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NUTRITION AND LAB VALUES Contents Identifying Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Estimating Nutritional Need . . . . . . . . . . . . . . . . . . . . . 8 Vitamins and Minerals . . . . . . . . . . . . . . . . . . . . . . . . . 12 Nutritional Intervention and Medical Nutrition Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Reading Food Labels . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Wound Care-Related Lab Values . . . . . . . . . . . . . . . . . 19 1 One of the most troublesome yet fundamental risk factors for the development and non-healing of chronic wounds is malnutrition. Numerous studies cite a strong link between deteriorating nutritional status and the development and healing of chronic, non-healing wounds. Many of the elderly suffer from malnutrition. It is no wonder that they are also the group at highest risk for the development of pressure ulcers. Side effects of poor nutrition are: • • • • • DID YOU KNOW TIPS! Side effects of poor nutrition are: • Muscle and soft tissue wasting • Compromised immune system • Increased susceptibility to infection • Loss of strength • Increased level of toxicity to drugs Muscle and soft tissue wasting Compromised immune system Increased susceptibility to infection Loss of strength Increased level of toxicity to drugs A nutritional assessment by a qualified registered dietitian can help you identify whether a patient has nutritional risk factors for impaired wound healing. Wound nutrition is nothing more than whole body nutrition. Patients with severe malnutrition are at higher risk for infection, sepsis, longer length of stay and ultimately death. Severe protein and calorie malnutrition impairs tissue regeneration, immune function and the inflammatory response, which is necessary for wound healing. Identifying Risk When is a nutritional assessment indicated? There are many warning signals that will alert you to the potential risk of malnutrition. An obvious one is involuntary weight loss. Some not so apparent indicators may include impaired cognitive patterns; altered communication, hearing or vision; impaired mood or behavior; diminished physical and functional capabilities, nothing by mouth (NPO) or very low intake for 7 days or more, nausea, vomiting, and/or diarrhea for more than 3 days. A Braden Scale Pressure Sore Risk score below 18 can indicate a risk for the development of pressure ulcers. This is an assessment that is most likely already being performed and can serve as an early warning to initiate further nutritional investigation. 2 A nutritional assessment considers four basic categories: A. B. C. D. Anthropometric information Biochemical data Clinical facts Dietary history Anthropometric Information Anthropometry measures height, weight, and size of relevant body parts, including skinfolds, to examine and evaluate the proportions under normal and abnormal conditions. TIPS! An easy way to remember the nutritional assessment categories is: Anthropometric Information Biochemical Data Clinical Facts Dietary History To begin, it is necessary to obtain a "usual weight," which will alert you to changes in weight. Usual weight is obtained by reviewing patient records. Following is a simple calculation for ideal body weight (IBW): • • Men: A standard weight for a five foot tall male is 106 lb. Add six lb. for every inch above five feet. Women: A standard weight for a five foot tall female is 100 lb. Add five lb. for every inch above five feet. A range of ± 10 percent accounts for differences in frame size. For example, a female patient who is five feet three inches tall would have an ideal body weight of 103.5 lb. to 126.5 lb. (100 + 15 = 115 lb., - 10 percent = 103.5 lb., + 10 percent = 126.5 lb.). Significant weight loss is considered greater than 5 percent of a patient’s usual body weight in one month or greater than 7.5 percent in three months. The incidence of unintentional weight loss in nursing homes is greater than 25 percent. Several cross-sectional studies have demonstrated that patients with pressure ulcers weigh significantly less than patients without pressure ulcers. Body Mass Index (BMI) The most common method used to assess the amount of body fat in relation to lean body mass is the body mass index (BMI), a mathematical calculation based on height and weight. The BMI is easy to use and helps predict the likelihood of developing health problems related to excessive weight. 3 BMI is an individual’s weight in pounds multiplied by 703, and then divided twice by their height in inches. BMI tables and calculators are readily available on the Internet. A BMI of between 25 and 29.9 indicates that an individual is overweight, whereas an obese adult has a BMI of 30 or higher. BMI is calculated as follows: ( Weight in Pounds ) X 703 ((Height in Inches) X (Height in Inches)) The following are examples of BMI calculations: Man: 6’0” who weighs 175 pounds: 175 X 703 72 X 72 = 23.7 BMI Woman: 5’4” who weighs 165 pounds: 165 X 703 64 X 64 = 28.3 BMI BMI Weight Classification <18.5 18.6 to 24.9 25 to 29.9 >30 Underweight Normal Overweight Obese Biochemical Data Biochemical data includes laboratory tests like serum albumin, serum pre-albumin, serum transferrin, total lymphocyte count and nitrogen balance. See the end of the chapter for a full description of lab values. 4 Nitrogen balance is also useful for assessment of protein requirements, since protein is 16 percent nitrogen. Nitrogen balance is the difference between nitrogen intake and output. It helps determine needs for protein maintenance and anabolism. Accurate measurements of food and fluid intake over a 24-hour period and a 24-hour continuous urine sample are needed. Nitrogen balance results can be questionable in the presence of kidney disease. Clinical Facts A vitamin or mineral deficiency is determined by physical assessment and other information that you are probably already monitoring. These indications include increased metabolic needs such as fever, infection, trauma, burns, growth, pregnancy, heavily draining wounds and kidney dialysis; chronic diseases such as diabetes, hypertension, kidney or liver disease and cancer; gastrointestinal diseases such as malabsorption, diarrhea and GI surgery; and assessment of gums, skin, face, eyes, mucous membranes, tongue, lips, teeth and hair. An example of a clinical sign of deficiency is cheilosis, or scaly red lips with fissures at the angular corners of the mouth. This may indicate a vitamin B deficiency. DID YOU KNOW Indications of a vitamin or mineral deficiency: increased metabolic needs chronic diseases gastrointestinal diseases clinical signs of deficiency Dietary History Dietary history includes several questions about dietary habits and an assessment of the patient’s food intake. Ask these questions of your patient: • • • • • • • Have you had any recent changes in your appetite or food intake? Do you have any food allergies, intolerances or aversions? Do you have any chewing or swallowing problems, nausea or vomiting? Do you use any vitamin, mineral or herbal supplements? How much alcohol do you drink? Have you noticed a loss of taste or smell? Do you avoid any specific food groups or have any cultural or religious food limitations? It is imperative to collect information on what your patient eats as well as any problems that could diminish his or her nutritional status. 5 Food Diary Keeping a food diary will allow you to identify the foods your patient eats and recognize eating patterns that may need to be changed. Be sure to include the following items in your chart and ask your patient to be as accurate and honest as possible: • • • • • • • Food Quantity Time Where Alone or with company Activity during meal Physical activity Some tips for your patients to remember: • • • Record everything you eat. Don’t forget that handful of pretzels, condiments, sauces or the piece of chocolate. Everything adds up! Be truthful. You only hurt yourself if you are not including everything you’ve eaten. Estimate amounts to the best of your ability. EXAMPLE FOOD DIARY Meal Food Quantity Time Where Alone or w/company Activity/ Physical Activity Breakfast Snack Lunch Snack Dinner Snack 6 COMPLETED FOOD DIARY SAMPLE Meal Breakfast Snack Lunch Snack Dinner Snack 7 Food Quantity Time Where Alone or w/company 5:30 a.m. Home Alone Activity/ Physical activity Two miles on the treadmill Coffee w/half & half Eggs Croissant Butter Bagel Low-fat cream cheese 8 oz. 2 1 1 tsp. 7:15 a.m. Kitchen With kids Talking 1/2 1 tbsp. 9:30 a.m. Work Alone None Plain tomato soup Small ham and cheese sandwich Chocolate cake with chocolate frosting Diet soda w/o caffeine 1 cup 11:45 a.m. Work With coworker’s Lunch meeting – working on report Chocolate chip cookies Coffee w/half & half 2 2:45 p.m. Work Alone None Baked chicken breast White rice Green beans 4 oz. 6:15 p.m. Kitchen With kids Talking & cooking Popcorn with butter 2 cups 8:30 p.m. Family room Alone Watching TV 9:00 p.m. Family room Alone 50 sit-ups in front of TV 1 3 in. pc. 1 8 oz. 1 cup 1 cup Chapter 4 Nutrition and Lab Values Estimating Nutritional Need After a nutritional assessment, the next step is devising a plan that estimates the nutritional needs of the patient, including energy, protein, fluid, vitamins and minerals. Worth remembering ... Energy Similar to the gasoline we put in our vehicles, some fuel is of better quality than others. Our bodies are fueled by the energy or calories (kcals) of food. Similar to the gasoline we put in our vehicles, some fuel is of better quality than others. However, all food and calories are not created equal. The Harris-Benedict Equation for basal energy needs is used for calculating basal (resting) energy expenditures (BEE). The large difference between male and female BEE is due to differences in muscle mass and metabolic rates. The Harris-Benedict Equation for the BEE of a resting individual is calculated as follows: Women: BEE = 655 + (9.6 x body weight in kg) + (1.8 x height in cm) - (4.7 x age in years) Men: BEE = 66 + (13.6 x body weight in kg) + (5 x height in cm) - (6.8 x age in years) To determine daily energy needs beyond resting, we must account for physical activity, surgery, infection, or other injuries such as pressure ulcers. After calculating the BEE, the result is multiplied by both an activity factor and a stress factor in order to calculate the patient’s daily caloric requirements. Some reports have shown that the Harris-Benedict Equation, with its activity factors and stress factors, may overestimate needs. HarrisBenedict calculation factors are as follows: Activity factors: • • Ambulatory = 1.3 Bedridden = 1.2 8 Stress factors: • • • • The entire equation should look like this: BEE x activity factors x stress factors = The patient's total daily caloric requirements TIPS! Continuous monitoring is essential to evaluate whether a patient's needs are being met. Minor surgery = 1.2 Skeletal trauma = 1.35 Major sepsis = 1.6 Severe burns = 2.1 Continuous monitoring is essential to evaluate whether a patient's needs are being met. A quick and easy way to calculate energy needs uses the weight of the patient. In severely malnourished patients, feeding should be gradually increased to prevent problems with refeeding syndrome. Also, avoid overfeeding in metabolically stressed patients. Best practices often dictate utilizing an adjusted weight if the patient is obese. Calories • • Normal or non-stressed patient: 20 to 25 kcals/kg of body weight. To heal severe or extensive wounds: 30 to 35 kcals/kg of body weight for slightly hypermetabolic (greatly increased metabolism), or 35 to 40 kcals/kg of body weight for a severely stressed patient. Carbohydrates Carbohydrates (CHOs) are broken down by the body for energy. Our body breaks the CHOs down into a simple sugar that is absorbed into the bloodstream and used for energy needs. There are simple sugars, such as table sugar or fruit sugars (fructose) and there are complex carbohydrates or starches, such as grain products like rice and breads. Simple CHOs are processed in the bloodstream faster and result in a hungry feeling after consumption. Complex CHOs are processed more slowly, usually leaving one with a satisfied feeling. 9 Fats There are several types of dietary fats; in general they are referred to as either saturated or unsaturated. Saturated fats usually refer to the fat derived from animal products such as beef, organ meats, milk and cheeses and plant sources such as coconut and palm oils. Saturated fats are responsible for high cholesterol levels, especially the LDL or low density lipoprotein (the “bad” cholesterol) and play a major role in coronary heart disease. Other fats, the unsaturated fats – both polyunsaturated and monounsaturated are found primarily in plant sources. DID YOU KNOW Protein It is important to know that the benefits of arginine are only observed when supplementing a balanced diet. Amino acids and protein are the building blocks of collagen. In order for wounds to heal the body must be in a positive nitrogen balance, or anabolism, the building phase. Protein deficiency can suppress the development of new blood vessels (angiogenesis), decreasing wound healing. Protein needs are calculated by using the following formulas: • • • Normal healthy adult: 0.8 grams of protein/kg/day Moderate stress (partial-thickness wound): 1.2 to 1.5 grams of protein/kg/day Severe stress (full-thickness wound, severe or multiple wounds): 1.5 to 2.0 grams of protein/kg/day Be alert for dehydration when supplementing protein greater than 1.5 grams/kg/day. Fluid needs increase with high supplementation. 10 Arginine Arginine is a single-chain amino acid that appears to benefit wound healing even if a deficient state is not present. Nitrogen retention and immune function appear enhanced in many studies where arginine was used; however, outcome studies are needed to confirm a clinical benefit. Additionally, it is important to know that the benefits of arginine are only observed when supplementing a balanced diet. Fluids Our bodies are composed of 70 to 80 percent water. As you know, we can live for days without food but not without water. Unfortunately, most of our patients are chronically dehydrated. Look for creative ways to increase daily fluid intake such as frozen popsicles during warm summer days and hot soup in the cooler months. Fluid needs can be calculated in the following ways: • • • General recommendation: 1 ml/kcal ingested Young healthy adult: 35 to 40 ml/kg of weight daily Elderly: 30 ml/kg of weight daily Be sure to monitor intake and output, especially when the patient has a history of heart disease or kidney failure. Adequate hydration is necessary to replace losses in patients with draining wounds, patients with fever, or those on high air-loss beds (air-fluidized support surfaces). Also, beware of beverages containing caffeine and alcohol. They act as diuretics and actually cause the patient to lose fluids. 11 Vitamins and Minerals Many registered dietitians include multivitamin or mineral supplements such as vitamin C and zinc as part of their preventive protocol for patients at high risk for ulcers or with existing ulcers. Supplementation beyond the RDA is not advised unless the patient has a known deficiency. Megadoses should not be administered without the recommendation of a physician or registered dietitian. Vitamin and mineral assays are useful to confirm suspected deficiencies. Unless the individual has a known deficit, supplementation has not been shown to be of any benefit. If the patient has a vitamin C deficit, up to 1 to 2 g/day of vitamin C may be recommended to promote wound healing. Since vitamin C is water soluble, dietary or supplemental forms must be ingested daily. If a zinc deficit exists, which is especially true of patients who are vegetarians or who have high-output fistulas or exudating wounds, supplementation with 15 to 30 mg/day is suggested. Zinc has not been shown to accelerate wound healing in patients with normal zinc levels. In fact, too much zinc may interfere with copper metabolism. When supplementing this mineral, have the patient take it with meals to avoid nausea, vomiting and diarrhea. 12 Various vitamin and mineral supplements and their role in wound healing: 13 Vitamin/ Mineral Food Sources Why it is Important Vitamin A Deep orange and yellow fruits and vegetables, leafy greens, tuna Vitamin A promotes a healthy immune system, is essential for the growth and development of cells, and keeps the skin healthy. Vitamin B1 (thiamin) Pork, sunflower seeds, whole grains The B vitamins help the body convert carbohydrates into energy and are necessary for the heart, muscles and nervous system to function properly. Vitamin B2 (riboflavin) Liver, duck, mackerel, dairy foods Riboflavin is essential for turning carbohydrates into energy and producing red blood cells. It is also important for vision. Vitamin B3 (niacin) Poultry, fish, veal Niacin helps the body turn food into energy. It aids in digestion and is important for nerve function. Vitamin B6 (pyridoxine) Potatoes, bananas, chickpeas, prune juice, poultry, fish, liver Vitamin B6 is important for brain and nerve function. It also helps the body break down proteins and make red blood cells. Vitamin B12 (cobalamin) Fish, shellfish, liver Vitamin B12 helps to build DNA, create red blood cells and is important for nerve cell function. Vitamin/ Mineral Food Sources Why it is Important Vitamin C Citrus fruits, melon, strawberries, tomatoes, dark leafy greens Vitamin C is essential for healthy bones, teeth, gums and blood vessels. It aids in wound healing, collagen synthesis, fibroblast formation, tensile strength and contributes to brain function. Vitamin D Fish, fortified milk, dairy Vitamin D strengthens bones by helping the body absorb bone-building calcium. A healthy dose of the sun also provides vitamin D to the body. Vitamin E Nuts, blackberries, apples, mangos Vitamin E is an antioxidant that helps protect cells from damage and is important for the health of red blood cells. Vitamin K Leafy green vegetables, tomatoes, egg yolks Vitamin K promotes blood clotting and prevents hemorrhaging. Folate Leafy greens, asparagus, liver, wheat germ Folate helps the body make red blood cells, break down proteins and helps keep the heart healthy. Calcium Yogurt, milk, cheese Calcium is vital for building strong bones and teeth, especially during childhood. 14 15 Vitamin/ Mineral Food Sources Why it is Important Chromium Whole grains, liver, meats, cheese, some fruits, broccoli, grape juice, potatoes, garlic, basil Chromium enhances the action of insulin and plays a role in controlling Type 2 diabetes. Copper Shellfish, liver, dried fruits, nuts, whole grains, lentils, green vegetables Copper helps regulate blood pressure and heart rate, and is needed for the body to absorb iron. It also aids in erythrocyte and elastin (a protein similar to collagen) formation. Iron Shellfish, meats, liver, pumpkin seeds Iron helps red blood cells carry oxygen to all parts of the body. Magnesium Nuts, fish, legumes, whole grains, leafy greens, fish Magnesium helps muscles and nerves to function, steadies the heart rhythm and helps keep bones strong. It also aids in wound healing. Manganese Whole grains, vegetables, nuts, fruits Manganese plays a role in cholesterol and carbohydrate metabolism, thyroid function, blood sugar control, anticancer activity, and the formation of bone, cartilage and skin. Potassium Fruits, bananas, orange juice, vegetables, fish, milk Potassium helps with muscle and nervous system function. It also helps the body to maintain water balance in the blood and body tissues. Selenium Shellfish, liver, nuts, whole grains, meat, dairy Selenium helps regulate thyroid function and play a role in the immune system. Zinc Shellfish, meats, liver Zinc is important for normal growth, strong immunity, wound healing, collagen synthesis, cell proliferation, immune function and epithelialization Nutritional Intervention and Medical Nutrition Therapy TIPS! Ask your patients for their input into their supplementation plan. You might be surprised! Nutritional intervention and medical diet therapy is required when the patient is deficient in calories, protein, fluids or nutrients. They include oral feeding and supplements, enteral or tube feeding, parenteral or total parenteral nutrition (TPN) feeding, and adjunctive therapy such as anabolic agents. These are directives prescribed by a physician in collaboration with a registered dietitian. Oral Feeding The easiest and most pleasant way to supplement a patient is with oral feeding. It also happens to be the least expensive and most convenient way. Much of our social life revolves around eating. A patient who is unable to consume food will suffer more than gastrointestinal problems and possible malnutrition. Find foods that the patient enjoys. Make sure they are calorie, vitamin and protein rich. Offer small frequent meals or snacks. These tend to be much less intimidating than large meals. Consider adding powdered milk to yogurt and pudding. There are many palatable choices on the market, not just supplemental shakes. Patients will not eat foods that they do not like. Ask your patients for their input into their supplementation plan. You might be surprised! One example of caring for long-term care patients involved an elderly man whose weight continued to drop despite efforts to supplement feedings and encourage his appetite. One evening, he was quizzed on what he really enjoyed eating and why his appetite had waned. He said he missed his evening treat of M&M’s® candy. With that information, he received a small bag of M&M’s each evening if he additionally drank a 16 oz. glass of milk with it and tried to eat at least 50 percent of each of his meals. In the months ahead his appetite, weight and outlook improved! The name of the game is customization when it comes to diet therapy and nutrition. 16 Enteral Nutrition If enteral feeding is needed, it can be accomplished with a small-bore feeding tube passed into the nares. Placement should always be checked by x-ray before initiating feeding. Mobile patients may prefer bolus feedings, or set amounts at specific times of the day, instead of continual feedings that often require a pump. Many formulas of tube feeding are available for different needs. For example, certain formulas are higher in protein, fiber or lower in carbohydrates. A registered dietitian can customize the choice of formula to the patient's needs. Complications of tube feeding include diarrhea, hyperglycemia (high blood sugar) and constipation. Total Parenteral Nutrition If the gastrointestinal tract is failing, nonfunctioning, or needs a rest, this is often a last resort for nutritional therapy. Total Parenteral Nutrition (TPN) is delivered by means of a central venous catheter (CVC) and dramatically increases the chances of infection. It is extremely expensive. An intravenous pump delivers the fluids; the components must be monitored continually and the tubing must be changed daily. This form of nutrition supplies everything that the body needs. The formula is calculated and customized especially for the patient by the registered dietician. Adjunctive Therapy Anabolic agents such as the human growth hormone (HGH), although not labeled for this use, are used when a patient has lost 10 percent or more of his or her usual body weight. Its use is contraindicated in patients with diabetes. HGH must be administered parenterally and can cause edema and a 10 percent rise in basal metabolic rate. Testosterone and synthetic derivatives are also used as adjunctive agents. One that is currently being prescribed is oxandrolone (Anavar®). Other drugs being utilized off-label to promote appetite include: miratazapine (Remeron SolTab®), an antidepressant; megestrol acetate (Megace®), which has shown promise in patients with cancer and AIDS; and dronabinol (Marinol®), a drug that has had particular success in patients with Alzheimer’s Disease. 17 Medical records should reflect the nutritional care and treatment provided and should include the following information: • • • • • • • • • Is the patient consuming the food and/or supplements? How much fluid is taken daily? Does the patient need assistance to eat? If the patient refuses a diet, have meal or supplement alternatives been made? How frequently does the dietician visit and discuss the plan of care (POC)? How often is the patient weighed? Are labs requested? Does the care plan reflect the nutritional care and how often is it updated? Does the patient understand the risks and benefits of intervention? Reading Food Labels Reading and understanding food labels can be helpful when planning meals, choosing snacks or purchasing food gifts. The nutrition facts box on a food product provides valuable information, but can also be confusing. The exact amount of calories, carbohydrate (CHO) and grams of fat per serving are found on the label. Let’s take a look at a sample food label: Serving size and servings per container. This will give the amount of the food product that is equal to one serving. The number followed by the “%” sign represents the percent that this food product provides based on the recommended daily amounts (RDA). Notice that this particular food product provides about 1/3 (29%) of the total sodium level recommended. A diabetic diet requirement may vary. 1 3 Nutrition Facts Serving Size 1 Package (170g) Servings per Container 1 2 Amount per Serving Calories 280 Calories from Fat 70 % Daily Value* Total Fat 8 g Saturated Fat 3.5g Trans Fat 0g Polyunsaturated Fat 1.5 g Monounsaturated Fat .5g Cholesterol 25 mg Sodium 690mg Potassium 120 mg Total Carbohydrate 32 g Dietary Fiber 5 g Sugars 3 g Protein 21g Vitamin A 15% Calcium 25% • • 12% 17% 8% 29% 3% 11% 21% Vitamin C 4% Iron 15% * Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs: Calories 2,000 2,500 Total Fat Less than 65g 80g Sat Fat Less than 20g 25g Cholesterol Less than 300mg 300mg Sodium Less than 2,400mg 2,400mg Potassium Less than 3,500mg 3,500mg Total Carbohydrate 300g 375 g Dietary Fiber 25g 30g 4 The second section represents the nutritional value of the food product. In the example, notice there are 32 grams of carbohydrates — a typical “diabetic lunch” is approximately 30 grams. The lower section provides information on the vitamin and minerals present in the food product. All food labels provide the recommended daily values based on a 2000 calorie diet. 18 Worth remembering ... We are what we eat! Remember, it is always important to treat the patient holistically. We must look at the "whole" patient, not just the "hole" in the patient. If we are not metabolizing (staying constant with regard to nutrition and energy) or anabolizing (building or growing), we are catabolizing (breaking down). In order to prevent or treat existing wounds, it is necessary to offer adequate calories, fluids, proteins and nutrients while monitoring nutritional risk and assessing nutritional needs. It is recommended to involve a registered dietician in your team assessment and treatment of patients at risk of developing pressure ulcers or those with existing pressure ulcers. Other elements such as mobility, activity, sensory perception, pressure, shear, friction and moisture reduction are all important parts of the equation. Pressure ulcer prevention and treatment should be considered along the continuum of care, which includes nutrition. Wound Care-Related Lab Values Wounds tell us what they need. They show signs of inflammation, evidence of filling and contracting and epithelialization, and they also indicate when they are not changing. Complete evaluation needs to include not only physical assessment, but lab values to ascertain specifically what is missing or is in abundance and affecting the ability of the wound to close. Several lab values that can lead us in the right direction include: • • • Assessment of red and white blood cells. Are there enough to carry nutrients, oxygen and other cellular components to promote wound closure? Are there deficiencies that may cause the wound to stop the healing process? A complete blood count (CBC) is ordered as part of a general assessment. The CBC is a simple blood collection that counts the number of red and white blood cells in a cubic millimeter (mm3) from a blood sample. The hemoglobin and hematocrit are also determined. If the white blood cell (WBC) differential is ordered, results for neutrophils, lymphocytes, monocytes, eosinophils and basophils will be included. Other tests that are commonly ordered include glucose, iron, certain electrolytes and platelets, and protein levels. 19 Red Blood Cells (RBC) Normal Values • • Males: 4.7 to 6.1 M/µL Females: 4.5 to 5.4 M/µL This is an integral part of the evaluation of anemic patients. The test is performed by counting the number of RBCs in a 1 mm3 sample of peripheral venous blood. Every RBC contains molecules of hemoglobin that permit the transport and exchange of oxygen and carbon dioxide to the tissues. Toward the end of the RBC’s life, the cell membrane becomes less pliable, the aged RBC is lysed (dissolved), and extracted from circulation by the spleen. This impacts the cascade of healing by reducing the body’s normal cellular response to close the wound. For example; low blood volume cannot bring the necessary nutrients, oxygen and cells that will activate the process for the wound to close. Below normal range Above normal range • • • • • • Anemia Cancers: lymphoma, multiple myeloma, leukemia, Hodgkin’s lymphoma Cirrhosis Dietary deficiency: iron, vitamin B12 Fluid overload Hemorrhage Normal pregnancy Renal disease Rheumatoid/collagenvascular diseases Red Blood Cells • • • • • • • • Congenital heart disease Erythrocytosis Hemoglobinopathies Severe chronic obstructive pulmonary disease (COPD) Severe dehydration (e.g. severe diarrhea or burns) White Blood Cells (WBC) Normal Value • 5.0 to 10.0 K/mm3 WBC is the total white cell count. It is helpful in the evaluation of the patient with infection, neoplasm, allergy or immunosuppression. 20 There are two components: • • The number of WBCs (leukocytes) in 1 mm3 of peripheral venous blood. The differential count, which measures the percentage of each type of leukocyte present in the specimen. The major functions of WBC’s include fighting infection and reacting against foreign bodies or tissues. In regard to wound healing, if the body makes poor or malformed cells, then the wound healing slows or halts and is often left in a state of chronic inflammation. Five types of WBCs are: • • • • • White Blood Cells Lymphocytes Monocytes Neutrophils Basophils Eosinophils Below normal range Above normal range • • • • • • • Autoimmune disease Bone marrow failure or infiltration Dietary deficiency (e.g. vitamin B12, iron) Drug toxicity Hypersplenism • • • • Infection Cancers: leukemia and non-marrow cancers Dehydration Inflammation Trauma, stress or hemorrhage Tissue necrosis Mean Corpuscular Volume (MCV) Normal Value • 80 to 95 µ³ The mean corpuscular volume is the average volume of the red blood cells in the body. MCV is used to classify various forms of anemia. MCV is derived by dividing the hematocrit by the total RBCs. Medications that may increase MCV results include zidovudine (AZT or Retrovir®), phenytoin (Dilantin®) and azathioprine (Imuran®). Wound healing can be delayed as the volume of RBCs is decreased. 21 Mean Corpuscular Volume Below normal range Above normal range • • • • • • • • Anemia or chronic illnesses Iron deficiency anemia Thalassemia Antimetabolite therapy Alcoholism Chronic liver disease Folic acid deficiency Pernicious anemia Mean Corpuscular Hemoglobin (MCH) Normal Value • 27 to 31 picograms (pg) The MCH is a measure of the average weight of hemoglobin in an RBC. MCH is derived by dividing the total hemoglobin concentration by the number of RBCs. Because macrocytic (a mature erythrocyte) cells generally have more hemoglobin and microcytic (smaller than normal) cells have less hemoglobin, the causes for these values closely resemble those for MCV. If this value is low, wound healing can be affected by not having sufficient oxygen and nutrient-containing cells within the system. Mean Corpuscular Hemoglobin Below normal range Above normal range • • • Microcytic anemia Hypochromic anemia Macrocytic anemia Mean Corpuscular Hemoglobin Concentration (MCHC) Normal Value • 32 to 36 percent The MCHC is a measure of the average concentration or percentage of hemoglobin in a single RBC. MCHC is derived by dividing the total hemoglobin concentration by the hematocrit. When values are decreased, the cell has a deficiency of hemoglobin and is said to be hypochromic. When values are normal, the anemia is said to be normocytic (e.g., hemolytic anemia). RBCs cannot be considered hyperchromic. Only 37 g/dL of hemoglobin can fit into an RBC. An alteration in the 22 shape of an RBC may cause automated counting machines to indicate MCHC levels above normal. Mean Corpuscular Hemoglobin Concentration Below normal range Above normal range • • • • • Iron deficiency anemia Thalassemia Intravascular hemolysis Cold agglutinins Spherocytosis Neutrophils Normal Value • 55 to 70 percent Neutrophils are the white blood cells essential for phagocytosis, or the removal of bacteria and debris, especially in wounds. They are essential for the process of autolytic debridement, where the body is “cleaning” the wound itself. The differential count measures the percentage of each leukocyte present in the specimen. An increase in the percent of one type of leukocyte means a decrease in another. When neutrophil production is significantly stimulated, early immature forms of neutrophils enter the circulation. These immature forms are called band cells. This occurrence, referred to as a “shift to the left” in WBC production, is indicative of an acute bacterial infection. A value of 8 percent or higher signals this left shift. Below normal range (Neutropenia) Above normal range (Neutrophilia) Neutrophils • • • • • • 23 Addison’s disease Aplastic anemia Chemotherapy (myelotoxic agents) Dietary deficiency Infection: bacterial or viral Radiation therapy • • • • • • • • Acute suppurative infection Cushing’s syndrome Eclampsia Gout Inflammatory disorders Metabolic disorders Myelocytic leukemia Stress (physical or emotional) Lymphocytes Normal Value • 20 to 40 percent Lymphocytes develop in the bone marrow and comprise roughly one quarter of the white cells in the human body. They increase in numbers to respond to infection. Further divided into both “T” and “B” cells, their main function is to react to and protect against infection. Below normal range (Lymphocytopenia) Lymphocytes • Drug therapy: adreno-corticosteroids, antineoplastics Immunodeficiency diseases Leukemia (nonlymphocytic) Sepsis (acute) Radiation therapy (current) • • • • Above normal range (Lymphocytosis) • Infection (chronic bacterial and viral) Infectious hepatitis Lymphocytic leukemia Multiple myeloma Post-radiation therapy • • • • Monocytes Normal Value • 2 to 8 percent Another type of white blood cell, monocytes typically have an oval or kidney-shaped nucleus. Monocytes Below normal range (Monocytopenia) Above normal range (Monocytosis) • • Drug therapy: prednisone • • • • Chronic inflammatory disorders Viral infections Tuberculosis Chronic ulcerative colitis Parasites (e.g. malaria) 24 Eosinophils Normal Value • 1 to 4 percent Slightly larger in diameter than the monocyte, this leukocyte makes up a small fraction of the total white cell count. Eosinophils Below normal range (Eosinopenia) Above normal range (Eosinophilia) • • • Increased adrenosteroid production Medication therapy steroids • • • Allergies or allergic reactions Autoimmune diseases Parasitic infections Leukemia Basophils Normal Value • 0.5 to 1 percent Basophils are the smallest in number of all white blood cells. Basophils Below normal range (Basopenia) Above normal range (Basophilia) • • • • Acute allergic reactions Hyperthyroidism Stress reactions • • Myeloproliferative disease (e.g., myelofibrosis, polycythemia rubravera) Leukemia Inflammatory phase of wound healing Hemoglobin (Hb or Hgb) Normal Values • • Males: 14 to 18 g/dL Females: 12 to 16 g/dL Hemoglobin is the protein compound vehicle for oxygen and carbon dioxide transport. Each red blood cell contains approximately 200 to 300 molecules of hemoglobin. Testing Hb can be used as a rapid indirect measurement of the RBC count. It is an integral part of the evaluation of anemic 25 patients. The oxygen-carrying capacity of the blood is determined by the Hb concentration. If the Hb is low, there is strain on the cardiopulmonary system to maintain its oxygen-carrying capacity. Hemoglobin Below normal range Above normal range • • • • • • • • • • • • • • • • Anemia Bone marrow failure Cirrhosis Dietary deficiency Hematologic cancers Hemoglobinopathy Hemorrhage Lymphoma Normal pregnancy Prosthetic valves Renal disease Rheumatoid/collagen vascular diseases (e.g., rheumatoid arthritis, lupus, sarcoidosis) • Congenital heart disease Erythrocytosis Polycythemia vera Severe dehydration (e.g., severe diarrhea, burns) Severe COPD Hematocrit (Hct) Normal Values • • Males: 42 to 52 percent Females: 37 to 47 percent Hematocrit is an indirect measurement of RBC number and volume. It is used as a rapid measurement of RBC count. It is repeated serially in patients with ongoing bleeding or as a routine part of the complete blood count. It is an integral part of the evaluation of anemic patients. Hematocrit is a measure of the percent of the total blood volume that is made up by the RBCs. 26 Below normal range Above normal range • • • • • • • • • • • • • • Hematocrit Anemia Hemoglobinopathy Cirrhosis Hemorrhage Dietary deficiency Bone marrow failure Prosthetic valves Renal disease Normal pregnancy Rheumatoid/collagen vascular diseases (e.g., rheumatoid arthritis, lupus, sarcoidosis) Lymphoma Hematologic cancers • • • Erythrocytosis Congenital heart disease Polycythemia vera Sever dehydration (e.g., severe diarrhea, burns) Severe chronic obstructive pulmonary disease Glucose, fasting Normal Value • 70 to 115 mg/dL This is the glucose level in the blood. It is commonly used to evaluate patients with diabetes. Through an elaborate feedback mechanism, glucose levels are controlled by insulin and glucagon. While fasting, glucagon, which is made in the alpha cells of the pancreatic islet of Langerhans, is secreted. Glucagon breaks down glycogen to glucose in the liver and blood glucose levels rise. If fasting persists, protein and fatty acids are broken down under glucagon stimulation and glucose levels continue to rise. Stress (e.g., trauma, general anesthesia, infection or burns) and caffeine can cause increased glucose levels. Patients receiving IV fluids with dextrose may have increased glucose levels. Pregnant women may experience glucose intolerance, called gestational diabetes. Drugs that may increase glucose levels include antidepressants (tricyclics), beta-adrenergic blocking agents, corticosteroids, diuretics, epinephrine, estrogens, glucagons, isoniazid, lithium and salicylates. Elevated glucose levels can effect wound healing by damaging cells such as fibroblasts and keratinocytes that are necessary for the formation of granulation tissue and to fill any deficit of the wound. 27 Below normal range Glucose, fasting • • • • • • Addison’s disease Hypothyroidism Hypopituitarism Insulinoma Insulin overdose Starvation Above normal range • • • • • • • • Acute stress response Acromegaly diabetes mellitus Chronic renal failure Corticosteroid therapy Cushing’s syndrome Diuretic therapy Glucagonoma Acute pancreatitis Hemoglobin A1c or A1C (Previously known as HbA1c) Normal Value • 6 to 8 percent This test provides a long-term index of the patient’s average blood glucose level and is used to monitor diabetes. It measures the amount of A1c in the hemoglobin of the blood. Hemoglobin A1c is the component that most strongly combines with glucose. Approximately 70 percent of HbA1c is glycosylated. The bond is not easily reversible. Only 20 percent of A1a and A1b are glycosylated hemoglobin. HbA1c is fast becoming the most common component measured. Hemoglobinopathies can affect results, because the quantity of hemoglobin A (and, as a result, HbA1) varies considerably in these diseases. Falsely elevated values occur when the RBC life span is extended. Hemoglobin A1c or A1C Below normal range Above normal range • • • • Chronic blood loss Chronic renal failure Hemolytic anemia • • • Diabetes (newly diagnosed or poorly controlled) Hyperglycemia (not with diabetes) Splenectomized patients Pregnancy (especially in gestational diabetes or pre-diabetes) 28 Ferritin Normal Value • 15 to 200 ng/ml Ferritin, the major iron-storage protein, is present in serum in concentrations directly related to iron storage. Generally, 1 ng/ml of serum ferritin corresponds to approximately 8 mg of stored iron. This is the most sensitive test to determine iron deficiency anemia and is a good indicator of available iron stores. Menstruating women may have decreased ferritin levels as a result of monthly menses. Recent administration of a radionuclide, transfusion, high iron diet or iron-containing medications can affect this level. This key nutrient in the maintenance of healthy red cells can be an indicator of the oxygen-carrying capacity of the cells, and thus wound healing. Ferritin Below normal range Above normal range • • • • Hemodialysis Iron deficiency anemia Severe protein deficiency • • • • • • Anemia: hemolytic and megaloblastic Advanced cancers Alcoholic/inflammatory hepatocellular disease Chronic illnesses such as leukemia, cirrhosis, chronic hepatitis or collagen vascular diseases Hemochromatosis Hemosiderosis Inflammatory disease Electrolytes Normal Values • • • • • • Calcium: 8.8 to 10.5 mg/dL Chloride: 90 to 110 mEq/L Magnesium: 1.6 to 2.8 mEq/L Phosphorus: 2.5 to 4.5 mg/dL Potassium: 3.5 to 5.2 mEq/L Sodium: 136 to 147 mEq/L In general, electrolytes are compounds that can dissociate into ions and are able to conduct electric current. Each electrolyte serves specific functions. Calcium and potassium are necessary for various muscle activity and sodium is essential for fluid balance within the body. These values are measured to help identify or evaluate functions that may be 29 Electrolytes, continued affected by increased or decreased amounts of electrolytes. Below normal range Above normal range • • • • • • • • • • • • • • • • • Electrolytes Alkalosis Burns, Hypoparathyroidism Congestive heart failure (CHF) Diabetic acidosis Diarrhea, high-output fistula Hypokalemia Malabsorption Malnutrition Metabolic alkalosis Osteomalacia Over-hydration Pancreatitis Renal failure Respiratory acidosis Ricketts Salt-losing nephritis Vomiting, gastric suction • • • • • • • • • • • • • • • Acromegaly, hyperthyroidism Addison’s Disease Dehydration Excessive intake of saline Hyperkalemia Hyperparathyroidism Prolonged immobilization Lymphoma Metabolic acidosis Metastatic bone tumor Milk-alkali syndrome Renal insufficiency Respiratory alkalosis Rhabdomyolysis Vitamin D intoxication Coagulation Platelets Normal Value • 140,000 to 450,000/mm3 Platelets are formed in the bone marrow, stored in the spleen and are the smallest cells in the blood. Platelets are necessary for hemostasis and blood clotting. The count is the number of platelets per mm3 of blood. 30 Coagulation Platelets Below normal range Above normal range • • • • • • • • • • • • • • • Chemotherapy DIC Graves disease Hemorrhage Hemolytic anemia Hypersplenism Infections (bacterial) Leukemia Pernicious anemia Systemic lupus erythematosus Thrombocytopenia • Iron deficiency anemia Malignant disorders Polycythemia vera Postsplenectomy syndrome Rheumatoid arthritis Total Protein Normal Value • 6 to 9 gm/dL Protein is a complex organic compound that is made of amino acids. Protein is the source of building material for many body components including muscle, skin, hair, internal organs and blood. There are more than 20 proteins identified as being important to life, and nine of those are not made within the body or essential. The essential proteins must be obtained through food or nutritional supplementation. This test is used indirectly to assess the body’s ability to grow and heal. It measures the protein in circulating blood and is helpful in diseases where there can be protein wasting. Low values can result in poor wound healing, mental depression and slow recovery from disease and infection. Total Protein Below normal range Above normal range • • • • • • • • • 31 Ascites Burns Increased capillary permeability Inflammatory diseases Liver disease Malnutrition Protein-losing processes Over-hydration Dehydration Albumin Normal Value • 3.2 to 4.5 g/dL Serum albumin is the major circulating plasma protein produced by the liver. It is a common indicator of the patient’s protein stores. Its half life (how long it will take before you see decreases in lab data) is about three weeks; therefore, the blood you draw from your patient today will indicate their protein stores from three weeks ago. Mild depletion is considered 3.5 gm/dL. An abnormally low level of serum albumin in the blood (hypoalbuminemia) is below 3.0 gm/dL. It is associated with tissue edema, which further increases the risk of pressure ulcers. Serum albumin levels are often used as an indicator of overall nutrition. Low serum albumin increases the risk of infection, morbidity and mortality. It impairs or prevents wound healing and decreases wound tensile (tearing) strength. Prealbumin Normal Value • 15 to 36 mg/dL Serum prealbumin is a more sensitive indicator of visceral (contained in the body's organs) protein status in acute stages of malnutrition. Its half life is only two to three days and can be helpful to evaluate the adequacy of nutritional therapy. Mild depletion is less than 15 mg/dL. Severe depletion is less than 5 mg/dL. If the patient has chronic kidney failure, prealbumin may be falsely elevated since it is eliminated in the kidneys. Albumin/ Prealbumin Below normal range Above normal range • • • • • • • • Malnutrition Liver damage Burns Inflammation Nephrotic syndrome Hodgkin’s lymphoma Chronic kidney disease Pregnancy 32 Transferrin Saturation Normal Value • 30 to 40 percent Serum transferrin has a half life of a little more than a week and is also an indicator of protein stores. A level below 200 mg/dL is considered low. This blood test may not be useful in the presence of liver disease or estrogen use, since transferrin levels (a globulin in blood plasma that carries iron) will be abnormally high. Additionally, liver disease, burns, cortisone or testosterone therapy, and chronic infection can lower serum transferrin levels. Transferrin Saturation Below normal range Above normal range • • • • • • Anemia (hemolytic, pernicious, sickle cell iron deficiency Cirrhosis Hypoproteinemia Inflammatory diseases Malnutrition • • • • • • Anemia, (iron deficiency and hemolytic) - false elevation Anemia, (iron deficiency and hemolytic) - false elevation Hemochromatosis Hemosiderosis Increase iron intake Polycythemia vera Pregnancy (late) Total Lymphocyte Count Normal Value • less than 2000 cells/mm3 Total lymphocyte count (TLC) reflects the immunosuppression and immunity of the patient. TLC is more useful as a screening parameter in non-critical individuals. Studies have shown that the lower the count, the higher the patient risk for morbidity and mortality. Total Lymphocyte Count 33 Below normal range Above normal range • • • • • • • • Immunosuppression Malnutrition Lymphoma Lupus Surgery Alcohol intake Autoimmune disorders Smoking References: Bergstrom N, Bennett MA, Carlson CE, et al. 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