in the renal
tubular cells into ferritin and hemosiderin.
Hemosiderin may, therefore, be found in urine a few
days after an episode of acute red cell hemolysis.
Hemosiderin also is found in the urine of individuals with hemochromatosis, a disorder of iron metabolism.37
BILIRUBIN AND UROBILINOGEN

If the urine sample for UA appears dark or if the
client is experiencing jaundice, the specimen can be
tested for the presence of bilirubin and excessive
urobilinogen. Both of these substances are bile
pigments that result from the breakdown of hemoglobin (Fig. 6–1).
The average life span of red blood cells is 120 days.
Old and damaged cells are broken down primarily in
the spleen and to some extent in the liver. The breakdown products are iron, protein, and protoporphyrin. The body reuses the iron and protein; the
protoporphyrin is converted into bilirubin and is
released into the circulation, where it combines with
albumin. This form of bilirubin is called unconjugated or prehepatic bilirubin. It does not pass into
the urine because the complex is insoluble in water
and is too large to pass through the glomerular
membrane. When circulating unconjugated bilirubin reaches the liver, it is conjugated with glucuronic
acid. The conjugated (posthepatic) bilirubin is
normally absorbed into the bile ducts, stored in the
gallbladder, and ultimately excreted via the intestine.38 In the intestine, bilirubin is converted into
urobilinogen by bacteria. Approximately half of the
urobilinogen is excreted in the stools, where it is
converted into urobilin; the remaining half is reabsorbed from the intestine back into the bloodstream.
From the bloodstream, urobilinogen is either recir-

CHAPTER 6—Studies

of Urine

229

Figure 6–1. Hemoglobin degradation. (From Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, Philadelphia,
2001, p 56, with permission.)

culated to the liver and excreted with bile or excreted
via the kidneys. Normally, only a small amount of
urobilinogen is found in the urine.39
Bilirubin may be found in the urine in liver
disease and is usually found in clients who have
biliary tract obstructions. Excessive urobilinogen
may also be found in the urine of those with liver
disease or hemolytic disorders. Urobilinogen is
absent from the urine in disorders that cause
complete obstruction of the bile ducts (Table 6–4).
Bilirubinuria can occur in clients with liver
disease when the integrity of liver cells is disrupted
and conjugated bilirubin leaks into the circulation;
this leakage may be seen in hepatitis and cirrhosis. In
fact, in these disorders, bilirubin may appear in the
urine before the client actually becomes jaundiced. If
liver function is impaired such that the liver cannot
conjugate bilirubin, excessive bilirubin will not be
found in the urine. Similarly, excessive bilirubin is
not seen in the urine of clients with hemolytic disorders. These disorders have marked destruction of
red blood cells with resultant high levels of unconjugated bilirubin. The normally functioning liver is
unable to conjugate the excessive load, and although
serum levels of unconjugated bilirubin rise, urinary
bilirubin excretion remains relatively unchanged.
TABLE 6–4

•

This condition, again, is a result of the kidney’s
inability to excrete unconjugated bilirubin.
If bile duct obstruction occurs, the conjugated
bilirubin cannot pass from the biliary tract into the
intestine. Instead, excess amounts are absorbed into
the bloodstream and excreted via the kidneys. Also,
because little or no bilirubin passes into the intestine, where urobilinogen is formed, the urine will be
negative for urobilinogen. Absence of urobilinogen
in urine is associated with complete obstruction of
the common bile duct. When absence of urobilinogen is combined with the presence of blood in the
stool, carcinoma involving the head of the pancreas
may be indicated.40
As noted previously, approximately half of the
urobilinogen formed in the intestines is reabsorbed
into the bloodstream. Normally, most of this
urobilinogen is circulated to the liver, where it is
processed and excreted via bile. A smaller amount is
excreted in the urine. When liver cells are damaged,
excretion of urobilinogen in bile is decreased,
whereas its urinary excretion is increased. This
condition may be seen in clients with cirrhosis,
hepatitis, and CHF with congestion of the liver.
Excessive urobilinogen also appears in the urine
in persons with hemolytic disorders. As noted, in

Urine Bilirubin and Urobilinogen in Jaundice
Urine Bilirubin

Bile duct obstruction

Urine Urobilinogen
Normal

Liver damage

Hemolytic disease

Negative

From Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, Philadelphia, 2001, p 57, with permission.

230

SECTION I—Laboratory

Tests

such disorders the amount of unconjugated bilirubin produced is more than the liver can handle, but
the liver attempts to compensate, and increased
amounts of urobilinogen are ultimately formed.
When this urobilinogen is recirculated back to the
liver, however, the liver is unable to process it further
and additional amounts are excreted in the urine.
A number of factors can cause spurious results
when urine is tested for bilirubin and urobilinogen.
Because excessive exposure of a urine sample to light
and room air may lead to false-negative results for
bilirubin, only fresh urine specimens should be
used. Large amounts of ascorbic acid and nitrates in
the urine also cause false-negative results. Note that
bilirubin excretion is enhanced in alkalotic states.
This also is true of urobilinogen and is a result of
decreased tubular reabsorption from alkaline urine.
Similarly, acidic urine results in decreased urinary
levels of urobilinogen. As noted, urobilinogen is
formed by bacterial action in the intestine. Broadspectrum antibiotics impair this process and result
in decreased urobilinogen production. As with
bilirubin, high levels of nitrates in the urine may also
cause false-negative results in tests for urobilinogen.41,42
NITRITE

Testing urine samples for nitrite is a rapid screening
method for determining the presence of bacteria in
the specimen. This test is based on the fact that
nitrate, which is normally present in urine, is
converted to nitrite in the presence of bacteria. The
test is performed by the dipstick method and, if
positive, indicates that clinically significant bacteriuria is present. Positive test results should always be
followed by a regular urine culture.
Several factors can interfere with the accuracy of
tests for nitrite. First, not all bacteria reduce nitrate
to nitrite. Those that do so include the gram-negative bacteria, the organisms most frequently involved
in UTIs. Because yeasts and gram-positive bacteria
may not convert nitrate to nitrite, the presence of
these organisms can cause a false-negative test result.
For bacteria to convert nitrate to nitrite, the
organisms must be in contact with urinary nitrate
for some period of time. Thus, freshly voided
random samples or urine that is withdrawn from a
Foley catheter may produce false-negative results.
The best urine samples for nitrite testing are first
morning samples from urine that has been in the
bladder overnight. Other causes of false-negative
results include inadequate amounts of nitrate in the
urine for conversion (may occur in individuals who
do not eat enough green vegetables), large amounts
of ascorbic acid in the urine, antibiotic therapy, and

excessive bacteria in the urine so that nitrite is
further reduced to nitrogen, which is not detected by
the test. False-positive reactions will occur if the
container in which the sample is collected is
contaminated with gram-negative bacteria.43,44
LEUKOCYTE ESTERASE

Testing urine samples for the presence of leukocyte
esterase is a rapid screening method for determining
the presence of certain white blood cells (i.e.,
neutrophils) in the sample and, thus, the possibility
of a UTI. This test is performed by the dipstick
method and is based on the fact that the esterases
present in neutrophils will convert the indoxyl
carboxylic acid ester on the dipstick to indoxyl,
which is converted to indigo blue by room air.
Approximately 15 minutes are needed for this reaction to take place if neutrophils are present. If positive, the test should be followed by a regular urine
culture.45
Some factors can interfere with the accuracy of
tests for leukocyte esterases. False-positive results
can occur if the sample is contaminated with vaginal
secretions.46 False-negative results can occur if high
levels of protein and ascorbic acid are present in the
urine. If the urine contains excessive amounts of
yellow pigment, a positive reaction will be indicated
by a change to green instead of blue.47

MICROSCOPIC ANALYSIS
The microscopic component of a UA involves examining the sample for formed elements, or urinary
sediment, such as red and white blood cells, epithelial cells, casts, crystals, bacteria, and mucus.
Microscopic analysis is performed by centrifuging
approximately 10 to 15 mL of urine for about 5
minutes. The resulting sediment is then examined
under the microscope. Microscopic analysis is the
most time-consuming component of the UA. It
involves both identifying and quantifying the
formed elements present.48
Note that the Addis count is a variation of the
microscopic urinalysis. For an Addis count, all urine
is collected for 12 hours and then the nature and
quantity of formed elements are determined. This
test, which was once used to follow the progress of
acute renal disease, is seldom used today, because
microscopic analysis of a single random sample
usually is sufficient.49
RED BLOOD CELLS

Red blood cells are too large to pass through the
glomerulus; thus, the finding of red blood cells in
the urine (hematuria) is considered abnormal. If red

CHAPTER 6—Studies

blood cells are present, damage to the glomerular
membrane or to the genitourinary tract is indicated.
For this test, the number of red blood cells is
counted. The result may indicate the nature and
severity of the disorder causing the hematuria.
Renal and genitourinary disorders associated with
the presence of red blood cells in the urine include
glomerulonephritis, lupus nephritis, nephritis associated with drug reactions, tumors of the kidney,
kidney stones, infections, trauma to the kidney, renal
vein thrombosis, hydronephrosis, polycystic kidney
disease, acute tubular necrosis (occasionally), and
malignant nephrosclerosis (occasionally).50
Red blood cells may also be seen with some
nonrenal disorders: acute appendicitis; salpingitis;
diverticulitis; tumors involving the colon, rectum,
and pelvis; acute systemic febrile and infectious
diseases; polyarteritis nodosa; malignant hypertension; and blood dyscrasias. Drugs that may lead to
hematuria include salicylates, anticoagulants,
sulfonamides, and cyclophosphamide. Strenuous
exercise can also cause red blood cells to appear in
the urine because of damage to the mucosa of the
bladder.51 Contamination of the sample with
menstrual blood may lead to false-positive results.
WHITE BLOOD CELLS

Normally, only a few white blood cells are found in
urine. Increased numbers of leukocytes in the urine
generally indicate either renal or genitourinary tract
disease. As with red blood cells, white blood cells
may enter the urine either through the glomerulus
or through damaged genitourinary tissues. In addition, white blood cells may migrate through undamaged tissues to sites of infection or inflammation. An
excessive amount of white blood cells in the urine is
termed pyuria.52
The most frequent cause of pyuria is bacterial
infection anywhere in the renal or genitourinary
system (e.g., pyelonephritis, cystitis). Noninfectious
inflammatory disorders, however, may also lead to
pyuria. Such disorders include glomerulonephritis
and lupus nephritis. In addition, tumors and renal
calculi may cause pyuria because of the resultant
inflammatory response.
A higher than normal number of leukocytes may
be seen if the sample is contaminated with genital
secretions. This finding is especially true in women.
White blood cells disintegrate in dilute, alkaline
urine and in samples that are allowed to stand at
room temperature for more than 1 to 2 hours.53
EPITHELIAL CELLS

Epithelial cells found in urine samples are derived
from three major sources: (1) the linings of the male

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231

and female lower urethras and the vagina (squamous epithelial cells); (2) the linings of the renal
pelvis, bladder, and upper urethra (transitional
epithelial cells); and (3) the renal tubules themselves.
Because it is normal for old epithelial cells to slough
from their respective areas, finding a few epithelial
cells in a urine sample is not necessarily abnormal.
Presence of a large numbers of cells, especially those
of renal tubular origin, is considered a pathological
situation. When large numbers of renal tubular cells
are shed, tubular necrosis is indicated. In addition to
acute tubular necrosis (ATN), excessive numbers of
tubular epithelial cells may be seen in renal transplant rejection, any ischemic injury to the kidney,
glomerulonephritis, pyelonephritis, and damage to
the kidney by drugs and toxins.54
Renal tubular epithelial cells may contain certain
lipids and pigments. Cells that contain lipoproteins,
triglycerides, and cholesterol are called oval fat
bodies. Presence of oval fat bodies occurs in lipid
nephrosis and results from lipids leaked through
nephrotic glomeruli. Histiocytes are fat-containing
cells that are larger than oval fat bodies and that
usually can be distinguished from the latter on
microscopic examination. Histiocytes may be seen
in nephrotic syndrome and in lipid-storage
diseases.55
Pigments that may be absorbed into renal tubular
epithelial cells include hemoglobin that is converted
to hemosiderin, melanin, and bilirubin.
Hemoglobin and bilirubin have been discussed
previously. Melanin may be found in tubular epithelial cells in the presence of malignant melanoma that
has metastasized to the genitourinary tract.
Finding increased epithelial cells from the lower
genitourinary tract is generally not of major clinical
significance, with one exception. If excessive
numbers of transitional epithelial cells are found in
large clumps, or sheets, carcinoma involving any
portion of the area from the renal pelvis to the bladder may be indicated.56
CASTS

Casts are gel-like substances that form in the renal
tubules and collecting ducts. They are termed casts
because they take the shape of the area of the tubule
or collecting duct in which they form. TammHorsfall protein, a mucoprotein secreted by the
distal renal tubular cells, is the major constituent of
casts. This protein forms a framework in which
other elements may be trapped (e.g., red and white
blood cells, bacteria, fats, urates). Healthy individuals may normally excrete a few casts, especially if
there is a low urinary pH, increased protein in the
urine, increased excretion of solutes, and decreased

232

SECTION I—Laboratory

Tests

rate of urine flow.57 As noted previously, proteinuria
may occur after strenuous exercise. This may lead to
the formation and excretion of an increased number
of casts in healthy individuals. Red blood cells may
also be found in casts excreted in response to such
exercise. Otherwise, excretion of an excessive
number of casts is usually associated with widespread kidney disease that involves the renal
tubules.58
Casts are classified according to the nature of the
substances present in them (Table 6–5). As can be
seen in the table, the finding of excessive numbers of
casts requires further diagnostic follow-up, because
such a condition may indicate serious renal disease.
CRYSTALS

Crystals form in urine because of the presence of the
salts from which they are precipitated. Of the
numerous types of crystals (Table 6–6), many are
not of major clinical significance. Also, several
factors affect the formation of urinary crystals: (1)
pH of the urine, (2) temperature of the urine, and
(3) concentration of the substances from which the
crystals are formed. Table 6–6 shows the pH of the
urine at which the several types of crystals are most
likely to be formed. In terms of the temperature of
the sample, crystals are most likely to be seen in
samples that have stood at room temperature for
several hours or have been refrigerated, depending
on the type of crystal. The concentration of various
substances that lead to the formation of crystals is
important in that the greater the concentration, the
greater the likelihood of precipitation of the
substance into the urine in crystal formation.
In analyzing crystals on microscopic examination,
it is important to determine the type of crystal present. The presence of certain crystals may indicate
disease states (e.g., liver disease, cystinuria). In addition, drug therapy or use of radiographic dyes can
cause precipitation of crystals that may portend
renal damage by blocking the tubules.59
OTHER SUBSTANCES

A number of other substances may be found on
microscopic urinalysis: bacteria, yeast, mucus, spermatozoa, and parasites. Bacteria are not normally
present but may be seen if UTI is present or if the
sample was contaminated externally. The number of
bacteria will increase if the specimen is allowed to
stand at room temperature for several hours.
Bacteria in the urine are generally not of major
significance unless accompanied by excessive
numbers of white blood cells, which may indicate an
infectious or inflammatory process. Yeast in the
urine usually indicates contamination of the sample

with vaginal secretions in women with yeast infections such as Candida albicans. Yeasts may also be
seen in the urine of clients with diabetes. Mucus in
urine generally reflects secretions from the genitourinary tract and is usually associated with
contamination of the sample with vaginal secretions. Spermatozoa may be found in urine after
sexual intercourse or nocturnal emissions. Parasites
are frequently of vaginal origin and may indicate
vaginitis caused by Trichomonas vaginalis. A true
urinary parasite is Schistosoma haematobium, seen in
the urine of individuals with schistosomiasis, an
uncommon disorder in the United States. If
pinworms and other intestinal parasites are found,
contamination of the sample with fecal material is
indicated.60
SUMMARY

The UA, which consists of macroscopic and microscopic components, yields a great deal of information about the client. All the tests may be performed
separately, especially those associated with macroscopic analysis. The most complete picture, however,
is obtained by synthesizing the data obtained from
the various tests.
Although a variety of disorders may be indicated
by abnormal results on a UA test, the most common
disorders indicated are the several types of renal
disease. Table 6–7 shows ways in which the results
of macroscopic and microscopic analyses are
combined to indicate certain types of renal disease.
Other types of disorders associated with abnormal
urinalysis results are listed in the indications for the
UA test.
INTERFERING FACTORS

Improper specimen collection so that the sample
is contaminated with vaginal secretions or feces
Use of collection containers contaminated with
bacteria
Therapy with medications or ingestion of foods
that may alter the color, odor, or pH of the sample
Delay in sending unrefrigerated samples to the
laboratory within 1 hour of collection, which may
lead to:
Deepening of the color of the sample
Increased alkalinity of the sample
Increased concentration of glucose, if already
present
Oxidation of bilirubin, if present, and
urobilinogen
Deterioration of urinary sediment
Multiplication of bacteria, if present
Failure to time properly those tests done by the
dipstick method (e.g., glucose and ketones)

CHAPTER 6—Studies

TABLE 6–5

•

Type
Hyaline

of Urine

233

Summary of Urine Casts
Origin

Tubular secretion of Tamm-Horsfall protein

Clinical Significance
Glomerulonephritis
Pyelonephritis
Chronic renal disease
Congestive heart failure
Stress and exercise

Red blood cell

Attachment of red blood cells to Tamm-Horsfall
protein matrix

Glomerulonephritis
Strenuous exercise
Lupus nephritis
Subacute bacterial endocarditis
Renal infarction
Malignant hypertension

White blood cell

Attachment of white blood cells to Tamm-Horsfall
protein matrix

Inflammation or infection
involving the glomerulus
Pyelonephritis
Lupus nephritis

Epithelial cell

Tubular cells remaining attached to Tamm-Horsfall
protein fibrils

Renal tubular damage

Granular

Disintegration of white cell casts

Stasis of urine flow

Bacteria

Urinary tract infection

Urates

Stress and exercise

Tubular cell lysosomes

Acute glomerulonephritis

Protein aggregates

Renal transplant rejection
Pyelonephritis
Lead poisoning

Waxy

Hyaline casts in an advanced stage of development

Stasis of urine flow
Renal transplant rejection
Renal tubular inflammation
and degeneration
Chronic renal failure
End-stage renal disease

Fatty

Renal tubular cells

Nephrotic syndrome

Broad casts

Oval fat bodies

Nephrotic syndrome

Formation in collecting ducts (i.e., casts are larger
than those formed in the tubules)

Extreme stasis of urine flow
Renal failure (severe)
Chronic glomerulonephritis

Adapted from Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, Philadelphia, 2001, p 93.

234

SECTION I—Laboratory

TABLE 6–6

Crystal

•

Tests

Major Characteristics and Clinical Significance of
Urinary Crystals
pH

Color

Clinical Significance

NORMAL

Uric acid

Acid

Yellow-brown

Gout
Leukemias and lymphomas, especially
if client is receiving chemotherapy

Amorphous urates

Acid

Brick dust or
yellow-brown

Not of major clinical significance

Calcium oxalate

Acid/neutral
(alkaline)

Colorless
(envelopes)

High doses of ascorbic acid
Severe chronic renal disease
Ethylene glycol toxicity
Crohn’s disease, hypercalcemia

Amorphous
phosphates

Alkaline,
neutral

White
colorless

May be found in urine that has
stood at room temperature for
several hours

Calcium phosphate

Alkaline,
neutral

Colorless

Not of major clinical significance

Ammonium biurate

Alkaline

Yellow-brown
(thorny apples)

Not of major clinical significance

Calcium carbonate

Alkaline

Colorless
(dumb-bells)

Not of major clinical significance

Triple phosphate

Alkaline

Colorless
(coffin lids)

Not of major clinical significance

Cystine

Acid

Colorless

Cystinuria (inherited metabolic
defect that prevents reabsorption of
cystine by the proximal tubules)

Cholesterol

Acid

Colorless
(notched plates)

High serum cholesterol
More likely to be seen in
refrigerated specimens

Leucine

Acid/neutral

Yellow

Severe liver disease

ABNORMAL

Tyrosine

Acid/neutral

Colorless, yellow

Severe liver disease

Sulfonamides

Acid/neutral

Green

Therapy with sulfonamides

Radiographic dye

Acid

Colorless

Dye excretion

Ampicillin

Acid/neutral

Colorless

Therapy with ampicillin

Adapted from Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, Philadelphia, 2001. pp 115–116.

INDICATIONS FOR ROUTINE URINALYSIS

The routine urinalysis is a screening technique that
is an essential component of a complete physical
examination, especially when performed on admission to a health-care facility or before surgery. It may
also be performed when renal or systemic disease is
suspected. Note that the components of a UA may be

performed separately, if necessary. This may be done
to monitor previously identified conditions. Other
indications or purposes for a UA include the following:
Detection of infection involving the urinary tract
as indicated by urine with a “fishy” or fetid odor
and presence of nitrite, leukocyte esterase, white
blood cells, red blood cells (possibly), and bacteria

TABLE 6–7

•

Laboratory Correlations in Renal Diseases

Disease

Macroscopic Examination

Acute glomerulonephritis

Macroscopic hematuria

RBCs

ASO titer ↑

Specific gravity ↑

RBC casts

GFR ↓

Protein 5 g/day

Granular casts

Sed rate ↑

Microscopic Examination

Remarks

Other Laboratory Findings

Microscopic hematuria remains
longer than proteinuria

WBCs

Macroscopic hematuria
Protein

RBCs
WBCs
Granular casts

BUN ↑
Creatinine ↑
FDP ↑
GFR ↓
Cryoglobulins ↑

Oliguria

Chronic glomerulonephritis

Macroscopic hematuria

RBCs

BUN ↑

Oliguria or anuria

Specific gravity 1.010

WBCs

Creatinine ↑

Nocturia

Protein

All types of casts
Broad casts

Serum phosphorus ↑
Serum calcium ↓

Anemia

Membranous
glomerulonephritis

Blood
Protein

RBCs
Hyaline casts

Positive ANA
Positive HBsAg

Microscopic hematuria

Membranoproliferative
(mesangioproliferative)
glomerulonephritis

Macroscopic hematuria
Protein

RBCs
RBC casts

BUN ↑
Creatinine ↑
ASO titer ↑
Complement ↓

Hematuria may be microscopic

Focal glomerulonephritis

Blood
Protein

RBCs
Fat droplets

IgA deposits on
membrane

Macroscopic or microscopic
hematuria

of Urine

(Continued on the following page )

CHAPTER 6—Studies

“Smoky” turbidity
Rapidly progressive
(crescentic)
glomerulonephritis

235

236

•

Laboratory Correlations in Renal Diseases (Continued)

Disease

Macroscopic Examination

Minimal change disease

Blood

Microscopic Examination

Other Laboratory Findings
Serum protein ↓

Oval fat bodies

Serum albumin ↓

Hematuria may be absent

Tests

RBCs

Remarks

Fat droplets
Hyaline casts
Fatty casts
Nephrotic syndrome

Protein

Oval fat bodies

Serum lipids ↑

Fat droplets

Serum protein ↓

Generalized casts

Serum albumin ↓

Heavy proteinuria 5 g/day

Waxy casts
Fatty casts
Pyelonephritis

Cloudy

WBCs

Protein

WBC casts

Nitrite

Bacteria

Leukocytes

RBCs

SECTION I—Laboratory

TABLE 6–7

Concentrating ability decreased
in chronic cases

Adapted from Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, Philadelphia, 2001, pp 124–130.
ANAantinuclear antibody, ASOantistreptolysin O, BUNblood urea nitrogen, FDPfibrin degradation products, GFRglomerular filtration rate, HbsAghepatitis B
surface antigen, IgAimmunoglobulin A.

CHAPTER 6—Studies

of Urine

237

Reference Values
Macroscopic Analysis
Color

Pale yellow to amber

Appearance

Clear to slightly cloudy

Odor

Mildly aromatic

Specific gravity

1.001–1.035 (usual range 1.010–1.025)

4.5–8.0

Protein

Negative

Glucose

Negative

Other sugars

Negative

Ketones

Negative

Blood

Negative

Bilirubin

Negative

Urobilinogen

0.1–1.0 Ehrlich units/dL (1–4 mg/24 hr)

Nitrate

Negative

Leukocyte esterase

Negative

Microscopic Analysis
Red blood cells (RBCs)

0–3 per high-power field (HPF)

White blood cells (WBCs)

0–4 per HPF

Epithelial cells

Few

Casts

Occasional (hyaline or granular)

Crystals

Occasional (uric acid, urate, phosphate, or calcium oxalate)

Critical values: RBC 0.50, WBC, or pathological crystals, as well as grossly bloody
urine, and 3 to 41 glucose or ketones, or both

Detection of uncontrolled diabetes mellitus as
indicated by the presence of glucose and ketones
(seen primarily in insulin-dependent diabetes
mellitus) and by urine with low specific gravity
Detection of gestational diabetes during pregnancy
Detection of possible complications of pregnancy
as indicated by proteinuria
Detection of bleeding within the urinary system,
as indicated by positive dipstick test for blood and
detection of red blood cells on microscopic examination
Detection of various types of renal disease (see
Table 6–7)
Detection of liver disease as indicated by the presence of bilirubin (possibly), excessive urobilinogen, and leucine or tyrosine crystals, or both
Detection of obstruction within the biliary tree as
indicated by presence of bilirubin and absence of
urobilinogen

Detection of multiple myeloma as indicated by
the presence of Bence Jones protein
Monitoring of the effectiveness of weight-reduction diets as indicated by the presence of ketones
in the urine
Detection of excessive red blood cell hemolysis
within the systemic circulation as indicated by the
presence of free hemoglobin and elevated
urobilinogen levels
Detection of extensive injury to muscles as
indicated by the presence of myoglobin in the
urine
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That results are most reliable if the specimen is
obtained upon arising in the morning, after urine
has accumulated overnight in the bladder
(Exception: Serial urine samples for glucose
should consist of fresh urine.)

238

SECTION I—Laboratory

Tests

Nursing Alert

Improper collection and disposition of sample
for UA may lead to spurious results (see
“Interfering Factors” section). The best
samples, in general, are those that are
collected first thing in the morning after urine
has collected in the bladder overnight. The
sample should be received in the laboratory
within 1 hour of collection. If this is not
possible, the sample can be refrigerated.
The time of collection and the source of the
sample must be noted, because this information is important in evaluating the results and
in distinguishing normal from abnormal
results.
Because many drugs and foods may alter
results, a thorough medication and diet
history is necessary for evaluating the data
obtained.

The proper way to collect the sample, if the client
is to do this independently (see Appendix II)
The importance of the sample being received in
the laboratory within 1 hour of collection
Prepare for the procedure:
The client should be provided with the proper
specimen container.
For women, a clean-catch midstream kit should
be provided.
Techniques for collecting samples from children
are described in Appendix II.
For catheterized specimens, a catheterization tray
is needed if an indwelling catheter is not already
present.
THE PROCEDURE

A voided or catheterized sample of approximately 15
mL is collected (see Appendix II).
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include observing
the color, clarity, and odor of the sample when it is
obtained. Perform dipstick tests for glucose, ketones,
protein, and blood on separate portions of the
sample, if desired.
Hydration state: Note and report intake and
output (I&O) ratio and adequacy, changes in
urinary pattern and diuresis, and dehydration and
fluid shifts. Monitor I&O and effect on specimen
collection and testing, urinary sample characteristics and amount, and urinary pattern changes.

Correct techniques: Store dipsticks in a dry, cool,
dark place. Immerse dipstick in the urine for an
appropriate time and examine in a well-lit place
after an appropriate time interval. Confirm all
abnormal test results.
Specific gravity: Note and report increases over
1.020. Monitor I&O. Assess for dehydration.
Administer additional fluids, if allowed. Note
decreases below 1.009. Monitor I&O and weight
for fluid overload. Assess for renal dysfunction.
Inform and instruct client in fluid intake necessary to maintain adequate hydration.
pH: Note and report increases over 6 (alkaline
urine). Assess for risk of or presence of UTI or
renal calculi. Increase fluid intake and restrict
foods that leave an alkaline ash (milk, citrus
fruits). Administer ordered vitamin C. Note
decreases below 6 (acid urine). Administer
medications to promote an alkaline urine. Assess
for possible metabolic or respiratory acidotic
states.
Protein: Note and report any trace or range of
protein from 0 to 41 or 10 to 1000 mg/dL. Collect
another specimen and test or prepare the client
for an ordered 24-hour urine analysis.
Glucose: Note and report any trace or range of
glucose from 0 to 41. Assess blood glucose level.
Also assess for drugs that cause elevations,
increased urinary output and thirst, or possible
dehydration state. Prepare for further testing for
glucose levels in the blood and urine.
Ketones: Note and report moderate acetone level
and blood level over 50 mg/dL. Assess weight,
dietary regimen, diarrhea, presence of diabetes
mellitus, or possible ketoacidotic state. Administer ordered insulin or other medications.
Blood: Note and report microscopic or macroscopic amounts of blood. Assess for anticoagulant
therapy, urinary tract or renal disorders, or toxic
response to drug therapy.
Bilirubin: Note and report presence of bilirubin.
Assess for jaundice of mucous membranes and
sclera and for clay color of stool. Also assess for
liver or biliary tract disorders and drug regimens
that cause liver damage.
Nitrite: Note and report positive result. Obtain a
clean-catch urine specimen for culture tests.
Leukocyte esterase: Note and report positive
results with a positive nitrite test. Obtain a cleancatch urine specimen for culture tests.
Critical values: Physician should be notified
immediately of a positive microscopic result of
high levels of red blood cells, greater than 50
white blood cells, or pathological crystals, as
well as grossly bloody urine, and 3 to 41 or 1 to

CHAPTER 6—Studies

2 percent of glucose or ketones, or both, by
dipstick testing.

TESTS OF RENAL FUNCTION
Renal function tests are used to evaluate the excretory, secretory, and osmolar regulation dynamics of
the kidney. Broad categories of such tests include (1)
clearance tests, (2) tubular function tests, and (3)
concentration tests.

CLEARANCE TESTS AND CREATININE
CLEARANCE
The term clearance refers to the relationship between
the renal excretory mechanisms and the circulating
blood levels of the materials to be excreted.
Clearance reflects the overall efficiency of glomerular functioning.
Substances filtered through the glomerulus are
(1) excreted into the urine unaltered by the renal
tubules, (2) reabsorbed partially or entirely by the
renal tubules, or (3) added to by the renal tubules.
For the purpose of clearance tests, substances that
pass through the glomerulus and are not altered by
the renal tubules are analyzed. The assumption is
that all of the substance is cleared from the plasma
via the glomerulus and is excreted unchanged into
the urine. Substances that may be measured in clearance tests include inulin, urea, para-aminohippuric
acid (PAH), and creatinine.61
Inulin is an inert sugar that is not metabolized,
absorbed, or secreted by the body. To determine
renal clearance, inulin must be infused IV at a
constant rate throughout the testing period. Renal
clearance is then calculated by measuring the
urinary excretion of inulin in relation to plasma
concentration. Because this test involves administration of an exogenous substance, it is not used
frequently.62 PAH is similar to inulin in that it also
must be administered IV for clearance tests.
Urea, an end product of protein metabolism, is
formed in the liver and excreted relatively
unchanged by the kidneys. Blood urea levels are
affected by a variety of factors, and, therefore, it is
not the ideal substance for renal clearance tests.
Blood urea levels may be elevated if shock, trauma,
sepsis, or tumors cause increased protein metabolism. A high-protein diet or state of dehydration will
also cause elevated blood urea levels. High blood
urea levels could result in normal clearance test
values even though renal function is depressed.
Creatinine is the ideal substance for determining
renal clearance because a fairly constant quantity is
produced within the body. As discussed in Chapter

of Urine

239

5, creatinine is the end product of creatine metabolism. Creatine resides almost exclusively in skeletal
muscle, where it participates in energy-requiring
metabolic reactions. In these processes, a small
amount of creatine is irreversibly converted to creatinine, which then circulates to the kidneys and is
excreted. The amount of creatinine generated in an
individual is proportional to the mass of skeletal
muscle present and remains fairly constant unless
there is massive muscle damage caused by crushing
injury or degenerative muscle disease.63 Because
muscle mass is usually greater in men than in
women, the quantity of creatinine excreted is usually
greater in men.
Creatinine clearance is a sensitive indicator of
glomerular function because those factors affecting
creatinine clearance are primarily caused by alterations in renal function. These factors include the
number of functioning nephrons, the efficiency with
which they function (i.e., if there is decreased functioning of some nephrons, others may function
more efficiently to compensate), and the amount of
blood entering the nephrons. In general, a 50 percent
reduction in functioning nephrons causes creatinine
clearance to be slightly decreased. Loss of two-thirds
of the nephrons, however, produces a sharp
decrease. Note that creatinine clearance tends to
decline with normal aging. Thus, it is important to
know the client’s age when interpreting test results.64
Renal disease is the major cause of reduced creatinine clearance. Other disorders that can result in
decreased creatinine clearance include shock, hypovolemia, and exposure to nephrotoxic drugs and
chemicals.
The creatinine clearance test is performed by
collecting all urine for 24 hours, measuring the creatinine present, and calculating clearance according
to the basic formula shown here. As indicated by the
formula, it is necessary to determine the plasma level
of creatinine at some point during the test.
C UV
P
where
C creatinine clearance
U amount of creatinine in urine
V volume of urine excreted per 24 hours
P plasma creatinine level
INTERFERING FACTORS

Incomplete urine collection may yield a falsely
lowered value.
Excessive ketones in urine and presence of
substances such as barbiturates, phenolsulfon-

240

SECTION I—Laboratory

Tests

Reference Values
Creatinine Clearance

Conventional Units

SI Units

Men

85–125 mL/min

1.41–2.08 mL/s/1.73 m2

Women

75–115 mL/min

1.21–1.91 mL/s/1.73 m2

phthalein, and sulfobromophthalein (Bromsulphalein [BSP]) may cause falsely lowered values.
INDICATIONS FOR CLEARANCE TESTS AND
CREATININE CLEARANCE

Determination of the extent of nephron damage
in known renal disease (i.e., at least 50 percent of
functioning nephrons must be lost before values
will be decreased)
Monitoring for the effectiveness of treatment in
renal disease
Determination of renal function before administering nephrotoxic drugs or drugs that may build
up if glomerular filtration is reduced
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
The necessity of collecting all urine for 24 hours
How to maintain the sample (e.g., on ice, refrigerated) if being collected at home
That a blood sample also will be collected once
during the test
Prepare for the procedure:
Provide the proper collection container.
Provide for proper preservation of the sample.
Use the techniques for collecting a 24-hour
sample as described in Appendix II.
THE PROCEDURE

Creatinine Clearance. A 24-hour urine sample is
collected (see Appendix II). A preservative may be
added to the collection container by the laboratory
to prevent degradation of the creatinine. If a preservative is not available, the urine should be kept on ice
or refrigerated throughout the collection period. A
blood sample is obtained at some point during the
urine collection to determine plasma creatinine level.
NURSING CARE AFTER THE PROCEDURE

Special aftercare interventions are not required for
this test.
Compromised renal function: Note and report
creatinine clearance that has decreased in
comparison to an increased serum creatinine and
estimated GFR. Monitor I&O and fluid and
protein restrictions. Instruct client in dietary,
fluid, and medication inclusions and exclusions.

TUBULAR FUNCTION TESTS AND
PHENOLSULFONPHTHALEIN TEST
Tubular function tests assess the ability of the renal
tubules to remove waste products and other
substances (e.g., drugs) from the blood and secrete
them into the urine. Normal tubular function is
dependent on two main factors: (1) adequate renal
blood flow and (2) effective tubular function.
According to Sacher and McPherson,65 although
tests of tubular function may provide valuable
physiological insight, they provide little diagnostic
information in individual clinical situations.
More appropriate information may be obtained by
measuring blood and urine levels of substances
such as glucose and electrolytes and comparing
the results. Elevated serum potassium levels, for
example, combined with decreased potassium in the
urine indicate impaired tubular secretion of potassium. Failure to excrete an appropriate acidic or
alkaline urine in relation to blood pH levels also
indicates disruption of normal tubular secreting
mechanisms.
If tubular function tests are to be performed, they
are usually carried out by injecting phenolsulfonphthalein (PSP) IV and then measuring its excretion
in serial urine samples. PSP is a dye that binds to
albumin in the bloodstream and, therefore, cannot
be excreted through the glomerulus. To be excreted,
the dye must be secreted by renal tubular cells. In the
proximal renal tubules, the dye has greater affinity
for the cells lining the tubules than it does for the
protein. When it dissociates from the protein, it can
be secreted by the tubules.66 Because it is a dye, PSP
imparts a pinkish color to alkaline urine upon excretion. Within 2 hours of injection, 75 percent of the
dose is excreted if renal blood flow and tubular function are normal.
Measurement of the dye that is present is accomplished with a spectrophotometer. Thus, any
substances that alter the color of urine (see Table
6–1) may also alter test results. The client must be
well hydrated so that renal perfusion is adequate and
urine flow is brisk. If the urine lacks sufficient alkalinity, substances such as sodium hydroxide may be
added to the sample in the laboratory to produce the
necessary pH for testing.

CHAPTER 6—Studies

of Urine

241

Reference Values
Adults

After 15 min, 25% of the dose is excreted
After 30 min, 50–60% of the dose is excreted
After 60 min, 60–70% of the dose is excreted
After 2 hr, 70–80% of the dose is excreted

Children

Amounts excreted are 5–10% higher at the preceding time intervals

INTERFERING FACTORS

Failure to collect the urine samples at the required
times (Reference Values are based on these times.)
Failure to completely empty the bladder each time
a specimen is collected
Presence in the urine of any substance that alters
the color of urine (see Table 6–1), because results
are based on dye excretion
Inadequately hydrated client such that the kidneys
are inadequately perfused or urine flow is
decreased
Presence in the blood of radiographic dye, salicylates, sulfonamides, and penicillin that may lead
to decreased excretion of the dye
High serum protein levels, which may lead to
decreased excretion of the dye
Severe hypoalbuminemia, excessive albuminuria,
or severe liver disease, which may lead to
increased excretion of the dye
INDICATIONS FOR TUBULAR FUNCTION TESTS
AND PHENOLSULFONPHTHALEIN TEST

Assessment of renal blood flow and tubular
secreting ability (The PSP test is of limited clinical
usefulness.)
Nursing Alert

The PSP excretion test should not be
performed on clients who have demonstrated
previous allergy to the dye.
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
The importance of increased fluid intake before
the test
That foods and drugs that impart color to the
urine (e.g., carrots, beets, rhubarb, azo drugs)
should be avoided for 24 hours before the test
That a dye that circulates through the blood and
then is excreted by the kidneys will be injected IV
That four urine specimens will be obtained at
timed intervals (i.e., 15 minutes, 30 minutes, 1
hour, and 2 hours) after injection of the dye

The importance of completely emptying the bladder each time a urine sample is obtained
Obtain a signed permission consent form. Then:
Ensure to the extent possible that dietary and
medication restrictions are followed.
Provide sufficient fluids to promote adequate
hydration.
Obtain four containers for the urine samples.
THE PROCEDURE

PSP Excretion Test. PSP dye is injected IV, after
which a pressure dressing is applied to the injection
site. Urine samples are then collected at 15-minute,
30-minute, 1-hour, and 2-hour intervals. Each specimen should consist of at least 50 mL. If the client
cannot void at the required time, a Foley catheter
may be inserted and the specimen obtained. The
catheter is then clamped until the next specimen
is due.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming
any withheld foods and medications.
Monitor the dye injection site for inflammation
and hematoma formation.
Remove a catheter if one has been inserted for the
test, and assess voiding pattern.
Allergic response: Note and report skin rash,
urticaria, and change in pulse and respirations.
Administer ordered antihistamine and steroid
therapy. Have resuscitation equipment and
oxygen on hand.
Urinary infection: Note and report urinary
pattern changes and characteristics (cloudy, foul
smelling). Obtain urine specimen for culture.
Monitor I&O. Administer antimicrobial therapy
as ordered.

CONCENTRATION TESTS AND
DILUTION TESTS
Concentration tests assess the ability of the renal
tubules to appropriately absorb water and essential
salts such that the urine is properly concentrated.
The glomerular filtrate entering the renal tubules

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normally has a specific gravity of 1.010. If the renal
tubules are damaged such that they cannot effectively reabsorb water and salt, the specific gravity of
the excreted urine will remain at 1.010. Loss of tubular concentrating ability is one of the earliest indicators of renal disease and may occur before blood
levels of urea and creatinine rise. In addition to the
various forms of renal disease, other situations in
which renal concentrating ability may be impaired
include failure to secrete antidiuretic hormone
(central diabetes insipidus), lack of renal response to
antidiuretic hormone (nephrogenic diabetes
insipidus), prolonged overhydration, osmotic diuresis (especially that caused by uncontrolled diabetes
mellitus), hypokalemia, hypocalcemia, lithium and
ethanol use, severe hypoproteinemia, multiple
myeloma, amyloidosis, sickle cell disease or trait, and
psychogenic polydipsia.
The concentration of urine may be determined by
measuring either the specific gravity or the osmolality of the sample. In some cases, a single early-morning specimen will suffice. In other situations, timed
tests conducted over 12 to 24 hours may be necessary. Another approach is to measure both the serum
and the urine osmolality and to compare the results.
Measuring the osmolality of urine is considered
more accurate than determining the specific gravity.
As noted previously, both the number and the size of
particles present influence the specific gravity of
urine. In contrast, osmolality is affected only by the
number of particles present. Thus, smaller molecules such as sodium and chloride, which are of
interest in renal concentration tests, contribute more
to urine osmolality measures than they do to specific
gravity determinations. In the laboratory, osmolality
is reported as milliosmols (mOsm).
Normally, the kidneys can concentrate urine to an
osmolality of about three to four times that of
plasma (normal plasma osmolality is 275 to 300
mOsm). If the client is overhydrated, the kidneys
will excrete the excess water and produce urine with
an osmolality as low as one-fourth or less that of
plasma.67 Because factors such as fluid intake, diet
(especially protein and salt intake), and exercise
influence urine osmolality, it has been difficult to
establish exact reference values. It is considered
more reliable to measure serum and urine osmolalities and compare the two in terms of a ratio relationship (see Chapter 5).
Timed concentration tests are performed if earlymorning samples indicate inadequate overnight
urine concentrating ability. In the Fishberg test, an
attempt is made to maximally concentrate urine
through fluid restriction. In the standard version of
this test, the client consumes no fluid for 24 hours

(from breakfast one day to breakfast the next). In the
simplified version, fluids are restricted from the
evening meal until breakfast the next morning (see
“The Procedure” later in this section).68 The 24hour fluid restriction should produce the maximum
concentration possible. The 12-hour overnight
restriction will increase the concentration to about
75 percent of maximum, partly because of the
normal increase in urine concentration that occurs
at night.69
The Mosenthal test also derives from the principle
of increased urine concentration at night. In this
test, two consecutive 12-hour urine specimens are
collected, one from approximately 8 AM to 8 PM and
one from 8 PM to 8 AM. If kidney function is normal,
the specific gravity of the nighttime collection
should be greater than that of the daytime collection.70
Note that tests of the kidney’s ability to produce
dilute urine are rarely performed. These tests involve
overhydrating the client and then observing for the
appearance of dilute urine with low specific gravity
and osmolality. The danger is that not all clients can
tolerate the fluid load needed to produce the desired
results.
INTERFERING FACTORS

Concentration Tests
Failure of the client to follow the fluid restrictions
necessary for the Fishberg test
Ingestion of a diet with an excessive or inadequate
amount of protein, sodium, or both
Presence of disorders that alter serum protein or
sodium levels
Dilution Tests
Inability of the client to ingest the required fluids
for the test
Inability of the client to tolerate the fluid load
required for the test
INDICATIONS FOR CONCENTRATION TESTS
AND DILUTION TESTS

Concentration Tests
Early detection of renal tubular damage (i.e.,
before serum levels of urea and creatinine are
elevated) as indicated by loss of tubular concentrating ability
Detection of disorders that impair renal concentrating ability (e.g., diabetes insipidus)
Differentiation of psychogenic polydipsia from
organic disease as indicated by a normal response
to timed concentration tests (e.g., Fishberg test)
Detection of excessive or prolonged overhydration

CHAPTER 6—Studies

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243

Reference Values
Concentration Tests
Specific gravity

1.001–1.035 (usual range 1.010–1.025)

Osmolality

50–1400 mOsm (usual range 300–900 mOsm; average 850 mOsm)

Ratio of urine to
serum osmolality

1.2:1 to 3:1

Fishberg test (standard)

Specific gravity 1.026 or higher on at least one sample

Fishberg test (simplified)

Specific gravity 1.022 or higher on at least one sample

Mosenthal test

Specific gravity 1.020 or higher with at least a 7-point
difference between the specific gravities of the daytime and nighttime
samples

Dilution Tests
Specific gravity

1.003

Osmolality

100 mOsm

Determination of decreased osmolality (overhydration) and increased osmolality (dehydration)
Dilution Tests
Evaluation of renal tubular response to high fluid
volume as indicated by production of urine with
low specific gravity and osmolality
Nursing Alert

Dilution tests should not be performed on
clients who may have difficulty tolerating an
increased fluid load (e.g., clients with CHF).

NURSING CARE BEFORE THE PROCEDURE

Urine Osmolality
There is no specific preparation other than reviewing with the client when the specimen is to be
obtained (e.g., first-voided morning urine) and
providing a collection container.
Fishberg Test (Standard Version)
Explain to the client:
That no fluids are to be taken after breakfast the
initial morning of the test until the test is
completed the next morning
That solid (dry) foods are not restricted
That client should completely empty the bladder
at approximately 10 PM before retiring
That client should remain in bed during the night
(i.e., during the usual hours of sleep)
That a urine specimen will be obtained at 8 AM
after 24 hours without fluids

That client should return to bed for 1 hour after
the first specimen is collected
That a second specimen will be collected at 9 AM
That client should resume normal activity for 1
hour after the second specimen is collected
That a third specimen will be collected at 10 AM
Prepare for the procedure:
Ensure to the extent possible that fluid restrictions
are followed.
Provide the proper specimen containers.
Fishberg Test (Simplified Version)
Explain to the client:
That no fluids should be taken from the time of
the evening meal until the test is completed
That client should completely empty the bladder
at approximately 10 PM before retiring
That urine samples will be collected at 7 AM, 8 AM,
and 9 AM, after approximately 12 hours without
fluids
Note: Some laboratories require that the evening
meal consist of a high-protein, low-salt diet with no
more than 200 mL fluid. If this is the case, the client
should be so informed. Then:
Ensure to the extent possible that fluid restrictions
are followed.
Provide the proper specimen containers.
Mosenthal Test
Explain to the client:
That two consecutive 12-hour urine collections
will be obtained: one from 8 AM to 8 PM in one
container and one from 8 PM to 8 AM in another
container

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The importance of collecting all urine voided
during the time period
That there are no diet or fluid restrictions
Prepare for the procedure:
Provide the proper specimen containers.
Dilution Tests
Explain to the client:
That it will be necessary to drink approximately
3 pt (1500 mL) of water in a 1/2-hour period
That hourly urine specimens will be obtained for
4 hours after ingestion of the water
That any symptoms of fluid excess (e.g., palpitations, shortness of breath) should be reported
immediately
Ensure to the extent possible that the client
consumes or receives the required fluids. Then:
Provide the proper specimen containers.
THE PROCEDURE

Specific Gravity and Urine Osmolality. A random
urine specimen of at least 15 mL is collected, preferably first thing in the morning.

NURSING CARE AFTER THE PROCEDURE

Specific Gravity and Urine Osmolality. There are
no special aftercare interventions.
Fishberg Tests. Resume normal fluid intake and
diet.
Mosenthal Test. There are no special aftercare
interventions.
Dilution Tests. Monitor response to the fluid load.
Note especially increased pulse rate or difficulty
breathing.
Hydration state: Note and report I&O ratio and
adequacy, changes in urinary pattern, and diuresis. Assess for dehydration signs and symptoms.
Monitor I&O and effect on specimen collection
and testing. Also monitor urinary amounts and
characteristics.
Critical values: Notify physician immediately if
the osmolality result is less than 100 mOsm
(overhydration) or greater than 800 mOsm
(dehydration).

Fishberg Test (Standard Version). The client eats
his or her usual breakfast, after which no further
fluids are ingested until the test is completed the
next morning. Solid (dry) foods are allowed. The
client voids at approximately 10 PM or before retiring. Urine specimens are collected the next morning
at 8 AM, 9 AM, and 10 AM. The client is to remain in
bed between the 8 AM and 9 AM specimens and to
resume normal activities between the 9 AM and 10
AM specimens.

MEASUREMENT OF OTHER
SUBSTANCES

Fishberg Test (Simplified Version). The client eats
his or her evening meal, after which no fluids are
ingested until the test is completed the next morning. Some laboratories require that the evening
meal consist of a high-protein, low-salt diet with no
more than 200 mL of fluid. The client voids at
approximately 10 PM or before retiring. Urine
samples are collected the next morning at 7 AM,
8 AM, and 9 AM.

One of the major functions of the kidney is the regulation of electrolyte balance. Electrolytes are filtered
through the glomerulus and reabsorbed in the renal
tubules. Those electrolytes most commonly measured in urine are sodium, chloride, potassium,
calcium, phosphorus, and magnesium. Tests for
electrolytes in urine usually involve 24-hour urine
collections. Serum determinations of electrolyte
levels are, therefore, preferred to the more cumbersome urinary determinations (see Chapter 5). An
exception is magnesium, which indicates deficiency
earlier than does serum assay.

Mosenthal Test. Two separate but consecutive 12hour urine collections are obtained, one from 8 AM
to 8 PM and one from 8 PM to 8 AM the next day.
Dilution Tests. These tests, although rarely
conducted, may be performed upon completion of
the Fishberg tests. The client ingests 1500 mL of
water over a 1/2-hour period. An alternative
approach is to administer IV fluids, with the type
and amount determined by the physician ordering
the test. Urine samples are collected every hour for 4
hours after ingestion or administration of the fluid.

A variety of substances can be measured in urine to
detect alterations in physiological function. Among
these are electrolytes, pigments, enzymes, hormones
and their metabolites, proteins and their metabolites, and vitamins and minerals.

ELECTROLYTES

SODIUM

Most of the sodium filtered through the glomerulus
is reabsorbed in the proximal renal tubule.
Additional amounts may be reabsorbed in the distal
tubule under the influence of aldosterone, a
hormone (mineralocorticoid) released by the adrenal cortex. Aldosterone is released in response to
decreased serum sodium, decreased blood volume,

CHAPTER 6—Studies

and increased serum potassium. Enhanced sodium
reabsorption is reflected in decreased amounts being
excreted in the urine. This may be seen in situations
such as hyperaldosteronism, hemorrhage, shock,
CHF with inadequate renal perfusion, and therapy
with adrenal corticosteroids. Increased loss of
sodium into the urine is associated with excessive
salt intake, diuretic therapy, diabetic ketoacidosis,
adrenocortical hypofunction, toxemia of pregnancy,
hypokalemia, and excessive licorice ingestion. Renal
failure may cause either retention or loss of sodium.
In acute renal disease involving the renal tubules
(e.g., ATN), excessive loss of sodium into the urine
may occur, because the tubules are too impaired to
reabsorb sodium normally.
CHLORIDES

Chlorides are generally reabsorbed passively along
with sodium. The kidney may also secrete either
chloride or bicarbonate, depending on the acid–base
balance of the body. Chloride excretion is directly
influenced by chloride intake. It is also influenced by
factors that affect sodium excretion. Chloride excretion may be impaired in certain types of renal
disease.71
POTASSIUM

Like sodium, potassium is filtered through the
glomerulus and reabsorbed through the tubules.
Adequate excretion of potassium from the body also
requires that the distal tubules and collecting ducts
secrete potassium into the urine. Aldosterone also
influences potassium excretion in that potassium is
excreted in exchange for the sodium that is reabsorbed. Urinary excretion also varies in relation to
dietary intake. Causes of excessive potassium loss in
the urine include diabetic ketoacidosis, therapy with
diuretics, and consumption of large amounts of
licorice. The most common cause of decreased
potassium in the urine is chronic renal failure, in
which tubular secretory activity is impaired.
CALCIUM

Calcium is the most abundant cation in the body,
with bone its major reservoir. Only a small amount
of calcium circulates in the blood, and most calcium
excretion takes place via the stools. Serum calcium
levels are largely regulated by the parathyroid glands
and vitamin D. Urinary calcium excretion varies
directly with the serum calcium level. If blood levels
are high, more calcium is excreted. Blood levels of
calcium vary with dietary intake, although they are
more influenced by increased intake than by
decreased intake. Calcium excretion is highest just
after a meal and lowest at night.72 Although many

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245

disorders may alter calcium excretion, determination of urinary calcium is made primarily to evaluate individuals with kidney stones or with suspected
parathyroid disorders.
Seventy-five percent of all kidney stones contain
calcium compounds. Contrary to popular belief, the
most common cause of calcium-containing kidney
stones is not excessive calcium intake. The hypercalcemia and increased calcium excretion associated
with calcium kidney stones are the result of lack of
appropriate renal tubular reabsorption of calcium,
increased calcium reabsorption in the intestines, loss
of calcium from bone, or low serum phosphorus
levels. A variety of disorders can cause these basic
defects,73 among them hyperparathyroidism;
sarcoidosis; renal tubular acidosis; cancers of the
lung, breast, and bone; multiple myeloma; and
metastatic cancer. Drugs that may lead to excessive
calcium excretion include toxic doses of vitamin D,
adrenocorticosteroids, and calcitonin.
Decreased calcium in the urine is related to
hypoparathyroidism, nephrosis, acute nephritis,
chronic renal failure, osteomalacia, steatorrhea, and
vitamin D deficiency. Drugs associated with
decreased calcium in the urine are thiazides and
viomycin.
As noted, a 24-hour urine collection is made to
determine the quantity of calcium lost in the urine.
Sulkowitch’s test, a qualitative measure, can be used
to determine the presence of calcium in random
urine specimens. If necessary, clients may be taught
to perform this test at home.
PHOSPHORUS

As with calcium, serum contains relatively small
amounts of phosphorus, with bone serving as the
major reservoir. Phosphorus levels also are regulated
by the parathyroid glands and vitamin D, with excretion controlled primarily by the kidneys. Causes of
increased loss of phosphorus in the urine include
hyperparathyroidism and renal tubular acidosis.
Causes of decreased loss in the urine are
hypoparathyroidism, nephrosis, nephritis, and
chronic renal failure. Toxic doses of vitamin D may
also result in decreased urinary excretion of phosphorus. Dietary intake of phosphates also influences
urinary excretion.
MAGNESIUM

Magnesium is an essential nutrient found in bone,
muscle, and red blood cells. Relatively little is found
in serum. Magnesium participates in the control of
serum electrolyte levels and increases intestinal
absorption of calcium. Signs and symptoms of
magnesium imbalance are manifested primarily in

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the central nervous and neuromuscular systems.
Urinary measures of magnesium may be used
instead of serum measures because changes in
magnesium levels are reflected more quickly in the
urine than in the blood and may facilitate prompt
diagnosis of the client’s problem. Causes of
increased magnesium excretion include alcoholism,
adrenocortical insufficiency, renal insufficiency,
hypothyroidism, hyperparathyroidism, and excessive ingestion of magnesium-containing antacids.
Thiazide diuretics and ethacrynic acid may also
produce excessive urinary excretion of magnesium.
Decreased urinary excretion is associated with
malabsorption syndromes, dehydration, hyperaldosteronism, diabetic acidosis, pancreatitis, and
advanced chronic renal disease. Increased calcium
intake also results in decreased urinary excretion of
magnesium.
INTERFERING FACTORS

antacids may lead to increased excretion of
magnesium.
INDICATIONS FOR MEASUREMENT OF URINARY
ELECTROLYTES

With the exception of magnesium, electrolytes are
more likely to be measured by serum determinations
than by urinary measures of the substances. General
reasons for analyzing electrolytes in urine are as
follows:
Suspected renal disease
Suspected endocrine disorder
History of kidney stones
Suspected malabsorption problem
Central nervous system (CNS) signs and symptoms of unknown etiology, especially if thought to
be a result of magnesium imbalance, which is
detected earlier in urine than in blood
NURSING CARE BEFORE THE PROCEDURE

Dietary deficiency or excess of the electrolyte to
be measured may lead to spurious results.
Increased calcium intake may result in decreased
magnesium excretion.
Increased sodium and magnesium intake may
cause increased calcium excretion.
Diuretic therapy with excessive loss of electrolytes
into the urine may falsely elevate results.
Therapy with adrenocorticosteroids may lead to
decreased sodium loss and increased calcium loss.
Excessive ingestion of magnesium-containing

For quantitative studies (i.e., studies to determine the
amount of the electrolyte present), client preparation
is the same as that for any test involving the collection of a 24-hour urine sample (see Appendix II).
For calcium studies, some laboratories require
that the client be on a diet with a set amount of
calcium for at least 3 days before beginning the
urine collection. If this is the case, the client
should be instructed about the diet.
Medications are not usually withheld, but the
laboratory should be informed about those taken.

Reference Values
Conventional Units

SI Units

Sodium

30–280 mEq/24 hr

30–280 mmol/day

Chloride

110–250 mEq/24 hr 110–250 mmol/day

Potassium

40–80 mEq/24 hr

40–80 mmol/day

Men

275 mg/24 hr

6.8 mmol/day

Women

250 mg/24 hr

6.2 mmol/day

Calcium
Quantitative

Qualitative
Sulkowitch’s test 0 to 2 turbidity
Phosphorus

0.9–1.3 g/24 hr

Magnesium

150 mg/24 hr
6.0–8.5 mEq/24 hr
3.0–4.3 mmol/day

29–42.0 mmol/day

CHAPTER 6—Studies

If the Sulkowitch test, a qualitative study, is used
for home monitoring of urinary calcium, the
client should be instructed in the procedure.
THE PROCEDURE

Quantitative Tests. A 24-hour urine collection is
obtained (see Appendix II). Check with the laboratory or individual ordering the test to see whether
the diet is to be modified for calcium studies. The
laboratory should be informed of any medications
taken by the client that may alter test results (see
“Interfering Factors” section).
Qualitative Tests (Sulkowitch’s Test). A random
urine specimen is obtained, 5 mL of which is poured
into a test tube. Acetic acid (5 mL of a 10 percent
solution) is added to the sample and the mixture is
boiled to remove protein. Distilled water is then
added to the sample until the original volume is
restored. Sulkowitch’s reagent (5 mL), which
contains oxalic acid and ammonium oxalate, is then
added. This reagent reacts with the calcium in the
sample and produces turbidity (cloudiness) in the
sample. Turbidity is graded on a scale of 0 to
14.74.74,75
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming
the client’s diet after the specimen collection is
completed.

PIGMENTS
Pigments that may be found in urine consist primarily of those substances involved in the synthesis
and breakdown of hemoglobin. These substances
consist of hemoglobin, hemosiderin, bilirubin,
urobilinogen, and porphyrins. Myoglobin, which is
related to hemoglobin but found primarily in skeletal muscle, is another type of pigment, as is melanin,
which is found in hair and skin. With the exceptions
of urobilinogen and porphyrins, these substances
are not normally found in urine.
Hemoglobin, hemosiderin, bilirubin, and
urobilinogen were previously discussed, as was
myoglobin. The presence of myoglobin is associated
with extensive damage to skeletal muscles. Melanin,
which may be incorporated into tubular epithelial
cells, is seen in malignant melanoma. The focus of
this section, therefore, is on the porphyrins.
PORPHYRINS

Porphyrins are produced during the synthesis of
heme (Fig. 6–2). If heme synthesis is deranged, these
precursors accumulate and are excreted in the urine

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247

in excessive amounts. Conditions producing
increased levels of heme precursors are called
porphyrias. The two main categories of genetically
determined porphyrias are erythropoietic porphyrias, in which major diagnostic abnormalities occur
in red cell chemistry, and hepatic porphyrias, in
which heme precursors are found in urine and feces.
Erythropoietic and hepatic porphyrias are very rare.
Acquired porphyrias are characterized by greater
accumulation of precursors in urine and feces than
in red blood cells. Lead poisoning is the most
common cause of acquired porphyria.
Those porphyrins for which urine may be tested
include aminolevulinic acid (ALA), porphobilinogen (PBG), uroporphyrin, and coproporphyrin.
Knowing the type of porphyrin excreted in excess
aids in diagnosing specific disorders. Tests for
porphyrins usually involve collection of 24-hour
urine samples to determine the quantity of the
specific substance present. Screening tests on
random specimens to determine the presence of
excessive amounts of porphyrins (i.e., qualitative
studies) also are available.
The presence of ALA in the urine is associated
with lead poisoning. It is also found in liver disease
(e.g., hepatic carcinoma and hepatitis) and in acute
intermittent and variegate porphyria. PBG is found
in the same disorders and may also be seen in clients
taking griseofulvin. Rifampin, elevated urobilinogen, and light exposure can falsely elevate values.
Uroporphyrin and coproporphyrin also are seen in
clients with lead poisoning and liver disease as well
as in those with uroporphyria and porphyria
cutanea tarda. Uroporphyrin may be found in
hemochromatosis, a disorder of iron metabolism
that affects the liver and certain other body organs.
Coproporphyrin is associated with obstructive jaundice and exposure to toxic chemicals.
Porphyrins are reddish fluorescent compounds.
Depending on the type of porphyrin present, therefore, the urine may be reddish or the color of port
wine (see Table 6–1). The presence of congenital
porphyria may be suspected when an infant’s wet
diaper shows a red discoloration. PBG is excreted as
a colorless compound. If a sample containing PBG is
acidic and is exposed to air for several hours,
however, a color change may occur.76
INTERFERING FACTORS

For random samples, delay in sending the specimen to the laboratory within 1 hour of collection
may lead to oxidation of bilirubin, if present, and
of urobilinogen; random samples for porphyrin
tests must be fresh and, thus, must be sent to the
laboratory immediately upon collection.

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Figure 6–2. Pathway of heme
formation, including stages
affected by the major disorders
of porphyrin metabolism. (From
Strasinger, SK: Urinalysis and
Body Fluids, ed 4. FA Davis,
Philadelphia, 2001, p 142, with
permission.)

For 24-hour samples, failure to collect the specimen in a dark container or in a container covered
with aluminum foil or a dark plastic bag can result
in invalid results. The specimen must also be
refrigerated or kept on ice throughout the collection period unless a preservative has been added
to the container by the laboratory. (If the client
has a Foley catheter, the drainage bag must be
covered with a dark plastic bag and placed in a
basin of ice.)
Therapy with griseofulvin, rifampin, and barbiturates may falsely elevate values in tests for
porphyrins.

INDICATIONS FOR ANALYSIS OF URINARY
PIGMENTS

Detection of liver disease as indicated by the presence of bilirubin (possible), excessive urobilinogen, and elevated porphyrins
Diagnosis of the source of obstructive jaundice
(i.e., obstruction in the biliary tree) as indicated
by the presence of bilirubin, absence of urobilinogen, and elevated coproporphyrins
Detection of suspected lead poisoning as indicated by elevated porphyrins, especially ALA and
PBG

CHAPTER 6—Studies

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249

Reference Values
Conventional Units

SI Units

Hemoglobin

Negative

Hemosiderin

Negative

Bilirubin

Negative

Urobilinogen
Random specimen
24-hr urine

0.1–1.0 Ehrlich U/dL

Negative

1–4 mg/24 hr

Myoglobin

Negative

Melanin

Negative

Porphyrins
Aminolevulinic acid
38.1 mol/L

Random specimen
Children

0.5 mg/dL

Adults

0.1–0.6 mg/dL

24-hr urine

7.6–45.8 mol/L

1.5–7.5 mg/dL/24 hr

11.15–57.2 mol/day

Porphobilinogen
Random specimen
24-hr urine

Negative

Negative
0–66 mol/day

0–1.5 mg/24 hr

Uroporphyrin
Random specimen

Negative

24-hr urine

10–30 g/24 hr
(Values may be slightly higher
in men than in women.)

12–37 nmol/day

Coproporphyrin
Random specimen
Adults

0.045–0.30 mol/L

24-hr urine
Children
Adults

0–80 g/24 hr

0–0.12 mol/day

50–160 g/24 hr
(Values may be slightly higher
in men than in women.)

Detection of excessive red blood cell hemolysis
within the systemic circulation as indicated by the
presence of free hemoglobin, elevated urobilinogen levels, and presence of hemosiderin a few days
after the acute hemolytic episode
Detection of extensive injury to muscles as indicated by the presence of myoglobin in the urine
Detection of malignant melanoma as indicated by
the presence of melanin in the urine

0.075–0.24 mol/day

NURSING CARE BEFORE THE PROCEDURE

For quantitative studies, client preparation is the
same as that for any test involving collection of a 24hour urine sample (see Appendix II).
The client should receive the proper container
and instructions for maintaining the collection
(e.g., refrigerated, protected from light).
For studies involving the porphyrins, medications

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Tests

such as griseofulvin, rifampin, and barbiturates
may be withheld. This practice should be
confirmed with the person ordering the test.
For random samples, there is no specific preparation other than informing the client that the
sample must be protected from light and sent
to the laboratory within 1 hour of collection.
The proper container should be provided to the
client.
THE PROCEDURE

Quantitative Tests. A 24-hour urine collection is
obtained in a dark container or in one covered with
aluminum foil or a dark plastic bag. The sample
must be kept refrigerated or on ice throughout the
collection period unless a preservative has been
added to the container by the laboratory. If the client
has a Foley catheter, the drainage bag must be
covered with a dark plastic bag and placed in a basin
of ice.
Random Specimens (Qualitative Tests). A random
sample is collected and sent promptly (within 1
hour) to the laboratory. The specimen must be
protected from excessive exposure to light.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the tests include resuming
any withheld medications after the specimen collection has been completed.

ENZYMES
As noted in Chapter 5, enzymes are catalysts that
enhance reactions without directly participating in
them. Enzymes are normally intracellular molecules.
When the cells and tissues in which these molecules
are found are damaged, enzymes are released and
increased levels are found in the blood and the
urine. Because some enzymes are specific to only
certain tissues, elevated levels may aid in pinpointing
the source of pathophysiological problems.
Although many enzymes can be measured in
blood, only a few are analyzed in urine, including
amylase, arylsulfatase A, lysozyme (muramidase),
and leucine aminopeptidase. All studies of urinary
enzymes involve the collection of 24-hour urine
samples, with the exception of amylase, which may
be evaluated in timed specimens over shorter periods of time (e.g.,1 or 2 hours).
AMYLASE

Amylase is a digestive enzyme that splits starch into
disaccharides such as maltose. Although many cells
have amylase activity, amylase circulating in serum

(and ultimately excreted in urine) derives from the
parotid glands and the pancreas. Unlike many other
enzymes, amylase activity is primarily extracellular;
it is secreted into saliva and the duodenum, where it
splits large carbohydrate molecules into smaller
units for further digestive action by intestinal
enzymes.
Urinary amylase levels generally parallel the levels
found in blood. There is, however, a lag time
between the rise of blood levels and urinary levels.
Elevated urine levels also return to normal more
slowly than blood levels. This difference between
blood and urinary levels of amylase aids in diagnosing and monitoring disorders associated with
elevated amylase levels.
ARYLSULFATASE A

Arylsulfatase A (ARS A) is a lysosomal enzyme
found in all body cells except mature red blood cells.
Its main sites of activity are in the liver, pancreas,
and kidney.
LYSOZYME (MURAMIDASE)

Lysozyme is a bactericidal enzyme present in tears,
saliva, mucus, and phagocytic cells. Lysozyme is
produced in granulocytes and monocytes.
LEUCINE AMINOPEPTIDASE

Leucine aminopeptidase (LAP) is an isoenzyme of
alkaline phosphatase, an enzyme that cleaves phosphate from compounds and is optimally active at a
pH of 9. Although widely distributed in body tissues,
LAP is most abundant in hepatobiliary tissues,
pancreas, and small intestine.
INTERFERING FACTORS

Incomplete specimen collection and improper
specimen maintenance may lead to spurious
results.
Amylase
Ingestion of drugs that may falsely elevate values
(morphine, codeine, meperidine, pentazocine,
chlorothiazides, aspirin, corticosteroids, oral contraceptives, alcohol, indomethacin, bethanechol
[Urecholine], secretin, and pancreozymin)
Inadvertent addition of salivary amylase to the
sample because of coughing or talking over it
may falsely elevate values.
Arylsulfatase A
Contamination of the sample with blood, mucus,
and feces may falsely elevate levels.
Abdominal surgery within 1 week of the collection may falsely elevate levels.

CHAPTER 6—Studies

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251

Reference Values

Amylase

Conventional Units

SI Units

10–80 amylase U/hr (Mayo Clinic)

265–680 U/day*

35–260 Somogyi U/hr

SI U/hr
6.5–48.1*

Arylsulfatase A
Children

1 U/L

Men

1.4–19.3 U/L

Women

1.4–11 U/L

Lysozyme (muramidase)

1.3–3.6 mg/24 hr

Leucine aminopeptidase

2–28 U/24 hr

* These values reflect routine testing methods used in many laboratories, not those under the Conventional
Units heading.

Lysozyme (Muramidase)
Presence of bacteria in the sample, which will
falsely decrease levels
Presence of blood and saliva in the sample, which
will falsely elevate levels
Leucine Aminopeptidase
Advanced pregnancy and therapy with drugs
containing estrogen and progesterone may falsely
elevate levels.
INDICATIONS FOR URINARY ENZYME TESTS

Amylase
Retrospective diagnosis of acute pancreatitis
when serum amylase levels have returned to
normal but urine levels remain elevated for 7 to
10 days77
Diagnosis of chronic pancreatitis revealed by
persistently elevated urinary amylase levels
Monitoring for response to treatment for pancreatitis
Assistance in identifying the cause of “acute
abdomen”
Differentiation between acute pancreatitis and
perforated peptic ulcer (Urinary amylase levels
are higher in pancreatitis.)
Diagnosis of macroamylasemia, a disorder seen in
alcoholism and malabsorption syndromes, as
revealed by elevated serum amylase and normal
urinary amylase
Confirmation of the diagnosis of salivary gland
inflammation
Arylsulfatase A
Suspected malignancy involving the bladder,

colon, or rectum as indicated by elevated
levels
Suspected granulocytic leukemia as indicated by
elevated levels
Family history of lipid storage diseases (e.g.,
mucolipidoses II and III), with support for the
diagnosis indicated by elevated levels
Suspected metachromatic leukodystrophy as indicated by decreased levels
Lysozyme (Muramidase)
Suspected acute granulocytic or monocytic
leukemia as indicated by elevated levels
Monitoring for the extent of destruction of
monocytes and granulocytes in known leukemias
Suspected renal tubular damage as indicated by
elevated levels
Monitoring of response to renal transplant with
rejection indicated by elevated levels78
Leucine Aminopeptidase
Elevated serum alkaline phosphatase or LAP
levels of unknown etiology
Suspected liver (cirrhosis, hepatitis, cancer),
pancreatic (pancreatitis, cancer), and biliary
diseases (obstruction caused by gallstones, strictures, atresia), especially when serum LAP levels
are normal (Urinary elevations lag behind serum
elevations.)
NURSING CARE BEFORE THE PROCEDURE

Amylase. Client preparation is the same as that for
any study involving a 24-hour or timed urine collection (see Appendix II). The proper container and
instructions for maintaining the collection (e.g.,

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refrigerated, protected from exposure to salivary
secretions) should be provided.
Drugs that may alter test results (see “Interfering
Factors” section) may be withheld during the test,
although this practice should be confirmed with
the person ordering the study.
Arylsulfatase A. Client preparation is the same as
that for any study involving a 24-hour urine collection. The proper container and instructions for
maintaining the collection (e.g., refrigerated, placed
on ice) should be provided.
Lysozyme (Muramidase). Client preparation is the
same as that for any study involving a 24-hour urine
collection. The proper container and instructions
for maintaining the collection (e.g., refrigerated,
placed on ice) should be provided. The client
should be cautioned to avoid touching the inside
of the collection container to avoid bacterial
contamination of the sample. The client also should
be cautioned to avoid contaminating the sample
with saliva (e.g., coughing over the specimen) or
blood.
Leucine Aminopeptidase. Client preparation is the
same as that for any study involving a 24-hour urine
collection. The proper container and instructions
for maintaining the collection (e.g., refrigerated,
placed on ice) should be provided. Because drugs
containing estrogens and progesterone may falsely
elevate levels, a medication history regarding these
types of drugs should be obtained.
THE PROCEDURE

Amylase. A timed urine collection is obtained. The
collection may be made over 1-, 2-, 6-, 8-, and 24hour periods. The sample must be kept refrigerated
or on ice throughout the collection period unless the
laboratory has added a preservative to the container.
If the client has a Foley catheter, the drainage bag
must be placed in a basin of ice. Care must be taken
to avoid adding salivary secretions to the sample by
coughing or talking over the specimen. The sample
should be sent promptly to the laboratory when the
collection is completed.
Arylsulfatase A. A 24-hour urine collection is
obtained. The sample must be kept refrigerated or
on ice throughout the collection period unless a
preservative has been added to the container by the
laboratory. If the client has a Foley catheter, the
drainage bag must be placed in a basin of ice. Care
must be taken not to contaminate the sample with
blood, mucus, or feces. The sample should be sent
promptly to the laboratory when the collection is
completed.

Lysozyme (Muramidase). A 24-hour urine collection is obtained. The sample must be kept refrigerated or on ice throughout the collection period
unless a preservative has been added to the container
by the laboratory. If the client has a Foley catheter,
the drainage bag must be placed on ice. Care must be
taken not to contaminate the sample with bacteria,
blood, or saliva. The sample should be sent promptly
to the laboratory when the collection is completed.
Leucine Aminopeptidase. A 24-hour urine collection is obtained. The sample must be kept refrigerated or on ice throughout the collection period
unless a preservative has been added to the container
by the laboratory. If the client has a Foley catheter,
the drainage bag must be placed on ice. The sample
should be sent promptly to the laboratory when the
collection is completed.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming
any withheld medications after the specimen collection has been completed.

HORMONES AND THEIR METABOLITES
Hormones are chemicals that control the activities
of responsive tissues. Some hormones exert their
effects in the vicinity of their release; others are
released into the extracellular fluids of the body and
affect distant tissues. Numerous hormones can be
measured in blood (see Chapter 5). Most urinary
measures focus on the hormones secreted by the
adrenal cortex, the adrenal medulla, the gonads, and
the placenta. Either the hormone itself or the
metabolites thereof can be measured.
Urinary measures of hormones and their metabolites usually involve collection of 24-hour urine
specimens. The advantage of such quantitative
measures over single blood level determinations is
that overall levels of hormone secretion are reflected.
This is important because blood levels of hormones
tend to vary, depending on time of day.
CORTISOL

The adrenal cortex secretes three types of steroids:
(1) glucocorticoids, which affect carbohydrate
metabolism; (2) mineralocorticoids, which promote
potassium excretion and sodium retention by the
kidneys; and (3) adrenal androgens, which the liver
converts primarily to testosterone. Cortisol is the
predominant glucocorticoid. It is produced and
secreted in response to adrenocorticotropic
hormone (ACTH), which is secreted by the adenohypophysis. Ninety percent of cortisol is bound to

CHAPTER 6—Studies

cortisol-binding globulin (CBG) and albumin. The
“free” (unbound) portion is responsible for its physiological activity and also is the portion excreted into
the urine. Cortisol stimulates gluconeogenesis,
mobilizes fats and proteins, antagonizes insulin, and
suppresses inflammation.
The purpose of urinary measures of cortisol is to
detect elevated levels of free cortisol, which may not
be apparent in random blood samples. Elevated
cortisol levels occur in Cushing’s syndrome, in
which there is excessive production of adrenocorticosteroids. Cushing’s syndrome may be caused by
pituitary adenoma, adrenal hyperplasia, benign or
malignant adrenal tumors, and nonendocrine
malignant tumors that secrete ectopic ACTH.
Therapy with adrenal corticosteroids may also
produce cushingoid signs and symptoms. Elevated
cortisol levels are additionally associated with stress,
hyperthyroidism, obesity, diabetic ketoacidosis,
pregnancy, and excessive exercise. Other drugs that
may elevate cortisol levels include estrogens, oral
contraceptives, lithium carbonate, methadone, alcohol, phenothiazines, amphetamines, morphine, and
reserpine.
ALDOSTERONE

Aldosterone, the predominant mineralocorticoid, is
secreted by the zona glomerulosa of the adrenal
cortex in response to decreased serum sodium,
decreased blood volume, and increased serum
potassium. Aldosterone is released in response to
direct stimulation by altered serum sodium and
potassium levels. In addition, decreased blood
volume and altered sodium and potassium levels
stimulate the juxtaglomerular apparatus of the
kidney to secrete renin. Renin is subsequently
converted to angiotensin II, which then stimulates
the adrenal cortex to secrete aldosterone. In normal
states, ACTH does not play a major role in aldosterone secretion. In disease states, however, ACTH
may also enhance aldosterone secretion.
Aldosterone increases sodium reabsorption in the
renal tubules, gastrointestinal tract, salivary glands,
and sweat glands. This subsequently results in
increased water retention, blood volume, and blood
pressure. Aldosterone also increases potassium
excretion by the kidneys in exchange for the sodium
ions that are retained.
Excessive aldosterone levels are categorized as
primary and secondary hyperaldosteronism.
Primary hyperaldosteronism represents inappropriate aldosterone secretion, which is usually caused by
benign adenomas or bilateral hyperplasia of the
aldosterone-secreting zona glomerulosa cells. In
primary aldosteronism, aldosterone is secreted inde-

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253

pendently of the renin–angiotensin system. A hallmark of primary aldosteronism is low plasma renin
levels.
Secondary hyperaldosteronism indicates an
appropriate response to pathological changes in
blood volume and electrolytes. Common causes of
secondary hyperaldosteronism include CHF, cirrhosis, nephrotic syndrome, chronic obstructive
pulmonary disease (COPD), and renal artery stenosis. Other causes of elevated aldosterone levels are
stress, excessive exercise, pregnancy, and several
drugs (diuretics, Apresoline, diazoxide, and nitroprusside). In secondary hyperaldosteronism, plasma
renin levels are elevated.
Decreased aldosterone levels are associated with
Addison’s disease, hypernatremia, hypokalemia,
diabetes mellitus, toxemia of pregnancy, excessive
licorice ingestion, and certain drugs (propranolol
and fludrocortisone).

17-HYDROXYCORTICOSTEROIDS
All glucocorticoids are degraded by the liver to
metabolites, which as a group are called 17-hydroxycorticosteroids (17-OHCS). These steroid metabolites also are called Porter-Silber chromogens
because of the method used to measure them in
urine. Because 80 percent of urinary 17-OHCS are
metabolites of cortisol, those disorders that are associated with elevated cortisol levels also are associated
with elevated 17-OHCS (e.g., Cushing’s syndrome).
Decreased levels of 17-OHCS are associated with
Addison’s disease, hypopituitarism, and myxedema.
As with cortisol, numerous drugs may alter urinary
excretion of 17-OHCS. Thus, a thorough medication history is necessary. Some medications may be
withheld before and during the test.
When adrenocortical hypofunctioning or hyperfunctioning is suspected, 17-OHCS may be measured in urine as part of the diagnostic process. Note,
however, that measurement of urinary cortisol levels
provides more accurate quantification than does
measurement of 17-OHCS levels in individuals
receiving drugs that alter hepatic metabolism of
steroids.

17-KETOSTEROIDS
17-Ketosteroids (17-KS) are metabolized from
androgenic hormones. In men, two-thirds of 17-KS
originate in the adrenal cortex and one-third derive
from the testes. In women, virtually all 17-KS originate in the adrenal cortex. 17-Ketosteroids do not
include testosterone. Components of 17-KS, which
can be measured individually, include androsterone,
dehydroepiandrosterone, etiocholanolone, 11hydroxyandrosterone, 11-hydroxyetiocholanolone,

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SECTION I—Laboratory

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11-ketoandrosterone, 11-ketoetiocholanolone, pregnanediol, pregnanetriol (see following section), 5pregnanetriol, and 11-ketopregnanetriol.
Levels of 17-KS are elevated in clients having
adrenogenital syndrome (congenital adrenal hyperplasia), Cushing’s syndrome, hormone-secreting
tumors of the adrenal glands or gonads, adrenocortical carcinoma, hyperpituitarism, and stressful
conditions. Decreased levels of 17-KS are associated with Addison’s disease, liver disease, hyopituitarism, hypothyroidism, gout, nephrotic
syndrome, and starvation. As with other urinary
hormones, drugs may alter the excretion of 17KS. Thus, a thorough medication history is necessary.

17-KETOGENIC STEROIDS
Cortisol and its many metabolites can be manipulated in the laboratory to form 17-ketosteroids. The
substances thus formed are called 17-ketogenic
steroids (17-KGS) and can be studied as an index of
overall glucocorticoid metabolism. Before urinary
17-KGS can be evaluated, the 17-KS of androgenic
origin must be either removed or measured separately.79 Because such a large array of steroid
metabolites is reflected in 17-KGS measures, this test
provides for a good overall assessment of adrenal
function.
PREGNANETRIOL

Pregnanetriol is a metabolite of the cortisone
precursor 17-hydroxyprogesterone. It should not be
confused with pregnanediol, which is a metabolite of
the hormone progesterone, secreted by the corpus
luteum and the placenta (see preceding discussion).
Elevated pregnanetriol levels are associated with
adrenogenital syndrome. In this disorder, cortisol
synthesis is impaired at the point of 17-hydroxyprogesterone conversion. The substance accumulates and its metabolite, pregnanetriol, is excreted in
the urine in increased amounts. Excessive amounts
of 17-hydroxyprogesterone, and the resultant pregnanetriol, are produced in response to feedback
mechanisms. Because cortisol synthesis is impaired,
serum cortisol levels are low. This, in turn, stimulates the adenohypophysis to secrete ACTH, which
normally causes cortisol levels to rise. Because cortisol synthesis is impaired, however, pregnanetriol
accumulates instead. Furthermore, the feedback
mechanism continues to stimulate ACTH production. Note that excessive 17-hydroxyprogesterone
can be converted to androgens. This conversion plus
excessive androgen secretion in response to ACTH
may result in virilization in women and in sexual
precocity in boys.

CATECHOLAMINES

The adrenal medulla, a component of the sympathetic nervous system, secretes epinephrine and
norepinephrine, which are collectively known as the
catecholamines. A third catecholamine, dopamine, is
secreted in the brain, where it functions as a neurotransmitter. Dopamine is a precursor of epinephrine
and norepinephrine. Serotonin, an amine related to
the catecholamines, is found in the platelets and in
the argentaffin cells of the intestines.
Epinephrine (adrenalin) and norepinephrine are
normally secreted in response to generalized sympathetic nervous system stimulation. Epinephrine
increases the metabolic rate of all cells, heart rate,
arterial blood pressure, blood glucose, and free fatty
acids. Norepinephrine, the predominant catecholamine, decreases heart rate while increasing
peripheral vascular resistance and arterial blood
pressure.
The most clinically significant disorder involving
the adrenal medulla is the catecholamine-secreting
tumor, pheochromocytoma. Pheochromocytomas
may release catecholamines—primarily epinephrine—continuously or intermittently. For this
reason, urinary measurements are helpful in quantifying overall excretory levels. Because the most
common sign of pheochromocytoma is arterial
hypertension, measurement of either plasma (see
Chapter 5) or urinary catecholamines and their
metabolites is indicated in new-onset hypertension
of unknown etiology.
Total catecholamines can be measured in either
random or 24-hour urine specimens. The individual
catecholamines, epinephrine and norepinephrine,
can be measured in 24-hour urine collections, as can
metanephrine, a metabolite of epinephrine.
Numerous drugs may alter blood and urine levels of
catecholamines, and stress, smoking, and strenuous
exercise may produce elevated levels. Thus, a thorough health history is required before testing.
VANILLYLMANDELIC ACID

Vanillylmandelic acid (VMA) is the predominant
catecholamine metabolite found in urine. VMA is
easier to detect by laboratory methods than are the
catecholamines themselves. Therefore, this test is
frequently used when pheochromocytoma is
suspected.
A disadvantage of the test is the need for a special
diet for 2 days before the study as well as on the day
the 24-hour urine specimen is collected. The following foods are restricted on a “VMA diet”: bananas,
nuts, cereals, grains, tea, coffee, gelatin foods, citrus
fruits, chocolate, vanilla, cheese, salad dressing, jelly,

CHAPTER 6—Studies

candy, chewing gum, cough drops, most carbonated
beverages, licorice, and foods with artificial flavoring
or coloring. Ingestion of such foods will falsely
elevate VMA levels. Note, however, that, as laboratory methods become more precise, it may be possible to dispense with the VMA diet in urinary
measures of VMA.80
HOMOVANILLIC ACID

Homovanillic acid (HVA) is a metabolite of
dopamine, a major catecholamine itself, as well as a
precursor to the catecholamines epinephrine and
norepinephrine. HVA is synthesized in the brain and
is associated with disorders involving the nervous
system. As with other metabolites, numerous drugs,
stress, and excessive exercise may alter HVA levels.

5-HYDROXYINDOLEACETIC ACID
5-Hydroxyindoleacetic acid (5-HIAA) is a metabolite of serotonin, which is normally present only in
the platelets and in the argentaffin cells of the intestines.
ESTROGENS AND ESTROGEN FRACTIONS

Estrogens are secreted in large amounts by the
ovaries and, during pregnancy, by the placenta.
Minute amounts are secreted by the adrenal glands
and, possibly, by the testes. Estrogens induce and
maintain the female secondary sex characteristics,
promote growth and maturation of the female
reproductive organs, influence the pattern of fat
deposition that characterizes the female form, and
cause early epiphyseal closure. They also promote
retention of sodium and water by the kidneys and
sensitize the myometrium to oxytocin.
Total estrogens as well as the estrogen fractions
(estrone, estradiol, and estriol) can be measured in
urine. In blood tests, only the fractions are routinely
measured (see Chapter 5). Estrone (E1) is the immediate precursor of estradiol (E2), which is the most
biologically potent fraction. Estriol (E3), in addition
to ovarian sources, is secreted in large amounts by
the placenta during pregnancy. It is also secreted by
maternal and fetal adrenal glands. Normally, estriol
levels should rise steadily during pregnancy.
In addition to advancing and multiple pregnancy,
elevated estrogen levels are associated with ovarian
and adrenal tumors as well as estrogen-producing
tumors of the testes. Drugs that elevate estrogen
levels include estrogen-containing drugs, adrenocorticosteroids, tetracyclines, ampicillin, and phenothiazines.
Decreased estrogen levels are seen with primary
and secondary ovarian failure, Turner’s syndrome,
hypopituitarism, adrenogenital syndrome, Stein-

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255

Leventhal syndrome, anorexia nervosa, and
menopause. Low or steadily decreasing levels of
estriol during pregnancy may indicate placental
insufficiency, impending fetal distress, fetal anomalies (e.g., anencephaly), and Rh isoimmunization.
Decreased estriol levels are also associated with
diabetes, hypertensive disorders, and other maternal
complications of pregnancy.
Note that, in ovulating women, estrogen levels
vary in relation to the menstrual cycle. Thus, the
date of the last menstrual period should be noted
when analysis of urinary estrogens is performed.
PREGNANEDIOL

Pregnanediol is the chief metabolite of progesterone,
which is secreted by the corpus luteum and by the
placenta during pregnancy. Progesterone also is
secreted in minute amounts by the adrenal cortex in
both men and women. Progesterone prepares the
endometrium for implantation of the fertilized
ovum, decreases myometrial excitability, stimulates
proliferation of the vaginal epithelium, and stimulates growth of the breasts during pregnancy. During
pregnancy, after implantation of the embryo, progesterone production increases, thus sustaining the
pregnancy. This increased production continues
until about the 36th week of pregnancy, after which
levels begin to diminish.
Although serum determination of progesterone
can be made (see Chapter 5), the study of its
metabolite, pregnanediol, in urine reflects overall
progesterone levels, which may not be apparent in
single blood measures. In addition to pregnancy,
elevated pregnanediol levels may be associated with
ovarian tumors and cysts, adrenocortical hyperplasia and tumors, precocious puberty, and therapy
with adrenocorticosteroids. Biliary tract obstruction
may also produce elevated levels.
Decreased levels of pregnanediol are associated
with placental insufficiency, fetal abnormalities
or demise, threatened abortion, and toxemia of
pregnancy. Other causes of decreased levels include
panhypopituitarism, ovarian failure, Turner’s
syndrome, adrenogenital syndrome, and SteinLeventhal syndrome. Therapy with drugs containing
progesterone may also lead to decreased pregnanediol levels.
In ovulating women, pregnanediol levels vary in
relation to the menstrual cycle. Thus, the date of the
last menstrual period should be noted when analysis
of pregnanediol is performed.
HUMAN CHORIONIC GONADOTROPIN

Human chorionic gonadotropin (hCG) is produced
only by the developing placenta, and its presence in

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blood (see Chapter 5) and urine has been used for
decades to detect pregnancy. Human chorionic
gonadotropin is secreted at increasingly higher levels
during the first 2 months of pregnancy, declining
during the third and fourth months, and then
remaining relatively stable until term.
Qualitative screening test kits for hCG are available for home use to determine pregnancy as early as
8 to 10 days after conception. These screening kits
have almost eliminated quantitative testing for hCG
to confirm pregnancy. A positive result indicates that
a visit to a physician is necessary to obtain confirmation tests and prenatal care, and a negative result
in the presence of symptoms of pregnancy indicates
that a visit to a physician is necessary for further
evaluation.
Elevated levels may be seen in nonendocrine
tumors that produce hCG ectopically (e.g., carcinomas of the stomach, liver, pancreas, and breast;
multiple myeloma; and malignant melanoma).
Decreased levels of hCG are associated with ectopic
pregnancy, fetal demise, threatened abortion,
and incomplete abortion. Drugs that may alter
test results include phenothiazines and anticonvulsants.
INTERFERING FACTORS

Improper specimen collection and improper
specimen maintenance may lead to spurious
results.
Numerous drugs may alter test results. A thorough medication history should be obtained
before testing. Some medications may be withheld.
Cortisol
Excessive exercise and stressful situations during
the testing period may lead to falsely elevated
levels.
Aldosterone
Ingestion of certain foods may lower levels (e.g.,
licorice and excessive sodium intake).
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
Radioactive scans within 1 week of the study may
alter results because urinary aldosterone determinations are made by radioimmunoassay method.
17-Hydroxycorticosteroids
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
17-Ketosteroids
Blood in the specimen may alter test results; the
test should be postponed if the female client is
menstruating.

Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
17-Ketogenic Steroids
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
Pregnanetriol
None, except drugs and improper specimen
collection and maintenance
Catecholamines
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
Vanillylmandelic Acid
Numerous foods may falsely elevate levels; the
client must follow a special diet for this test.
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
Homovanillic Acid
Excessive exercise and stressful situations during
the testing period may falsely elevate levels.
5-Hydroxyindoleacetic Acid
Certain foods (bananas, plums, pineapples, avocados, eggplants, tomatoes, and walnuts) will falsely
elevate levels and must be withheld for 4 days
before the test.81
Severe gastrointestinal disturbance or diarrhea
may alter test results.
Estrogens and Estrogen Fractions
Maternal disorders (e.g., hypertension, diabetes,
anemia, malnutrition, hemoglobinopathy, liver
disease, intestinal disease) may result in decreased
estriol levels during pregnancy.
Threatened abortion, ectopic pregnancy, and
early pregnancy may result in falsely decreased
estriol levels.
Pregnanediol
None, except drugs and improper specimen
collection and maintenance
Human Chorionic Gonadotropin
Proteinuria and hematuria may lead to falsely
elevated levels.
INDICATIONS FOR MEASUREMENT OF URINARY
HORMONES AND THEIR METABOLITES

Cortisol
Diagnostic evaluation of signs of Cushing’s
syndrome without definitive elevation of plasma
cortisol levels (Adrenal hyperplasia raises the
urinary cortisol level more significantly than it
does the plasma cortisol level.)
Diagnostic evaluation of obesity of undetermined

CHAPTER 6—Studies

of Urine

257

Reference Values
Conventional Units
Cortisol
Aldosterone

20–90 g/24 hr
2–26 g/24 hr

SI Units
55–230 mol/day
5.6–72 nmol/day

17-Hydroxycorticosteroids
Children

1.5–4.0 mg/24 hr (age related: the younger
the child, the less hormone secreted)

Men

5.5–14.4 mg/24 hr

15.2–39.7 mol/day

Women

4.9–12.9 mg/24 hr

13.5–35.6 mol/day

4.1–11.0 mol/day

17-Ketosteroids
Children

1–3 mg/24 hr (age related: the younger
the child, the less hormone secreted)

3–10 mol/day

Men

8–25 mg/24 hr

27–85 mol/day

Women

5–15 mg/24 hr

17–52 mol/day

Elderly persons

4–8 mg/24 hr

13.5–28 mol/day

17-Ketogenic steroids
Children

2–6 mg/24 hr (age related: the younger
the child, the less hormone secreted)

6–17 mol/day

Men

5–23 mg/24 hr

17–80 mol/day

Women

3–15 mg/24 hr

10–52 mol/day

Elderly persons

3–12 mg/24 hr

10–42 mol/day

Pregnanetriol
Children, 6 yr

Up to 0.2 mg/24 hr

0.6 mol/day

Children, 7–16 yr

0.3–1.1 mg/24 hr

0.9–3.3 mol/day

Adults

3.5 mg/24 hr

10.4 mol/day

Catecholamines
Total
Random urine

0–14 g/dL

0.73 nmol/day

24-hour urine

100 g/24 hr

160 nmol/day

Epinephrine

10 ng/24 hr

55 nmol/day

Norepinephrine

100 ng/24 hr

591 nmol/day

Metanephrine

0.1–1.6 mg/24 hr

0.5–8.7 mol/day

0.7–6.8 mg/24 hr

3–34 mol/day

0–25 mg/24 hr

1–126 mol/day

Vanillylmandelic acid (VMA)
Homovanillic acid (HVA)
Children
1–2 yr
2–10 yr

0.5–10 mg/24 hr

3–55 mol/day

10–15 yr

0.5–12 mg/24 hr

3–66 mol/day

258

SECTION I—Laboratory

Tests

Reference Values (continued)
Conventional Units
Adult
5-Hydroxyindoleacetic acid

8 mg/24 hr
2–9 mg/24 hr

SI Units
1–14 mol/day
10.4–46.8 mol/day

Estrogens
Total
4–24 g/24 hr

4–24 g/day

5–25 g/24 hr

5–25 g/day

Ovulatory phase

24–100 g/24 hr

24–100 g/day

Luteal phase

12–80 g/24 hr

12–80 g/day

Adult men
Nonpregnant women
Preovulatory phase

Postmenopausal women

10 mg/24 hr

10 mg/day

Estrone
Children

0.2–1 g/24 hr

0.7–4 nmol/day

Men

3.4–8.2 g/24 hr

12–37 nmol/day

Early in cycle

4–7 g/24 hr

1.6–3.5 mmol/mol

Luteal phase

11–31 g/24 hr

4.6–15.7 mmol/mol

Nonpregnant women

Postmenopausal women

0.8–7.1 g/24 hr

Estradiol
Children

0–0.2 g/24 hr

0–0.69 nmol/day

Men

0–0.4 g/24 hr

0–1.39 nmol/day

Early in cycle

0–3 g/24 hr

0–10.4 nmol/day

Luteal phase

4–14 g/24 hr

Nonpregnant women

Postmenopausal women

0–2.3 g/24 hr

13.9–49.6 nmol/day
0–8.0 nmol/day

Estriol
Children

0.3–2.4 g/24 hr

1.04–8.33 nmol/day

Men

0.8–7.5 g/24 hr

2.8–26.0 nmol/day

Early in cycle

0–15 g/24 hr

0–52.0 nmol/day

Luteal phase

13–54 g/24 hr

6.1–187.4 nmol/day

Nonpregnant women

Postmenopausal women

0.6–6.8 g/24 hr

2.08–23.6 nmol/day

Pregnant women

Up to 28 mg/24 hr (When
plotted on a graph, levels
should steadily rise during
pregnancy.)

Up to 97 mol/day

CHAPTER 6—Studies

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259

Reference Values
Conventional Units

SI Units

Pregnanediol
Men

1.5 mg/24 hr

4.7 mol/day

0.5–1.5 mg/24 hr

1.6–4.7 mol/day

2–7 mg/24 hr

6.2–22 mol/day

0.2–1 mg/24 hr

0.6–3.1 mol/day

Nonpregnant women
Proliferative phase
Luteal phase
Postmenopausal women
Pregnant women
16 wk

5–21 mg/24 hr

15–65 mol/day

20 wk

6–26 mg/24 hr

18–81 mol/day

24 wk

12–32 mg/24 hr

37–100 mol/day

28 wk

19–51 mg/24 hr

59–160 mol/day

32 wk

22–66 mg/24 hr

68–206 mol/day

36 wk

22–77 mg/24 hr

40–240 mol/day

40 wk

23–83 mg/24 hr

72–197 mol/day

Human chorionic gonadotropin
Random urine

Negative if not pregnant

Men

Not measurable

Nonpregnant women

Not measurable

1st trimester

Up to 500,000 IU/24 hr

Up to 500,000 IU/L6

2nd trimester

10,000–25,000 IU/24 hr

10,000–25,000 IU/L6

3rd trimester

5,000–15,000 IU/24 hr

5,000–15,000 IU/L6

24-hr urine

Pregnant women

etiology (Obesity may raise plasma cortisol levels
but does not significantly elevate free cortisol
levels in urine.)
Quantification of cortisol excess, regardless of its
source
More accurate quantification than 17-OHCS in
individuals receiving drugs that alter hepatic
metabolism of steroids
Aldosterone
Suspected hyperaldosteronism, especially when
serum aldosterone levels are not definitive for the
diagnosis
17-Hydroxycorticosteroids
Signs and symptoms of adrenocortical hypofunctioning or hyperfunctioning

Suspected Cushing’s syndrome as indicated by
elevated levels
Suspected Addison’s disease as indicated by
decreased levels
17-Ketosteroids
Suspected adrenocortical dysfunction, especially
if urinary levels of 17-OHCS are normal
Suspected Cushing’s syndrome as indicated by
elevated levels
Suspected adrenogenital syndrome as indicated
by elevated levels
Monitoring of response to therapy for adrenogenital syndrome
17-Ketogenic Steroids
Suspected adrenal hypofunctioning or hyperfunc-

260

SECTION I—Laboratory

Tests

tioning (The test provides a good overall assessment of adrenal function.)
Suspected Cushing’s syndrome as indicated by
elevated levels
Suspected Addison’s disease as indicated by
decreased levels
Monitoring for response to therapy with corticosteroid drugs or other drugs that alter adrenal
function

Detection of placental and fetal problems as indicated by estriol levels that fail to show a steady
increase over several days or weeks (A sharp
decline over several days indicates impending fetal
demise; consistently low levels may indicate fetal
anomalies.)
Detection of maternal disorders of pregnancy as
indicated by estriol levels that fail to show a steady
increase over several days or weeks

Pregnanetriol
Suspected adrenogenital syndrome (virilization in
women, precocious sexual development in boys)
as indicated by elevated levels
Family history of adrenogenital syndrome
Monitoring of response to cortisol therapy for
adrenogenital syndrome82
Suspected testicular tumors as indicated by
elevated levels
Suspected Stein-Leventhal syndrome as indicated
by elevated levels

Pregnanediol
Verification of ovulation in planning a pregnancy
or in determining the cause of infertility as indicated by normal values in relation to the
menstrual cycle
Diagnosis of placental dysfunction, as indicated
by either low levels or failure of levels to progressively increase, and identification of the need for
progesterone therapy to sustain the pregnancy
Detection of fetal demise as indicated by
decreased levels, although levels may remain
within normal limits if placental circulation is
adequate

Catecholamines
Hypertension of unknown etiology
Suspected pheochromocytoma as indicated by
elevated levels
Acute hypertensive episode (A random sample is
collected in such cases.)
Suspected neuroblastoma or ganglioneuroma as
indicated by elevated levels
Vanillylmandelic Acid
Hypertension of unknown etiology
Suspected pheochromocytoma as indicated by
elevated levels
Suspected neuroblastoma or ganglioneuroma as
indicated by elevated levels
Homovanillic Acid
Suspected neuroblastoma or ganglioneuroma as
indicated by elevated levels
Diagnosis of benign pheochromocytoma as indicated by normal HVA levels with elevated VMA
levels
Diagnosis of malignant pheochromocytoma as
indicated by elevated HVA and VMA levels
5-Hydroxyindoleacetic Acid
Detection of early carcinoid tumors (argentaffinomas) of the intestine as indicated by elevated
levels
Estrogens and Estrogen Fractions
Suspected tumor of the ovary, testicle, or adrenal
gland as indicated by elevated total estrogens and
fractions
Suspected ovarian failure as indicated by
decreased total estrogens and fractions

Human Chorionic Gonadotropin
Confirmation of pregnancy within 8 to 10 days
after conception, especially in women with a
history of infertility or habitual abortion or in
women who may desire a therapeutic abortion
Suspected hydatidiform mole as indicated by
elevated levels
Suspected choriocarcinoma or testicular tumor as
indicated by elevated levels
Suspected nonendocrine tumor that produces
hCG ectopically as indicated by elevated levels
Threatened abortion as indicated by decreased
levels
NURSING CARE BEFORE THE PROCEDURE

All urine studies for hormones and their metabolites
involve collecting 24-hour urine samples (see
Appendix II); exceptions are catecholamines and
hCG, which can also be analyzed in random
samples. The client should, therefore, be instructed
on how to collect the sample. The proper container
and instructions for maintaining the collection (e.g.,
refrigerated or on ice) should be provided.
Drugs that may alter test results may be withheld
during the test, although this practice should be
confirmed with the person ordering the study.
The client should be cautioned to avoid excessive
exercise and stress during the following studies:
cortisol, aldosterone, 17-OHCS, 17-KS, 17-KGS,
catecholamines, VMA, and HVA.
The client also should be instructed on the following dietary restrictions in relation to specific tests:

CHAPTER 6—Studies

(1) aldosterone—maintain a normal salt intake;
(2) VMA—maintain a “VMA diet” (see earlier
discussion) for 2 days before the test and for the
day of the test; and (3) 5-HIAA—maintain a diet
low in serotonin (see earlier discussion) for 4 days
before the test.
For gonadal and placental hormone studies, the
date of the last menstrual period should be noted.

of Urine

261

protein) as an indicator of the accuracy of the collection because the amount excreted in 24 hours
should be fairly constant. Measurement of urinary
levels of uric acid are discussed later. Amino acids
are also products of protein metabolism. As
discussed later, abnormal metabolism and congenital disorders (e.g., phenylketonuria) are associated
with excessive levels of certain amino acids.

THE PROCEDURE

URIC ACID

All urine studies for hormones and their metabolites
involve collecting 24-hour urine specimens; exceptions are catecholamines and hCG, which can also be
analyzed in random samples. For 24-hour collections, an acidifying preservative is added to the
container by the laboratory. In addition, some laboratories require that the sample be refrigerated or
placed on ice throughout the collection period.
Special diets may be required before collection of
24-hour urines for VMA and 5-HIAA (see preceding
“Nursing Care Before the Procedure” section).
Random samples for catecholamines can be
collected at any time but frequently are obtained
after a hypertensive episode. Random samples for
hCG are more reliable if collected first thing in the
morning because dilute urine may lead to falsenegative results.
All specimens should be sent promptly to the
laboratory when the collection is completed.

Uric acid is an end product of purine metabolism.
Purines are constituents of nucleic acids in the body
and appear in the urine in the absence of dietary
sources of purines. Dietary sources of purines
include organ meats, legumes, and yeasts. Uric acid
is filtered, absorbed, and secreted by the kidneys and
is a common constituent of urine.
The amount of uric acid produced in the body
and the efficiency of renal excretion affect the
amount of uric acid found in urine. Excessive
amounts of uric acid may be found in excessive
dietary intake of purines, in massive cell turnover
with degradation of nucleic acids, and in disorders
of purine metabolism. The body’s ability to filter,
reabsorb, and secrete uric acid affects the amount of
uric acid ultimately found in urine.83
Elevated urinary uric acid is commonly associated
with neoplastic disorders such as leukemia and
lymphosarcoma. It may be found also in individuals
with pernicious anemia, sickle cell anemia, and polycythemia. Disorders associated with impaired renal
tubular absorption (e.g., Fanconi’s syndrome and
Wilson’s disease) also lead to elevated uric acid levels
in urine.84
Drugs used to treat elevated serum uric acid levels
frequently work by increasing urinary excretion of
the substance. Such drugs include probenecid and
sulfinpyrazone. Allopurinol also decreases serum
uric acid levels but without necessarily leading to
excessive urinary levels.85 Note that colchicine, a
drug frequently used to treat gout, does not alter
urinary levels of uric acid. Other drugs associated
with elevated urinary uric acid include aspirin (large
doses), adrenocorticosteroids, coumarin anticoagulants, and estrogens.
Although gout is associated with elevated serum
uric acid levels (see Chapter 5), decreased amounts
of uric acid are often found in urine because of
impaired tubular excretion. Decreased amounts of
urinary uric acid also are associated with various
renal diseases for the same reason. Decreased
urinary uric acid levels are associated with lactic
acidosis and ketoacidosis because of impaired renal
excretion and also with ingestion of alcohol, aspirin
(small doses), and thiazide diuretics.

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming
the client’s usual diet, medications, or activities at
completion of specimen collection.

PROTEINS AND THEIR METABOLITES
Normally, the urine contains only a scant amount of
protein. Excessive amounts of protein in the urine
are generally associated with renal disease. Thus,
part of the screening process in a UA is to test
the sample for protein. If increased amounts are
found, a quantitative 24-hour urine collection is
performed. The presence of certain types of proteins
in urine also is diagnostic of specific disease states.
The presence of Bence Jones protein in the urine, for
example, is associated with multiple myeloma.
Protein metabolites such as creatinine and uric
acid can also be measured in urine. Creatinine,
which is produced at a fairly constant rate within the
body, is a sensitive indicator of glomerular function
because factors affecting creatinine clearance are
primarily the result of alteration in renal function.
Creatinine levels can also be measured along with
24-hour measures of other substances in urine (e.g.,

262

SECTION I—Laboratory

Tests

AMINO ACIDS

Elevated amino acid levels in urine are associated
with congenital defects and disorders of amino acid
metabolism. The major inherited disorders include
phenylketonuria (PKU), tyrosyluria, and alkaptonuria. PKU occurs when the normal conversion of
phenylalanine to tyrosine is impaired, leading to the
excretion of increased keto acids such as
phenylpyruvate in the urine, which can be detected
on screening tests. If undetected and untreated, PKU
results in severe mental retardation. Blood tests for
PKU may also be performed.
Tyrosyluria occurs because of either inherited
disorders or metabolic defects. It is most frequently
seen in premature infants with underdeveloped liver
function, but it seldom results in permanent
damage. Acquired severe liver disease also leads to
tyrosyluria, as well as to the appearance of tyrosine
crystals in the urine.
Alkaptonuria represents another defect in the
phenylalanine–tyrosine conversion pathway. In this
disorder, homogentisic acid accumulates in the
urine. Alkaptonuria generally manifests in adulthood and leads to deposition of brown pigment in
the body, arthritis, liver disease, and cardiac disorders.86
URINE HYDROXYPROLINE

A special urinary test for a specific amino acid is
measurement of urine hydroxyproline, a component
of collagen in skin and bone. Foods such as meat,
poultry, fish, and foods containing gelatin falsely
elevate levels and must, therefore, be restricted for at
least 24 hours before the test. Drugs such as ascorbic
acid, vitamin D, glucocorticoids, aspirin, mithramycin, and calcitonin will also elevate levels, as will
skin disorders such as burns and psoriasis.87
INTERFERING FACTORS

Improper specimen collection and improper
specimen maintenance
Ingestion of foods and drugs that may alter test
results or failure to ingest certain foods (e.g., a
low-purine diet leads to decreased levels of
urinary uric acid; lack of protein intake may lead
to false-negative PKU test results in infants)
Skin disorders such as psoriasis and burns that
may falsely elevate urine hydroxyproline levels
INDICATIONS FOR MEASUREMENT OF
URINARY PROTEINS

Protein
Detection of various types of renal disease as indicated by elevated levels

Detection of possible complications of pregnancy
as indicated by elevated levels
Bence Jones Protein
Detection of multiple myeloma
Creatinine
Assessment of glomerular function with
decreased levels indicating impairment (see also
preceding “Reference Values” section)
Assessment of the accuracy of 24-hour urine
collections for other substances
Uric Acid
Monitoring for urinary effects of disorders that
cause hyperuricemia
Monitoring for response to therapy with uricosuric drugs
Comparison of urine levels with serum uric acid
levels to provide for an index of renal function
Amino Acid Screening Tests
Detection of inherited and metabolic disorders
such as PKU, tyrosyluria, alkaptonuria, cystinuria,
and maple syrup urine disease
Urine Hydroxyproline
Detection of disorders associated with increased
bone reabsorption (e.g., Paget’s disease, metastatic
bone tumors, and certain endocrine disorders)
Monitoring of treatment for Paget’s disease
NURSING CARE BEFORE THE PROCEDURE

The client should be instructed in the method to be
used for obtaining the sample (e.g., 24-hour urine,
2-hour urine, clean-catch midstream sample).
A medication history should be obtained.
Drugs that may alter test results may be withheld
during the test, although this practice should be
confirmed with the person ordering the study.
The client also must be instructed in any dietary
modifications needed for the test. Such dietary
modifications may be necessary in uric acid and
urine hydroxyproline tests.
THE PROCEDURE

Protein, Creatinine, and Uric Acid. A 24-hour
urine specimen is collected. For creatinine measures,
a preservative is usually added to the collection
container by the laboratory. It may be necessary also
to refrigerate the sample.
Bence Jones Protein. An early morning sample of
at least 60 mL is collected. The sample should be sent
promptly to the laboratory. It is recommended that
the sample be collected using the clean-catch
midstream technique (see Appendix II) to avoid

CHAPTER 6—Studies

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263

Reference Values
Conventional Units
Protein

SI Units

0–150 mg/24 hr

0–150 mg/day

Men

1–1.9 g/24 hr

8.8–17.6 mmol/day

Women

0.8–1.7 g/24 hr

7–15.8 mmol/day

Bence Jones protein

Negative

Uric acid

250–750 mg/24 hr

1.5–4.5 mmol/day

Negative

Men

0.4–5 mg/2 hr

3.1–38 mol/2 hr

Women

0.4–2.9 mg/2 hr

3.1–22 mol/2 hr

14–45 mg/24 hr

0.11–0.36 mmol/day

Notify physician of protein
levels 4 g/24 hr

Notify physician of protein
levels 50 nmol/day

Creatinine

Amino acids
Screening tests (e.g., for PKU,
tyrosyluria, alkaptonuria,
cystinuria, maple
syrup urine disease)
Urine hydroxyproline
2-hour sample

24-hour sample
Adults
Critical values

Note: Values are higher in children and during the third trimester of pregnancy

contaminating the sample with other proteins from
bodily secretions.
Amino Acid Screening Tests. A random urine specimen of at least 20 mL is collected. In infants, collection involves application of a urine-collecting
device. The specimen should be sent immediately to
the laboratory. The PKU (phenylpyruvic acid) test is
performed no fewer than 3 days after birth. It is
performed by pressing a Phenistix reagent strip on a
wet diaper or by dipping the strip into a sample
obtained with a urine-collecting device, waiting
30 seconds, and comparing it to a color chart. The
chart is scaled at milligram concentrations of the
substance, ranging from 0 to 100.
Urine Hydroxyproline. A 2- or 24-hour urine specimen is collected in a container to which preservative
has been added. It may also be necessary to refrigerate the sample.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming

the any withheld or modified diet and medications.
Compromised renal function: Note and report
presence of or increases in proteins. Monitor I&O
and fluid and protein restrictions. Instruct in
dietary and fluid inclusions and exclusions.
Critical values: Notify physician immediately
of a protein level of greater than 4 g/24 hr.

VITAMINS AND MINERALS
The functions and serum assays of vitamins and
minerals are discussed in Chapter 5. In general,
serum assays are preferred to the more cumbersome
urine level determinations, which require 24-hour
urine collections.
VITAMINS

Fat-soluble vitamins are not readily excreted in
the urine, and therefore urinary determinations
focus on water-soluble vitamins B and C. Urinary
determinations for vitamins B1 (thiamine), B2
(riboflavin), and C may be made in suspected defi-

264

SECTION I—Laboratory

Tests

ciency states. The Schilling test for vitamin B12
absorption is discussed in Chapter 20, because it is
used to diagnose an abnormality of hematopoiesis.
MINERALS

Minerals are essential to normal body metabolism.
In urine, three commonly measured minerals
include iron (found in hemosiderin), copper, and
oxalate. Copper aids in the formation of hemoglobin
and is a component of certain enzymes necessary for
energy production.88 Elevated urinary copper levels
are associated with Wilson’s disease, an inherited
disorder of copper metabolism. Oxalate is found in
combination with calcium in certain kidney stones.
Elevated urinary oxalate levels are seen in hyperoxaluria, a disorder in which oxalate accumulates in
soft tissues, especially those of the kidney and bladder.89 Oxalate levels can also be elevated by excessive
ingestion of strawberries, tomatoes, rhubarb, or
spinach.
INTERFERING FACTORS

Improper specimen collection and maintenance
may affect test results.
Ingestion of strawberries, tomatoes, rhubarb, or
spinach may falsely elevate oxalate levels.
INDICATIONS FOR MEASUREMENT OF VITAMINS
AND MINERALS IN URINE

Detection of vitamin deficiency states
Screening for and detection of Wilson’s disease as
indicated by elevated urinary copper levels
Detection of hyperoxaluria as indicated by
elevated oxalate levels

NURSING CARE BEFORE THE PROCEDURE

The client should be instructed in the method of
obtaining the sample (i.e., usually a 24-hour urine
collection).
THE PROCEDURE

A 24-hour urine specimen is collected. Samples for
oxalate should be collected in containers that have
been protected from light and to which hydrochloric
acid has been added.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include resuming
the client’s usual diet, medications, or activities at
completion of specimen collection.

MICROBIOLOGIC EXAMINATION
OF URINE
Urine tests for culture and sensitivity (C&S) indicate
the type and number of organisms present in the
specimen (culture) and the antibiotics to which the
organisms are susceptible (sensitivity). In urine, it is
common to culture out only one organism, although
polymicrobial infections may be seen in individuals
with Foley catheters. Most organisms infecting the
urinary tract are derived from fecal flora that have
ascended the urethra. Organisms commonly found
in urine include Escherichia coli, Enterococcus,
Klebsiella, Proteus, and Pseudomonas.90
After treatment with the appropriate antibiotic, as
indicated by sensitivity tests, follow-up urine
cultures may be undertaken to determine the effectiveness of treatment.

Reference Values
Conventional Units

SI Units

Vitamins
B1 (thiamine)

100–200 g/24 hr

B2 (riboflavin)
Men

0.51 mg/24 hr

1356 nmol/day

Women

0.39 mg/24 hr

1037 nmol/day

C (ascorbic acid) 30 mg/ 24 hr
Minerals
Copper

15–60 g/24 hr

0.24–0.94 mol/day

Oxalate

40 mg/24 hr

456 mol/day

CHAPTER 6—Studies

Reference Values
Negative for pathologic organisms
Critical values: Notify physician if the culture
result is greater than 100,000 organisms/mL (SI
1,000,000 CFU/L).

of Urine

265

to detect cancer of the bladder and cytomegalic
inclusion disease.91 In these disorders, abnormal
cells are shed into the urine and can be detected
upon examination of the sample.
Reference Values
Negative for abnormal cells and inclusions

INTERFERING FACTORS

Improper specimen collection so that the sample
is contaminated with nonurinary organisms
Delay in sending the specimen to the laboratory
(Bacteria may multiply in nonrefrigerated
samples.)
INDICATIONS FOR MICROBIOLOGIC
EXAMINATION OF URINE

Suspected UTI
Identification of antibiotics to which the cultured
organism is sensitive
Monitoring for response to treatment for UTIs

INTERFERING FACTORS

Improper specimen collection such that the
sample is contaminated with extraneous cells
Delay in sending the sample to the laboratory
(Cells may begin to disintegrate.)
INDICATIONS FOR CYTOLOGIC
EXAMINATION OF URINE

Suspected cancer of the bladder or other urinary
tract structure, especially in individuals exposed
to environmental carcinogens
Suspected infection with cytomegalovirus

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of either a clean-catch
midstream urine specimen, a catheterized specimen,
or a suprapubic aspiration (see Appendix II).

NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of a clean-catch midstream
urine specimen, a catheterized specimen, or a suprapubic aspiration (see Appendix II).

THE PROCEDURE

A sample of at least 5 to 10 mL is obtained either by
clean-catch technique, catheterization, or suprapubic aspiration. The sample is placed in a sterile
container and is transported to the laboratory
immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the test include assessing
the suprapubic site for inflammation if the specimen
was obtained by aspiration. Cover the area with a
sterile dressing.

THE PROCEDURE

A sample of at least 180 mL in adults and 10 mL
in children is obtained either by the clean-catch
technique, catheterization, or suprapubic aspiration.
Depending on the laboratory, a special container
or preservative, or both, may be needed. The
sample must be transported to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Critical values: Notify physician immediately if
the culture result is greater than 100,000 organisms/mL (SI 1,000,000 CFU/L).

Care and assessment after the test include assessing
the suprapubic site for inflammation if the specimen
was obtained by aspiration.
Cover the area with a sterile dressing.

CYTOLOGIC EXAMINATION
OF URINE

DRUG SCREENING TESTS
OF URINE

Cytology is the study of the origin, structure, function, and pathology of cells. In clinical practice, cytologic examinations are generally performed to detect
cell changes caused by malignancies or inflammatory conditions.
Cytologic examination of urine is performed
when cancer or inflammatory disorders of the
urinary tract are suspected. It is especially indicated

Toxicological analysis of urine is performed to identify drugs that have been used and abused. Urine is
preferred for drug screening because most drugs are
detectable in urine but not in blood. The exception
is testing for alcohol concentration. The screening
tests are performed in groups according to the pharmacological classification of the drugs. Commonly
used substances that involve a risk for psychological,

266

SECTION I—Laboratory

Tests

physical, or both psychological and physical dependence and are tested are the following:
Sedatives: benzodiazepines, methaqualone
Depressants: alcohol, barbiturates, opiates
(codeine, morphine, methadone)
Stimulants: amphetamines, cocaine, “crack,”
methylphenidate
Hallucinogens:
cannabinoids
(marijuana,
hashish), phencyclidine (PCP), lysergic acid
diethylamide (LSD), mescaline92
Drug abuse includes the recreational use of drugs
(illicit use); unwarranted use of drugs to relieve
problems or symptoms, leading to dependence and
later continued use; and therapeutic use to prevent
the consequences of withdrawal. These substances
act on the CNS to reduce anxiety and tension,
produce euphoria and other pleasurable mood
changes, increase mental and physical ability, and
alter sensory perceptions and change behaviors.93
Detection of levels varies with the time of the last
dose of a specific drug and can range from hours to
days to weeks.
Anabolic steroids (synthetic derivatives of testosterone) are used to enhance athletic performance
primarily in power-related sports and, in some
instances, to improve appearance. Its use (known as
“sports doping”) results in a change in body bulk,
strength, and energy. Psychological effects include
mood swings, aggressiveness, and irrational behavior. Physical effects include liver dysfunction and
cardiovascular dysfunction that result from hypertension and increased low-density lipoproteins.
Anabolic steroid metabolites can be detected in the
urine for up to 6 months after drug use.94
Reference Values
Negative for drugs in group tested
INTERFERING FACTORS

High or low pH of urine (alkaline or acid levels)
Blood or other abnormal constituents in the urine
Urine that has a low specific gravity, causing dilution
INDICATIONS FOR DRUG SCREENING
TESTS OF URINE

Determination of abuse of drugs before or during
employment in which public welfare is at stake
Identification of use of drugs to enhance athletic
ability and success
Detection and identification of specific drugs
when use and abuse is suspected so as to differentiate it from other causes of a set of signs and
symptoms

Confirmation of a diagnosis of drug overdose
after death
Detection of drug use before prescribing a
medication or treatment regimen
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as for any test involving the collection of a random urine specimen (see
Appendix II).
If drug abuse is suspected, the collection and
delivery of the urine sample should be witnessed
by a legally responsible person and labeled with a
code instead of a name and other personal information.
The client should be informed of the procedure to
collect and test the specimen, the reporting protocol, and possible implications of the results.
THE PROCEDURE

A random sample of 50 to 100 mL of urine is
collected in a clean container and covered with a lid
and labeled with a code while a trained witness
observes to ensure that the specimen has been
obtained from the correct client. The specimen
container is placed in a plastic bag and sealed to
ensure that any tampering with the package will
be revealed. The signatures of the individual
who collects the specimen and anyone who handles
it in any way are required on a document. The
specimen is examined by enzyme immunoassay
or fluorescence polarization immunoassay procedures. Confirmation tests are performed to ensure
that false-positive results are resolved. Because
of the legal implications, documented testing
procedures for a positive, negative, or unconfirmed
result with evidence to support the result should
accompany the test report. After the complete
testing of the specimen, the sample is resealed in the
labeled bag and stored for 30 days or as long as
needed.95
NURSING CARE AFTER THE PROCEDURE

No specific care is needed after these tests. Inform
the client of the possible economic, psychological,
and legal implications of a confirmed positive test.
Abnormal results: Note and report effect of
results on client’s psychological and physical
health, economic status (work, sports), and legal
status (illicit drug use). Ensure that correct testing
and confirmation were performed and reported.
Advise client to consider drug abuse counseling or
educational programs, or both, provided by
school officials, coaches, physicians, and other
health-care professionals.

CHAPTER 6—Studies

REFERENCES
1. Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis,
Philadelphia, 2001, p 25.
2. Ibid, pp 25–26.
3. Porth, CM: Pathophysiology: Concepts of Altered Health States, ed
5. JB Lippincott, Philadelphia, 1998, p 580.
4. Strasinger, op cit, p 25.
5. Ibid, p 27.
6. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 699.
7. Ibid, p 699.
8. Strasinger, op cit, p 35.
9. Schweitzer, GB, and Schumann, GB: Examination of urine. In
Henry, JB: Clinical Diagnosis and Management by Laboratory
Methods, ed 18. WB Saunders, Philadelphia, 1991, p 393.
10. Strasinger, op cit, p 35.
11. Ibid, p 36.
12. Schweitzer and Schumann, op cit, p 394.
13. Ibid, p 395.
14. Strasinger, op cit, p 41.
15. Ibid, p 37.
16. Ibid, p 38.
17. Schweitzer and Schumann, op cit, p 400.
18. Strasinger, op cit, p 46.
19. Schweitzer and Schumann, op cit, p 399.
20. Ibid, p 399.
21. Ibid, p 400.
22. Ibid, p 402.
23. Ibid, p 401.
24. Strasinger, op cit, p 48.
25. Schweitzer and Schumann, op cit, p 401.
26. Strasinger, op cit, p 47.
27. Porth, op cit, p 573.
28. Schweitzer and Schumann, op cit, p 405.
29. Ibid, pp 407–408.
30. Strasinger, op cit, p 53.
31. Ibid, p 54.
32. Schweitzer and Schumann, op cit, p 409.
33. Ibid, p 410.
34. Ibid, p 410.
35. Strasinger, op cit, p 55.
36. Schweitzer and Schumann, op cit, p 410.
37. Ibid, p 410.
38. Strasinger, op cit, p 56.
39. Ibid, p 58.
40. Schweitzer and Schumann, op cit, p 415.
41. Ibid, p 415.
42. Strasinger, op cit, pp 60–61.
43. Ibid, p 61.
44. Schweitzer and Schumann, op cit, p 416.
45. Strasinger, op cit, p 62.
46. Schweitzer and Schumann, op cit, p 417.

47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.

of Urine

267

Strasinger, op cit, p 62.
Ibid, pp 68.
Schweitzer and Schumann, op cit, p 421.
Strasinger, op cit, p 77.
Schweitzer and Schumann, op cit, p 421.
Strasinger, op cit, p 79.
Schweitzer and Schumann, op cit, p 423.
Ibid, p 424.
Ibid, p 424.
Ibid, p 424.
Strasinger, op cit, p 87.
Schweitzer and Schumann, op cit, p 425.
Strasinger, op cit, pp 95–99.
Ibid, p 103.
Sacher and McPherson, op cit, pp 711–712.
Strasinger, op cit, p 15.
Sacher and McPherson, op cit, p 711.
Ibid, p 712.
Ibid, p 713.
Strasinger, op cit, p 20.
Sacher and McPherson, op cit, p 714.
Strasinger, op cit, p 18.
Sacher and McPherson, op cit, p 715.
Strasinger, op cit, p 37.
Corbett, JV: Laboratory Tests and Diagnostic Procedures with
Nursing Diagnoses, ed 3. Appleton & Lange, Norwalk, Conn, 1992,
p. 127.
Sacher and McPherson, op cit, p 721.
Schweitzer and Schumann, op cit, p 433.
Ibid, p 459.
Strasinger, op cit, pp 36–37.
Strasinger, op cit, pp 142–143.
Springhouse Corporation: Nurse’s Reference Library: Diagnostics,
ed 2. Springhouse, Springhouse, Pa, 1986, p 374.
Ibid, pp 376–377.
Sacher and McPherson, op cit, p 564.
Ibid, p 581.
Ibid, pp 403–404.
Ibid, pp 394–396.
Ibid, p 330.
Nurse’s Reference Library, op cit, p 423.
Sacher and McPherson, op cit, p 331.
Strasinger, op cit, pp 138–139.
Nurse’s Reference Library, op cit, pp 418–419.
Ibid, p 451.
Ibid, pp 464–465.
Sacher and McPherson, op cit, p 499.
Fischbach, FT: A Manual of Laboratory Diagnostics Tests, ed 4. JB
Lippincott, Philadelphia, 1992, pp 709–710.
Sacher and McPherson, op cit, pp 686–688.
Berkow, R (ed): The Merck Manual, ed 16. Merck Sharp and
Dohme Research Laboratory, Rahway, NJ, 1992, p 1549.
Ibid, p 2277.
Fischbach, op cit, p 186.

CHAPTER

Sputum Analysis
TESTS COVERED
Gram Stain and Other Stains, 269
Culture and Sensitivity, 271

Acid-Fast Bacillus Smear and Culture, 272
Cytologic Examination, 272

OVERVIEW OF SPUTUM PRODUCTION AND ANALYSIS

Sputum is the material
secreted by the tracheobronchial tree and, by definition, brought up by coughing. The submucosal glands and secretory cells of the tracheobronchial mucosa normally secrete up to 100 mL
of mucus per day as part of bronchopulmonary cleansing. The secretions form a thin layer over
the ciliated epithelial cells and travel upward toward the oropharynx, carrying inhaled particles
away from the bronchioles. From the oropharynx the secretions are swallowed; therefore, the
healthy person does not produce sputum.
In addition to its mechanical cleansing action, mucus attacks inhaled bacteria directly. This
antibacterial effect is primarily the result of antibodies, which are predominantly IgA, but
also of lysozymes and slightly acid pH. Normally, the contents of the lower respiratory tract are
sterile.
Environmental factors, drugs, and respiratory tract disease alter tracheobronchial secretions
and may lead to sputum production. Tobacco smoke, cold air, alcohol, and sedatives depress
ciliary action and may cause stasis of secretions. Respiratory infections cause an increase in
secretions and may lead to a more acidic pH and changes in the chemical composition. A pH
below 6.5 inhibits ciliary action, as does increased sputum viscosity. Leukocytes present in
respiratory secretions also rise during infection, and membrane permeability increases because
of the normal inflammatory response. Thus, antibiotics and other elements normally found in
the blood may be present in the sputum. The quantity of sputum produced in pathological
states is roughly parallel to the severity of the problem. Specific characteristics and constituents
of sputum help to determine the nature of the disorder.1
The most common laboratory tests performed on sputum are (1) Gram stain and other
staining tests, (2) culture and sensitivity, (3) examination for acid-fast bacilli (AFB), and (4)
cytologic examination. The gross appearance of the specimen should, however, be observed
and documented before sending the sample to the laboratory. Respiratory secretions are
normally clear, colorless, odorless, and slightly watery.
Abnormal sputum can be described as mucoid (consisting of mucus), mucopurulent
(consisting of mucus and pus), and purulent (consisting of pus). Expectoration of mucoid
sputum is seen in chronic bronchitis and asthma. A change from mucoid to mucopurulent
sputum indicates infection superimposed on the chronic inflammatory condition.2 Purulent
sputum may indicate acute bacterial pneumonia, bronchiectasis, or rupture of a pulmonary
abscess. Foul-smelling sputum is also associated with bronchiectasis and lung abscess, as well as
with cystic fibrosis. Viscous (tenacious) secretions are seen in clients with cystic fibrosis,
Klebsiella pneumonia, and dehydration.3
268

CHAPTER 7—Sputum

Analysis

269

Purulent sputum is yellow to green. Gray sputum may indicate inhaled dust; grayish-black
sputum is seen after smoke inhalation. Frothy pink or rusty-colored sputum is associated with
congestive heart failure (CHF). It is abnormal to expectorate blood (hemoptysis), whether the
quantity involves only a few scant streaks or a life-threatening hemorrhage. In addition to being
associated with CHF, rusty-colored sputum may be seen also in pneumococcal pneumonia,
whereas bright streaks of blood are associated with Klebsiella pneumonia. Dark blood in small
amounts is associated with tuberculosis, tumors, and trauma caused by instrumentation.
Bright blood in moderate to large amounts is associated with cavitary tuberculosis, broncholithiasis, and pulmonary thrombosis.

SPUTUM TESTS
GRAM STAIN AND OTHER STAINS
Gram staining is one of the oldest and most useful
microbiologic staining techniques. It involves
smearing a small amount of sputum on a slide and
then exposing it to gentian or crystal violet, iodine,
alcohol, and safranine, a red dye. This technique
allows for morphological examination of the cells
contained in the specimen and differentiates any
bacteria present into either gram-positive organisms, which retain the iodine stain, or gram-negative
organisms, which do not retain the iodine stain but
can be counterstained with safranine.
Gram staining can be used to differentiate true
sputum from saliva and upper respiratory tract
secretions. True sputum contains polymorphonuclear leukocytes and alveolar macrophages. It should
also contain a few squamous epithelial cells.
Excessive squamous cells or the absence of polymorphonuclear leukocytes usually indicates that the
specimen is not true sputum.
Another stain used in sputum examinations is
polychromase chain reaction, used when pulmonary
alveolar proteinosis or Pneumocystis carinii pneumonia is suspected. A characteristic of pulmonary
alveolar proteinosis is compacted protein, which can
be found either inside mononuclear cells, free in
round or laminated clumps, or in aggregates with
cleftlike spaces. The round and laminated clumps
may resemble the cysts of P. carinii.
Reference Values
Normal sputum contains polymorphonuclear
leukocytes, alveolar macrophages, and a few
squamous epithelial cells.

INTERFERING FACTORS

Improper specimen collection
Delay in sending specimen to the laboratory

INDICATIONS FOR GRAM STAIN AND OTHER
STAIN TESTS

Gram Stain
Differentiation of sputum from upper respiratory
tract secretions, the latter being indicated by
excessive squamous cells or the absence of polymorphonuclear leukocytes
Determination of types of leukocytes present in
sputum (e.g., neutrophils indicating infection and
eosinophils seen in asthma)
Differentiation of gram-positive from gram-negative bacteria in respiratory infections
Identification of Curschmann’s spirals, which are
associated with asthma, acute bronchitis, bronchopneumonia, and lung cancer4
Wright’s Stain
Confirmation of the types of leukocytes present in
sputum
Polychromase Chain Reaction
Identification of compacted proteins associated
with pulmonary alveolar proteinosis
Identification of cysts associated with P. carinii
infections
Confirmation of the presence of cysts associated
with P. carinii infections
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That results are most reliable if the specimen is
obtained in the morning upon arising, after secretions have accumulated overnight
That a sample of secretions from deep in the
respiratory tract, not saliva or postnasal drainage,
is needed
The methods by which the specimen will be
obtained (i.e., by coughing or by tracheal suctioning)
That increasing fluid intake before retiring for the
night aids in liquefying secretions and may make
them easier to expectorate

270

SECTION I—Laboratory

Tests

That humidifying inspired air also helps to liquefy
secretions
That, if feasible, the client should brush the teeth
or rinse the mouth before obtaining the specimen
to avoid excessive contamination of the specimen
with organisms normally found in the mouth
Proper handling of the container and specimen, if
the client is to obtain the specimen independently
The number of samples to be obtained, because it
may be necessary to analyze more than one
sample for accurate diagnosis
Prepare for the procedure:
Assist in providing extra fluids, unless contraindicated, and proper humidification.
Assist with mouth care as needed.
Provide sputum collection container(s).
If the specimen is to be obtained by tracheal
suctioning, it is recommended that oxygen be
administered for 20 to 30 minutes before the
procedure.
Hyperventilation with 100% O2 should be
performed before and after suctioning.
THE PROCEDURE

The procedure varies with the method for obtaining
the sputum specimen. The nurse should wear gloves,
face mask, and possibly glasses or goggles when
obtaining the sputum sample.
Expectorated Specimen. The client should sit
upright, with assistance and support (e.g., with an
overbed table) as needed. The client should then
take two or three deep breaths and cough deeply.
Any sputum raised should be expectorated directly
into a sterile container. The client should not touch
the lip or the inside of the container with the hands
or mouth. A 10- to 15-mL specimen is adequate.
If the client is unable to produce the desired
amount of sputum, several strategies may be
attempted. One approach is to have the client drink
two glasses of water and then assume the positions
for postural drainage of the upper and middle lung
segments. Support for effective coughing may be
provided by placing the hands or a pillow over the
diaphragmatic area and applying slight pressure.
Another approach is to place a vaporizer or other
humidifying device at the bedside. After sufficient
exposure to adequate humidification, postural
drainage of the upper and middle lung segments
may be repeated before attempting to obtain the
specimen.
It may also be helpful to obtain an order for an
expectorant and administer it along with additional
water approximately 2 hours before attempting to
obtain the specimen. In addition, chest percussion

and postural drainage of all lung segments may be
used. If the client still is unable to raise sputum, the
use of an ultrasonic nebulizer (“induced sputum”)
may be necessary. This is usually undertaken by a
respiratory therapist.
Tracheal Suctioning. Suction equipment, a suction
kit, and a Lukens tube or in-line trap are obtained.
The client is positioned with head elevated as high as
tolerated. Sterile gloves are applied, with the dominant hand maintained as “sterile” and the nondominant hand as “clean.” The suction catheter is
attached with the “sterile hand” to the rubber tubing
of the Lukens tube or in-line trap. The suction
tubing is then attached to the male adapter of the
trap with the “clean” hand. The suction catheter is
lubricated with sterile saline.
Nonintubated clients should be instructed, if
feasible, to protrude the tongue and take a deep
breath as the suction catheter is passed through the
nostril. When the catheter enters the trachea, a reflex
cough is stimulated; the catheter is immediately
advanced into the trachea, and suction is applied.
Suction should be maintained for approximately
10 seconds and never for more than 15 seconds. The
catheter is then withdrawn without applying
suction. The suction catheter and suction tubing are
separated from the trap, and the rubber tubing is
placed over the male adapter to seal the unit. The
specimen is labeled and sent to the laboratory
immediately.
For clients who are intubated or have a
tracheostomy, the aforementioned procedure is
followed, except that the suction catheter is passed
through the existing endotracheal or tracheostomy
tube rather than through the nostril. The client
should be hyperoxygenated before and after the
procedure in accordance with usual protocols for
suctioning such clients.
NURSING CARE AFTER THE PROCEDURE

For specimens obtained by expectoration or nasotracheal suctioning, care and assessment after the
procedure include mouth care offered or provided
after the specimen has been obtained.
Provide a cool beverage to aid in relieving throat
irritation caused by coughing and suctioning.
Assess the client’s color and respiratory rate, and
administer supplemental oxygen as necessary.
For specimens obtained by endotracheal tube or
tracheostomy, hyperoxygenate the client after the
procedure according to usual protocols.
Additional suctioning may be necessary to clear
secretions raised during suctioning to obtain the
specimen.

CHAPTER 7—Sputum

The characteristics (e.g., color, consistency,
volume) of the sample should be noted and documented.
Infection or hypoxemia: Note and report tachypnea, dyspnea, diminished breath sounds, change
in skin color (cyanosis), and elevated temperature. Administer oxygen and have emergency
intubation equipment on hand.
Transmission of respiratory pathogens: Place on
respiratory precautions. Use mask when in
contact with client. Dispose of used articles
according to standard precautions and transmission-based isolation procedures.
Critical values: Notify physician immediately if
test result is positive.

CULTURE AND SENSITIVITY
Sputum tests for culture and sensitivity (C&S) indicate the type and number of organisms in the specimen (culture) and the antibiotics to which the
organisms are susceptible (sensitivity). Although
examination of the organisms found in sputum by
microscopy or stain may lend support in the diagnosis of suspected infectious disorders, growth of a
pathogen in culture is more definitively diagnostic.
The pathogenic organisms most often cultured
from the sputum of individuals with bacterial pneumonia are Streptococcus pneumoniae, Haemophilus
influenzae, Staphylococcus, and gram-negative
bacilli. Other pathogens that may be identified in
sputum cultures include Klebsiella pneumoniae,
Mycobacterium tuberculosis, fungi such as Candida
and Aspergillus, Corynebacterium diphtheriae, and
Bordetella pertussis. In contrast, other organisms that
can cause pneumonia, such as mycoplasmas, respiratory viruses, and rickettsiae, are not detected on
routine culture.5 Sputum collected by expectoration
or suctioning with catheters and by bronchoscopy
cannot be cultured for anaerobic organisms. Instead,
transtracheal aspiration or lung biopsy must be
used.6
Interpretation of the results of sputum cultures
requires knowledge of the client’s symptomatology
and the nature of the pathogen cultured. Pathogens
may be identified in the sputum of individuals who
do not have pneumonia or whose pneumonia is
actually caused by an organism not identified on
culture. Similarly, a person may be diagnosed as
having pneumonia on the basis of sputum cultures,
when the infection is caused by an obstruction by
tumors or foreign bodies, pulmonary infarction, or
pulmonary hemorrhage. If Candida or Aspergillus is
found on culture, the client must be further evalu-

Analysis

271

ated, because these environmental contaminants
may be the cause of serious pulmonary disease.7 In
legionnaires’ disease, sputum cultures and Gram
staining are negative, despite clinical signs of severe
pneumonia. When this disease is suspected, confirmation must be obtained through immunologic
blood tests (see Chapter 3).8
Rapidity of results from sputum cultures varies
according to the rate of growth of the organisms.
Routine cultures of M. tuberculosis, for example,
may take weeks to become positive. To provide more
rapid and reliable diagnostic information, some
laboratories use immunologic methods such as
counterimmunoelectrophoresis (CIEP) to identify
microbial pathogens. In CIEP, antibodies specific
to the suspected organisms are used, and rapid
confirmation of significant tissue involvement is
possible.9
Reference Values
Normal respiratory flora include Moraxella
catarrhalis, C. albicans, diphtheroids, -hemolytic streptococci, and some staphylococci.
INTERFERING FACTORS

Improper specimen collection
Delay in sending specimen to the laboratory
C&S should be performed before antimicrobial
therapy to evaluate effectiveness of therapy.
INDICATIONS FOR CULTURE AND SENSITIVITY
TEST

Support for diagnosing the cause of respiratory
infection as indicated by the presence or absence
(e.g., viral infections, legionnaires’ disease) of
organisms in culture
Confirmatory diagnosis of tuberculosis (see also
AFB smear and culture)
Monitoring for response to treatment for respiratory infections, especially tuberculosis
Identification of antibiotics to which the cultured
organism is sensitive
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of sputum or lower respiratory secretions (see section under “Gram Stain and
Other Stains”).
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the “Gram Stain and
Other Stains” section.

272

SECTION I—Laboratory

Tests

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving collection of sputum
or lower respiratory secretions.
Depending on the nature of the suspected or
confirmed infection, respiratory isolation or
drainage and secretion precautions may be used,
although these infection-control protocols may
have been already implemented before obtaining
sputum cultures.
Abnormal test results, complications, and
precautions: Respond the same as for stains (see
earlier section). The client should be informed
that culture results for the more common pathogenic microorganisms can be obtained in 24 to 48
hours and that sensitivity results can cause a
change in antimicrobial therapy.

ACID-FAST BACILLUS SMEAR
AND CULTURE
The acid-fast staining method is used primarily to
identify tubercle bacilli (M. tuberculosis). Acid-fast
bacilli have a cell wall that resists decolorization by
acid treatment10; that is, they retain the stain applied
to the specimen, a small portion of which is smeared
on a slide, even after treatment with an acid-alcohol
solution.
Because the tubercle bacillus is slow growing and
culture results may take weeks, an acid-fast bacillus
(AFB) smear aids in early detection of the organism
and timely initiation of antituberculosis therapy. In
addition to organisms of the Mycobacterium genus,
Nocardia spp. and Actinomyces spp. can also be identified by acid-fast techniques.
AFB cultures are used to confirm both positive
and negative results of AFB smears. By specifying
that AFB is the organism to be detected on culture,
the laboratory is alerted to the fact that several weeks
may be needed for conclusive results. As noted,
immunologic methods may also be used in diagnosing tuberculosis by sputum analysis.
Reference Values
Negative for AFB

Monitoring for response to treatment for
pulmonary tuberculosis
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of sputum or lower respiratory secretions (see section under “Gram Stain and
Other Stains”).
The client should be informed that it may be
several weeks before culture results are available.
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the section under “Gram
Stain and Other Stains”).
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of
sputum or lower respiratory secretions.
If tuberculosis is suspected, the client may be
placed on AFB or respiratory isolation, pending
AFB smear results.

CYTOLOGIC EXAMINATION
Cytology is the study of the origin, structure, function, and pathology of cells. In clinical practice, cytologic examinations are generally performed to detect
cell changes resulting from malignancies or inflammatory conditions. Lipid droplets contained in
macrophages may be found on cytologic examination and may indicate lipoid or aspiration pneumonia.11
Sputum specimens for cytologic examination
may be collected by expectoration alone, during
bronchoscopy, or by expectoration after bronchoscopy. The method of reporting results of cytologic examinations varies according to the
laboratory performing the test. Terms used to report
results include negative (no abnormal cells), inflammatory, benign atypical, suspect for malignancy, and
positive for malignancy.
Reference Values
Negative for abnormal cells, Curschmann’s
spirals, fungi, ova, and parasites

INTERFERING FACTORS

Improper specimen collection
Delay in sending specimen to the laboratory
INDICATIONS FOR ACID-FAST BACILLUS SMEAR
AND CULTURE

Suspected pulmonary tuberculosis

INTERFERING FACTORS

Improper specimen collection
Delay in sending specimen to the laboratory
INDICATIONS FOR CYTOLOGIC EXAMINATION

Suspected lung cancer

CHAPTER 7—Sputum

History of cigarette smoking, which may lead to
metaplastic (nonmalignant) cellular changes
History of acute or chronic inflammatory or
infectious lung disorders, which may lead to
benign atypical or metaplastic cellular changes
Known or suspected viral disease involving the
lung
Known or suspected fungal or parasitic infection
involving the lung
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of sputum or lower respiratory secretions (see section under “Gram Stain and
Other Stains”).
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the “Gram Stain and
Other Stains” section. It is common practice to
collect three sputum specimens for cytologic examination, usually on three separate mornings. After
bronchoscopy, however, serial specimens may be
obtained from sputum expectorated within 12 to 24
hours of the procedure. Specimens are collected in
either sterile containers or sterile containers to

Analysis

273

which 50 percent alcohol has been added, depending
on specific laboratory procedures.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of
sputum or lower respiratory secretions.
Abnormal test results, complications, and
precautions: The client should be offered additional support if the diagnostic findings indicate a
premalignant or malignant condition and if
further diagnostic procedures or chemotherapy/
radiation therapy is advised.
REFERENCES
1. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 10. FA Davis, Philadelphia,
1991, p 747.
2. Ibid, p 748.
3. Ibid, p 749.
4. Ibid, p 749.
5. Ibid, p 749.
6. Ibid, p 453.
7. Ibid, p 749.
8. Ibid, p 456.
9. Ibid, pp 460–461.
10. Ibid, pp 460-461.
11. Ibid, p 749.

CHAPTER

Cerebrospinal
Fluid Analysis
TESTS COVERED
Routine Cerebrospinal Fluid Analysis, 275
Microbiologic Examination of
Cerebrospinal Fluid, 279

Cytologic Examination of Cerebrospinal
Fluid, 281
Serologic Tests for Neurosyphilis, 281

OVERVIEW OF CEREBROSPINAL FLUID FORMATION AND ANALYSIS
Cerebrospinal fluid (CSF) is secreted into the ventricles of the brain by specialized capillaries
called choroid plexuses. Most of the CSF arises in the lateral ventricles, although additional
amounts are secreted in the third and fourth ventricles. CSF formed in the ventricles circulates
into the central canal of the spinal cord and also enters the subarachnoid space through an
opening in the wall of the fourth ventricle near the cerebellum, after which it circulates around
the brain and spinal cord. Although 500 to 800 mL of CSF are formed daily, only 125 to 140 mL
are normally present. Thus, almost all of the CSF formed is reabsorbed via arachnoid granulations, which project from the subarachnoid space into the venous sinuses, and is subsequently
returned to the venous circulation. The functions of CSF include cushioning the brain against
shocks and blows, maintaining a stable concentration of ions in the central nervous system
(CNS), and providing for removal of wastes.1
CSF is produced by the processes of filtration, diffusion, osmosis, and active transport.
Initially, sodium is actively transported into the CSF; then water follows passively by osmosis.
Facilitated diffusion allows glucose to move between the blood and CSF. Although similar in
composition to plasma, CSF generally contains more sodium and chloride and less potassium,
calcium, and glucose. Most constituents of CSF, however, parallel those found in plasma and
are found in amounts equal to or slightly less than those in the blood.2,3
In addition to entering CSF via the choroid plexuses, substances may pass into CSF from the
blood through capillaries in the parenchyma and meninges of the brain and spinal cord.
“Barriers” exist between the blood and the CSF and between the brain and the CSF; that is,
substances do not pass as readily into the CSF as they would pass into extracellular fluid
through other capillary beds. Water, carbon dioxide, oxygen, glucose, small molecules, lipidsoluble substances, nonionized substances, and some drugs (e.g., erythromycin and sulfadiazine) pass rapidly into CSF, whereas large molecules, ionized substances, various toxins, and
certain other drugs (e.g., chlortetracyclines and penicillins) do not pass readily into CSF.4
Under pathological conditions, elements normally held back by the blood–brain barrier may
enter CSF. Red cells and white cells can enter the CSF either from rupture of vessels or from
meningeal reaction to irritation. Unconjugated (prehepatic) bilirubin may be found after
intracranial hemorrhage, whereas conjugated bilirubin may be found if the circulating plasma
274

CHAPTER 8—Cerebrospinal

Fluid Analysis

275

contains large amounts. Fibrinogen, which is normally absent from CSF, may be found along
with albumin and globulins when inflammatory disorders cause increased permeability of the
blood–brain barrier. Urea, lactic acid, and glutamine levels in CSF will rise if plasma levels of
these or related substances are elevated. Bacteria and fungi found in CSF indicate infection with
these organisms.5
As a general rule, routine CSF analysis includes a cell count and differential as well as determinations of protein and glucose levels. In addition, CSF may be analyzed for electrolytes, lactic
acid, urea, glutamine, and enzymes. Microbiologic studies of CSF include culture and sensitivity (C&S), Gram stain and other stains, acid-fast bacillus (AFB) smear and culture, and the
Limulus assay for gram-negative bacteria. Cytologic examination for malignant cells, as well as
serologic tests for syphilis, may be performed on CSF.
The gross appearance, opening pressure, and closing pressure should be noted during the
procedure and documented. The pH of the sample may also be noted. CSF is normally clear,
colorless, and of the consistency of water. Turbidity indicates the presence of a significant
number of leukocytes (i.e., greater than 200 to 500 white cells per cubic millimeter). Yellowish
discoloration of CSF (xanthochromia) usually indicates previous bleeding but may also be seen
when CSF protein levels are greatly elevated. Fresh blood in the specimen may be due to traumatic spinal tap, although clearing should be noted as the second and third tubes are withdrawn
in such a case. Bleeding from a traumatic tap adds approximately one to two white cells and 1
mg/dL of protein for every 1000 red cells per cubic millimeter contained in the sample. If blood
does not clear as subsequent samples are obtained, bleeding due to subarachnoid hemorrhage
is usually indicated. Brown CSF generally indicates a chronic subdural hematoma with CSF
stained from methemalbumin.6
Because fibrinogen is normally absent from CSF, the sample should not clot. Clotting may
occur, however, when the protein content of the sample is elevated. In conditions involving
spinal subarachnoid block, CSF may be yellow and have a tendency toward rapid spontaneous
clotting. The pH of CSF is normally slightly lower than that of blood, with a range of 7.32 to
7.35 when arterial blood pH is within normal limits.7
CSF specimens must be transported to the laboratory immediately. Within 1 hour of collection, any red cells contained in the sample begin to lyse and may cause spurious coloration of
the specimen. Neutrophils and malignant cells may also disintegrate in a short time. Bacteria
and other cells will continue to metabolize glucose, such that delays in analysis may alter chemical values.8
The opening CSF pressure (OP) is measured after the spinal needle is determined to be in the
subarachnoid space. CSF pressure may be elevated if clients are anxious and hold their breath
or tense their muscles. It may also be elevated if there is venous compression such as may occur
if the client’s knees are flexed too firmly against the abdomen. Significant elevations in CSF
pressure may occur with intracranial tumors and with purulent or tuberculous meningitis. Less
marked increases (i.e., 250 to 500 mm of water) are associated with low-grade inflammatory
processes, encephalitis, or neurosyphilis. Decreases in CSF pressure are rare but may occur with
dehydration, high obstruction to CSF flow, or previous aspiration of spinal fluid.9
The closing pressure (CP) is recorded before removal of the spinal needle from the subarachnoid space. Normally, CSF pressure decreases 5 to 10 mm of water for every milliliter of CSF
withdrawn. The expected decrease in CSF pressure does not occur in disorders in which the
total quantity of CSF is increased (e.g., hydrocephalus). In contrast, a large drop in pressure
indicates a small CSF pool and is seen in tumors or spinal block.10

CEREBROSPINAL FLUID TESTS
ROUTINE CEREBROSPINAL
FLUID ANALYSIS
Routine CSF analysis includes a cell count and
differential, as well as determinations of protein

and glucose levels. CSF may also be analyzed for
electrolytes, lactic acid, urea, glutamine, and
enzymes.
CELL COUNT AND DIFFERENTIAL

Normal spinal fluid is free of cells. Note that crypto-

276

SECTION I—Laboratory

Tests

coccal organisms in the sample may be mistaken for
small lymphocytes.
PROTEINS

CSF normally contains very little protein because
most proteins cannot cross the blood–brain barrier.
In addition to determining the amount of protein
present in CSF, levels of certain types of protein may
also be measured. Albumin, for example, is a relatively small molecule and may pass more easily into
CSF. For this reason, the albumin-to-globulin (A-G)
ratio is normally higher in CSF than in serum.
Protein electrophoresis may also be performed on
CSF samples.
The protein concentration in CSF may rise as a
result of increased permeability of the blood–brain
barrier because of inflammation and infection. CSF
protein levels may also be elevated in clients with
diabetes mellitus and cardiovascular disease because
of increased permeability of the blood–brain
barrier.11
GLUCOSE

The glucose concentration of CSF is altered by the
presence of microorganisms. Because all types of
organisms consume glucose, levels will be decreased
if the CSF contains bacteria, fungi, protozoa, or
tubercle bacilli. However, this decrease is not as
pronounced or may not be seen at all in viral meningitis.
Bacterial and other cells present in CSF continue
to metabolize glucose even after the sample has been
collected. Thus, spuriously low glucose levels may be
found in CSF if analysis is delayed.
OTHER SUBSTANCES

Other substances for which CSF may be analyzed
include electrolytes, lactic acid, urea, glutamine, and
enzymes. The electrolyte levels found in CSF are
similar to those of plasma, with the exceptions of
sodium and chloride, which are higher, and potassium and calcium, which are lower. The significance
of electrolyte levels in CSF is questionable. Some
writers, for example, indicate that chlorides are
decreased in tuberculosis and bacterial meningitis.12,13 Others state that chloride levels provide no
specific diagnostic information.14 The calcium
found in CSF is that fraction not bound by protein
and is about half that of serum levels. Calcium levels
rise with CSF protein levels; it is more important to
determine the protein level in such cases, however,
than to measure calcium.15
Lactic acid in CSF reflects local glycolytic activity
and adds to diagnostic information when results of
other analyses are inconclusive. Severe systemic
lactic acidosis causes CSF lactate to rise accordingly.

Elevated CSF lactate without a parallel elevation in
serum level indicates increased CSF glucose metabolism, which is usually due to bacterial or fungal
meningitis. In early or partially treated bacterial or
fungal meningitis, CSF cell count and glucose levels
may be similar to those found in viral meningitis or
noninfectious conditions. Lactate levels above 35
mg/dL rarely occur, however, unless the client has
bacterial or fungal meningitis. Lactate levels remain
elevated until the individual has received effective
antibiotic therapy for several days. Persistent elevation of CSF lactate levels indicates inadequate treatment of meningitis.16
Urea levels in CSF and blood are approximately
equal; thus, CSF urea levels rise when blood levels
are elevated, as in uremia. Urea is sometimes administered intravenously (IV) to lower intracranial pressure. In such cases, the subsequent elevation in CSF
urea levels causes fluid to shift from the brain to the
CSF. CSF urea levels may remain elevated for 24 to
48 hours after IV administration of urea. Glutamine
is synthesized in the CNS from ammonia and
glutamic acid. CSF glutamine levels rise when blood
ammonia levels are high, a situation seen in cirrhosis with altered hepatic blood flow and encephalopathy. Glutamine levels in CSF have been found to
correlate as well or better than blood ammonia levels
with the degree of hepatic encephalopathy. Enzymes
that have been measured in CSF include lactic dehydrogenase (LDH), alanine aminotransferase (ALT,
SGPT), and aspartate aminotransferase (AST,
SGOT). Levels of these enzymes are normally lower
than those found in the blood. CSF enzymes may
rise in inflammatory, hemorrhagic, or degenerative
diseases of the CNS. CSF enzyme levels are not
measured under routine conditions, however, and
may not add to the diagnostic information obtained
from more routinely available tests.17
INTERFERING FACTORS

Delay in transporting sample to the laboratory
(may cause spurious discoloration as a result of
lysis of any red cells present, disintegration of any
neutrophils present, and false decrease in glucose
as a result of continued utilization by cells in the
sample)
Blood in the sample caused by traumatic tap
(adds one to two white cells and 1 mg/dL of
protein for every 1000 red cells per cubic millimeter contained in the sample)
INDICATIONS FOR ROUTINE CEREBROSPINAL
FLUID ANALYSIS

Suspected viral meningitis, cerebral thrombosis,
or brain tumor as indicated by a cell count of 10
to 200 per cubic millimeter, consisting mostly of

CHAPTER 8—Cerebrospinal

Fluid Analysis

277

Reference Values
Conventional Units
Color

SI Units

Clear

Pressure
Children

50–100 mm H2O

Adults

75–200 mm H2O (120 mm H2O average)

Cell count and differential
Children

Up to 20 small lymphocytes per cubic millimeter

Adults

Up to 5 small lymphocytes per cubic millimeter
No RBC or granulocytes

Protein
Total proteins
Infants

30–100 mg/dL

0.30–1.0 g/L

Children

14–45 mg/dL

0.14–0.45 g/L

Adults

15–45 mg/dL (lumbar area) or less
than 1% of serum levels

0.15–0.45 g/L

A-G ratio

8:1

IgG

3–12% of total protein

Glucose
Infants

20–40 mg/dL

1.11–2.22 mmol/L

Children

35–75 mg/dL

1.94–4.16 mmol/L

Adults

40–80 mg/dL or less than 50–80% of blood
glucose level 30–60 min earlier

2.22–4.44 mmol/L

Chloride

118–132 mEq/L

118–132 mmol/L

Calcium

2.1–2.7 mEq/L

1.05–1.35 mmol/L

Sodium

144–154 mEq/L

144–154 mmol/L

Potassium

2.4–3.1 mEq/L

2.4–3.1 mmol/L

Lactic acid (lactate)

10–20 mg/dL

1.1–2.2 mmol/L

Urea

10–15 mg/dL

3.6–5.3 mmol/L

Glutamine

Less than 20 mg/dL

1370.0 mol/L

Lactic dehydrogenase (LDH)

1/10 that of serum level

Electrolytes

lymphocytes, a mild elevation (to 300 mg/dL) in
total proteins, and normal or slightly decreased
glucose level
Suspected multiple sclerosis or neurosyphilis as
indicated by a normal or slightly elevated cell
count, consisting mostly of lymphocytes, slightly
elevated protein (less than 100 mg/dL), slightly

elevated globulins, elevated IgG on protein electrophoresis, and a normal or slightly decreased
glucose level
Suspected acute bacterial or syphilitic meningitis,
herpes infection of CNS as indicated by a cell
count of greater than 500 per cubic millimeter,
consisting largely of granulocytes, moderate or

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SECTION I—Laboratory

Tests

pronounced elevation in protein (greater than 300
mg/dL), pronounced decrease in glucose, and
decreased chloride18
Suspected tuberculous meningitis as indicated by
a cell count of 200 to 500 per cubic millimeter,
consisting of lymphocytes or mixed lymphocytes
and granulocytes, moderate or pronounced
elevation in proteins, pronounced reduction in
glucose, and decreased chloride
Suspected early bacterial or fungal meningitis as
indicated by CSF lactate level above 35 mg/dL,
even when cell count and glucose level are only
slightly altered
Evaluation of effectiveness of treatment for bacterial or fungal meningitis, with effective treatment
indicated by decreasing lactate levels after several
days of antimicrobial therapy
Suspected CNS leukemia as indicated by a cell
count of 200 to 500 per cubic millimeter, consisting mainly of blast cells and a moderate reduction
in glucose
Suspected spinal cord tumor as indicated by a cell
count of 10 to 200 per cubic millimeter, moderate
or pronounced elevation in protein, and normal
or slightly decreased glucose
Support for diagnosing subarachnoid hemorrhage as indicated by the presence of red blood
cells, elevated proteins, and a moderate reduction
in glucose
Support for diagnosing hepatic encephalopathy as
indicated by elevated glutamine levels
Support for diagnosing Guillain-Barré syndrome
(ascending polyneuritis) as indicated by pronounced elevation in proteins
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That the procedure will be performed by a physician and requires 20 to 30 minutes
The positioning used for the procedure and the
necessity of remaining still while the procedure is
being performed
That a local anesthetic will be injected at the
needle insertion site
That the needle is inserted below the end of the
spinal cord (for lumbar punctures)
That a sensation of pressure may be felt when the
needle is inserted
The necessity of remaining flat in bed for 6 to 8
hours after the procedure (for lumbar punctures)
and that turning from side to side is permitted as
long as the head is not raised
That taking fluids after the procedure will aid in
returning the CSF volume to normal (provided
that this is not contraindicated for the particular
client)

Prepare the client for the procedure:
Have the client void.
Provide a hospital gown.
Take and record vital signs, assess legs for neurological status (strength, movement, and sensation) for comparison with postprocedure
assessment.
Obtain a signed informed consent if required by
the agency.
THE PROCEDURE

The necessary equipment is assembled (e.g., lumbar
puncture tray). The client is assisted to a side-lying
position, with the head flexed as far as comfortable
and the knees drawn up toward, but not pressing on,
the abdomen. Support in maintaining this position
may be provided by placing one hand on the back of
the client’s neck and the other behind the knees.
Lumbar punctures may also be performed with the
client seated while leaning forward with arms resting
on an overbed table or other support.
The lumbar area is cleansed with an antiseptic
and protected with sterile drapes. The skin is infiltrated with a local anesthetic and the spinal needle
with stylet is inserted into a vertebral interspace
between L2 to S1, usually L3–4 or L4–5. The stylet is
then removed and, if the needle is properly positioned in the subarachnoid space, spinal fluid will
drip from the needle. A sterile stopcock and
manometer are then attached to the needle. The
opening pressure is read (see earlier discussion) and,
if indicated, Queckenstedt’s test is performed. When
the needle and manometer are properly positioned,
the CSF level should fluctuate several millimeters
with respiration.19
Queckenstedt’s test is based on the principle that
a change in pressure in one area of the closed
system—composed of the ventricular spaces,
intracranial subarachnoid space, and vertebral
subarachnoid space—will be reflected in other areas
of the system as well. The test is indicated when total
or partial spinal block (e.g., due to tumor) is
suspected, and it is performed by compressing both
jugular veins while monitoring lumbar CSF pressure. Temporary occlusion of the jugular veins
impairs the absorption of intracranial fluid and
produces an acute rise in CSF pressure. If CSF flow
is unimpeded, the pressure elevation will be transmitted to the lumbar area, and the fluid level in the
manometer will rise. Total or partial spinal block is
diagnosed if the CSF pressure fails to rise or if more
than 20 seconds is required for the pressure to return
to the pretest level after pressure on the jugular veins
is released. Queckenstedt’s test is risky in clients with
increased intracranial pressure of highly reactive
carotid body receptors. Radiologic examinations

CHAPTER 8—Cerebrospinal

such as myelograms and computed axial tomography (CAT) scans may give more information and
carry less risk.20
The manometer is then removed and CSF is
allowed to drip into three sterile test tubes, 3 to 10
mL per tube. The tubes are numbered in order of
filling, labeled with the client’s name, and sent to the
laboratory immediately. The manometer may then
be reattached and the closing pressure recorded. The
spinal needle is removed, and pressure is applied to
the site. If no excessive bleeding or CSF leakage is
noted, an adhesive bandage is applied to the site and
the client is assisted to a recumbent position.
Alternatives to the lumbar puncture include
cisternal and ventricular punctures. These procedures may be used when lumbar puncture is not
feasible because of bony abnormalities or infection
at the lumbar area. For a cisternal puncture, the
client is assisted to a side-lying position with the
neck flexed and the head resting on the chest. The
back of the neck may require shaving before the
procedure. After the skin is infiltrated with local
anesthetic, the needle is inserted at the base of the
occiput, between the first cervical vertebra and the
foramen magnum. CSF samples are then obtained in
the same manner as for lumbar punctures. Cisternal
punctures are considered somewhat hazardous,
because the needle is inserted close to the brainstem;
however, clients are said to be less likely to experience postprocedure headaches and may resume
usual activities within a few hours of the procedure.21
Ventricular punctures are surgical procedures
(i.e., usually performed in an operating room) in
which CSF samples are obtained directly from one of
the lateral ventricles in the brain. For this procedure,
a scalp incision is made and a burr hole is drilled in
the occipital area of the skull. The needle is then
inserted through the hole and into the lateral ventricle, and CSF samples are obtained. This procedure is
rarely performed.22
The cell count and protein content of CSF
samples obtained by cisternal or ventricular punctures are normally lower than those found in lumbar
samples. The higher levels of cells and protein found
in CSF from lumbar punctures are thought to be
caused by stagnation of CSF, which occurs in the
lumbar sac.23
NURSING CARE DURING THE PROCEDURE

Note any distress, especially dyspnea, that may be
caused by positioning.
Observe for signs of brainstem herniation such as
decreased level of consciousness, irregular respirations, and a unilaterally dilating pupil (uncal
herniation).

Fluid Analysis

279

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client to a recumbent position and
having the client maintain a flat position for 6 to 8
hours to prevent the occurrence of headache.
Remind the client that turning from side to side is
permitted, as long as the head is not raised.
Assist the client in taking liberal amounts of
fluids to replace the CSF loss, unless otherwise
contraindicated.
A dressing can be applied after pressure to the
puncture site.
Care after cisternal and ventricular punctures is
essentially the same as that for lumbar punctures.
For cisternal punctures, provide bed rest for only
2 to 4 hours, after which usual activities may be
resumed. For ventricular punctures, maintain bed
rest for 24 hours.
Take and record vital signs every hour for the first
4 hours and then every 4 hours for 24 hours (for
hospitalized clients).
Perform a neurological check each time vital signs
are taken to determine nerve damage affecting the
legs.
Assess the puncture site for bleeding, CSF
drainage, and inflammation each time vital signs
are taken during the first 24 hours and daily thereafter for several days. (Family members or
support persons should be instructed to do this
for nonhospitalized clients.)
Observe for signs of meningeal irritation such as
fever, nuchal rigidity, and irritability indicating
infection.
Assess the client’s comfort level, noting presence
or absence of headache. Administer an ice bag to
the head and a mild analgesic if ordered.

MICROBIOLOGIC EXAMINATION
OF CEREBROSPINAL FLUID
Microbiologic studies of CSF include C&S, Gram
stain and other stains, AFB smear and culture, and
the Limulus assay for gram-negative bacteria.
Numerous microorganisms can cause meningitis,
encephalitis, and brain abscess. Thus, whenever CNS
infection is suspected, CSF should be tested for the
presence of bacteria, fungi, protozoa, and tubercle
bacilli, because more than one organism may be
present.24 The CSF is also tested for bacterial antigens in addition to culturing for bacteria. CSF rarely
contains abundant organisms, so specimens for
microbiologic examination must be collected and
handled with strict aseptic technique. The usual
laboratory procedure is to centrifuge a few milliliters
of CSF to concentrate any organisms present. After

280

SECTION I—Laboratory

Tests

culture plates with several different media are inoculated, the remaining CSF sediment is examined
with Gram staining and AFB staining techniques
(see Chapter 7).25
Failure to isolate organisms on stained smear does
not necessarily mean that organisms are absent from
the CSF sample. Reliably positive results are
obtained only when at least 105 bacteria per milliliter
are present. Gram stains, for example, are positive in
only 80 to 90 percent of individuals with untreated
meningitis. CSF is almost routinely examined and
cultured for AFB when the cause of the CNS disorder is unknown, because tuberculous meningitis can
develop insidiously and presents with few clear diagnostic indicators.26
When infection with the fungus Cryptococcus is
suspected, the specimen may be examined by testing
for cryptococcal antigen.27 The cryptococcal antigen
test, in which a strong anticryptococcal antibody is
used, may elicit antigenic elements even when cryptococcal organisms are undetected by other methods.28
Amebae may also cause meningitis, especially in
individuals who swim in lakes or indoor swimming
pools. A wet-mount preparation of CSF is examined
for motile cells when such an infection is suspected.29
Spinal fluid is normally cultured on several different media to test for different organisms. The
meningococcal organism (Neisseria meningitidis),
for example, prefers to grow in a medium with
a high carbon dioxide atmosphere. Counterimmunoelectrophoresis (CIEP) can also be used to detect
bacterial antigens when usual techniques fail to
demonstrate bacteria in CSF.30
The presence of gram-negative organisms in CSF
can be demonstrated rapidly with the Limulus assay.
This test uses the bloodlike fluid of the horseshoe
crab of the genus Limulus, which is coagulated by
gram-negative endotoxins. This test, therefore,
provides a quick means of diagnosing gram-negative
infections of the CNS and gram-negative endotoxemia. The test is more reliable when performed on
CSF than when performed on blood.31
Acute bacterial meningitis occurs most
commonly in children younger than age 5 years and
in adults who have experienced head trauma. Gramnegative bacilli (Escherichia coli, Klebsiella,
Enterobacter, Proteus) are the usual etiologic agents
of meningitis in premature infants and newborns. In
infants, the causative agents include Streptococcus
agalactiae (group B) and Listeria monocytogenes. In
young children, meningitis is most frequently
caused by gram-negative bacilli (Haemophilus
influenzae). In adolescents, the agent is most likely to

be N. meningitidis. In adults, meningitis may also be
caused by Streptococcus pneumoniae. In elderly
persons, the agent is a gram-negative bacillus. Viral
infections, tuberculous meningitis, and fungal and
protozoal infections may occur at any age and often
present as insidious or misleading syndromes.32
Reference Values
Organisms are not normally present in CSF.

INTERFERING FACTORS

Delay in transporting the sample to the laboratory
(Organisms may disintegrate if the sample is held
at room temperature for more than 1 hour.)
Contamination of the sample with normal skin
flora or other organisms because of improper
collection or handling of the sample
INDICATIONS FOR MICROBIOLOGIC EXAMINATION
OF CEREBROSPINAL FLUID

Suspected meningitis, encephalitis, or brain
abscess
CNS disorder of unknown etiology without clear
diagnostic indicators
Head trauma with possible resultant CNS infection
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of CSF samples (see section
under “Routine Cerebrospinal Fluid Analysis”).
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the “Routine Cerebrospinal Fluid Analysis” section. Extreme care must
be used in obtaining and collecting the sample, so as
not to contaminate the sample or introduce organisms into the CNS.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a CSF
sample (see section under “Routine Cerebrospinal
Fluid Analysis”).
Depending on the nature of the suspected or
confirmed infection, use infectious disease
precautions.
Complications and precautions: Note and report
signs and symptoms of brain disorder such as
fever, irritability, or headache. Perform neurological checks and take and record vital signs. Notify
physician immediately of a positive stain result.

CHAPTER 8—Cerebrospinal

CYTOLOGIC EXAMINATION OF
CEREBROSPINAL FLUID
Cytologic examination of CSF is performed primarily to detect malignancies involving the CNS.
Cellular changes caused by malignancies whose
primary site is the CNS (e.g., brain tumors) or
malignancies that have metastasized to the CNS
from other sites (e.g., breast and lung) may be
detected. Abnormal cells resulting from acute
leukemia involving the CNS may also be seen.
Reference Values

Fluid Analysis

281

ment fixation tests and the Venereal Disease
Research Laboratory (VDRL) and rapid plasma
reagin (RPR) flocculation tests. The best specific test
is the fluorescent treponemal antibody (FTA) test.
Nonspecific reagin tests are usually used for
routine testing of CSF because they are cheaper and
more readily available than the FTA test. The falsepositive results that can occur when blood is tested
with reagin tests occur fairly rarely in CSF specimens. Nonspecific tests are, however, less sensitive
than the FTA test. Thus, if neurosyphilis is a serious
diagnostic consideration, the FTA is the test of
choice.33

No abnormal cells
Reference Values
INTERFERING FACTORS

Delay in transporting the sample to the laboratory
(Cells may disintegrate if the sample is held at
room temperature for more than 1 hour.)
Contamination of the sample with skin cells
INDICATIONS FOR CYTOLOGIC EXAMINATION
OF CEREBROSPINAL FLUID

Suspected malignancy with primary site in the
CNS
Suspected metastasis of malignancies to the CNS
Suspected CNS involvement in acute leukemia
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of CSF samples (see section
under “Routine Cerebrospinal Fluid Analysis”).
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the “Routine Cerebrospinal Fluid Analysis” section. Care must be
taken not to contaminate the sample with skin cells.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a CSF
sample (see section under “Routine Cerebrospinal
Fluid Analysis”).

SEROLOGIC TESTS FOR NEUROSYPHILIS
When syphilis involving the CNS (neurosyphilis) is
suspected, serologic tests are performed on samples
of CSF. Blood tests for syphilis (see Chapter 3)
consist of two main types: (1) nonspecific tests that
demonstrate syphilitic reagin and (2) specific tests
that demonstrate antitreponemal antibodies. Reagin
tests include the Wassermann and Reiter comple-

Negative
INTERFERING FACTORS

Delay in transporting the sample to the laboratory
(Organisms may disintegrate if the sample is held
at room temperature for more than 1 hour.)
INDICATIONS FOR SEROLOGIC TESTS FOR
NEUROSYPHILIS

Suspected neurosyphilis
NURSING CARE BEFORE THE PROCEDURE

Client preparation is the same as that for any test
involving the collection of CSF samples (see section
under “Routine Cerebrospinal Fluid Analysis”).
THE PROCEDURE

The procedures for obtaining the specimen are the
same as those described in the “Routine
Cerebrospinal Fluid Analysis” section.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure are the
same as for any test involving the collection of a CSF
sample (see section under “Routine Cerebrospinal
Fluid Analysis”).
REFERENCES
1. Porth, CM. Pathophysiology: Concepts of Altered Health, ed 5. JB
Lippincott, Philadelphia, 1998, pp 868–869.
2. Ibid, p 868.
3. Sacher, RA, and McPherson, RA: Widmann’s Clinical
Interpretation of Laboratory Tests, ed 11. FA Davis, Philadelphia,
2000, p 537.
4. Porth, op cit, p 870.
5. Sacher and McPherson, op cit, pp 731, 735.
6. Ibid, p 729.
7. Ibid, p 732.
8. Ibid, p 733.
9. Ibid, p 730.
10. Ibid, p 731.
11. Ibid, pp 732–733.

282

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Tests

12. Fischbach, FT: A Manual of Laboratory Diagnostic Tests, ed 4. JB
Lippincott, Philadelphia, 1992, p 255.
13. Springhouse Corporation: Nurse’s Reference Library: Diagnostics,
ed 2. Springhouse, Springhouse, Pa, 1986, p 776.
14. Sacher and McPherson, op cit, p 735.
15. Ibid, p 735.
16. Ibid, p 733.
17. Ibid, pp 733, 735.
18. Ibid, pp 731–732.
19. Ibid, p 730.
20. Ibid, pp 730–731.
22. Nurse’s Reference Library, op cit, p 779.

23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.

Ibid, p 779.
Sacher and McPherson, op cit, p 732.
Ibid, p 735.
Ibid, p 495.
Ibid, p 735.
Ibid, p 735.
Ibid, p 735.
Ibid, p 735.
Ibid, p 735.
Ibid, p 734.
Ibid, p 734
Ibid, p 736.

CHAPTER

Analysis of Effusions
TESTS COVERED
Pericardial Fluid Analysis, 284
Pleural Fluid Analysis, 286

Peritoneal Fluid Analysis, 289
Synovial Fluid Analysis, 292

OVERVIEW OF EFFUSIONS Effusions are excessive accumulations of fluid in body cavities lined with serous or synovial membranes. Such cavities normally contain only small
amounts of fluid (i.e., less than 50 mL). Serous membranes line the closed cavities of the thorax
and abdomen and cover the organs within them. Membranes lining cavities are termed parietal
membranes; membranes covering organs are called visceral membranes. Serous membranes
consist of a layer of simple squamous epithelium (mesothelium) that covers a thin layer of
connective tissue.1 Serous membranes secrete a small amount of watery fluid into the potential
space between the parietal and visceral membranes. Serous fluid serves as a lubricant, allowing
the internal organs to move without excessive friction. Although there is no actual space
between visceral and parietal serous membranes, the potential space between them is called a
cavity. In certain disease states, these cavities may contain large amounts of fluid (i.e., effusions). Three such serous cavities are the pericardial cavity, the pleural cavity, and the peritoneal
cavity.
Synovial membranes line the cavities of most joints, the bursae, and the synovial tendon
sheaths. These membranes consist of fibrous connective tissue, which overlies loose connective
tissue and adipose tissue.2 Synovial cells are found in layers one to three cells thick; wide gaps
are often found between adjacent synovial cells. Synovial membranes secrete a thick, colorless
fluid with a high mucin content. As with serous fluid, synovial fluid acts as a lubricant in joint
cavities. It also provides nourishment to articular cartilage.3
Serous fluid is formed by diffusion from adjacent capillaries via interstitial fluid and may be
described as an ultrafiltrate of plasma. Thus, substances that normally diffuse from capillaries
(e.g., water, electrolytes, glucose) diffuse into serous fluid. Similarly, substances can diffuse from
serous fluid back into the capillaries. Protein may also collect in serous cavities because of capillary leakage. Protein and excess fluids are normally removed from these cavities by the
surrounding lymphatics.
Synovial fluid is formed in a manner similar to that of serous fluid but additionally contains
a hyaluronate–protein complex (i.e., a mucopolysaccharide containing hyaluronic acid and a
small amount of protein) that is secreted by the connective tissue cells of the synovial
membrane.4 As with serous cavities, excess proteins and fluids are normally drained from
synovial cavities by the lymphatics.
Changes in fluid production and drainage can lead to the development of effusions in serous
and synovial cavities. Mechanical factors that can cause effusions include increased capillary
permeability, increased capillary hydrostatic pressure, decreased capillary colloidal osmotic
pressure, increased venous pressure, and blockage of lymphatic vessels. Damage to the serous
283

284

SECTION I—Laboratory

Tests

and synovial membranes (e.g., caused by inflammation or infection) can also cause excessive
fluid buildup.
Effusions involving serous cavities may be differentiated as transudates or exudates.
Transudates occur because of abnormal mechanical factors and are generally characterized by
low-protein, cell-free fluids. Exudates are caused by infection or inflammation and contain cells
and excessive amounts of protein. Pleural and peritoneal effusions can be either transudates or
exudates; pericardial effusions, however, are almost always exudates.5 Chylous effusions caused
by the escape of chyle from the thoracic lymphatic duct may form in the pleural and peritoneal
cavities. Accumulation of large amounts of fluid in the peritoneal cavity is termed ascites.
Samples of effusions for laboratory analysis are obtained by needle aspiration. Centesis is a
suffix denoting “puncture and aspiration of.”6 Thus, aspiration of pericardial fluid is called pericardiocentesis, aspiration of pleural fluid is called thoracentesis, aspiration of peritoneal fluid is
called paracentesis, and aspiration of synovial fluid is called arthrocentesis.
Serous fluids are normally clear and pale yellow, occurring in amounts of 50 mL or less in the
pericardial and peritoneal cavities and 20 mL or less in the pleural cavity. Cloudy (turbid) fluid
suggests an inflammatory process that may be caused by infection. Milky fluid is associated with
chylous effusions or chronic serous effusions (pseudochylous effusions). Bloody fluid may indicate a hemorrhagic process or a traumatic tap. Bloody pericardial fluid is associated with a
number of disorders, including hemorrhagic and bacterial pericarditis, postmyocardial infarction and postpericardiectomy syndromes, metastatic cancer, aneurysms, tuberculosis, systemic
lupus erythematosus (SLE), and rheumatoid arthritis. Bloody pleural effusions are most often
the result of malignancies involving the lung but may also be seen in pneumonia, pulmonary
infarction, chest trauma, pancreatitis, and postmyocardial infarction syndrome. Bloody pleural
transudates also have been noted in congestive heart failure (CHF) and cirrhosis of the liver.
Bloody peritoneal fluid is associated primarily with malignant processes and abdominal
trauma. Greenish peritoneal fluid is seen in perforated duodenal ulcers, intestines, and gallbladders, as well as with cholecystitis and acute pancreatitis.7
As with serous fluid, synovial fluid is normally clear and pale yellow, occurring in amounts
of approximately 3 mL or less per joint cavity. Synovial fluid is more viscous than serous fluid
because of the presence of the hyaluronate–protein complex secreted by the synovial cells.
Arthritis and other inflammatory conditions involving the joints may affect the production of
hyaluronate and lead to decreased viscosity of synovial fluid. The mucin clot test (Ropes test),
in which synovial fluid is added to a 2 to 5 percent acetic acid solution, can be used to assess the
viscosity of synovial fluid in relation to the type of clot formed (e.g., solid, soft, friable, or
none).8 This test, however, is not as accurate as specific synovial fluid cell counts and other
analyses.9
Cloudy synovial fluid suggests an inflammatory process. Substances such as crystals, fibrin,
amyloid, and cartilage fragments can also result in cloudy synovial fluid. Milky synovial fluid is
associated with various types of arthritis as well as with SLE. Purulent fluid may be seen in acute
septic arthritis, whereas greenish fluid may occur in Haemophilus influenzae septic arthritis,
chronic rheumatoid arthritis, and acute synovitis caused by gout. Bloody synovial fluid may be
the result of a traumatic tap but is most commonly associated with fractures or tumors involving the joint and traumatic or hemophilic arthritis.10
Tests of serous and synovial effusions include cell count and differential, measurement of
substances normally found in the fluid (e.g., glucose), culture and sensitivity (C&S) testing, and
cytologic examination. These tests are discussed subsequently in relation to the cavity from
which the fluid is obtained.

TESTS OF EFFUSIONS
PERICARDIAL FLUID ANALYSIS
Pericardial effusions are most commonly caused by
pericarditis, malignancy, or metabolic damage. As
noted previously, most pericardial effusions are

exudates. Tests commonly performed on pericardial
fluid include red cell count, white cell count and
differential, determination of glucose level, and
cytologic examination. Gram stains and cultures of
pericardial fluid are not routinely performed unless
bacterial endocarditis is suspected.11

CHAPTER 9—Analysis

of Effusions

285

Reference Values
Red blood cells

None normally present

White blood cells

1000/mm3

Glucose

80–100 mg/dL or essentially the same as the blood
glucose level drawn 2–4 hr earlier

Cytologic examination

No abnormal cells

Gram stain and culture

No organisms present

Critical values

Positive Gram stain or culture

Cytologic examination of pericardial fluid is
undertaken to detect malignant cells. Gram stain
and culture reveal the causative agent when infection
is suspected.
INTERFERING FACTORS

Blood in the sample because of traumatic pericardiocentesis
Undetected hypoglycemia or hyperglycemia
Contamination of the sample with skin cells and
pathogens
INDICATIONS FOR PERICARDIAL FLUID ANALYSIS

Pericardial effusion of unknown etiology
Suspected hemorrhagic pericarditis as indicated
by the presence of red cells and an elevated white
cell count
Suspected bacterial pericarditis as indicated by
the presence of red cells, elevated white cell
count with a predominance of neutrophils, and
decreased glucose
Suspected postmyocardial infarction syndrome
(Dressler’s syndrome) as indicated by the presence of red cells and elevated white cell count with
a predominance of neutrophils
Suspected tuberculous or fungal pericarditis as
indicated by the presence of red cells and an
elevated white cell count with a predominance of
lymphocytes
Suspected viral pericarditis as indicated by the
presence of red cells and an elevated white cell
count with neutrophils predominating
Suspected rheumatoid disease or SLE as indicated
by the presence of red cells, elevated white cell
count, and decreased glucose levels
Suspected malignancy as indicated by the presence of red cells, decreased glucose, and presence
of abnormal cells on cytologic examination
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That the procedure will be performed by a physician and will require approximately 20 minutes

Where the test will be performed (i.e., it is sometimes performed in the cardiac laboratory)
Any dietary restrictions (fasting for 6 to 8 hours
before the test may be required)
That an intravenous (IV) infusion will be started
before the procedure and discontinued afterward
That a sedative may be administered before the
procedure
That the skin will be injected with a local anesthetic at the chest needle insertion site and that
this may cause a stinging sensation
That, after the skin has been anesthetized, a needle
will be inserted through the chest wall below and
slightly to the left of the breast bone into the fluidfilled sac around the heart
That a sensation of pressure may be felt when the
needle is inserted to obtain the pericardial fluid
That heart rate and rhythm will be monitored
during the procedure
The importance of remaining still during the
procedure
Any activity restrictions after the test (usually a
few hours of bed rest)
Prepare for the procedure:
Withhold anticoagulant medications and aspirin
as ordered.
Have the client void.
Provide a hospital gown.
Take and record vital signs.
Administer premedication as ordered.
THE PROCEDURE (PERICARDIOCENTESIS)

The necessary equipment is assembled, including a
pericardiocentesis tray with solution for skin preparation, local anesthetic, 50-mL syringe, needles of
various sizes including a cardiac needle, sterile
drapes, and sterile gloves. Sterile test tubes (same as
those used for collecting blood samples) also are
needed; at least one red-topped, one green-topped,
and one lavender-topped tube should be available.
Containers for culture and cytologic analysis of pericardial fluid samples may also be needed. Cardiac
monitoring equipment should be obtained, along

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with an alligator clip for attaching a precordial (V)
lead to the cardiac needle.
The client is assisted to a supine position with the
head elevated 45 to 60 degrees. The limb leads for
the cardiac monitor are attached to the client, and
the IV infusion is started. The skin is cleansed with
an antiseptic solution and protected with sterile
drapes. The skin at the needle insertion site is then
infiltrated with local anesthetic. Strict aseptic technique is used during the entire procedure.
The precordial (V) cardiac lead wire is attached to
the hub of the cardiac needle with the alligator clip.
The needle is then inserted just below and slightly to
the left of the xiphoid process. Gentle traction is
sustained on the plunger of the 50-mL syringe until
fluid appears, indicating that the needle has entered
the pericardial sac. Fluid can be aspirated with ultrasound guidance. Fluid samples are then withdrawn
and placed in appropriate tubes. The samples are
labeled and sent promptly to the laboratory.
When the desired samples have been obtained,
the cardiac needle is withdrawn. Pressure is applied
to the site for 5 minutes. If there is no evidence of
bleeding or other drainage, a sterile bandage is
applied. If the client’s cardiac rhythm is stable,
cardiac monitoring is discontinued.
NURSING CARE DURING THE PROCEDURE

Observe the client for respiratory or cardiac distress.
Possible complications of a pericardiocentesis
include cardiac dysrhythmias (atrial or ventricular),
laceration of the pleura, laceration of the cardiac
atrium or coronary vessels, injection of air into a
cardiac chamber, and contamination of pleural
spaces with infected pericardial fluid.
Monitor the electrocardiograph for position of
the needle tip to note any puncture of the right
atrium.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client to a position of comfort and
reminding the client of any activity restrictions.
Resume any foods or fluids withheld before the
test and any medications withheld on the physician’s order.
Continue IV fluids until vital signs are stable and
the client is able to resume normal fluid intake.
Take and record vital signs as for a postoperative
client (i.e., every 15 minutes for the first hour,
every 30 minutes for the second hour, every hour
for the next 4 hours, and then every 4 hours for 24
hours). Assess for abnormalities in ECG patterns.
Assess the puncture site for bleeding, hematoma
formation, and inflammation each time vital signs

are taken and daily thereafter for several days.
Observe the client for any cardiac or respiratory
distress.
Provide support when diagnostic findings are
revealed.
Note relief of symptoms of cardiac tamponade or
pericarditis: absence of distended neck veins;
normal cardiac output, heart rate, and heart
sounds; absence of chest pain and pulsus paradoxus.
Administer antibiotics specific to the causative
agent and anti-inflammatory drugs to reduce the
inflammatory response.
Notify physician immediately if the Gram stain
and culture are positive.

PLEURAL FLUID ANALYSIS
Pleural effusions are most commonly caused by
CHF, hypoalbuminemia (e.g., resulting from cirrhosis of the liver), hypoproteinemia (e.g., resulting
from nephrotic syndrome), neoplasms, and
pulmonary infections (e.g., pneumonia, tuberculosis). Other causes include trauma and pulmonary
infarctions, both of which are associated with
hemorrhagic effusions, rheumatoid disease, SLE,
pancreatitis, and ruptured esophagus. Chylous pleural effusions occur when damage or obstruction to
the thoracic lymphatic duct has occurred. Pleural
effusions can be either transudates or exudates.
Tests commonly performed on pleural fluid
include red cell count, white cell count and differential, Gram stain, C&S, and cytologic examination.
The pH of the sample is usually determined, and the
fluid is tested for levels of glucose, protein, lactic
dehydrogenase (LDH), and amylase. Triglycerides
and cholesterol may also be measured when chylous
effusion is suspected.
Gram stain and C&S tests are generally performed
to identify the causative organism when infection is
suspected. Cytologic examination is undertaken to
detect malignant cells.
Pleural effusions may also be tested for levels of
immunoglobulins, complement components, and
carcinoembryonic antigen (CEA) (see Chapter 3)
when disorders of immunologic and malignant
origin are suspected. Elevated immunoglobulins and
CEA or decreased complement levels, or both, are
seen in inflammatory or neoplastic reactions involving the pleural membranes.12
INTERFERING FACTORS

Blood in the sample because of traumatic thoracentesis
Undetected hypoglycemia or hyperglycemia

CHAPTER 9—Analysis

of Effusions

287

Reference Values
Red blood cells

0–1000/mm3

White blood cells

0–1000/mm3, consisting mainly of lymphocytes

Gram stain and culture

No organisms present

Cytologic examination

No abnormal cells

7.37–7.43 (usually 7.40)

Glucose

Parallels serum levels

Protein

3.0 g/dL

Pleural fluid:serum protein ratio

0.5 or less

Lactic dehydrogenase

71–207 IU/L

Pleural fluid:serum LDH ratio

0.6 or less

Amylase

180 Somogyi U/dL or 200 dye U/dL

Triglycerides
Cholesterol
Immunoglobulins
Carcinoembryonic antigen (CEA)
Complement
Critical values

Parallel serum levels

Positive Gram stain or culture

Contamination of the sample with skin cells and
pathogens
INDICATIONS FOR PLEURAL FLUID ANALYSIS

Pleural effusion of unknown etiology
Differentiation of pleural transudates from
exudates (Table 9–1)
Suspected traumatic hemothorax as indicated by
bloody pleural fluid, elevated red cell count, and
hematocrit similar to that found in whole blood
Suspected pleural effusion caused by pulmonary
tuberculosis as indicated by presence of red blood
cells (fewer than 10,000 per cubic millimeter);
white cell count of 5,000 to 10,000 per cubic
millimeter, consisting mostly of lymphocytes;
presence of acid-fast bacilli (AFB) on smear and
culture; pH of less than 7.30, decreased glucose
(sometimes); and elevated protein, pleural
fluid:serum protein ratio, LDH, and pleural
fluid:serum LDH ratio
Suspected pleural effusion caused by pneumonia
(parapneumonic effusion) as indicated by presence of red blood cells (5,000 per cubic millimeter); white cell count of 5,000 to 25,000 per cubic
millimeter, consisting mainly of neutrophils and
sometimes including eosinophils; pH less than
7.40; and elevated protein, pleural fluid:serum

protein ratio, LDH, and pleural fluid:serum LDH
ratio. (If the pneumonia is of bacterial origin, the
organism may be demonstrated on culture and
the pleural fluid glucose level may be decreased.)
Suspected bacterial or tuberculous empyema as
indicated by red cell count of less than 5,000 per
cubic millimeter; white cell count of 25,000 to
100,000 per cubic millimeter, consisting mostly of
neutrophils; pH less than 7.30; decreased glucose;
and increased protein, LDH, and related ratios13
Suspected pleural effusion caused by carcinoma as
indicated by presence of red blood cells (1,000 to
more than 100,000 per cubic millimeter); white
cell count of 5,000 to 10,000 per cubic millimeter,
consisting mostly of lymphocytes and sometimes
including eosinophils; detection of malignant
cells on cytologic examination; pH less than
7.30; decreased glucose (sometimes); increased
protein, LDH, and related ratios; elevated CEA
and immunoglobulins; and decreased complement14
Suspected pleural effusion caused by pulmonary
infarction as indicated by red cell count of 1,000
to 100,000 per cubic millimeter; white cell count
of 5,000 to 15,000 per cubic millimeter, consisting
mainly of neutrophils and sometimes including
eosinophils; pH greater than 7.30; normal

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SECTION I—Laboratory

TABLE 9–1

•

Tests

Differentiation of Pleural Transudates From Exudates
Transudates

Exudates

Appearance

Clear

Cloudy; may be bloody

Red blood cells

1000/mm

1000/mm3 (usually)

White blood cells

1000/mm3

7.40 or higher

7.40

Glucose

Parallels serum level

May be less than serum level

Protein

3.0 g/dL

Pleural fluid:serum protein ratio

0.5

Lactic dehydrogenase

200 IU/L

Pleural fluid:serum LDH ratio

0.6

Common causes

Congestive heart failure

Pneumonia

Cirrhosis

Tuberculosis

Nephrotic syndrome

Empyema
Pulmonary infarction
Rheumatoid disease
Systemic lupus erythematosus
Carcinoma
Pancreatitis

glucose; and elevated protein, LDH, and related
ratios15
Suspected pleural effusion caused by rheumatoid
disease as indicated by a normal red cell count; a
white cell count of 1,000 to 20,000 per cubic
millimeter with either lymphocytes or neutrophils predominating; pH less than 7.30; decreased
glucose; elevated protein, LDH, and related ratios;
and elevated immunoglobulins16
Suspected pleural effusion caused by SLE as indicated by findings similar to those in rheumatoid
disease, except that glucose is not usually
decreased
Suspected pleural effusion caused by pancreatitis
as indicated by red cell count of 1,000 to 10,000
per cubic millimeter; white cell count of 5,000 to
20,000 per cubic millimeter, consisting mostly of
neutrophils; pH greater than 7.30; normal
glucose; elevated protein, LDH, and related ratios;
and elevated amylase
Suspected pleural effusion caused by esophageal
rupture as indicated primarily by a pH as low as
6.0 and elevated amylase17
Differentiation of chylous pleural effusions
caused by thoracic lymphatic duct blockage from
pseudochylous (chronic serous) effusions, with

chylous effusions indicated primarily by a triglyceride level two to three times that of serum;
decreased cholesterol; and markedly elevated
chylomicrons
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That the procedure will be performed by a physician and requires approximately 20 minutes
That there are no food or fluid restrictions before
the test
That a sedative is not usually given before the
procedure, although a cough suppressant may be
given to prevent coughing
The positioning used for the procedure
(supported sitting or side-lying)
That the skin will be injected with a local anesthetic at the chest needle insertion site and that
the injection may cause a stinging sensation
That, after the skin has been anesthetized, a needle
will be inserted through the posterior chest into
the space near the lungs where excessive fluid has
accumulated
That a sensation of pressure may be felt when the
needle is inserted
The importance of remaining still during the

CHAPTER 9—Analysis

procedure and the need to control breathing,
coughing, and movement
Any activity restrictions after the test (usually 1
hour of bed rest)
Prepare for the procedure:
Withhold anticoagulant medications and aspirin
as ordered.
Have the client void.
Provide a hospital gown.
Take and record vital signs.
Administer cough suppressant, if ordered.
THE PROCEDURE (THORACENTESIS)

The necessary equipment is assembled, including a
thoracentesis tray with solution for skin preparation,
local anesthetic, 50-mL syringe, needles of various
sizes including a thoracentesis needle, sterile drapes,
and sterile gloves. Sterile collection bottles and
containers for culture and cytologic examination
also are needed.
The client is assisted to the position that will be
used for the test. The usual position is sitting on the
side of a bed or treatment table, leaning slightly
forward to spread the intercostal spaces, with arms
supported on an overbed table with several pillows.
Alternatively, the client may sit on the bed or table
with legs extended on it and arms supported as
described earlier. If the client cannot assume either
sitting position, the side-lying position is used. In
such situations, the client lies on the unaffected side.
The skin is cleansed with an antiseptic solution
and protected with sterile drapes. The skin at the
needle insertion site is then infiltrated with local
anesthetic. The thoracentesis needle is inserted.
When fluid appears, a stopcock and 50-mL syringe
are attached to the needle and the fluid is aspirated.
The pleural fluid samples are placed in appropriate
containers, labeled, and sent promptly to the laboratory.
If the thoracentesis is being performed for therapeutic as well as diagnostic reasons, additional pleural fluid may be withdrawn. When the desired
amount of fluid has been removed, the needle is
withdrawn, and slight pressure is applied to the site
for a few minutes. If there is no evidence of bleeding
or other drainage, a sterile bandage is applied to the
site.
NURSING CARE DURING THE PROCEDURE

Observe the client for signs of respiratory distress or
pneumothorax (e.g., anxiety, restlessness, dyspnea,
cyanosis, tachycardia, and chest pain). Possible
complications of a thoracentesis include pneumothorax, mediastinal shift, and excessive reaccumulation of pleural fluid.

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289

NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client in lying on the unaffected side
and reminding the client that this position should be
maintained for approximately 1 hour.
Elevate the head for client comfort.
Prepare for a post-thoracentesis chest x-ray examination ordered to ensure that a pneumothorax as
a result of the tap has not occurred and to evaluate the amount of fluid removed.
Take and record vital signs as ordered (e.g., every
15 minutes for the first half hour, every 30
minutes for the next hour, and then every 4 hours
for 24 hours or until stable).
Observe the client for respiratory distress or
hemoptysis, diaphoresis, or skin color changes.
Auscultate breath sounds. Absent or diminished
breath sounds on the side used for the thoracentesis may indicate pneumothorax.
Assess the puncture site for bleeding, hematoma
formation, and inflammation each time vital signs
are taken and daily thereafter for several days.
Provide support when diagnostic findings are
revealed and information is given about subsequent therapy based on the findings.
Note relief of chest pain, dyspnea, or diminished
breath sounds.
Note response to antibiotic or cytotoxic drugs if
injected into the cavity after fluid removal.
Notify physician immediately if the Gram stain or
culture is positive.

PERITONEAL FLUID ANALYSIS
Peritoneal transudates are most commonly caused
by CHF, cirrhosis of the liver, and nephrotic
syndrome. Peritoneal exudates occur with
neoplasms including metastatic carcinoma, infections (e.g., tuberculosis, bacterial peritonitis),
trauma, pancreatitis, and bile peritonitis. Chylous
peritoneal effusions occur when there is damage or
obstruction to the thoracic lymphatic duct.
Accumulation of large amounts of fluid in the peritoneal cavity is termed ascites, and the peritoneal
fluid is referred to as ascitic fluid.
Peritoneal fluid is removed by paracentesis or by
paracentesis and lavage with normal saline or
Ringer’s lactate. Lavage involves instilling the desired
solution over 15 to 20 minutes, then removing it and
analyzing it for cells and other constituents.
Tests commonly performed on peritoneal or
ascitic fluid include red cell count, white cell count
and differential, Gram stain, C&S, AFB smear and
culture, and cytologic examination. The fluid may

290

SECTION I—Laboratory

Tests

also be tested for glucose, amylase, ammonia, alkaline phosphatase, and CEA. Urea and creatinine may
be measured if there is suspicion of ruptured or
punctured urinary bladder.
Gram stain and C&S tests are generally performed
to identify the causative organism when infection is
suspected. If tuberculous effusion is suspected, an
AFB smear and culture can be performed, although
positive results are seen in only 25 to 50 percent
of cases.18 Cytologic examination is used to detect
malignant cells.
INTERFERING FACTORS

Blood in the sample as a result of traumatic paracentesis
Undetected hypoglycemia or hyperglycemia
Contamination of the sample with skin cells and
pathogens
INDICATIONS FOR PERITONEAL FLUID ANALYSIS

Ascites of unknown cause
Suspected peritoneal effusion caused by abdominal malignancy as indicated by elevated red cell
count, decreased glucose, elevated CEA, and
detection of malignant cells on cytologic examination
Suspected abdominal trauma as indicated by
elevated red cell count of greater than 100,000 per
cubic millimeter19

Suspected ascites caused by cirrhosis of the liver as
indicated by elevated white cell count, neutrophil
count of greater than 25 percent but less than 50
percent, and an absolute granulocyte count of less
than 250 per cubic millimeter
Suspected bacterial peritonitis as indicated by
elevated white cell count, neutrophil count
greater than 50 percent, and an absolute granulocyte count of greater than 250 per cubic
millimeter20
Suspected tuberculous peritoneal effusion as indicated by elevated lymphocyte count, positive AFB
smear and culture in about 25 to 50 percent of
cases, and decreased glucose
Suspected peritoneal effusion caused by pancreatitis, pancreatic trauma, or pancreatic pseudocyst
as indicated by elevated amylase levels
Suspected peritoneal effusion caused by gastrointestinal perforation, strangulation, or necrosis as
indicated by elevated amylase, ammonia, and
alkaline phosphatase levels21
Suspected rupture or perforation of the urinary
bladder as indicated by elevated ammonia, creatinine, and urea levels
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That the test will be performed by a physician and
takes approximately 30 minutes

Reference Values
Red blood cells

100,000/mm3

White blood cells

300/mm3 (undiluted peritoneal fluid)
500/mm3 (lavage fluid)

Neutrophils

25%

Absolute granulocyte count

250/mm3

Gram stain and culture

No organisms present

AFB smear and culture

No AFB present

Cytologic examination
Glucose
Amylase
Ammonia
Alkaline phosphatase
Creatinine
Urea
Carcinoembryonic antigen
Critical values

No abnormal cells present

Parallel serum levels

Positive Gram stain or culture

CHAPTER 9—Analysis

That there are no food or fluid restrictions before
the test
The positioning used for the procedure (seated or
in high-Fowler’s position)
That the skin will be injected with a local anesthetic at the abdominal needle insertion site
and that this injection may cause a stinging sensation
That, after the skin has been anesthetized, a large
needle will be inserted through the abdominal
wall
That a “popping” sensation may be experienced as
the needle penetrates the peritoneum
The importance of remaining still during the
procedure
Any activity restrictions after the test (usually 1
hour or more of bed rest)
Prepare for the procedure:
Withhold anticoagulant medications and aspirin
as ordered.
Have the client void, or catheterize the client if he
or she is unable to void to ensure an empty bladder that is not as likely to be punctured by the
needle.
Provide a hospital gown and have the client put it
on with the opening in the front.
Take and record vital signs.
If the client has ascites, obtain weight and measure abdominal girth.
If the abdomen is hirsute, it may be necessary to
shave the area of the puncture site.
THE PROCEDURE (PARACENTESIS)

The necessary equipment is assembled, including a
paracentesis tray with solution for skin preparation,
local anesthetic, 50-mL syringe, needles of various
sizes including large-bore paracentesis needle or
trocar and cannula, sterile drapes, and sterile gloves.
Specimen collection tubes and bottles for the tests to
be performed also are needed.
The client is assisted to the position that will be
used for the test. The usual position is sitting on the
side of a bed or treatment table, with the feet and
back supported. An alternative approach is to place
the client in bed in a high-Fowler’s position.
The skin is cleansed with an antiseptic solution
and protected with sterile drapes. The skin at the
needle or trocar insertion site is then infiltrated with
local anesthetic. The paracentesis needle is inserted
approximately 1 to 2 inches below the umbilicus. If
a trocar with cannula is to be used, a small skin incision may be made to facilitate insertion. The 50-mL
syringe with stopcock is attached to the needle or
cannula after the trocar has been removed. Gentle
suction may be applied with the syringe to remove

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291

fluid. For peritoneal lavage, sterile normal saline or
Ringer’s lactate may be infused via the needle or
cannula over 15 to 20 minutes. The client is then
turned from side to side before the lavage fluid is
removed.
Samples of peritoneal or ascitic fluid are obtained,
placed in appropriate containers, labeled, and sent
promptly to the laboratory. If the paracentesis is
being performed for therapeutic as well as diagnostic reasons, additional fluid is removed. No more
than 1000 to 1500 mL of fluid should be removed at
any one time to avoid complications such as hypovolemia and shock resulting from abdominal pressure changes and massive fluid shifts into the space
that has been drained by paracentesis.
When the desired amount of fluid has been
removed, the needle or cannula is withdrawn and
slight pressure is applied to the site for a few
minutes. If there is no evidence of bleeding or other
drainage, a sterile dressing is applied to the site.
NURSING CARE DURING THE PROCEDURE

If feasible, check the client’s vital signs every 15
minutes during the procedure.
Observe the client for pallor, diaphoresis, vertigo,
hypotension, tachycardia, pain, or anxiety. Rapid
removal of fluid may precipitate hypovolemia and
shock.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client to a position of comfort and
reminding the client of any activity restrictions.
Redress the puncture site using sterile technique if
excessive drainage is present.
Take and record vital signs as for a postoperative
client (i.e., every 15 minutes for the first hour,
every 30 minutes for the next 2 hours, every hour
for the next 4 hours, and then every 4 hours for
24 hours). Take temperature every 4 hours for
24 hours. Monitor intake and output for at least
24 hours.
Assess the puncture site for bleeding, excessive
drainage, and signs of inflammation each time the
vital signs are taken and daily thereafter for several
days.
Continue to observe the client for pallor, vertigo,
hypotension, tachycardia, pain, or anxiety for at
least 24 hours after the procedure.
If a large amount of fluid was removed, measure
abdominal girth and weigh the client.
Provide support when diagnostic findings are
revealed and information is given about subsequent therapy (antibiotics) based on findings.
Have IV fluids and albumin on hand if hypoten-

292

SECTION I—Laboratory

Tests

sion results from the fluid shift from the vascular
space.
Note severe abdominal pain. Rigid abdominal
muscles indicate that peritonitis is developing
from the paracentesis.
Notify physician immediately of a positive Gram
stain or culture.

SYNOVIAL FLUID ANALYSIS
Synovial fluid is a clear, pale yellow, and viscous
liquid formed by plasma ultrafiltration and by secretion of a hyaluronate–protein complex by synovial
cells. It is secreted in small amounts (i.e., 3 mL or
less) into the cavities of most joints. Synovial effusions are associated with disorders or injuries involving the joints. Samples for analysis are obtained by
aspirating joint cavities. The most commonly aspirated joint is the knee, although samples can also be
obtained from the shoulder, hip, elbow, wrist, and
ankle if clinically indicated.
Synovial fluid analysis is used primarily to determine the type or cause of joint disorders. Joint disorders can be classified according to five categories
based on synovial fluid findings: (1) noninflammatory (e.g., degenerative joint disease), (2) inflammatory (e.g., rheumatoid arthritis, SLE), (3) septic (e.g.,
acute bacterial or tuberculous arthritis), (4) crystal
induced (e.g., gout or pseudogout), and (5) hemorrhagic (e.g., traumatic or hemophilic arthritis).22
Tests commonly performed on synovial fluid
include red cell count, white cell count and differential, white cell morphology, microscopic examination for crystals, Gram stain, and C&S. Determination of protein, glucose, and uric acid levels
also aids in diagnosis. Various immunologic tests
such as determination of complement, rheumatoid
factor, and antinuclear antibodies also have been
used in synovial fluid analysis. In the recent past, the
mucin clot test has been used in analyzing synovial
fluid, but this test is not considered as reliable as
specific cell counts and other measurements of
synovial fluid constituents. Lactate and pH measurements can be used as nonspecific indicators of
inflammation and to differentiate between infection
and inflammation.23
Table 9–2 lists the types of white blood cells and
inclusions seen in synovial fluid, along with the
disorders with which the presence of such cells is
associated.
Examination of synovial fluid for crystals is used
in diagnosing crystal-induced arthritis. The several
types of crystals that can be identified are listed in
Table 9–3. Monosodium urate (MSU) crystals are
associated with arthritis caused by gout, whereas

calcium pyrophosphate (CPP) crystals are seen in
pseudogout. Cholesterol crystals are associated with
chronic joint effusions, which may be caused by
tuberculous or rheumatoid arthritis. Arthritis associated with the presence of apatite crystals is
commonly recognized as a cause of synovitis.
Corticosteroid crystals may be seen for a month or
more after intra-articular injections of steroids and
may induce acute synovitis. Although usually of a
rhomboid shape, corticosteroid crystals are sometimes needle shaped and may be confused with MSU
or CPP crystals. Not shown in Table 9–3 are talcum
crystals. These crystals, which are shaped like
Maltese crosses, are most commonly seen after joint
surgery and reflect contamination of the joint with
talcum powder from surgical gloves.24
Gram stain and C&S tests are used to identify the
causative organisms when infection is suspected.
AFB smear and culture can be performed when
tuberculous arthritis is suspected, but results are
frequently negative. When the results of microbiologic tests of synovial fluid are inconclusive, synovial
biopsy may be necessary to establish the diagnosis.25
The need to perform immunologic tests of
synovial fluid is indicative of the association of the
immune system with inflammatory joint disorders.
Substances measured include rheumatoid factor
(RF), antinuclear antibodies (ANA), and complement, all of which can also be measured in serum
(see Chapter 3).
Determination of complement levels in synovial
fluid aids in differentiating arthritis of immunologic
origin from that with nonimmunologic causes.
Decreased synovial fluid complement levels are
seen in approximately 60 to 80 percent of individuals with rheumatoid arthritis and SLE. Decreased
complement levels are occasionally seen in rheumatic fever, gout, pseudogout, and bacterial arthritis; however, synovial complement levels may be
high in these disorders if serum levels also are
elevated. Complement levels in synovial fluid can be
measured as total complement (CH50) or as individual components (C1q, C4, C2, and C3). Because
synovial fluid complement levels parallel synovial
fluid protein levels, complement levels can be
expressed as ratios in relation to protein levels to
ensure that abnormal findings are not caused by
changes in synovial fluid membrane filtration.26,27
INTERFERING FACTORS

Blood in the sample caused by traumatic arthrocentesis
Undetected hypoglycemia or hyperglycemia or
failure to comply with dietary restrictions before
the test, or both

CHAPTER 9—Analysis

TABLE 9–2

•

of Effusions

293

White Blood Cells and Inclusions Seen in Synovial Fluid

Cell/Inclusion
Neutrophil

Description

Significance

Polymorphonuclear leukocyte

Bacterial sepsis
Crystal-induced inflammation

Lymphocyte

Mononuclear leukocyte

Nonseptic inflammation

Macrophage (monocyte)

Large mononuclear leukocyte; may be
vacuolated

Normal
Viral infections

Synovial lining cell

Similar to macrophage but may be multinucleated, resembling a mesothelial cell

Normal

LE cell

Neutrophil containing characteristic
ingested “round body”

Lupus erythematosus

Reiter cell

Vacuolated macrophage with ingested
neutrophils

Reiter’s syndrome
Nonspecific inflammation

RA cell (ragocyte)

Neutrophil with dark cytoplasmic granules
containing immune complexes

Rheumatoid arthritis
Immunologic inflammation

Cartilage cells

Large, multinucleated cells

Osteoarthritis

Rice bodies

Macroscopically resemble polished rice

Tuberculosis, septic and
rheumatoid arthritis

Microscopically show collagen and fibrin
Fat droplets

Refractile intracellular and extracellular
globules

Traumatic injury

Stain with Sudan dyes
Hemosiderin

Inclusions within synovial cells

Pigmented villonodular
synovitis

From Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, 2001, p 182, with permission.

TABLE 9–3

•

Synovial Fluid Crystals

Crystal

Shape

Monosodium urate

Needles

Calcium pyrophosphate

Rods
Needles
Rhombics

Cholesterol

Notched rhombic plates

Apatite

Small needles

Corticosteroid

Flat, variable-shaped plates

Adapted from Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis, 2001, p 183.

294

SECTION I—Laboratory

Tests

Reference Values
Red blood cells

2000/mm3

White blood cells

200/mm3

Neutrophils

25%

White cell morphology

No abnormal cells or inclusions (see Table 9–2)

Crystals

None present (see Table 9–3)

Gram stain and culture

No organisms present

Acid-fast bacillus smear and culture

No AFB present

Protein

3 g/dL

Glucose

Not 10 mg/dL of blood level or not 40 mg/dL

Uric acid

Parallels serum level

Lactate

0.6–2.0 mmol/L or 5–20 mg/dL

Antinuclear antibodies
Rheumatoid factor
Complement

Critical values

Contamination of the sample with pathogens
Improper handling of the specimen (Refrigeration of the sample may result in an increase in
MSU crystals because of decreased solubility of
uric acid. Exposure of the sample to room air with
a resultant loss of carbon dioxide and rise in pH
encourages the formation of calcium CPP crystals.)28
INDICATIONS FOR SYNOVIAL FLUID ANALYSIS

Joint effusion of unknown etiology
Suspected trauma, tumors involving the joint, or
hemophilic arthritis as indicated by an elevated
red cell count, elevated protein level, and possibly
fat droplets if trauma is involved (see Table 9–2)
Suspected joint effusion caused by noninflammatory disorders (e.g., osteoarthritis, degenerative
joint disease) as indicated by a white cell count of
less than 5000 per cubic millimeter with a normal
differential and the presence of cartilage cells (see
Table 9–2)
Suspected rheumatoid arthritis as indicated by a
white cell count of 2,000 to 100,000 per cubic
millimeter with an elevated neutrophil count (i.e.,
30 to 50 percent), presence of rheumatoid arthritis cells and possibly rice bodies (see Table 9–2),
cholesterol crystals if effusion is chronic, elevated
protein level, decreased glucose level, moderately
elevated lactate level (i.e., 2 to 7.5 mmol/L),

Parallel serum levels
Positive Gram stain or culture

decreased pH, presence of RF (60 percent of
cases), and decreased complement
Suspected SLE involving the joints as indicated by
a white cell count of 2,000 to 100,000 per cubic
millimeter with an elevated neutrophil count (i.e.,
30 to 40 percent), presence of LE cells (see Table
9–2), elevated protein level, decreased glucose
level (i.e., 2 to 7.5 mmol/L), decreased pH, presence of ANA (20 percent of cases), and decreased
complement
Suspected acute bacterial arthritis as indicated by
a white cell count of 10,000 to 200,000 per cubic
millimeter with a markedly elevated neutrophil
count (i.e., as high as 90 percent), positive Gram
stain (50 percent of cases), positive cultures (30 to
80 percent of cases), possible presence of rice
bodies (see Table 9–2), decreased glucose, lactate
level greater than 7.5 mmol/L, pH less than 7.3,
and complement levels paralleling those found in
serum (i.e., may be elevated or decreased)29
Suspected tuberculous arthritis as indicated by a
white cell count of 2,000 to 100,000 per cubic
millimeter with an elevated neutrophil count (i.e.,
30 to 60 percent), possible presence of rice bodies
(see Table 9–2), cholesterol crystals if effusion is
chronic, positive AFB smear and culture in some
cases (results are frequently negative), decreased
glucose, elevated lactate levels, and decreased pH
Suspected joint effusion caused by gout as indi-

CHAPTER 9—Analysis

cated by a white cell count of 500 to 200,000 per
cubic millimeter with an elevated neutrophil
count (i.e., approximately 70 percent), presence of
MSU crystals (see Table 9–3), decreased glucose,
elevated uric acid levels, and complement levels
paralleling those of serum (may be elevated or
decreased)30,31
Differentiation of gout from pseudogout as indicated primarily by finding CPP crystals (see Table
9–3), which are associated with pseudogout
(Other findings in pseudogout are similar to those
of gout except that the white cell count may not be
as high.)
NURSING CARE BEFORE THE PROCEDURE

Explain to the client:
That it will be performed by a physician and
requires approximately 20 minutes
Any dietary restrictions (fasting for 6 to 12 hours
before the test is recommended if the synovial
fluid is to be tested for glucose)
The positioning to be used (seated or supine for
knee, shoulder, elbow, wrist, or ankle aspiration;
supine for hip joint aspiration)
That the skin at the site will be injected with a
local anesthetic and that it may cause a stinging
sensation
That, after the skin has been anesthetized, a large
needle will be inserted into the joint capsule
That discomfort may be experienced as the joint
capsule is penetrated
The importance of remaining still during the
procedure
Any activity restrictions after the test (The client
usually is advised to avoid excessive use of the
joint for several days after the procedure to
prevent pain and swelling.)
That ice packs or analgesics or both may be
prescribed after the procedure to prevent swelling
and alleviate discomfort
Prepare for the procedure:
Withhold anticoagulant medications and aspirin
as ordered.
Ensure to the extent possible that any dietary
restrictions are followed.
Have the client void.
Provide a hospital gown if necessary to allow
access to the site without unduly exposing the
client.
Take and record vital signs.
If the client is extremely hirsute, it may be necessary to shave the area of the puncture site.
THE PROCEDURE (ARTHROCENTESIS)

The necessary equipment is assembled, including an

of Effusions

295

arthrocentesis tray with solution for skin preparation, local anesthetic, a 20-mL syringe, needles of
various sizes, sterile drapes, and sterile gloves.
Specimen collection tubes and containers for the
tests to be performed also are obtained. For cell
counts and differential, lavender-topped tubes
containing ethylenediaminetetra-acetic acid (EDTA)
are used. Green-topped tubes containing heparin are
used for certain immunologic and chemistry tests,
whereas samples for glucose are collected in either
plain red-topped tubes or gray-topped tubes
containing potassium oxalate. Plain sterile tubes
(e.g., red-topped tubes) are recommended for
microbiologic testing and crystal examination.32
The client is assisted to the position that will be
used for the test (sitting or supine). The skin is
cleansed with antiseptic solution, protected with
sterile drapes, and infiltrated with local anesthetic.
The aspirating needle is inserted into the joint space
and as much fluid as possible is withdrawn. The
specimen should contain at least 10 mL of synovial
fluid, but more may be removed to reduce swelling.
Manual pressure may be applied to facilitate fluid
removal.
If medication is to be injected into the joint, the
syringe containing the sample is detached from the
needle and replaced with the one containing the
drug. The medication is injected with gentle pressure. The needle is then withdrawn and digital pressure is applied to the site for a few minutes. If there
is no evidence of bleeding, a sterile dressing is
applied to the site. An elastic bandage may also be
applied to the joint.
The samples of synovial fluid are placed in the
appropriate containers, labeled, and sent to the laboratory immediately.
NURSING CARE AFTER THE PROCEDURE

Care and assessment after the procedure include
assisting the client to a position of comfort.
Apply an ice pack to the site and administer analgesics as needed.
Resume any foods, fluids, or medications withheld before the test on the physician’s order.
Remind the client of any activity restrictions and,
if indicated, site care requirements.
Apply an elastic bandage to the joint to provide
support and to minimize edema formation.
Take and record vital signs.
Assess comfort level and response to measures
such as ice packs and analgesics.
Assess the puncture site for bleeding, bruising,
inflammation, and excessive drainage of synovial
fluid approximately every 4 hours for 24 hours
and then daily thereafter for several days.

296

SECTION I—Laboratory

Tests

Provide support when diagnostic findings are
revealed and information is provided about
subsequent treatment based on findings (antiinflammatory drugs, immobilization of the joint,
analgesics).
Notify physician immediately of a positive Gram
stain or culture.
REFERENCES
1. Hole, JW: Human Anatomy and Physiology, ed 4. Wm C Brown,
Dubuque, Iowa, p 158.
2. Ibid, p 158.
3. Kjeldsberg, CR, and Krieg, AF: Cerebrospinal fluid and other body
fluids. In Henry, JB: Clinical Diagnosis and Management by
Laboratory Methods, ed 18. WB Saunders, Philadelphia, 1991, p
457.
4. Strasinger, SK: Urinalysis and Body Fluids, ed 4. FA Davis,
Philadelphia, 2001, p 191.
5. Kjeldsberg and Krieg, op cit, p 463.
6. Miller, BF, and Keane, CB: Encyclopedia and Dictionary of
Medicine, Nursing and Allied Health, ed 4. WB Saunders,
Philadelphia, 1987, p 226.
7. Kjeldsberg and Krieg, op cit, p 468.

8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.

Strasinger, op cit, p 173.
Kjeldsberg and Krieg, op cit, p 461.
Ibid, p 458.
Strasinger, op cit, p 182.
Ibid, p 182.
Ibid, p 180.
Ibid, p 182.
Kjeldsberg and Krieg, op cit, p 464.
Strasinger, op cit, p. 183.
Kjeldsberg and Krieg, op cit, p 465.
Ibid, p 469.
Ibid, p 468.
Strasinger, op cit, p 184.
Kjeldsberg and Krieg, op cit, p 469.
Strasinger, op cit, pp 172–173.
Kjeldsberg and Krieg, op cit, pp 461–462.
Ibid, pp 459–460.
Ibid, pp 462–463.
Ibid, p 462.
Strasinger, op cit, p 178.
Ibid, p 174.
Ibid, p 177.
Ibid, p 174.
Kjeldsberg and Krieg, op cit, p 462.
Strasinger, op cit, p 172.

CHAPTER

Amniotic Fluid Analysis
TESTS COVERED
Tests for Genetic and Neural Tube
Defects, 298

Tests for Hemolytic Disease of the
Newborn, 299
Tests for Fetal Maturity, 300

OVERVIEW OF AMNIOTIC FLUID FORMATION AND ANALYSIS

Amniotic fluid
is produced in the membranous sac that surrounds the developing fetus. This sac appears
during the second week of gestation and arises from a membrane called the amnion. Amniotic
fluid is derived from the exchange of water from maternal blood across fetal membranes, from
fetal cellular metabolism, and later in pregnancy from fetal urine. Amniotic fluid serves several
purposes. It prevents the amniotic membranes from adhering to the embryo and protects the
fetus from shocks and blows. It also aids in controlling the embryo’s body temperature and
permits the fetus to move freely, thus aiding in normal growth and development.1 Amniotic
fluid can be thought of as an extension of the extracellular fluid space of the fetus.2 Testing
samples of amniotic fluid for various constituents and substances can, therefore, be used to
assess fetal well-being and maturation. Specifically, amniotic fluid analysis is used to test for
various inherited disorders, anatomic abnormalities such as neural tube defects, hemolytic
disease of the newborn, and fetal maturity.
Amniotic fluid is normally clear and colorless in early pregnancy. Later in pregnancy, it may
appear slightly opalescent because of the presence of particles of vernix caseosa and may be pale
yellow because of fetal urine. The presence of meconium in amniotic fluid is normal in breech
presentations but abnormal in vertex presentations and indicates relaxation of the anal sphincter from hypoxia. Amniotic fluid stained the color of port wine generally indicates abruptio
placentae.
As the fetus begins to produce urine, it also swallows amniotic fluid in amounts that nearly
equal urinary output (i.e., 400 to 500 mL per day).3 Failure to swallow sufficient amounts of
amniotic fluid results in excessive accumulation of fluid in the amniotic sac (polyhydramnios).
This occurrence is commonly associated with anencephaly and esophageal atresia but can also
occur in the presence of maternal diabetes and hypertensive disorders of pregnancy. Excessive
amounts of amniotic fluid also are seen with fetal edema, which is associated with fetal heart
failure, hydrops fetalis, and multiple births. Excessive swallowing of amniotic fluid results in
decreased volume (oligohydramnios) and is associated with chronic illness of the fetus, placental insufficiency, fetal urinary tract malformations, and multiple births.4 By the 14th to 16th
weeks of pregnancy, the amniotic sac normally contains at least 50 mL of fluid; at term, the sac
contains 500 to 2500 mL of amniotic fluid, with an average volume of 1000 mL.
Samples of amniotic fluid are obtained by needle aspiration (Fig. 10–1). As noted in Chapter
9, centesis is a suffix denoting “puncture and aspiration of ”; thus, aspiration of fluid from the
amniotic sac is called amniocentesis. For suspected genetic and neural tube defects, amniocen297

298

SECTION I—Laboratory

Tests

tesis is generally performed early in the
second trimester of pregnancy (i.e., 14th to
16th weeks), when there is sufficient amniotic fluid for sampling yet enough time for
safe abortion, if desired. For hemolytic

Figure 10–1.

disease of the newborn, a series of amniocenteses may be performed beginning with the
26th week. Tests for fetal maturity usually are
not performed until at least the 35th week of
gestation.

Amniocentesis with needle placement to obtain an amniotic fluid sample.

TESTS OF AMNIOTIC FLUID
Tests of amniotic fluid are discussed hereafter in
relation to the three general purposes for which they
are performed: (1) to detect genetic and neural tube
defects, (2) to test for hemolytic disease of the
newborn, and (3) to assess fetal maturity.

TESTS FOR GENETIC AND NEURAL
TUBE DEFECTS
Tests for genetic and neural tube defects include
gender determination, chromosome analysis, and
measurement of -fetoprotein (AFP) and acetylcholinesterase levels. Determination of the gender
of the fetus is indicated when sex-linked inherited
disorders are suspected (e.g., hemophilia, Duchenne’s muscular dystrophy). In such disorders, the
abnormal gene is carried by women, although the
disorder itself is inherited only by male offspring.
Although no specific tests for these disorders are
currently available, knowing the gender of the fetus
may aid in deciding whether to continue the preg-

nancy. Some couples carrying these disorders, for
example, choose to abort all male fetuses, even
though some would have been normal.5
Determining the chromosomal makeup (karyotype) of the fetus may also assist in the prenatal
diagnosis of disorders such as Down syndrome
(trisomy 21) and Tay-Sachs disease. Karyotyping,
especially when augmented by staining techniques,
includes determination of the number of chromosomes as well as specific morphologic changes in the
chromosomes that may indicate various genetic
disorders. Karyotyping is performed by culturing
fetal cells and then photographing individual chromosomes during the metaphase of mitosis.6 Among
the disorders that can be detected are alterations in
carbohydrate, lipid, and amino acid metabolism.
Karyotyping can take from 2 to 4 weeks before
results are available to the client. Specimens for
chromosome analysis must be delivered promptly to
the laboratory performing the test. If immediate
culturing is not possible, the sample must be incubated at normal body temperature for no longer
than 2 days.7

CHAPTER 10—Amniotic

Neural tube and other anatomic defects in the
fetus can be determined by measuring levels of AFP
and acetylcholinesterase in amniotic fluid. In the
embryo, the central nervous system develops from
the neural tube, which begins to form at about 22
days of gestation. Failure of the neural tube to close
properly can result in disorders such as anencephaly,
spina bifida, and myelomeningocele. During gestation, the major fetal serum protein is AFP. Similar to
albumin, this protein is manufactured in large
quantities by the fetal liver until the 32nd week
of gestation, with peak production occurring at 13
weeks (see Chapter 3). With a severe neural tube
defect, higher than normal amounts of AFP escape
into the amniotic fluid as well as into the maternal
circulation. Routine prenatal screening includes
determination of the mother’s serum AFP level at 13
to 16 weeks of pregnancy. Causes of elevated maternal AFP levels are listed in Table 10–1. If maternal
levels are elevated on two samples obtained 1 week
apart, an ultrasound is performed to determine
gestational age and to check for twins or gross fetal
anomalies.
If the ultrasound is normal, amniotic fluid
samples are obtained and analyzed for AFP levels.8,9
If AFP levels are elevated in amniotic fluid, the presence of acetylcholinesterase in the fluid can be
determined to confirm the presence of a neural tube
defect. Using electrophoretic methods, the isoenzyme of acetylcholinesterase, which originates in
fetal spinal fluid, can also be demonstrated and is
more specific to the diagnosis of neural tube
defect.10
AFP and acetylcholinesterase may be falsely

Fluid Analysis

299

elevated if the sample is contaminated with fetal
blood. The level of the fetal spinal fluid isoenzyme of
acetylcholinesterase is not, however, so affected.

TESTS FOR HEMOLYTIC DISEASE OF
THE NEWBORN
One of the oldest uses of amniotic fluid analysis is in
evaluating suspected hemolytic disease of the
newborn, in which the mother builds antibodies
against fetal red blood cell antigens (isoimmunization). The result is hemolysis of fetal erythrocytes
with release of bilirubin into the amniotic fluid. The
most common causes are ABO and Rh incompatibilities (e.g., an Rh-negative mother carrying an Rhpositive fetus), although other red cell antibodies
may also be involved. Maternal IgG antibodies may
cross the placenta to react with fetal red blood cells
as early as the 16th week of pregnancy. As fetal red
blood cells are broken down, bilirubin is released
and can be detected in the amniotic fluid.11
Normally, the bilirubin level in amniotic fluid is
highest between the 16th and 30th weeks of gestation. Much of this bilirubin is in the unconjugated
form and can be excreted by the placenta. As the fetal
liver matures, it begins to conjugate the bilirubin;
this can occur as early as 28 weeks of gestation. The
conjugated bilirubin is not, however, cleared by the
placenta; instead, it is excreted by the fetal biliary
tract and absorbed by the intestine. After the 30th
week of gestation, the bilirubin level in amniotic
fluid normally decreases as pregnancy progresses.
This is partly because of dilution of any bilirubin
present by the normal increase in amniotic fluid

Image/Text rights unavailable

300

SECTION I—Laboratory

Tests

volume. At term, bilirubin is nearly absent from
amniotic fluid.12
In hemolytic disease of the newborn, fetal red cell
destruction leads to excessive bilirubin levels, which
overwhelm both placental and fetal liver mechanisms for its clearance. Bilirubin levels in amniotic
fluid continue to rise throughout the pregnancy and
consist primarily of unconjugated bilirubin.13 The
amount of bilirubin present in the amniotic fluid
indicates the degree of fetal red hemolysis and, indirectly, the degree of fetal anemia.
When hemolytic disease of the newborn is
suspected or if maternal IgG levels are elevated, or
both, serial amniocenteses for bilirubin determinations are performed beginning at approximately the
26th week of pregnancy. Bilirubin measurement in
amniotic fluid is performed by spectrophotometric
analysis, with the optical density (OD) of the fluid
measured at wavelength intervals between 365 and
550 mm. When excessive bilirubin is present, a rise
in OD at 450 mm, the wavelength of maximum
bilirubin absorption, is seen.14 The results of spectrophotometric analysis can be compared with the
Liley graph (Fig. 10–2) to predict fetal outcome or to
plan medical management of the problem.
Substances other than bilirubin may cause
abnormal spectrophotometric results. Maternal

hemoglobin from a traumatic amniocentesis,
methemalbumin, and meconium in amniotic fluid
may cause false elevations, as will fetal acidosis. Fetal
hemoglobin can be differentiated from maternal
hemoglobin by staining and cytologic techniques.
The presence of methemalbumin indicates marked
hemolysis and impending fetal demise.15 Falsely
decreased bilirubin levels can occur if the amniotic
fluid sample is exposed to light or if excessive amniotic fluid volume causes dilution. Other disorders
that can cause elevated amniotic fluid bilirubin
levels include anencephaly and intestinal obstruction.16

TESTS FOR FETAL MATURITY
Tests for fetal maturity are generally performed after
the 35th week of pregnancy, when preterm delivery
is being considered because of fetal or maternal
problems. The lungs are the last of the fetal organs to
mature; therefore, the most common complication
of early delivery is newborn respiratory distress
syndrome (RDS). Tests of amniotic fluid for fetal
maturity focus on determining fetal lung maturity
and include the lecithin:sphingomyelin (L:S) ratio,
as well as measures of other lung surface lipids such
as phosphatidylglycerol and phosphatidylinositol.

Image/Text rights unavailable

CHAPTER 10—Amniotic

If the lungs are found to be mature by these tests,
the other body organs also are assumed to be
mature.17,18 Tests of amniotic fluid, which can be
used to indicate maturity of other fetal organ
systems, include creatinine and bilirubin determinations, as well as examination of fetal cells for type
and lipid content.
During the last trimester of pregnancy, fetal lung
enzyme systems initiate the production of surfactant
by type II pneumocytes, which line the alveoli.
Surfactant, a phospholipid mixture, lowers the
surface tension in the alveoli and prevents them
from collapsing during exhalation. The phospholipid components of surfactant are (1) lecithin
(phosphatidylcholine), (2) sphingomyelin, (3) phosphatidyl glycerol (PG), (4) phosphatidylethanolamine (PE), (5) phosphatidylinositol (PI), and (6)
phosphatidylserine (PS). Surfactant appears in
amniotic fluid as a result of fetal respiratory movements that cause it to diffuse from fetal airways.19
L:S RATIO

Lecithin constitutes about 75 percent of surfactant
in mature lungs and is re