CBC (Complete Blood Count)

A complete blood count (CBC), also known as full blood count (FBC) or full

blood exam (FBE) or blood panel, is a test panel requested by a doctor or

other medical professional that gives information about the cells in a patient's

blood. A scientist or lab technician performs the requested testing and provides

the requesting medical professional with the results of the CBC.

It measures the following:

 The number of red blood cells (RBCs)

 The number of white blood cells (WBCs)

 The total amount of hemoglobin in the blood

 The fraction of the blood composed of red blood cells (hematocrit)

 The mean corpuscular volume (MCV) — the size of the red blood cell

Normal Values:

TEST NORMAL VALUES

X1000 cells/mm³
Leukocyte (White Blood Cell)
(µL)
Birth 9.0-30.0
24 hours 9.4-34.0
1 month 5.0-19.5
1-3 years 6.0-17.5
4-7 years 5.5-15.5
8-13 years 4.5-13.5
Adult 4.5-11.0
3-5% (total WBC
Neutrophils Bands
count)
Segs 54-62%
Lymphocytes 25-33%
Monocytes 3-7%
Eosinophils 1-3%
Basophils 0-0.75%

Erythrocytes (Red Blood Cells)

Cord 3.9-5.5 million/mm³
1-3 days 4.0-6.6 million/mm³
1 week 3.9-6.3 million/mm³
2 weeks 3.6-6.2 million/mm³
1 month 3.0-5.4 million/mm³
2 months 2.7-4.9 million/mm³
3-6 months 3.1-4.5 million/mm³
0.5-2 years 3.7-5.3 million/mm³
2-6 years 3.9-5.3 million/mm³
6-12 years 4.0-5.2 million/mm³
12-18 years (male) 4.5-5.3 million/mm³
12-18 years (female) 4.1-5.1 million/mm³

Hemoglobin
1-3 days 14.5-22.5 g/dL
2 months 9.0-14.0 g/dL
6-12 years 11.5-15.5 g/dL
12-18 years (male) 13.0-16.0 g/dL
12-18 (female) 12.0-16.0g/dL

Hematocrit
1 day 48-69%
2 days 48-75%
3 days 44-72%
2 months 28-42%
6-12 years 35-45%
12-18 years (male) 37-49%
12-18 years (female) 36-46%

Mean Corpuscular Volume (MCV)

1-3 days 95-121µm³
0.5-2 years 70-86 µm³
6-12 years 77-95 µm³
12-18 years (male) 78-98 µm³
12-18 years (female) 78-102 µm³

Mean Corpuscular Hemoglobin (MCH)

Birth 31-37 pg/cell
1-3 days 31-37 pg/cell
1 week-1 month 28-40 pg/cell
2 months 26-34 pg/cell
3-6 months 25-35 pg/cell
0.5-2 years 23-31 pg/cell
2-6 years 24-30 pg/cell
6-12 years 25-33 pg/cell
12-18 years 25-35 pg/cell

Mean Corpuscular Hemoglobin

Concentration (MCHC)
Birth 30-36 g Hg/dL RBC
1-3 days 29-37 g Hg/dL RBC
1-2 weeks 28-38 g Hg/dL RBC
1-2 months 29-37 g Hg/dL RBC
3 months-2 years 30-36 g Hg/dL RBC
2-18 years 31-37 g Hg/dL RBC

Reticulocyte Count
Infants 2-5% of RBCs
Children 0.5-4% of RBCs
12-18 years (male) 0.5-1% of RBCs
12-18 years (female) 0.5-2.5% of RBCs

Platelet Count
Birth-1 week 84,000-478,000/mm³
Thereafter 150,000-400,000/mm³

ERYTHROCYTE SEDIMENTATION
RATE (ESR)

TEST NORMAL VALUE

Westergren
Child 0-10 mm/hour
Adult (male) 0-15 mm/hour
Adult (female) 0-20 mm/hour

Wintrobe
Child 0-13 mm/hour
Adult (male) 0-9 mm/hour
Adult (female) 0-20 mm/hour
What Abnormal Results Mean:

High numbers of RBCs may indicate:

 Low oxygen tension in the blood

o Congenital heart disease

o Cor pulmonale

o Pulmonary fibrosis

 Polycythemia vera

 Dehydration (such as from severe diarrhea)

 Renal (kidney) disease with high erythropoietin production

Low numbers of RBCs may indicate:

 Blood loss

o Anemia (various types)

o Hemorrhage

 Bone marrow failure (for example, from radiation, toxin, fibrosis, tumor)

 Erythropoietin deficiency (secondary to renal disease)

  Hemolysis (RBC destruction)

 Leukemia

 Multiple myeloma

 Malnutrition (nutritional deficiencies of iron, folate, vitamin B12, or

vitamin B6)

Low numbers of WBCs (leukopenia) may indicate:

 Bone marrow failure (for example, due to infection, tumor or fibrosis)

 Presence of cytotoxic substance

 Autoimmune/collagen-vascular diseases (such as lupus erythematosus)

 Disease of the liver or spleen

 Radiation exposure

High numbers of WBCs (leukocytosis) may indicate:

 Infectious diseases

 Inflammatory disease (such as rheumatoid arthritis or allergy)

 Leukemia
  Severe emotional or physical stress

 Tissue damage (SUCH AS burns)

Low hematocrit may indicate:

 Anemia (various types)

 Blood loss (hemorrhage)

 Bone marrow failure (for example, due to radiation, toxin, fibrosis,

tumor)

 Hemolysis (RBC destruction) related to transfusion reaction

 Leukemia

 Malnutrition or specific nutritional deficiency

 Multiple myeloma

 Rheumatoid arthritis

High hematocrit may indicate:

 Dehydration

o Burns
 o Diarrhea

 Polycythemia vera

 Low oxygen tension (smoking, congenital heart disease, living at high

altitudes)

Low hemoglobin values may indicate:

 Anemia (various types)

 Blood loss

INDICATIONS:

1. Eosinophils

2. Neutrophil

3. Basophil

4. Red blood cell

5. Lymphocyte

6. Monocyte

7. Platelet

Purposes:
The CBC provides valuable information about the blood and to some extent the

bone marrow, which is the blood-forming tissue. The CBC is used for the

following purposes:

 as a preoperative test to ensure both adequate oxygen carrying capacity

and hemostasis

 to identify persons who may have an infection

 to diagnose anemia

 to identify acute and chronic illness, bleeding tendencies, and white blood

cell disorders such as leukemia

 to monitor treatment for anemia and other blood diseases

 to determine the effects of chemotherapy and radiation therapy on blood

cell production

Preparation:

There is no special preparation needed

How the Test is Performed:

  Blood is drawn from a vein, usually from the inside of the elbow or the

back of the hand.

 The puncture site is cleaned with antiseptic. An elastic band is placed

around the upper arm to apply pressure and cause the vein to swell with

blood.

 A needle is inserted into the vein, and the blood is collected in an air-tight

vial or a syringe.

 During the procedure, the band is removed to restore circulation.

 Once the blood has been collected, the needle is removed, and the

puncture site is covered to stop any bleeding.

 In infants or young children, the area is cleansed with antiseptic and

punctured with a sharp needle or a lancet. The blood may be collected in

a pipette (small glass tube), on a slide, onto a test strip, or into a small

container. A bandage may be applied to the puncture site if there is any

bleeding.

PROCEDURE:

Samples
  blood is drawn in a test tube containing an anticoagulant (EDTA,

sometimes citrate) to stop it from clotting, and transported to a laboratory.

Automated blood count

 The blood is well mixed (though not shaken) and placed on a rack in the

analyzer.

 This instrument has many different components to analyze different

elements in the blood. The cell counting component counts the numbers

and types of different cells within the blood. The results are printed out or

sent to a computer for review.

 Blood counting machines aspirate a very small amount of the specimen

through narrow tubing.

 The two main sensors used are light detectors, and electrical impedance.

One way the instrument can tell what type of blood cell is present is by

size. Other instruments measure different characteristics of the cells to

categorize them.

Manual blood count

  Counting chambers that hold a specified volume of diluted blood (as there

are far too many cells if it is not diluted) are used to calculate the number

of red and white cells per litre of blood.

 To identify the numbers of different white cells, a blood film is made, and

a large number of white cells (at least 100) are counted. This gives the

percentage of cells that are of each type. By multiplying the percentage

with the total number of white blood cells, the absolute number of each

type of white cell can be obtained.

 The advantage of manual counting is that automated analysers are not

reliable at counting abnormal cells. That is, cells that are not present in

normal patients and are only seen in the peripheral blood with certain

haematological conditions.

RECENT GADGET:
Complete blood count performed by an automated analyser. Differentials

missing.

COMPLICATION:

 Risk for other than potential bruising at the puncture site, and/or

dizziness, there are no complications associated with this test.

 RBC (Red Blood Cells)

Red blood cells (also referred to as erythrocytes) are the most common type

of blood cell and the vertebrate organism's principal means of delivering

oxygen (O2) to the body tissues via the blood flow through the circulatory

system. They take up oxygen in the lungs or gills and release it while squeezing

through the body's capillaries.

These cells' cytoplasm is rich in hemoglobin, an iron-containing biomolecule

that can bind oxygen and is responsible for the blood's red color.

Normal levels:

The ranges for a normal RBC count (expressed in million red cells per

microliter {uL} of blood) are:

 Women: 4.2 to 5.4 million/uL

 Men: 4.7 to 6.1 million/uL

 Children: 4.6 to 4.8 million/uL

INDICATIONS:
  Levels of RBCs out of the normal range (higher or lower) can be an

indication of certain conditions.

 Polycythemia is the presence of an elevated RBC count;

 anemia is a decreased RBC count.

Polycythemia may be caused by several conditions including:

 congenital heart disease

 cor pulmonale

 dehydration (such as from severe diarrhea)

 obstructive lung disease

 pulmonary fibrosis

 excess RBC production (polycythemia vera).

Anemia may occur as a result of:

 bleeding (including internal)

 hemolysis

 kidney disease

 leukemia

 multiple myeloma

 bone marrow failure

  erythropoietin deficiency

 or deficiencies in iron, folate, vitamin B12, or vitamin B6.

PURPOSE:

 Red blood cell indices help classify types of anemia, a decrease in the

oxygen carrying capacity of the blood. Healthy people have an adequate

number of correctly sized red blood cells containing enough hemoglobin

to carry sufficient oxygen to all the body's tissues. Anemia is diagnosed

when either the hemoglobin or hematocrit of a blood sample is too low.

CONTRAINDICATIONS:

 previous malaria or hepatitis.

 history of drug abuse

 donors who have received human pituitary hormone.

 donors with high risk sexual behaviour

 donors who have previously been transfused (depending on geographic

location)

PREPARATION:
  RBC indices require 3–5 mL of blood collected by vein puncture with a

needle. A nurse or phlebotomist usually collects the sample.

After care:

 Discomfort or bruising may occur at the puncture site. Pressure to the

puncture site until the bleeding stops reduces bruising

 Warm packs relieve discomfort.

 Some people feel dizzy or faint after blood has been drawn and should be

allowed to lie down and relax until they are stable.

PROCEDURE:

 A blood sample will be taken, normally from the arm. If several tests are

ordered, more than one vial of blood will be taken.

 If your RBC count has been low in the past, taking blood might seem

counterproductive, but the CBC count can be a very useful tool to your

physician in diagnosing and treating many health conditions.

COMPLICATION:

 Febrile nonhemolytic and chill-rigor reactions.(most common)

  The most serious complications are acute hemolytic reaction due to ABO

incompatible transfusion and transfusion-related acute lung injury

 potential bruising at the puncture site, and/or dizziness

CellTrans Post-operative Autologous Blood Transfusion System

Hgb/Hct Determination

 Hematocrit and hemoglobin measurements are blood tests. They are part

of a complete blood count, or CBC. Hematocrit measures the amount of

red blood cells that are in blood.

 Hemoglobin is a protein-iron compound in the blood that carries oxygen

from the lungs to all cells. A hemoglobin test determines how much

hemoglobin is in the blood.

 Together, the hematocrit and hemoglobin tests help diagnose anemia and

polycythemia. Anemia is a shortage of red blood cells due to reduced

 production of red cells, destruction of red cells, or loss of red cells from

internal or external bleeding. Polycythemia is production of too many red

blood cells.

Normal values vary with age and sex. Some representative ranges are:

 at birth: 42-60%

 six to 12 months: 33-40%

 adult males: 42-52%

 adult females: 35-47%

PURPOSE:

 The hematocrit is used to screen for anemia, or is measured on a person to

determine the extent of anemia.

 A low hematocrit, combined with other abnormal blood tests, confirms

the diagnosis.

 The hematocrit is decreased in a variety of common conditions including

chronic and recent acute blood loss, some cancers, kidney and liver

diseases, malnutrition, vitamin B12 and folic acid deficiencies, iron

 deficiency, pregnancy, systemic lupus erythematosus, rheumatoid arthritis

and peptic ulcer disease. An elevated hematocrit is most often associated

with severe burns, diarrhea, shock, Ad dison's disease, and dehydration,

which is a decreased amount of water in the tissues.

 An elevated hematocrit may also be caused by an absolute increase in

blood cells, called polycythemia. This may be secondary to a decreased

amount of oxygen, called hypoxia, or the result of a proliferation of blood

forming cells in the bone marrow (polycythemia vera).

 The hematocrit is also used as a guide to how many transfusions are

needed. Each unit of packed red blood cells administered to an adult is

expected to increase the hematocrit by approximately 3% to 4%.

CONTRAINDICATION:

 Fluid volume in the blood affects hematocrit values

 the blood sample should not be taken from an arm receiving IV fluid or

during hemodialysis

 It should be noted that pregnant women have extra fluid, which dilutes

the blood, decreasing the hematocrit

  Dehydration concentrates the blood, which increases the hematocrit.

PREPARATION:

 These tests require taking a blood sample from the arm.

 This is a relatively painless procedure that can occur in a clinic, office,

hospital, or lab.

 A nurse or technician wraps a rubber strap tightly around the upper arm.

 The needle puncture may cause slight discomfort for a moment. For

infants, blood is usually taken from a finger or heel.

 Occasionally, a small amount of blood collects under the skin at the

puncture site.

 A cool washcloth held against it will help reduce swelling.

MATERIALS:

Hematocrit
If the hematocrit must be determined quickly, as is often the case when a

patient hemorrhages, it may be necessary to measure the hematocrit directly

without the use of an automated counter. The materials needed are:

 Lancets

 Alcohol prep pads

 Gauze pads

 Microhematocrit tubes (heparinized)

 Sealant ("Seal-Ease," "Crit-Seal," etc)

 Microhematocrit centrifuge

 Microhematocrit reader

 If venipuncture is required: tourniquet, syringe, tube containing

anticoagulant (EDTA, citrate)

PROCEDURE:

 For hematocrits obtained by fingerstick, wipe the fingertip pad of the

fourth finger of the nondominant hand with the alcohol prep pad. Make

certain the area is allowed to dry.

 Prick the fingertip with the lancet. Place the hematocrit tube near the

incision site and allow the blood to flow via capillary action into the

hematocrit tube until it is two-thirds to three-fourths full or to a

predesignated mark on the tube.

 Avoid "milking" the finger if possible; this causes the expression of tissue

fluids and may result in a falsely low hematocrit. Always fill at least three

tubes.

 For hematocrits obtained by venipuncture, draw a sample of blood into

the tube containing anticoagulant and mix well.

 Dip the hematocrit tube into the blood and allow the blood to rise to the

desired two-thirds to three-quarters level. Because blood cells naturally

sediment, a prior thorough mixing of the blood in the tube is necessary to

ensure accurate reading.

 After cleaning the outside of the hematocrit tubes of excess blood, invert

the tube slowly so that the blood migrates just short of the bottom end of

the tube.
  Seal the bottom of the tube with sealant. Make certain that little or no air

is interspersed in the column of blood. If the seal is incomplete, leakage

will occur during centrifugation and false readings will be obtained.

 Place the tubes in a microhematocrit centrifuge and spin for 3 to 5

minutes at high speed. A shorter spin will not allow for complete

sedimentation.

Hemoglobin

Hemoglobin determinations will usually be performed by an automated cell

counter from a tube of well-mixed EDTA-anticoagulated blood filled to a

predetermined level.

Ultrasound hematocrit

COMPLICATIONS:
Other than potential bruising at the puncture site, and/or dizziness, there are no

complications associated with this test.

RBC INDICES

DEFINITION:

 Red blood cell (RBC) indices are part of the complete blood count (CBC)

test. They are used to help diagnose the cause of anemia, a condition in

which there are too few red blood cells.

 The indices include:

 Average red blood cell size (MCV)

 Hemoglobin amount per red blood cell (MCH)

  The amount of hemoglobin relative to the size of the cell (hemoglobin

concentration) per red blood cell (MCHC)

Mean corpuscular volume


is a measure of the average red blood cell volume (i.e. size) that is

reported as part of a standard complete blood count.


In patients with anemia, it is the MCV measurement that allows

classification as either a microcytic anemia (MCV below normal range),

normocytic anemia (MCV within normal range) or macrocytic anemia

(MCV above normal range).


It can be calculated (in litres) by dividing the hematocrit by the red blood

cell count (number of red blood cells per litre). The result is typically

reported in femtolitres.


The normal reference range is typically 80-100 fL[1]


In presence of hemolytic anaemia, presence of reticulocytes can increase

MCV. In pernicious anemia (macrocytic), MCV can range up to 150

femtolitres. An elevated MCV is also associated with alcoholism[2]

 Vitamin B12 and/or Folic Acid deficiency has also been associated with

macrocytic anemia (high MCV numbers).


The most common causes of microcytic anemia are iron deficiency (due

to inadequate dietary intake, gastrointestinal blood loss, or menstrual

blood loss), thalassemia, or chronic disease.


It can be as low as 60 to 70 femtolitres. In cases of thalassemia, the MCV

may be low even though the patient is not iron deficient.

Mean corpuscular hemoglobin

 The mean corpuscular hemoglobin, or "mean cell hemoglobin" (MCH),

is the average mass of hemoglobin per red blood cell in a sample of

blood. It is reported as part of a standard complete blood count. MCH

value is diminished in hypochromic anemias.

 It is calculated by dividing the total mass of hemoglobin by the number of

red blood cells in a volume of blood.

 A normal value in humans is 27 to 31 picograms/cell [1]. Conversion to

SI-units: 1pg of hemoglobin = 0,06207 femtomol [3]. Normal value

converted to SI-units: 1,68 - 1,92 fmol/cell.

Mean corpuscular hemoglobin concentration

The mean corpuscular hemoglobin concentration, or MCHC, is a

measure of the concentration of hemoglobin in a given volume of packed

red blood cells. It is reported as part of a standard complete blood count.


It is calculated by dividing the hemoglobin by the hematocrit. Reference

ranges for blood tests are 32 to 36 g/dl,[1] or between 4.9 [2] to 5.5[2]

mmol/L. It is thus a mass or molar concentration. Still, many instances[3][4]

measure MCHC in percentage (%), as if it was a mass fraction (mHb /

mRBC). Numerically, however, the MCHC in g/dl and the mass fraction of

hemoglobin in red blood cells in % are identical, assuming a RBC density

of 1g/mL and negligible hemoglobin in plasma.


MCHC is diminished ("hypochromic") in microcytic anemias, and normal

("normochromic") in macrocytic anemias (due to larger cell size, though

the hemoglobin amount or MCH is high, the concentration remains

normal). MCHC is elevated ("hyperchromic") in hereditary spherocytosis,

sickle cell disease and homozygous hemoglobin C disease.[5]

INDICATION
  Patients experiencing signs and symptoms of anemia such as dyspnea,

koilonychias, pallor, jaundice, bone deformities, body malaise and leg

ulcers.

PURPOSE

 These RBC Indices are used to diagnose types of anemia

CONTRAINDICATION:

 Patients taking certain prescription medications such as zidovudine

(Retrovir), phenytoin (Dilantin), and azathioprine (Imuran). ( These drugs

might affect the results.)

MATERIALS

 syringe with g21 or g22

 tourniquet

 tubes

 clean gloves

 antiseptic swabs
  dry cotton balls

 small glass tube (pipette), on a slide, onto a test strip, or into a small

container

PREPARATION and PROCEDURE

1. Review the procedure and assemble the equipments at bedside.

2. Explain to the client what you are going to do, why it is necessary, and

how he or she can cooperate. Discuss how the results will be used in

planning further care or treatment.

3. Wash hands and observe other appropriate infection control procedure.

4. Provide privacy.

5. Select and prepare a site for collecting a blood sample.

 Choose a site with visible vein (antecubital fossa).

 Wrap an elastic band around the upper arm to apply pressure to the

area and make the vein swell with blood.

 Clean the site with antiseptic swab and allow it to dry completely.
6. Obtain the blood specimen.

 Put on gloves.

 The vein can be anchored by placing the thumb about two

centimeters below the vein and pulling gently to make the skin a

little taut.

 The needle is beveled upward, should be pushed smoothly and

quickly into the vein, to minimize the possibility of hemolysis as a

result of vascular damage. 

 Immediately after the insertion, the tourniquet should be released to

minimize the effect of hemoconcentration.

 Asked the client to apply gentle pressure with a piece of gauze or

cotton balls to the place where the needle went in.

 The blood collects into a small glass tube called a pipette, or onto a

slide or test strip.

 A bandage may be placed over the area if there is any bleeding.

COMPLICATIONS:

 Excessive bleeding

 Fainting or feeling light-headed

 Hematoma (blood accumulating under the skin)

 Infection (a slight risk any time the skin is broken)

 Discomfort or bruising may occur at the puncture site

PICTURE:

CELLS

with IRON DEFICIENCY ANEMIA

 PERIPHERAL BLOOD SMEAR

DEFINITION

 Examination of the peripheral blood smear should be considered, along

with review of the results of peripheral blood counts and red blood cell

indices, an essential component of the initial evaluation of all patients

with hematologic disorders.

 The examination of blood films stained with Wright's stain frequently

provides important clues in the diagnosis of anemias and various

disorders of leukocytes and platelets.

WHY GET TESTED?

 To determine if red blood cells, white blood cells, and platelets are

normal in appearance and number;

 to distinguish between different types of white blood cells and to

determine their relative percentages in the blood;

 to help diagnose a range of deficiencies, diseases, and disorders

involving blood cell production, function, and destruction;

  to monitor cell production and cell maturity in diseases such as leukemia,

sickle cell anemia, malaria, during chemo/radiation therapy, or in the

evaluation for hemoglobin variants.

MATERIALS USED:

- sterilized lancets or needles

- 20 clean microscope slides and coverslips

- Canada balsam or other medium for permanent preparations

- 95% ethyl or methyl alcohol

- distilled water

- Giemsa stain

- low containers (you can make them with aluminum sheet also) or Petri dishes

- microscope which magnifies 200 times at least

PREPARATION AND PROCEDURE:

1. TAKING BLOOD

 Handwashing
 Cleanse the fingertip of the client before pricking

 Keep all the materials needed ready and protected from dust, particularly

the clean microscope slides

2. MAKING THE SMEAR

 Place a small drop of blood near an end of a slide.

 With a single drop of blood, you can make several smears. In fact, to

make a smear, it is enough to leave a spot of blood of 3 mm about in

diameter on the slide. It is useful to perform many smears.

 To avoid producing clots, you must make each smear with fresh blood

and straight after having deposited it.

 With the microscope, you should observe the smears to check that some

of them are properly made. The red cells must not overlap each other, nor

be so scarce as to be too spread out.

3. FIXING
 A simple and effective fixing technique consists of dipping the smear in a

vessel containing 95% ethyl or methyl alcohol for 3-5 minutes. In order to

put alcohol on the smear, you can also use a dropper or a bottle dispenser.

4. STAINING

 Normally Giemsa stain is used. It is a mixture of stains, based on

methylene blue and eosin. It consists of a concentrated solution which

you have to dilute in the proportion1/10, that is one part of Giemsa in

nine of distilled water, or buffer solution (pH = 6,8-7,2). You can buy the

stain in a store of chemicals and laboratory equipment.

 To stain a smear:

 Take a slide with a fixed and dry smear.

 Put on the slide a drop of stain until it is fully covered.

 Stain for about 16 minutes, renewing the stain about four times.

Then rinse the slide with distilled water at room temperature. Drain

off the water and leave the slide to dry.

5. CHECKING

 With the microscope, verify that the cells are well stained.
 If necessary, apply the stain for a few more minutes.

6. COVER-SLIPPING

 After drying the slide, place a drop of Canada balsam or another medium

mountant on the smear, then mount the coverslip.

7. OBSERVATION

 A magnification of 200 times is enough to allow you to observe and

identify the different types of cells.

 You can examine either with dry objectives or with the oil immersion

technique.

 If you have put on a coverslip, you must wait a day to allow the balsam to

set, otherwise, when you move the slide, oil will displace the coverslip.
 RETICULOCYTE COUNT

DEFINITION

 The reticulocyte count is used to help determine if the bone marrow is

responding adequately to the body’s need for red blood cells (RBCs).

 To help determine the cause of and classify different types of anemia.

 If the number of reticulocytes is not elevated when you are anemic, then

it is likely that there is some degree of bone marrow dysfunction or

failure and/or a deficiency of erythropoietin.

INDICATION

 Bleeding

 Hemolytic Anemia

 Hemolytic disease of the newborn

 Iron deficiency anemia

 Pernicious anemia or folic acid deficiency

 Aplastic anemia

 Radiation therapy

 Bone marrow failure caused by infection or cancer

The Preparation

 A health professional will usually draw the blood from a vein

 After cleaning the skin surface with antiseptic and placing an elastic band

(tourniquet) around the upper arm to apply pressure and cause veins to

swell with blood.

  A needle is inserted into a vein and blood is withdrawn and collected in a

vial or syringe.

THE PROCEDURE

1. Stain Solution (Stains ribosomes)

 New methylene blue or Azure B 1.0 grams

 Dissolve stain in 100 ml Citrate-Saline

 Tri-sodium citrate 3% (one part)

 Saline 0.85% (four parts)

 Filter solution

 Store at 4 degrees celsius

2. Staining method

 Start with 2-3 drops of stain in tube

 Add 2-3 drops of patient's blood

 Use more blood in anemic patients

 Use less blood in polycythemia

 Incubate at 37 degrees celsius for 15-20 minutes

 Gently mix
  Create a thin film on slide

 Allow films to dry

3. Counting method

A. View field of undistorted cells at x100 oil immersion

 Reticulocytes stain deep blue

 Red Blood Cells stain pale-greenish blue

B. Use Miller ocular insert

 nRBC: average Red Blood Cells in small square

 nRetic: Number of Reticulocytes in 'nField' fields

C. Calculate Reticulocyte Count

 Calculate Reticulocytes per 1000 red cells

 Retic Count = (nRetic) / (9 * nRBC * nField)

Risks

 fainting or feeling lightheaded

 hematoma (blood accumulating under the skin causing a lump or bruise)

 pain associated with multiple punctures to locate a vein

 ANTIGLOBULIN TEST- DIRECT AND INDIRECT

DEFINITION

 An antiglobulin test is a laboratory test to identify antibodies that can

bind to the surface of red blood cells or platelets and destroy them.

 This test is used to diagnose certain blood disorders in which patients

make antibodies to their own red blood cells or platelets. It is also used to

determine blood type.

 Also called Coomb's test.

 DIRECT ANTIGLOBULIN TEST

  The direct antiglobulin test (DAT) is used primarily to help determine if

the cause of hemolytic anemia, a condition in which red blood cells

(RBCs) are being destroyed more quickly than they can be replaced, is

due to antibodies attached to RBCs.

PROCEDURE

 STEP 1. Place one drop of a 2 to 5 percent saline suspension of cells to

test in a labeled 10-x 75-mm tube. Wash 3 or 4 times with saline. After

last wash, decant completely. Add one or two drops of antiglobulin

serum: mix.

  STEP 2. Centrifuge and examine for agglutination with an optical aid;

 Grade and record results. (The manner in which the RBCs are dislodged

from the bottom of the tube is critical. The tube should be held at an angle

and shaken gently until all cells are dislodged.

 Then it should be tilted gently back end forth until an even suspension of

cells or agglutinates is observed.)

   STEP 3. To control for inadvertent contamination of the antiglobulin

serum, add one drop of lgG-sensitized RBCs to any tubes that have been

recorded as negative and recentrlfuge.

 If the patient's cells were washed adequately in the first stage of the test,

the control cells should be agglutinated, and the negative result on the

patient is valid

INDICATION

 hemolytic anemia

 hemolytic disease of the newborn,

 when there are signs and symptoms of a blood transfusion reaction

 INDIRECT ANTIGLOBULIN TEST

 The indirect antiglobulin test is used to demonstrate antibodies that may

cause RBC sensitization "in vitro".

  The antibody-containing serum is incubated with specific RBCs, which,

following washing, are reacted with antiglobulin serum to see whether

RBC sensitization has occurred.

INDICATION

 Detection and identification of unexpected antibodies.

 Crossmatching.

 Detecting RBC antigens not demonstrable by other techniques.

 Special studies, (for example, leukocyte and platelet antibody tests

SUMMARY OF INDIRECT ANTIGLOBULIN TEST

1. Incubate cells with serum at 37oC for the recommended time. (Usually 15

to 30 minutes.) 

2. After incubation wash the cells three to four times.  

3. Add AHG, Coombs reagent, centrifuge and read for agglutination.  

 4. If the test is negative, add Coombs Control Check Cells to check for false

negatives.

COMPLICATION

 Bruising or excessive bleeding after extraction of blood.

 Dizziness or may faint

Coagulation Screening Test

 Definition

 It is used to determine if the level of the clotting factor is low or

absent, associated with reduced clot formation and bleeding too much

clot formation and.

 Coagulation factor levels may also be measured to monitor the level

during therapy.

 It is also used to provide rapid, useful, non-specific information, which

allows an initial broad categorization of the haemostatic problem.

 Also used to discern whether the bleeding problem to a platelet,

coagulation or a vascular defect.

PT with INR

(Prothrombin Time with International Normalized Ratio)

 Definition

 The prothrombin time (PT) measures the integrity of the extrinsic and

common pathways of coagulation (factors VII, X, V and II).

 Evaluates the ability of blood to clot properly

 It is used to adjust anticoagulant medications to maintain an INR at 2.0.

Reported INRs that are elevated are increased to reduce the risk of

bleeding or decreased to adjust therapy to be more effective.

 The International Normalized Ratio (INR) is used to monitor the

effectiveness of blood thinning drugs such as warfarin (Coumadin).

 Used to screen patients for any previously undetected bleeding problems

prior to surgical procedures.

 Patients taking anticoagulant drugs should have an INR of 2.0 to 3.0 for

basic “blood-thinning” needs. For some patients who have a high risk of

clot formation, the INR needs to be higher - about 2.5 to 3.5. the doctor

will use the INR to adjust the drug to get the PT into the range that is

right for the patient.

  Due to manufacturer variation in the production of thromboplastin

leading to different PT times between laboratories, it is standard practice

to convert the PT to the international normalized ratio (INR) and report

that value.

 Indication

 For patients taking anti-coagulant drug

 The PT may be ordered when a patient who is not taking anti-coagulant

drugs has signs or symptoms of a bleeding disorder, which can range

from nosebleeds, bleeding gums, bruising, heavy menstrual periods,

blood in the stool and/or urine to arthritic-type symptoms (damage from

bleeding into joints), loss of vision, and chronic anemia.

 Sometimes the PT may be ordered when a patient is to undergo an

invasive medical procedure, such as surgery, to ensure normal clotting

ability.

 Purposes

 Evaluates the ability of blood to clot properly.

 Contraindication
  To patients who are taking drugs that can affect the result of the test,

unless these medications are stopped for about a week.

 Materials

 Near-patient testing (NPT) /Home INR monitoring example: Roche

Coaguchek device

 blood plasma

 Test tube

 Preparation:

 Many medicines can change the results of this test. Interview the client

regarding what medications she is taking.

 Ask the client if he have been nauseated, light-headed, or have fainted

during blood tests in the past

 Procedure:

 Most commonly measured using blood plasma.

1. Blood is drawn into a test tube containing liquid citrate, which

acts as an anticoagulant by binding the calcium in a sample

2. The blood is mixed, then centrifuged to separate blood cells from

plasma.
3. The plasma is analyzed by a biomedical scientist on an automated

instrument at 37°C, which takes a sample of the plasma.

4. An excess of calcium is added (thereby reversing the effects of

citrate), which enables the blood to clot again.

5. For an accurate measurement the proportion of blood to citrate

needs to be fixed

6. For the prothrombin time test the appropriate sample is the blue

top tube, or sodium citrate tube, which is a liquid anticoagulant.

7. Tissue factor (also known as factor III) is added, and the time the

sample takes to clot is measured optically.

8. The prothrombin ratio is the prothrombin time for a patient,

divided by the result for control plasma

9. To convert to INR : each manufacturer assigns an ISI value

(International Sensitivity Index) for any tissue factor they

manufacture. The ISI value indicates how a particular batch of

tissue factor compares to an internationally standardized sample.

The ISI is usually between 1.0 and 2.0.

 10. The INR is the ratio of a patient's prothrombin time to a

normal (control) sample, raised to the power of the ISI value for

the analytical system used.

11.

 Using the NPT

1. A drop of capillary blood is obtained with an automated finger-

prick, which is almost painless.

2. This drop is placed on a disposable test strip with which the

machine has been prepared.

3. The resulting INR comes up on the display a few seconds later.

(Present pictures or gadget)

Complication

 During a blood draw, a bruise or infection may occur at the puncture site.

 Possible formation of scar tissue.

PTT

 Definition

 Is a performance indicator measuring the efficacy of both the "intrinsic"

and the common coagulation pathways.

 A complex method for testing the normalcy of intrinsic coagulation

process.

 Employed to identify deficiencies factors, prothrombin, and fibrinogen

  Used to monitor heparin therapy (and other anticoagulants).

 Values below 25 seconds or over 39 s (depending on local normal

ranges) are generally abnormal

 Normal: 60- 70 seconds

 Indication

 It is also used to monitor the treatment effects with heparin (and other

anticoagulants).

 For patients experiencing abnormal bleeding or bruising.

 Indicated for patients under heparin therapy to monitor its effectiveness.

 Purposes

 Used to monitor patients who are taking heparin, a blood thinner.

 It is used in measuring the efficacy of both the "intrinsic" and the

common coagulation pathways.

 To find the cause of abnormal bleeding or bruising.

 To asses for low levels of blood clotting.

 To asses blood clotting time before a surgery.

 Contraindication
  To patients who are taking drugs that can affect the result of the test,

unless these medications are stopped for about a week.

 Ongoing bleeding can be a problem for people with bleeding disorders.

Aspirin, warfarin (Coumadin), and other blood-thinning medicines can

make bleeding more likely. If you have bleeding or clotting problems, or

if you take blood-thinning medicine, tell your doctor before your blood

sample is taken.

 Materials

 vacu-tubes

 Phospholipid

 plasma

 Preparation

1. Many medicines can change the results of this test. Interview the client

regarding what medications she is taking.

Procedure
 1. A phlebotomist collects blood samples in vacu-tubes with oxalate or

citrate to arrest coagulation by binding calcium.

2. The specimen is then delivered to the laboratory.

3. In order to activate the intrinsic pathway, phospholipid, an activator

(such as silica, celite, kaolin, ellagic acid), and calcium (to reverse the

anticoagulant effect of the oxalate) are mixed into the plasma sample .

4. The time is measured until a thrombus (clot) forms. (Present pictures or

gadget)

 Pictures:

This is a photo-optical clot detection system for determining prothrombin

times, activated partial thromboplastin times and other related tests

 Complication

There is very little chance of a problem from having blood sample taken from a

vein.

 Patient may get a small bruise at the site.

 In rare cases, the vein may become swollen after the blood sample is

taken. A warm compress can be used several times a day to treat this.

 Ongoing bleeding can be a problem for people with bleeding disorders.

Aspirin, warfarin (Coumadin), and other blood-thinning medicines can

make bleeding more likely. Ask the patient if he has bleeding or clotting

problems.
 BLEEDING TIME

 Definition

 Bleeding time is a crude test of hemostasis It indicates how well platelets

interact with blood vessel walls to form blood clots

 Normal bleeding time is from 2 to 6 minutes. Bleeding time is increased

in disorders of platelet count, uremia, and ingestion of aspirin and other

anti-inflammatory

 Test for determining the time interval required for hemostasis to occur

after a standardized wound has been made in the capillary bed

 Indication

 Usually used on patients who have a history of prolonged bleeding after

cuts

 Usually used to patients who have a family history of bleeding disorders.

 Sometimes performed as a preoperative test to determine a patient's likely

bleeding response during and after surgery.

 Purposes
  Most often to detect qualitative defects of platelets, such as Von

Willebrand's disease.

 The test helps identify people who have defects in their platelet function.

 Contraindication:

 To patients who are taking drugs that can affect the result of the test,

unless these medications are stopped for about a week.

 Materials

1. Stopwatch

2. Sphygmomanometer (blood pressure cuff)

3. Filter paper.
tm
4. Surgicutt Automated Incision Making Instrument (International

Technidyne Corp.)

5. Alcohol prep

6. Butterfly bandages

 Preparation

1. Many medicines can change the results of this test. Interview the client

regarding what medications she is taking.

 2. The patient must not take aspirin for 10 days before the test

3. Example: Aspirin and other cyclooxygenase inhibitors can prolong

bleeding time significantly. While warfarin and heparin have their major

effects on coagulation factors, an increased bleeding time is sometimes

seen with use of these medications as well.

 Procedure

1. Select a site on the patient's arm on the lateral aspect volar surface that is

free of veins, bruises, edematous areas, and scars and is approximately 5 cm

below the antecubital crease.

2. Clean the site with the alcohol prep.

3. Place the sphygmomanometer around the patient's arm approximately two

inches above the elbow and maintain 40 mm Hg.

4. Remove the "trigger" safety and place the incision device on the site with

minimal pressure so that both ends of the device touch the skin. Do not press

hard.

5. Depress the "trigger" to make the incision then remove the device.

Discard the device in a "sharps" container.

6. Start the timing device and blot the edge of the incision at 30-second
 intervals with the filter paper. Do not touch the incision with the filter paper.

7. Note the time that bleeding stops and report to the nearest 30 seconds.

 Complication

 Excessive bleeding

 Fainting or feeling light-headed

 Hematoma (blood accumulating under the skin)

 Infection (a slight risk any time the skin is broken)

 Multiple punctures to locate veins

  Possible formation of scar tissue.

Capillary Fragility Test (tourniquet test, Rumple-Leede Test)

 determines capillary fragility

 method used to determine hemorrhagic tendency

 requisite for diagnosis of dengue fever

 is used to identify thrombocytopenia

Materials include:

* BP cuff

* watch

Preparation:
 1. Verify identity of client and explain the procedure

2. Interview if client has any injuries on extremities and check if he/she has

sun damaged skin

3. If client is a female ask if she is at premenstrual or postmenstrual

Procedure:

1. Assess present blood pressure of the patient

2. Inflate blood pressure cuff to a point between systolic and diastolic

pressure for 5 minutes

3. The test is positive if more than 20 petechiae (small red or purple spot)

per square inch is present

 Clotting time

 the time required for blood to clot

 also called coagulation time specifically in venous blood

 average clotting time in a glass tube is 5-15 minutes

 this process is used to diagnose hemophilia

Materials include:

*lancet
 *Capillary tube

Preparation:

1. Verify identity of client and explain the procedure

2. Interview if client is taking medication causing bleeding (heparin,

aspirin)

Procedure:

1. Site is cleaned with anti-septic and is pricked using lancet

2. Blood is collected by phlebotomist/MT using capillary tube and is

placed in glass tube

3. Apply pressure on extracted area

4. Bring specimen directly to the lab

 5. The first appearance of clot is noted and timed (normal coagulation

time is 5-15 minutes)

Clot Retraction

 indicates function and number of platelets

 measures time needed for blood clot to move away from test tube

 is used to identify glandzmann’s thromboasthenia (absence of

fibrinogen bridging)

Materials needed:

*airtight vial with needle *timer

*test tube with 2/3 castor oil

*tourniquet

Preparation:

1. Verify identity of client and explain the procedure

2. Interview if client is taking medication causing bleeding (heparin,

aspirin)
Procedure:

1. Site is cleaned with anti-septic; place tourniquet around the upper arm

to apply pressure to the area and make the vein swell with blood.

2. Health care provider gently inserts a needle into the vein and collects

into an airtight vial or tube attached to the needle. The elastic band is removed

(nursing consideration: bring specimen right away to the laboratory)

3. A drop of blood is placed in a test tube with castor oil

4. Observe for dimpling in the blood

*normal standing blood clot is completely retracted in about 24

hours

dimpling withing:

2-4 hours = normal

4-24 hours = poor

not at all
Thrombin time

Definition

 Thrombin Time (TT), is a blood test which measures the time it takes

for a clot to form in the plasma from a blood sample in

anticoagulant which had added an excess of thrombin. This test is

repeated with pooled plasma from normal patients.

Normal values and significance

 10-15sec – Prolonged time indicates DIC or hypofibrinogenemia;

presence in blood of excess heparin or other antigoagulants.

Indication

 Afibrinogenaemia or hypofibrinogenaemia.

 Dysfibrinogenaemia (a dysfunctional fibrinogen)

 DIC

 Following thrombolytic therapy

 Liver disease
  Malignancy

 Unfractionated heparin

 Heparin-like anticoagulants

 Amyloid

 Hyperfibrinogenaemia

 Hypoalbuminaemia

Purpose

 Measures functional fibrinogen available, as ashown by the time needed

to form fibrin clot after thrombin is added.

Contraindication

 cardio-pulmonary bypass

 receiving high concentrations of heparin (8-10 IU/mL)

Materials

 syringe with g21 or g22

 tourniquet
  tubes

 clean gloves

 antiseptic swabs

 dry cotton balls

 Patient's plasma

 Normal control plasma

 Barbitone buffered saline, pH 7.4

 Bovine Thrombin

Preparation and Procedure

7. Review the procedure and assemble the equipments at bedside.

8. Explain to the client what you are going to do, why it is necessary, and

how he or she can cooperate. Discuss how the results will be used in

planning further care or treatment.

9. Wash hands and observe other appropriate infection control procedure.

10. Provide privacy.

11. Select and prepare a site for collecting a blood sample.

 Choose a site with visible vein (antecubital fossa).

 Place the tourniquet above the vein.

 Clean the site with antiseptic swab and allow it to dry completely.

12. Obtain the blood specimen.

 Put on gloves.

 The vein can be anchored by placing the thumb about two

centimeters below the vein and pulling gently to make the skin a

little taut.

 The needle is beveled upward, should be pushed smoothly and

quickly into the vein, to minimize the possibility of hemolysis as a

result of vascular damage. 

 Immediately after the insertion, the tourniquet should be released to

minimize the effect of hemoconcentration.

  Asked the client to apply gentle pressure with a piece of gauze or

cotton balls to the place where the needle went in.

13. Perform the thrombin time method.

 Add 0.1 ml buffered saline to 0.1 ml normal plasma and leave in the

water-bath at 370C for four minutes.

 Add 0.1 ml thrombin, and mix by shaking and simultaneously start

the stop-watch.

 Measure the clotting time.

 Repeat with the patient's plasma in duplicate followed by a second

sample of the normal plasma.

 Express results as the mean values for the patient and normal.

Repeat the test if duplicate measurements differ by more than 5%.

14. Document the result on the client’s record.

Pictures
 Bovine thrombin

Complication

 Anxiety

 Discomfort

 Bruising

 Hematoma

Forced Spirometry
Description
 Spirometry is the most common of the Pulmonary Function Tests (PFTs),
measuring lung function, specifically the measurement of the amount
(volume) and/or speed (flow) of air that can be inhaled and exhaled.
Spirometry is an important tool used for generating pneumotachographs
which are helpful in assessing conditions such as asthma, pulmonary fibrosis,
cystic fibrosis, and COPD.

Name of the test Normal values

Forced vital capacity 4.8 L-M

3.7 L-F
Forced Expratory Volume in One Adults:
Second/FVC-ratio 0.75-0.80

Forced Expiratory volume in One Adults:

second 75-80%

I. Moderate * FEV1/FVC < 0.7 Symptoms during this stage

COPD progress, with shortness of breath
* 50% </= FEV1 < 75% developing upon exertion.
predicted

II. Severe * FEV1/FVC < 0.7 Shortness of breath becomes

COPD worse at this stage and COPD
* 30% </= FEV1 < 50% exacerbations are common.
predicted

III. Very * FEV1/FVC < 0.7 Quality of life at this stage is

Severe gravely impaired. COPD
 COPD exacerbations can be life
* FEV1 < 30% predicted or threatening
FEV1 < 50% predicted with
chronic respiratory failure

Indication
Spirometry is used to establish baseline lung function, evaluate dyspnea,
detect pulmonary disease, monitor effects of therapies used to treat
respiratory disease, evaluate respiratory impairment, evaluate operative risk,
and perform surveillance for occupational-related lung disease.

Purposes

Spirometry is the most commonly performed pulmonary function test (PFT).

The test can be performed at the bedside, in a physician's office, or in a
pulmonary laboratory. It is often the first test performed when a problem with
lung function is suspected. Spirometry may also be suggested by an abnormal
x ray, arterial blood gas analysis, or other diagnostic pulmonary test result.
The National Lung Health Education Program recommends that regular
spirometry tests be performed on persons over 45 years old who have a
history of smoking. Spirometry tests are also recommended for persons with a
family history of lung disease, chronic respiratory ailments, and advanced age.

Spirometry measures ventilation, the movement of air into and out of the
lungs. The spirogram will identify two different types of abnormal ventilation
patterns, obstructive and restrictive.

Common causes of an obstructive pattern are cystic fibrosis, asthma,

bronchiectasis, bronchitis, and emphysema. These conditions may be
collectively referred to by using the acronym CABBE. Chronic bronchitis,
emphysema, and asthma result in dyspnea (difficulty breathing) and
ventilation deficiency, a condition known as chronic obstructive pulmonary
disease (COPD). COPD is the fourth leading cause of death among Americans.

Common causes of a restrictive pattern are pneumonia, heart disease,

pregnancy, lung fibrosis, pneumothorax (collapsed lung), and pleural effusion
(compression caused by chest fluid).

Contraindications
Relative contraindications for spirometry include hemoptysis of unknown
origin, pneumothorax, unstable angina pectoris, recent myocardial infarction,
thoracic aneurysms, abdominal aneurysms, cerebral aneurysms, recent eye
surgery (increased intraocular pressure during forced expiration), recent
abdominal or thoracic surgical procedures, and patients with a history of
syncope associated with forced exhalation.

Materials
 Spirometer

Preparations
Two choices are available with respect to bronchodilator and medication use
prior to testing.

 Patients may withhold oral and inhaled bronchodilators to establish

baseline lung function and evaluate maximum bronchodilator response,
or they may continue taking medication as prescribed.
 If medications are withheld, a risk of exacerbation of bronchial spasm
exists.

Procedure

The basic forced volume vital capacity (FVC) test varies slightly depending on
the equipment used.
 1. Generally, the patient is asked to take the deepest breath they can, and
then exhale into the sensor as hard as possible, for as long as possible.
2. It is sometimes directly followed by a rapid inhalation (inspiration), in
particular when assessing possible upper airway obstruction.

3. Sometimes, the test will be preceded by a period of quiet breathing in

and out from the sensor (tidal volume), or the rapid breath in (forced
inspiratory part) will come before the forced exhalation.

4. During the test, soft nose clips may be used to prevent air escaping
through the nose. Filter mouthpieces may be used to prevent the spread
of microorganisms, particularly for inspiratory maneuvers.

Present Pictures & Gadgets

Spirometry Device

Modern USB PC-based spirometer

Chamber for Spirometry

Complications
 Cross Infections due to the use of the mouthpiece

Lung Volume Determination

Description& Procedure
Here are the tests to determine lung volume:

Value
Measurement Calculation Description
(Male/Female)
The volume of air
contained in the lung at
Total lung TLC = IRV + Vt +
= 6.0 / 4.7 L the end of maximal
capacity (TLC) ERV + RV
inspiration. The total
volume of the lung.
Vital capacity = 4.6 / 3.6 L VC = IRV + Vt + ERV The amount of air that can
(VC) be forced out of the lungs
after a maximal
inspiration. Emphasis on
 completeness of
expiration. The maximum
volume of air that can be
voluntarily moved in and
out of the respiratory
system.[3]
The amount of air that can
be maximally forced out of
Forced vital
= 4.8 / 3.7 L measured the lungs after a maximal
capacity (FVC)
inspiration. Emphasis on
speed.[4][5]
The amount of air
breathed in or out during
Tidal volume normal respiration. The
= 500 / 390 mL measured
(Vt) volume of air an individual
is normally breathing in
and out.
The amount of air left in
the lungs after a maximal
exhalation. The amount of
air that is always in the
Residual
= 1.2 / 0.93 L measured lungs and can never be
volume (RV)
expired (i.e.: the amount
of air that stays in the
lungs after maximum
expiration).
Expiratory = 1.2 / 0.93 L measured The amount of additional
reserve volume air that can be pushed out
(ERV) after the end expiratory
level of normal breathing.
(At the end of a normal
breath, the lungs contain
the residual volume plus
the expiratory reserve
 volume, or around 2.4
litres. If one then goes on
and exhales as much as
possible, only the residual
volume of 1.2 litres
remains).
The additional air that can
be inhaled after a normal
Inspiratory tidal breath in. The
measured or
reserve volume = 3.0 / 2.3 L maximum volume of air
IRV=VC-(Vt+ERV)
(IRV) that can be inspired in
addition to the tidal
volume.
The amount of air left in
Functional the lungs after a tidal
residual = 2.4 / 1.9 L FRC = ERV + RV breath out. The amount of
capacity (FRC) air that stays in the lungs
during normal breathing.
The maximal volume that
Inspiratory
= 3.5 / 2.7 L IC = Vt + IRV can be inspired following a
capacity (IC)
normal expiration.
The volume of the
Anatomical conducting airways.
= 150 / 120 mL measured
dead space Measured with Fowler
method.[6]
The anatomic dead space
Physiologic
= 155 / 120 mL plus the alveolar dead
dead volume
space.

Abnormal results:

Type Examples Description FEV1/FVC

 pulmonary fibrosis,
Infant Respiratory
restrictive volumes are often in a normal
Distress Syndrome, weak
diseases decreased range (0.8 - 1.0)
respiratory muscles,
pneumothorax
volumes are often low (Asthma can
essentially reduce the ratio to
obstructive
asthma or COPD normal but flow 0.6, Emphysema can
diseases
rates are reduce the ratio to 0.3
impeded - 0.4)

Indications
Lung volumes determinations (CPT code 94240 [FRC or RV], 94260 [thoracic
gas volume by body plethysmography]) are used in the evaluation of
suspected restrictive lung disease and the evaluation of hyperinflation.

Contraindications
Inability to follow instructions is a contraindication. Patients with
claustrophobia may not tolerate being closed into a confined space (body
plethysmograph).

Preparations
Use of supplemental oxygen just prior to a nitrogen washout test may cause
underestimation of FRC unless the initial exhaled nitrogen is considered in the
calculations. Duplicate measurements of FRC by either gas dilution technique
should be delayed until a post-test interval is equivalent to 1.5 times the
equilibration time to eliminate the effects of residual oxygen or helium.
Present Pictures and Gadgets

Device that helps in determining lung volume( Spirometer)

Complications
No reports of complications adter test is performed.
Diffusion Capacity
Description
Lung diffusion testing measures how well the lungs exchange gases. This is an
important part of lung testing, because the major function of the lungs is to
allow oxygen to "diffuse" or pass into the blood from the lungs, and to allow
carbon dioxide to "diffuse" from the blood into the lungs.

Contraindication
Inability to follow instructions is a contraindication to a DLCO test (CPT code
94070). Patients should be alert, oriented, able to exhale completely and
inhale to total lung capacity, able to maintain an airtight seal on a
mouthpiece, and able to hold a large breath for 10 seconds

Preparations
 Do not eat a heavy meal before the test.
 Do not smoke for at least 4 - 6 hours before the test.
 If you use a bronchodilator or inhaler medications, ask your health care
provider whether or not you can use them before the test.

Procedure
 You breathe in (inhale) air containing a very small amount of a tracer
gas, such as carbon monoxide.
 You hold your breath for 10 seconds, then rapidly blow it out (exhale).
  The exhaled gas is tested to determine how much of the tracer gas was
absorbed during the breath.

Present Pictures and Gadgets

Complications
There is no significant risk in taking this test
 Capnography 

DEFINITION:

the measurement of carbon dioxide (CO2) in exhaled breath

direct monitor of the inhaled and exhaled concentration or partial

pressure of CO2, and an indirect monitor of the CO 2 partial pressure in

the arterial blood

is usually presented as a graph of expiratory CO 2 plotted against

time, or, less commonly, but more usefully, expired volume

INDICATION:

detect life-threatening conditions (malposition of tracheal tubes,

unsuspected ventilatory failure, circulatory failure and defective

breathing circuits)

asthma, congestive heart failure, diabetes, circulatory shock,

pulmonary embolus, acidosis,

in patients with normal lung function, upper and lower airway

disease, seizures, and diabetic ketoacidosis

monitor any patients receiving pain management or sedation

(enough to alter their mental status) for evidence of hypoventilation

and/or apnea

Patients with head injury

Patients who experience anaphylactic reaction

PURPOSES:

provides a breath by breath measurement of a patient's ventilation

enables paramedics to objectively evaluate a patient’s ventilatory

status (and indirectly circulatory and metabolic status)

monitors patient ventilation, providing a breath by breath trend of

respirations and an early warning system of impending respiratory crisis

utilized to differentiate the nature of the cardiac arrest

clinical judgment alone in the early detection of adverse respiratory

events such as hypoventilation, esophageal intubation and circuit

disconnection;

CONTRAINDICATION:

Patients with Atelactasis

Pulmonary embolism or hypovolemia

exacerbation of main disease;

Clinical or laboratory symptoms of endocrine disorder;

coronary deficiency of the 2-3 stage;

breath deficiency of the 3 stage;

chronic pulmonary heart in the stage of sub- or

decompensation;

serious disorder of heart rhythms and conductivity;

serious diseases of central nerve system or affective disorders.

MATERIALS USED:

Capnogram

PREPARATION:

Clinicians administering sedation/analgesia should be familiar with

sedation oriented aspects of the patient's medical history and how these

might alter the patient’s response to sedation / analgesia

Patients (or their legal guardians in the case of minors or legally

incompetent adults)

should be informed of and agree to the administration of sedation /

analgesia including the benefits,

risks, and limitations associated with this therapy, as well as possible

alternatives.

Recording of LOC, oxygenation, hemodynamics

Recording of the paramaters

Use of supplemental oxygen

PROCEDURE:

1.    Perform hand hygiene.

2.    Position the client.

3.    Assess client’s condition/ make an initial assessment prior to

procedure.

4.    Attach capnography filter to the ET tube prior to intubation, use the

monitor to assist placement.

5.    Check if the device was successfully attached.

6.    See CPR oscillations on the monitor screen immediately upon

intubating, replaced by larger wave forms once the ambu-bag has been

attached and ventilations begun

7.    Auscultate the lungs; assess for presence and equality of breathe

sounds

􀂃 Movement of air through the tube

 􀂃 Presence of condensation in the tube

􀂃 Auscultate the stomach; assess for absence of air movement

8.  Apply capnometer or capnography if available.

9.  Document use of continuous ETCO2 monitoring and attach wave

form strips to their PCRs.

10. Print a strip on intubation, periodically during care and transport, and

then just prior to moving the patient from your stretcher to the hospital

table and then immediately after transfer. This will timestamp and

document your tube as good

PICTURES/GADGETS:

COMPLICATIONS:
A patient taking in a large tidal volume can still hyperventilate with

a normal respiratory rate just as a person with a small tidal volume can

hypoventilate with a normal respiratory rate.

Patients with extended down times may have ETCO2 readings so

low that quality of compressions will show little difference in the

number.

Some diseases may cause the CO2 to go down, then up, then down.

Imperfect positioning of nasal cannula capnofilters may skew

readings

Unique nasal anatomy, obstructed nares and mouth breathers may

require repositioning of the cannula

oxygen by mask  which may lower the reading by 10% or more.

NORMAL VALUES & SIGNIFICANCE:

ETCO2 35-45 mm Hg
The normal wave form appears as straight boxes on the monitor screen:.

The capnogram wave form begins before exhalation and ends with

inspiration. Breathing out comes before breathing in.

Abnormal Values and Wave Forms

ETCO2 Less Than 35 mmHg = "Hyperventilation/Hypocapnia"

ETC02 Greater Than 45 mmHg = "Hypoventilation/Hypercapnia"

Hyperventilation

When a person hyperventilates, their CO2 goes down.

Hyperventilation can be caused by many factors from anxiety to

bronchospasm to pulmonary embolus.

Other reasons C02 may be low: cardiac arrest, decreased cardiac

output, hypotension, cold, severe pulmonary edema.

Hypoventilation

When a person hypoventilates, their CO2 goes up.

Hypoventilation can be caused by altered mental status such as

overdose, sedation, intoxication, postictal states, head trauma, or stroke,

or by a tiring CHF patient.

Other reasons CO2 may be high: Increased cardiac output with

increased breathing, fever, sepsis, pain, severe difficulty breathing,

depressed respirations, chronic hypercapnia.

2. Confirming, Maintaining , and Assisting Intubation

Continuous end-tidal CO2 monitoring can confirm a tracheal intubation.

When exhaled CO2 is detected (positive reading for CO2) in

cardiac arrest, it is usually a reliable indicator of tube position in the

trachea.

Reasons ETCO2 is zero: The tube is in the esophagus.*

Reductions in ETCO2 during CPR are associated with comparable

reductions in cardiac output

increase in ETCO2 presumably providing better chest compressions

Pulse Oximetry

DEFINITION:

Pulse oximetry is a simple non-invasive method of monitoring

the percentage of haemoglobin (Hb) which is saturated with

oxygen.
 A sensor is placed on a thin part of the patient's body, usually

a fingertip or earlobe, or in the case of a neonate, across a foot,

INDICATION:

whenever a patient's oxygenation may be unstable, as in intensive

care, critical care, and emergency department areas of a hospital

The need to monitor the adequacy of arterial oxyhemoglobin

saturation

The need to quantitate the response of arterial oxyhemoglobin

saturation to therapeutic interventionor to a diagnostic procedure (eg,

bronchoscopy)

PURPOSES:

The oxygen content of the blood

The amount of oxygen dissolved in the blood

The respiratory rate or tidal volume i.e. ventilation

The cardiac output or blood pressure

 as a screening tool that could supplement or supplant

respiratory rate as a 'pulmonary vital sign

screening for respiratory failure

CONTRAINDICATION:

Patient who take vasopressor drugs

highly calloused skin

shivering

carbon monoxide poisoning,

The presence of an ongoing need for measurement of pH,

PaCO2, total hemoglobin, and abnormal hemoglobins

MATERIALS USED:

pulse oximeter and related accessories (probe of appropriate

size)

PREPARATION:

1.    Select the appropriate type of pulse oximeter that fits your needs as

well as the use of BP cuff, arterial catheter, and/or peripheral IV line

2.    Find a pulse oximeter that is easy to use.

3.    Test the pulse oximeter against someone who can manually take

your pulse and oxygen saturation measurements if you have this

opportunity

4.    Prepare the client & explain the procedure if necessary

5.    Check factors that may affect the result of the procedure

a)   Motion artifact

b)   Intravascular dyes

c)    exposure of measuring probe to ambient light during

measurement

d)   low perfusion states

e)    skin pigmentation

f)     nail polish or nail coverings with finger probe

 PROCEDURE:
1.    Perform hand hygiene

2.    Select a part of the patient’s body where you can put the device

(adult: fingertip or earlobe; neonate: across a foot)

D-25 Digit or D-20 Pediatric Sensor:

Place the sensor, adhesive side up, over

the patient’s finger. Position the dashedcenter line directly above

the     fingertip

I-20 and N-25 Sensor

Wrap sensor around finger tip or foot.

Position dashed line at either medial or lateral border of

extremity

3. Make an initial assessment of the patient’s condition

4. Read & interpret results displayed in the computerized unit

(percentage of Hb saturation, pulse beat, heart rate, blood flow)

5. Press the sensor onto the patient’s finger or toe and wrap the

adheasive strip circumferentially around the digit

6.results should be documented in the patient's medical record and

should detail the conditions under which the readings were obtained:

a)    date, time of measurement, and pulse oximeter reading;

patient's position, activity level, and location;(4)during

monitoring, assure that patient's activity is according to

physician's order;

b)   inspired oxygen concentration or supplemental oxygen

flow, specifying the type of oxygen delivery device;

c)    probe placement site(4) and probe type;

d)    model of device (if more than one device is available for

use);

e)    results of simultaneously obtained arterial pH, PaO2, and

PaCO2, and directly measured saturations of COHb, MetHb,

 and O2Hb4 (if direct measurement was not simultaneously

performed, an additional, one time statement must be made

explaining that the SpO2 reading has not been validated by

comparison to directly measured values); 

f)     Stability of readings (length of observation time and

range of fluctuation, for continuous or prolonged studies,

review of recording may be necessary);

g)     Clinical appearance of patient--subjective assessment of

perfusion at measuring site (eg, cyanosis, skin temperature);

h)   Agreement between patient's heart rate as determined by

pulse oximeter and by palpation and oscilloscope

7. When disparity exists, possible causes should be explored before

results are reported.

COMPLICATIONS:

false-negative results for hypoxemia and/or false-positive

results for normoxemia or hyperoxemia

 tissue injury may occur at the measuring site as a result of

probe misuse

NORMAL VALUES & SIGNIFICANCE:

  Normal range Significance

Percentage of arterial 95 to 100 percent SpO2 < 90%= 

hemoglobin desaturation

SpO2  95%= 

Common pulsatile signals on a pulse

oximeter. (Top panel) Normal signal

showing the sharp waveform with a

clear dicrotic notch. (Second panel)

Pulsatile signal during low perfusion

showing a typical sine wave.

(Third panel) Pulsatile signal with superimposed 

 Arterial Blood Gas (ABG)

Definition

An arterial blood gas (ABG) is a blood test that is performed using

blood from an artery. It involves puncturing an artery with a thin needle

and syringe and drawing a small volume of blood. The most common

puncture site is the radial artery at the wrist, but sometimes the femoral

artery in the groin or other sites are used. The blood can also be drawn

from an arterial catheter. Arterial blood gas analysis is used to measure

the partial pressures of oxygen (PaO2) and carbon dioxide (pacO2)' and

the pH of an arterial sample. Oxygen content (O2CT), oxygen saturation

(SaO2) and bicarbonate (RCO3 -) values are also measured.

Indication

The test is used to determine the pH of the blood, the partial

pressure of carbon dioxide and oxygen, and the bicarbonate level. Many

blood gas analyzers will also report concentrations of lactate,

hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin

and methemoglobin. ABG testing is mainly used in pulmonology, to

determine gas exchange levels in the blood related to lung function, but

has a variety of applications in other areas of medicine. Combinations of

disorders can be complex and difficult to interpret, so calculators [1],

nomograms, and rules of thumb[2] are commonly used.

Contraindications

 Abnormal modified Allen’s test is indicative of inadequate

collateral circulation to the hand and suggests the need to select

another extremity as the site for puncture.

 Arterial puncture should not be performed through a lesion or

through or distal to a surgical shunt (e.g., as in a dialysis patient).

If there is evidence of infection or peripheral vascular disease

involving the selected limb, an alternate site should be selected.

 A coagulopathy or medium-to-high-dose anticoagulation therapy

(e.g., heparin or coumadin, streptokinase, and tissue plasminogen

activator but not necessarily aspirin) may be a relative

contraindication for arterial puncture.

Purpose

 To evaluate gas exchange in the lungs.

 To assess integrity of the ventilatory control system.

 To determine the acid-base level of the blood.

 To monitor respiratory therapy.

 To evaluate the adequacy of ventilatory (PaCO2) acid-base (pH

and PaCO2), and oxygenation (PaO2 and SaO2) status, and the

oxygen-carrying capacity of blood (PaO2, HbO2, Hbtotal, and

dyshemoglobins).

 To quantitate the patient's response to therapeutic intervention

and/or diagnostic evaluation (e.g., oxygen therapy, exercise

testing).

 To monitor severity and progression of a documented disease

process

Materials
 Appropriately anticoagulated sterile glass or plastic (low

diffusibility) syringe with needle.

 Waste syringe (for 3 ml of waste) if arterial line draw.

 Patient label and lab collection slip.

 70% isopropyl alcohol or other suitable antiseptic solution.

 Gauze square or similar material (omit if from indwelling catheter).

 Well-fitting non-latex gloves.

 Biohazard laboratory specimen bag.

 Needle cap allowing for single-handed recapping or device designed

to allow single-handed insertion of the sample needle point after

withdrawal from the artery (this should provide some resistance to

insertion and should not allow the needle to completely traverse it).

 Syringe cap.

 Local anesthetic is not generally considered necessary for single

punctures (unless for placement of indwelling catheter).

 'Waste' syringe (if from indwelling catheter).

 Protective eyewear and outerwear (in the anticipation of splashing)

(if from indwelling catheter).

 Container with ice deep enough to immerse syringe beyond the level

of the specimen (to immerse syringe barrel if specimen will not be

analyzed within l5 min).

Preparation

Patients do not need to restrict food or drink before the test. For

patients receiving oxygen therapy, the oxygen concentration must

remain constant for 20 minutes before sample collection; if the test is

specifically ordered to be without oxygen, the gas must be turned off for

20 minutes before the blood sample is taken to guarantee accurate test

results. The patient should breathe normally during sample collection.

Infants and children may require physical and psychological preparation

appropriate to the child's age. A parent or other trusted adult may be

enlisted to restrain the child during sample collection.

Patient Preparation

 Explain to the patient that this test is used to evaluate how well the

lungs are delivering oxygen to blood and eliminating carbon

dioxide.

 Tell him that the test requires a blood sample. Explain who will

perform the arterial puncture and when and which site - radial,

brachial, or femoral artery - has been selected for the puncture.

 Inform him that he needn't restrict food or fluids.

 Instruct the patient to breathe normally during the test, and warn

him that he may experience a brief cramping or throbbing pain at

the puncture site.

Procedure

1. Obtain needed equipment.

2. Perform Allen’s test (both the radial and ulnar arteries should be

compressed at a level approximately 1 centimeter proximal to the

wrist joint while the patient’s hand is squeezed for approximately 5

seconds then relaxed. The palmar surface of the hand should be

blanched. Release compression on the ulnar artery. It is normal for

the palmar surface to flush within 5 seconds. Prolonged delay

before flushing indicates decreased ulnar artery flow. Radial

arteries lacking collateral ulnar circulation should be avoided as

puncture sites if possible. In adults if the radial artery is unsuitable

as a puncture site, the brachial artery is the second choice,

followed by the femoral artery).

3. The skin over the puncture site is cleaned with 70% isopropyl

alcohol or other suitable antiseptic solution.

4. Palpate the site trying to stabilize the artery. Slight hyperextension

of the wrist or elbow can be achieved by placing a rolled up towel

under the joint; this can aid palpation and stabilization of the

artery.
5. Hold the syringe so the bevel of the needle faces upward, keeping

the needle at a 25° to 45° angle to the artery. Insert the needle

through the skin into the artery taking care not to puncture the

posterior wall of the artery (if any venous blood is obtained the

procedure should be restarted with a new syringe). If the artery is

not entered immediately the needle may be slightly pulled back

then redirected into the artery

6. Arterial pressure should cause the blood to flow into the syringe.

7. Withdraw the needle when an adequate sample has been obtained.

Immediately place dry gauze or cotton over the puncture site and

apply pressure.

8. Maintain pressure over puncture site for a minimum of 5 minutes

(longer if the patient has taken aspirin or anticoagulants).

9. Single-handedly cap needle then remove from syringe.

10. Expel any air bubbles from the sample and cap the syringe.

11. Mix sample by rolling and tilting syringe.

12. If not analyzed immediately, store the sample in ice (2-4°C).

Iced samples should be analyzed within 3 hours.

13. The puncture site should be compressed for a minimum of 5

minutes, longer if the patient is taking anticoagulant therapy,

aspirin or has a prolonged prothrombin time. After 5 minutes, the

puncture site should be inspected for several seconds to ensure that

clotting has taken place. During this inspection, palpate the pulse

proximal and distal to the puncture site to assess the presence of

arterial spasm.

14. A sterile bandage should be placed over the puncture site to

keep the puncture site clean while healing. A bandage is not a

substitute for compression of the puncture site.

Pictures

Complications

 Hematoma
 Arteriospasm

 Air or clotted-blood emboli

 Anaphylaxis from local anesthestic

 Introduction of contagion at sampling site and consequent infection

in patient; introduction of contagion to sampler by inadvertent

needle 'stick.'

 Hemorrhage

 Trauma to the vessel

 Arterial occlusion

 Vasovagal response

 Pain

 Repeated puncture of a single site increases the likelihood of

hematoma, scarring, or laceration of the artery. Care should be

exercised to use alternate sites for patients requiring multiple

 punctures. An indwelling catheter may be indicated when multiple

sampling is anticipated.

Ventilation – Perfusion Lung Scan – Ventilation Scan

Definition

A lung perfusion scan and ventilation study are two diagnostic

imaging studies. A lung perfusion scan assesses blood flow to the lungs.

A lung ventilation study reveals the distribution of air space within the

lungs. These are two separate studies that are often performed

sequentially. The tests are called by different names, including perfusion

lung scan, aerosol lung scan, ventilation lung scan, xenon lung scan,

ventilation/perfusion scanning (VPS), pulmonary scintiphotography, or

most commonly, V/Q scan.

Indication

People who have signs or symptoms of a pulmonary embolism

(PE) may need lung ventilation/perfusion (VQ) scans.

A PE occurs when a blood clot travels to the lungs and blocks blood

flow. Signs and symptoms of PE include chest pain, trouble breathing,

rapid breathing, coughing, coughing up blood, and a rapid heart rate.

Some clots travel to the lungs from veins deep in the legs. This can

cause pain and swelling in the affected limb(s).

Doctors use VQ scans to help find out whether a PE is causing these

signs and symptoms. A VQ scan alone, however, won’t confirm whether

you have PE. Your doctor also will consider other factors when making

a diagnosis.

Doctors also use VQ scans to detect poor blood flow in the lungs’ blood

vessels and to examine the lungs before some types of surgery.

Contraindication
  Contraindication for anticoagulant therapy provided there was no

evidence of deep venous thrombosis on ultrasonographic or

impedance plethysmographic studies of the legs.

 Contraindication for spiral CT angiography or pulmonary

angiography.

Purpose

 Lung scans may be performed for patients with chest pain, for

those coughing up blood (hemoptysis), or for those having

difficulty breathing (dyspnea).

 A perfusion scan alone or both tests are frequently performed for

patients with a suspected pulmonary embolism (blood clot in the

lung) or for follow-up in patients with known pulmonary

embolism.

 Lung scans are a sensitive method for demonstrating the presence

of pulmonary disease but are not often specific for a certain

disease. For example, an abnormal scan may also be caused by

 chronic obstructive pulmonary disease (COPD), asthma,

pneumonia, venous hypertension, pleural effusion, and

cardiomegaly.

Materials

 These tests use inhaled and injected radioactive material

(radioisotopes) to measure breathing (ventilation) and circulation

(perfusion) in all areas of the lungs.

 Technetium DTPA, technetium MAA, Chext X-ray, , The

perfusion phase of the test involves the intravenous injection of

radioactive technetium macro aggregated albumin (Tc99m-MAA).

A gamma camera acquires the images for both phases of the study.

Preparation

 To accompany the lung scan, the patient should have a chest x ray

within 12 to 24 hours of the study.

 Otherwise, there is no special preparation needed for these tests.

  The patient may eat and drink normally before the procedure. You

do not need to stop eating (fast), eat a special diet, or take any

medications before the test.

Procedure

 The patient is injected intravenously with radioactive particles,

known as Tc 99m MAA (macroaggregated albumin). The particles

pass through the larger blood vessels and become temporarily

trapped in small blood vessels. The images thus reflect blood

perfusion in the lungs. Images are obtained anteriorly, posteriorly,

laterally, and obliquely.

 For a lung ventilation scan, the patient inhales a radioactive gas

through a mask placed over the nose and mouth. Images of the

ventilation lung scan show the distribution of the gas in the lungs.

The test typically consists of three phases.

  The first stage is the initial, or ventilation stage, which reflects the

rate of ventilation of the different lung segments.

 Second is the equilibrium stage, which represents gas volume of

the lungs.

 The third stage is the wash-out phase, which demonstrates any gas

trapping that may occur in obstructive diseases.

 Images are typically obtained posteriorly, although additional

views may also be performed. Each test takes approximately 15 to

30 minutes. If possible, the patient usually sits up while the images

are taken.

Pictures
Complications

 Allergic reaction to Isotopes

 Complications from radiation