008 Mark Klimek

The transcript highlights the importance of knowing and prioritizing lab values in healthcare. It emphasizes that not all lab values are of equal significance, and understanding which values are high priority is crucial. The speaker introduces a prioritization system using letters A, B, C, and D to categorize lab abnormalities based on their urgency. They explain this system using examples of creatinine and INR levels, stressing the need to take immediate action for high priority values. The protocol for responding to abnormal lab values is discussed, emphasizing the steps of holding, assessing, preparing, and calling in a specific order. The importance of correctly interpreting and responding to lab values, such as potassium levels, is also highlighted. And we'll start on page 35, lab values, you have to know your lab values. But the good news is you don't have to know them all. Just certain ones that everybody else knows. The only... Well, there's kind of more bad news, and that is not only do you have to know lab values, you have to know which lab values are more dangerous than what other lab values. So if you knew ten lab values, you need to know which ones are high priority, which ones are middle priority, and which ones are low priority. Because they will ask you to prioritize people according to their lab values. Like, they'll give you four different patients. A patient with a potassium is 7.4, a potassium with a pH of 6.8, a person with a hemoglobin of 10, and a person with a BUN of 54, and they want to know who's your highest priority patient. That kind of thing. So it's not good enough just to know the values themselves. Because they will give you four people, all of them have abnormal lab values. All of them do. So what you have to do is then rank them. You know, on who's highest, who's lowest priority. So what I want to do is teach you that because I don't believe any school I know of teaches students how to prioritize lab values. They teach you the lab values. They teach you the numbers, the ranges, what's normal, what's abnormal. They teach you what high means, what low means. They teach you the significance of the test, but they don't teach you that a hemoglobin of 7 is a higher priority than a person with an INR of 3.4. You see what I'm saying? They don't get to that. Now, am I mistaken? Are some schools doing that? Are any schools doing that? They just say, potassium is bad. Probably on board that's probably the least you should know, at least that. But I'm going to give you a scheme here. You see the legend at the top of the page where it says A, B, C, D? A means that it's not a priority. It's a low priority. It's not a big deal. Yes, it's abnormal. The lab is abnormal. But really there's nothing you need to do about it. In fact, in real life, if... See, what I'm going to do is... Let me go back up. What I'm going to do is, for every lab value I give you, I'll tell you whether the abnormal is an A, a B, a C, or a D. I'll assign a priority letter to it. Are you understanding where we're headed with this? And when I tell you that a lab abnormality is a level A, what I'm trying to communicate to you is that, yes, it is abnormal. And, yes, it could mean there is a presence of disease. But in the scheme of things, this is really no big deal. In fact, you don't have to do anything about it. In other words, if a lab report came back and it's an A level, you could ignore it all night long and have the doctor discover it in the morning and you wouldn't be in any trouble for having that happen. Do you understand what I'm saying? However, if I tell you it's a C level, level C, letter C, and you do nothing about it all night long and the doctor finds out about it in the morning, you are in major trouble. So I'm trying to give you a feel for how important it is that you must report these or do something immediately. So an A is abnormal, yes, but you do nothing about it. It's no big deal. A letter B, it is abnormal and you need to be concerned, but there's nothing you need to do. You just kind of watch them closer. Have you had the experience where you had a lab value that was abnormal, but it really wasn't all that bad? So you didn't have to do anything, but that lab abnormality said to you, watch them closer, watch them closer. That's what I'm trying to tell you a B is. When I tell you that a lab value is a C, we've now crossed the line from low priority to high priority. When a lab reaches a C value, it is critical. You must do something about it. You can't just sit on that lab value and do nothing. If I tell you that a lab abnormality is a D, I'm trying to communicate to you that it is the highest priority that you can possibly have with a lab value. So what's the lowest priority? A. Followed by? B. And then what are two high priorities? C. And the highest of all is? D. D, okay. Does everybody know where we're headed here? Okay, now let's start into this lecture. In the first column, there's the name and anything I want to tell you about it. In the middle column, you'll write the range, the normal range. And in the last column, we'll assign the A, the B, the C, or the D. All right? Let's talk about creatinine. I told you two days ago that it is the best indicator of kidney or renal function. Now, in this case, I am talking about the serum creatinine because they will not talk about, they will not give you the values for a creatinine clearance, 24-hour creatinine clearance. They are going to test you on that. But they will test you on the serum creatinine. Now, the serum creatinine is 0.6 to 1.2, which is actually the same numbers as the lithium range. If you recall that from yesterday, the lithium and the creatinine are the same range. Okay, in the middle column, you have that. In the last column, an abnormal creatinine is just a level A. You would never prioritize a person with a high creatinine as your highest priority. Now, do they have kidney disease? If they have a high creatinine, yes. But are they going to die in the next four hours? No. The next morning, the doctor can come in and go, oh, his creatinine is high. He must have kidney disease. And that's fine. You're not going to be in any trouble for it. Probably the only time that I would ever make a high creatinine something that I would actually make a phone call to a doctor about is if they were going for a test that had a dye in it that next morning. Like, for example, if they're having a cardiac catheterization where they put the dye in. If the question tells you that they're going to have a dye procedure in the morning, I might make a high creatinine something that I would report. But it wouldn't be in the next hour. It would just be sometime, like, for example, if you got the high creatinine back at midnight, I wouldn't call the doctor until 5 or 6 in the morning. At the earliest, I might wait until 7. I certainly wouldn't call them at 1 in the morning. But there are certain lab values you're going to see, and you call them right away. So even then, it wouldn't be a super high priority, but it would be higher than just a plain high creatinine. Does everybody understand that? Okay. The INR, the International Normalized Ratio, it monitors cumulative therapy. It's like the PT. It's a variation of the prothrombin time. Its normal range should be 2 and 3, in the 2s and 3s. In other words, you want your INRs to be in the 2s and the 3s, like 2.1, 3.8, that's what you want. In the last column, anything that's above 4, or 4 and above, is a C, which means it's high priority. You have to do something. This is not one you can ignore. You can ignore the creatinine, but you cannot ignore this one. An INR of 4.2, which is C, would be a higher priority than a creatinine of 30. Now, when I assign something a letter C, what do I say are the implications of that? It's critical, and you have to what? You do something. Now, the question you should be asking is, Well, whenever you get a situation where they want to know, what are you going to do about something, there's a protocol you need to follow, an order, because this would be a click and drag. You always hold. That's the first thing you do. What do I mean by hold? If there's something that's causing a problem, stop it first. First. After you hold, then you assess. What would you assess? A whole, complete, head-to-toe physical exam, yes or no? No. Yes or no? No, a focus assessment. Focused on what? The area that the lab value is telling you there's a problem with. But do a focus assessment. Then you prepare, which means you prepare to give. Now, you don't always give, but you prepare to. And after you prepare, then you call, meaning call a physician, or call a respiratory, or call whomever is appropriate. But before you call a physician, you always hold, assess, and prepare. Now, if we apply this to the INR of 4.7, let's say you get an INR of 4.7, and they want to know what are you going to do, in what order, and you have to click and drag, what would you click first? Hold. Hold what? Hold cumulative. Hold on cumulative. Then what would you do? Assess. Assess for what? Bleeding. Then you would? Vitamin K. Vitamin K, prepare to get vitamin K, and then you would? Follow your diet. In that order. Now, sometimes, there may be nothing to hold. You understand what I'm saying? There's nothing to hold. There's nothing causing a problem, so you jump immediately to what? Assess. Assess. And sometimes there may not be anything to prepare, so you jump to? Call. Call, but you should intellectually go through that process with everything you do something about so that you're thorough, so that you don't miss a step. All right, potassium. Potassium, there's nothing I want to say about it in the first column, except that it's not really a good indicator of anything, but it is an indicator that something's wrong, but you don't know why. Its range is 3.5, and then flip it around, 5.3. 3.5 to 5.3. Now, for hep C, for hep C, it's 3.5 to 5.0. For hep C, it's 3.5 to 5.0. But for bores, it's 3.5 to 5.3. Why? Why the difference? Bores is a nationalized, hep C uses whatever Elsevier lab book says. Okay. So, to hep C, a 5.1 potassium is an elevation. On bores, a 5.1 is not an elevation. Now, let's talk about the last column. A low potassium, meaning lower than 3.5, is a C. You have to do something. Okay. Now, let's go through our protocol. If your potassium is low, is there anything you have to hold? No. So, what do you do? What are you assessing? What's your focus? Heart. Assess heart. Prepare to administer vitamin K. Vitamin K. Potassium. I always do that. I always used to do that. Everybody ever do that? Vitamin K and potassium K? I screwed that up for like 10 years. Okay. And then I what? Call the doc. Alright. What if it's between 5.4 and 5.9? That gets a C. So, now you have to do something. Well, is it high or low? High. So, what do you think we would first do? Hold all potassium. Potassium. And that may mean ripping down the D5W with 20 of KCL. Does that mean getting that torn down? Then you assess the? Heart. Heart. Then you? What? Now, Lasix does make you lose potassium, but we don't give Lasix for the purpose of losing potassium. KCL and D5W and regular insulin. Remember yesterday? KCL and D5W and regular insulin. And then you call your doc. However, in the last column, if the potassium is greater than or equal to 6, it's a D. It is deadly dangerous. This person could die soon, like in the next two minutes. So, what do you do? You do everything we just said. You rip down the IV. You assess the heart. You prepare the D5W, regular insulin, and the KCL. You call your doc. You do all that what? That. So, how many people have to be involved? You've probably got one nurse ripping out the potassium. You've got somebody calling for an EKG coming. One nurse is preparing the D5W and regular insulin while the secretary is calling the doctor's staff. You see what I'm saying? And you stay with your patient. Got it? Because you cannot leave the bedside of a D. You understand what I'm saying? Can you leave the bedside of a C? Do you know what I'm talking about? D's and C's. Okay, got it. Can you leave the bedside of a C? Yeah. Can you leave the bedside of a D? No. So, one of the things you're going to have to remember when you're answering these D questions is you stay at the bedside and you do what you can do at the bedside, but everybody else helps you do everything else. You don't run out and get the EKG and leave your patient by themselves with a potassium of 7, okay? Now, I'm not saying you do this in real life. You should do it in real life, but I'm saying this is what the book wants you to do. And really, if you really did this, you wouldn't get in trouble. Your patient would be in good shape. Okay. The pH, 7.35, 7.45 is the range which you told me the other day. In the last column, the only thing that matters is a pH in the sixes is a D. Now, I don't mean 7.6. I'm talking about 6-point-something in the sixes. Now, you notice that I don't... Do you notice with the creatinine, I didn't go... I didn't talk about a low creatinine. Did you notice that? And in an INR, I didn't talk about a low INR. And here, I'm not talking about a high pH because those aren't that clinically significant and they're not usually tested at all. These are the things that are tested over and over and over again. So, rather than have you learn everything, let's focus on what's essential. All righty. pH in the sixes. So, what do you do? Is there anything to hold? I can't think of anything. What would you assess? Now, this is interesting. What do you think you'd assess? Somebody said respiration. Somebody said pulse. There you go. Lump them together. Check your vital signs. Because the pH is going in what direction? Down. And as the pH goes, so does your patient. So, the patient is going to be going what? Down and out. And you're checking... I mean, with a pH in the sixes, to be totally transparent and honest with you, you're doing the vitals to make sure they're still alive. I know that sounds ridiculous, but you really are. Because, I mean, usually when you have a six, you're dead. So, you're just making sure they're alive. And then, is there anything to prepare? Not really. Used to be, years ago, because they were severely acidotic, we would prepare bicarbonate to give bicarb. But you don't do that anymore. You don't indiscriminately give bicarbonate. Like, if you've ever been taught that, no, you don't do that. You don't give bicarb anymore to acidotic patients because it confuses the whole issue. The key is to correct this acidosis. The only way you can correct it is to treat the underlying cause. And there is nothing a nurse can do to treat the underlying cause. The physician has to get here, determine the cause, and treat the cause. So, with a low pH, you have to get the physician in on the case faster than anything else we'll talk about today. So, that's why you just assess their vital signs and you call your doc. And you skip hold and you skip prepare. Now, why are you getting the vitals? Because when you call the doc, what are they going to say? Is he alive? You know, are he brave? What's his heart doing? So, get a set of vitals. That's all you need. Set of vitals. Call the doc. And you stay. So, who gets the vitals? You do. Who calls the doc? Maybe some, you know, get a trauma light or whatever and however you communicate to your secretary, unit secretary, and have them call back. Okay, BUN, blood urea nitrogen. BUN. It has a lot to do with nitrogen waste products in the blood. Its range is 8 to 25. 8 to 25. The way I remember that is B-U-N spells what English word? BUN. BUNs, like hamburger buns, hot dog buns. When you buy hamburger buns or hot dog buns, how many are in the pack? Eight. There's your eight. BUNs, eight. Eight to 25. And if the BUN is elevated, it's no big deal. All you do is assess them for dehydration. Assess them for dehydration. By the way, a little hint. Good guessing strategy here. If they give you an elevated blood value and you have no clue what's going on and they ask you, for what would you assess them? Dehydration is a great answer. Because when you dehydrate, what happens to all blood values? They go up because of concentration. So it's just a really good guess to say when the BUN's up, well, I don't know what it is. Well, pick dehydration. Good answer. You may be wrong, but it was a good answer. Might not have made the top ten surveys, but you know, not bad. I don't know why I added an extra L on the end of elevated, but you know. Hemoglobin is the next one. It's 12 to 18. Now, yeah, I know it's 12 to 16 for women and 14 to 18 for men. But for humans, it's 12 to 18. And four doesn't get into lab values versus men versus women, children versus adults, newborn versus... They could be on your test, but those are really hard questions and you do not have to get those right. But if you don't know a normal adult hemoglobin, you're in trouble. If it's eight to 11, if the hemoglobin is eight to 11, it's a B. And you would assess them for what? Low hemoglobin. Anemia, a bleeding or malnutrition. If the hemoglobin, however, falls below an eight, it's a C. And you must do something. Okay, well, what are you going to do? You going to hold anything? Not that I know of. You're going to assess for? Bleeding. You're going to prepare? To administer? Blood. And you're going to call? The doctor. Now, LPN, you would prepare, but you would call, not on this, but on everything where we've said call doctor, you could substitute notify RN. You see what I'm saying? This could say hold, assess, prepare, notify RN. All right? Bicarb. The bicarb is what? Two plus two plus two equals six, right? 22 to 26. And an abnormal bicarb is an A. We don't care. So what? You know, I've never in 37 years of being a nurse, I have never been yelled at by anybody because I didn't tell them what somebody's bicarb was. This is not a major issue. Okay, CO2, carbon dioxide. This you are getting from an arterial blood gas, by the way. The normal range is 35 to 45. It's the same as the pH just dropping off to seven point. Correct? In the last column, a CO2 that's high, but in the 50, like 51, 57, 56, 59, those are C levels. That's a C, which means it's critical. You can't just sit on it. You got to do something about that. That's not good. Now, I want to say a disclaimer. I'm not talking about COPD clients here at all. That changes everything. This is for people without COPD. So what do you do? Well, is there anything to hold? A high CO2, anything to hold? I don't think so. What would you assess? Respiration. Respiratory status. Now, when it comes to prepare on this one, there is actually something you can do. There is actually something you can independently, as an LPN or an RN, do. What would that be? Breathing in a bag actually recirculates the CO2, so we don't want that. That would be raising the CO2. What's that? Oxygen is used for low oxygen, not for high CO2. What's that? What's that? Oh, yeah, yeah, yeah. Or they'll say the candle, this is a candle, blow out the candle. That is called first-lip breathing. Have you heard of that? This is what you're going to pick, first-lip breathing. Because with first-lip breathing, you're prolonging the exhalation, and if you prolong exhaling, you're getting rid of CO2. Now, most of the time, that will correct the problem, so you never have to move to what? Home. How do you know it's going to correct the problem? They will breathe easier. Because when they're in the 50s, it's going to be dissonant. They'll be dissonant when there's CO2 in the 50s. So that will solve that problem. However, what if the CO2 is in the 60s? That's a D. That's one of the criteria for making the diagnosis respiratory failure. Have you heard of respiratory failure? Well, how do you know someone's in respiratory failure? Well, one of the ways you know is if the CO2 is 60 and above. Now, here again, we're not talking about COPDers. So this is a medical emergency. This is a super high-priority patient. So you do not what? Leave the room. You stay with them. So is there anything to hold in this case? Nope. Assess their respiratory status. Now, pursuant breathing isn't going to cut it. Now, I will probably do it with them just to decrease their anxiety and maybe take the edge off of it. But I'm going to have to prepare for what two things because they're in respiratory failure. Intubate and ventilate. So you prepare to intubate and ventilate. Ventilate. And then who do you call? There's two people to call. Who do you call first? Respiratory therapy first. Call respiratory therapy first. Then call the physician. But you stay with your patient. Yes. Like a code? A pre-code? Yeah. On board, they really don't have anything that's called an emergency response pre-code T. They don't. That's... Certain hospitals have that. Some don't. And because it's not a universal phenomenon across the nation in every hospital, they won't even go there. But I would say if I were you and I had one of those teams at my disposal in a hospital, yes, at this point I would because the person's going to end up on a bed. And that's the best that's going to happen. The worst could happen before. No. Yeah. All right. Hematocrit. Hematocrit is 36 to 54. 36 to 54. Now, I don't remember that. That's why I had to think for a few seconds before I said it. I never remember that because that's a clumsy number, 36, 64. You know, it's just sloppy. Well, it's three times the hemoglobin. So whatever the hemoglobin is, multiply that by three, and that's why I had to do the math in my head there for a second before I told you. So 12 times 3 is 36, and 18 times 3 is 54. So it's 36 to 54. Okay, an elevated hematocrit. An elevated hematocrit. It's abnormal. It's a B. An elevated hematocrit, what would you assess for? Dehydration. Good job. Dehydration. But it's no big deal. Okay, let's talk about the oxygen level, the PO2, the oxygen level. Here again, you're getting this from the arterial blood gas. This is not what you're getting when you put on the pulse pox on their finger or their earlobe. That is not the PO2. The PO2 is from the blood gas. Now, the PO2 normally should be 78 to 100. 78 to 100 is the normal range. Okay. If it is low, but still in the 70s, like 70 to 77, that is a C, which means you have to do something. It's critical. So, is there anything to hold? No. You assess what? Respiratory. Now, there is something you can do, both LPNs and RNs, without a physician's order, and what is that? Give them oxygen, because their oxygen is low. So, now you give them oxygen. And 9 times out of 10, what will happen? Will it correct it or not? It will correct it, and you will not have to call your physician. And how will you know it corrected? Because you're not having a continuous arterial blood gas measurement. You don't know because the dyspnea goes away, and the restlessness and the anxiety and the tachycardia. By the way, just an interesting thing, so I know everybody knows this, because they love to test this. When someone is hypoxic, which rate increases first? The respiratory rate or the heart rate? Heart rate. Heart rate. So, when you go hypoxic, your heart rate will speed up first. Then, when the heart can no longer compensate for it, your respiratory rate goes up. A lot of people think, oh, hypoxic, your respiratory rate will go up first. No, it won't. Your heart rate goes up first. If you ever work coronary care, what are the two most common causes of episodic tachycardia in heart patients? Hypoxia and dehydration. So, a coronary care nurse knows that when you get these episodic tachycardias, all you have to do is increase the IV rate and give them some oxygen, and it goes away, and you never have to call your doctor. I would have to say 90% of the time that I have episodic tachycardia in the coronary care unit when I worked night shift there for 10 years. It was at Mercy Medical Center in Springfield, now called Springfield Regional whatever Mall. I never had to call doctors because I would just up the IV rate or give them oxygen, and the tachycardia would go away. You always could tell a new nurse who came into coronary care because they were calling doctors in the middle of the night for episodic tachycardia, and the doctor would say, well, did you increase the IV rate? No. Did you give them oxygen? No. Well, do that and call me back if it doesn't work, you know, and I'm saying it politely. Okay, well, what if it's low in the 60s, meaning 68, 69, 64, 63? That's a D. That's the other criteria for respiratory failure. So what are the two defining characteristics for respiratory failure? CO2 in the 60s and an O2 in the 60s. When they're both in the 60s, that's when you need to intubate and ventilate them. So if it's in the 60s, there's nothing to hold, you assess the respiratory status, you prepare to intubate and ventilate, you call respiratory therapy, and you call the doctor. Now, you can put oxygen on them during that time. It's not going to solve the problem, but it's going to make them a little more calm. So if I had to click and drag on that one, where would I put the oxygen? I'd probably do this. I'd probably hold. I wouldn't hold anything. I'd assess. Well, no, I'd probably leave. There's nothing to hold. I'd probably throw on the O2 just to make them more comfortable. Then I'd assess them, and then I'd prepare to intubate and ventilate, call respiratory therapy, and call the doctor. Yeah? No. No, you're not. That's a gross oversimplification. She said that she was taught that in an order question, you always assess before you do. That's true 80% of the time. 20% of the time, it's wrong because there's something you need to hold before you assess. For example, you're getting a blood transfusion and somebody complains of itching and you see hives. What do you do? Stop the blood. Then you do your assessment. That would probably, I don't think, just in my impression, I think if you ask 50 nurses, you'd have half and half on that. And so I don't really, I can't conceive that they would write that question on board because it would be such an interpretive thing. Subjective kind of thing. But if the INR is five, every nurse says, I'm going to stop the coup and then I'm going to find out a set. You know, they would all say that. And if the set's in six, they'd say, I turned off the IV, then assess their heart. So yeah, it's going to be, there are certain things where, I always tell people this. Assess before you do. Unless delaying doing puts your patient at higher risk. And if you would assess for signs of blood transfusion reaction, if you delay stopping the blood to do an assessment of are they having a reaction, you would be putting the person at increased risk. So therefore you do before you assess. Does that, so what's the rule everybody? Assess before you do. Unless delaying doing in order to assess puts the patient at risk. For example, a patient pulls out their arterial line. They are bleeding in bright red spurts from their radial artery. What's the first thing you do? Assess their vital signs. Apply pressure. Okay, well ones assess, ones do, right? Well, if you delay putting pressure in order to take a set of vitals, are you increasing the risk to the patient? Yes, therefore do will precede assess. And that's an obvious one, but I'm trying to illustrate the principle. Are you seeing that? Okay, good. Good question. That's one that everybody's taught. How many were taught? Assess before you do, assess before you do. But you have to understand, whenever you use a rule like that, you have to understand there's always an exception and what's the exception? Yes? It's not common when we've always had a question on aesthetic or a sense of health. Are you talking about a respiratory situation where she was birthed and it had head of the bed and oxygen and you were talking about if that's an issue or not an issue? Yeah, the thing is if I was between somebody's having dyspnea, acute dyspnea, one would elevate the head of the bed, the other would put on oxygen, the other was call the doctor and the other would do a respiratory assessment. What would I do? I would elevate the head of the bed first. Alrighty? Because if I do a respiratory assessment with him lying flat, I'm just, it's just, I'm getting data that's not going to be helpful. He's not going to cooperate with me. I'm not going to get good data. I'm not going to get full. So I'm going to elevate the head of the bed first. I always like to do, if I'm between two dudes, I like to position first. You know, if I'm between two dudes and one's a position and one's another action, I find that the position usually wins over the other action. How many have found that out? Sort of seen that? So I would probably elevate the head of the bed, I would put the oxygen on, I would do an assessment, and then I would call the physician. Now what did ACI say, I wonder? Is that what ACI said? Because I almost always position first. When I'm between, what, two dudes, I always position first. And see, my rule there would be, if somebody's in significant dyspnea and hypoxia, would delaying putting their head up and delaying giving them oxygen while I did a respiratory assessment put them in greater risk? And the answer is yes, you would be. You see, so then I would precede the assess with the dude. Do you see that? Yeah, question? So if you raise the head of the bed first, would you use the bed if you raise the head of the bed first? Big up. Pretty smart. Big up. You hear what she said? She said, but what if it's not a first question, what if it's a best? And you're between oxygen and raising head of bed. Well, in a best question, I'm really glad. Are you here for a refresher, or is this the first time we've taken this up? First time? Good job. Because if you had to do one, raise her head without giving her oxygen or keep her flat with oxygen, she really will benefit better from the oxygen lying flat than she will up with no O2. So best would be O2. First would be raise head of bed. Raise head of bed. Is everybody seeing that? Good call. Okay. The O2 stat, the oxygen stat, should be 93 to 100. Anything less than 93 is a C. Critical. There's nothing to hold. You assess them. You throw on the O2. Now you could, I don't think with an SAO2, unless they're in real, real danger, although SAO2 is not like an 88, there's no reason to throw on the O2 right away. You know what I'm saying? There's no big deal there. In fact, I can't even believe I'm telling you that an SAO2 below 93 is that bad because I'm happy with SAO2s of 88 and above. If you think that you're going to run around calling doctors in the middle of the night for SAO2s of 91, they're not going to last long. But on HESI in particular, and on boards, if it's a 92 SAO2, they're in bad shape. And I'm telling you, that's not real life. But that's the book. You got me? Because HESI has a question on there where it says they give you four patients and want to know who's your highest priority. And I remember taking it when the patient was a 91 SAO2. And I went, oh, that's fine. And then I went to B, and they were okay. And I went to C, and they were fine. And I went to D, and they were good too. And I thought, oh my goodness, they're all fine. And I thought, wait a minute, wait a minute, wait a minute, 90, it's not 93, it's 91. So that's the one that's in bad shape. So I picked them. I got it right. So you're just going to have to go with that, all right? Now, does anybody ever want to work peds? And pediatrics, you better freak out when it's below 95. Okay, because little kids don't desaturate. Without older people, we desaturate all the time. You know, it's just what we do. But little kids don't desaturate. They usually won't go to COPD because that's anything to do, there's no, with COPD, they're going to have abnormal blood gases. But there's no pattern to tell you what it's going to do and what it's not going to do. It's something like, they can't say, well, you know, a respiratory failure for a COPDer, it's not 60 and 60, it's 70 and 50. There's no, there are no parameters. Every COPD is, their blood gases are individually judged on their level of functioning at that blood gas. So if you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD and you have a COPD If only one was a COPDer If only one was a COPDer If only one was a COPDer If only one was a COPDer with a CO2 of 55 with a CO2 of 55 and an O2 of 71 and an O2 of 71 and an O2 of 71 even though those are even though those are letter C's for you and I letter C's for you and I letter C's for you and I I would not make them I would not make them a high priority. a high priority. BFT BFT Oh, by the way, Oh, by the way, when is your SAO2 invalid? when is your SAO2 invalid? What invalidates your What invalidates your finger probe SAO2 rating? finger probe SAO2 rating? Anemia Anemia falsely elevates it. falsely elevates it. So if somebody's anemic So if somebody's anemic they're going to look they're going to look a lot better than they a lot better than they actually are. actually are. So if you have an anemic So if you have an anemic patient, your SAO2 patient, your SAO2 is not helpful. is not helpful. You need to look at You need to look at other indicators of other indicators of oxygenation. oxygenation. The other thing that The other thing that invalidates it invalidates it is if they've had a is if they've had a blood color. blood color. And what does that And what does that read? read? color. color. So you're going to So you're going to have falsely elevated have falsely elevated SAO2s with anemia SAO2s with anemia and after-diet and after-diet procedures. procedures. So in both cases So in both cases you're going to you're going to when you get your when you get your SAO2, you're going to think the patient think the patient is what? is what? Okay, BMP, which is Okay, BMP, which is the brain natural the brain natural uretic peptide. uretic peptide. Don't worry about Don't worry about that. that. It's the best indicator It's the best indicator of congestive heart of congestive heart failure. failure. It should be It should be under 100. under 100. And elevated BMP And elevated BMP is a B, which just is a B, which just means you've got congestive heart means you've got congestive heart See, it sounds See, it sounds kind of funny that a kind of funny that a heart value is not heart value is not a high priority. a high priority. But this is a heart But this is a heart value, which is value, which is indicating a chronic indicating a chronic condition. condition. Do you understand Do you understand why it's not why it's not high priority? high priority? Because it indicates that a chronic that a chronic condition, not an acute one. acute one. If the sodium If the sodium is high, you is high, you assess for is high, you assess for dehydration. dehydration. If the sodium If the sodium is low, you is low, you assess for overload. overload. Remember, hyperendotremia, Remember, hyperendotremia, hypoendotremia, the one with the the one with the E is dehydration, the one with E is dehydration, the one with O is overload. O is overload. However, if the However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. However, if the O is overload. 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