NCLEX: Mark Klimek - Lecture 8 (Prioritization Based on Lab Values)

In the ABCD scheme to prioritize patients, A is considered what priority?

Low priority... can be ignored for a few hours.

In the ABCD scheme to prioritize patients, B is considered what priority?

Concerning.... Needs to be closely monitored.

In the ABCD scheme to prioritize patients, C is considered what priority?

Critical... You need to do something for this lab.

In the ABCD scheme to prioritize patients, D is considered what priority?

HIGH priority... STAY at the bedside.

What is the normal range for Creatinine (Cr)?

0.6-1.2

What is/are the priority level(s) for creatinine?

Level A at normal level.

Level B if dye procedure (like a catheterization) is involved.

What is the normal range for INR?

2-3

What is/are the priority level(s) for INR?

Level C when 4 and above

What are the actions to take for a patient with high INR lab values?

- HOLD COUMADIN

- Focus assessment for bleeding

- Prepare to give Vit K

- Call HCP

What is the normal range for Potassium?

3.5-5.3

What is/are the priority level(s) for Potassium?

Level C if low

Level C if high

Level D if OVER 6

What are the actions to take for a patient with LOW potassium lab values?

- Assess heart (EKG)

- Prepare to give insulin/kayexalate

- Call HCP

What are the actions to take for a patient with HIGH potassium lab values?

- HOLD K+

- Assess heart (EKG)

- Prepare to give insulin/kayexalate (STAT if level is >6)

- Call HCP (STAY w/ patient if level is >6)

What is the normal range for pH?

7.35-7.45

What is/are the priority level(s) for pH?

Level D: 6s

What are the actions to take for a patient with a pH level in the 6s?

Assess v/s and call HCP

What is the normal range for Blood urea nitrogen (BUN)?

8-25

What is/are the priority level(s) for BUN?

Level A at normal range.

What are the actions to take for a patient with elevated BUN levels?

- Assess for dehydration

- Prepare IV fluids

- Call HCP

What is the normal range for Hemoglobin (Hgb)?

12-18

What is/are the priority level(s) for Hgb?

Level B if 8-11

Level C if <8

What are the actions to take for a patient with high Hgb?

IF LEVEL C:

- Assess for bleeding/anemia/malnutrition

- Prepare blood for administration

- Call HCP

What is the normal range for Bicarbonate (CO2)?

22-26

What is/are the priority level(s) for CO2?

Level A at normal range

Level C if in the 50s

Level D if in the 60s

What are the actions to take for a patient with high CO2?

For Level C:

- Assess for breathing

- Ask pt to perform purse-lipped breathing

- Call HCP

For Level D:

- Prepare to intubate/ventilate

- Call HCP; Do NOT leave patient!!

What is the normal range for Hematocrit (Hct)?

36-54

What is/are the priority level(s) for Hct?

Level B at normal range

What is the normal range for O2 or PaO2?

78-100

What is/are the priority level(s) for O2 or PaO2?

Level C if 70-77

Level D if in the 60s or lower (respiratory failure)

What are the actions to take for a patient with low O2 or PaO2?

Level C:

- Assess for respiratory difficulty and dyspnea

- Prepare to give O2

- Call HCP

Level D:

- Prepare to intubate/ventilate

- Call respiratory therapist

- Call HCP; Do NOT leave patient!!

What is the normal range for O2 Saturation?

93-100

What is/are the priority level(s) for O2 sats?

Level C if <93

What are the actions to take for a patient with low O2 sats?

Give O2

What can invalidate an O2 sat reading?

- Anemia

- Dye procedure (it colors blood)

- Both falsely elevates O2 sats

What is the normal range for Brain natriuretic peptide (BNP)?

<100

What is/are the priority level(s) for BNP?

Level B if >100; it's considered CHF.

What is the normal range for Sodium?

135-145

What is/are the priority level(s) for Na+?

Level B if abnormal

Level C if abnormal with change in LOC

What are the actions to take for a patient with abnormal sodium levels?

Level B: Assess patient for dehydration or fluid overload.

HypErnatremia = dEhydrated = Give fluids

HypOnatremia = Overload = prepare Furosemide

- Call HCP

- Patient becomes a safety issue at level C.

What is the normal range for white blood cells (WBC)?

4,000-11,000

What is/are the priority level(s) for WBC?

Level C at <4,000.

What is the normal range for Absolute neutrophil count (ANC)?

>500

What is/are the priority level(s) for ANC?

Level C at <500

What is the normal range for CD4?

>200

What is/are the priority level(s) for CD4?

Level C at <200

What levels do CD4 indicate and what are the priority actions?

>200 but <500 = HIV

<200 = AIDS

- Assess patient

- Put pt on neutropenic precautions

What is the normal range for Platelets (PLT)?

150,000-450,000

What is/are the priority level(s) for platelets?

Level C if <90,000

Level D if <40,000

What is the normal range for red blood cells (RBC)?

4mil-6mil

What is/are the priority level(s) for RBCs?

Level B if abnormal

What are the Five Deadly "Ds" referring to?

- K+ >6

- pH in the 6s

- CO2 in the 60s

- pO2 <60

- Platelets <40,000

What are the rules for neutropenic precautions?

• Strict hand washing

• Vital q4 hrs

• Dedicated stethoscope, BP cuff

• Reverse/protective isolation

• Shower BID with microbial soap

• Avoid crowds

• Private room

• Limit staff/visitors

• No fresh flowers/potted plants

• No raw fruits/veggies/undercooked meat

• No water pitcher standing for over 15 minutes

• Check WBC daily

• No indwelling catheters

• Do not reuse cups or disposable plates

When do you know to prepare to intubate/ventilate a patient?

When CO2 is in the 60s and O2 is <60.

What are the Level C priority lab values?

- INR when >4

- K+ if low (<3.5) or high (>5.4)

- Hgb if <8

- CO2 in the 50s

- O2 or PaO2 if 70-77

- O2 sats <93

- Na+ if abnormal with change in LOC

- WBC <4,000

- ANC <500

- CD4 <200

- Platelets <90,000