• Help promote Carlos’s independence by encouraging him to keep to his own testing rou- tine. Carlos should keep his glucometer and other equipment with him. However, testing should occur in the clinical room where used equipment can be safely disposed of. Staff should observe Carlos while he is doing the test and recording the reading.
• Carlos should keep a record of his blood glucose readings. Staff should physically check that he is doing this on a regular basis.
• Staff should keep a note of the blood glucose readings in Carlos’s case notes.
• Carlos takes metformin 500 mg twice daily along with meals. Staff should dispense medication as per NMC (2008) guidelines and ensure that Carlos takes the medica- tion.
• Staff should observe Carlos for both positive and negative side-effects of medication.
• Staff should liaise with Carlos’s diabetic nurse specialist and share information as appro- priate.
Carlos has a reduced calorie diet that he needs to maintain. However, this has proved very challenging and he frequently has problems maintaining it.
• Staff should liaise with the dietitian regarding Carlos’s diet and explore ways of maintain- ing it.
• Carlos should be referred to occupational therapy for advice on food preparation.
• Carlos should have his blood pressure, pulse, BMI, and waist-to-hip ratio recorded and monitored.
• Staff should give Carlos health education and promotion advice.
• Staff should encourage Carlos to be physically active during the day.
• Carlos should be referred to a smoking cessation therapist for advice on how to reduce/
stop his smoking.
• Staff should discuss the benefits of stopping smoking with Carlos and introduce him to the idea of nicotine replacement therapy (Nrt).
• Staff should observe Carlos for both positive and negative side-effects of poor diet.
• Night staff should be aware of the care plan to reduce Carlos snacking inappropriately at night and to promote continuity of care.
• Carlos’s care plan should be regularly monitored to determine progress.
Evaluate
• Daily evaluation will be conducted at the end of each shift. this will include monitoring baseline observations, blood glucose levels, medication compliance, and dietary intake.
• the care plan will be re-evaluated if Carlos experiences any serious complications, e.g.
hypoglycaemia or diabetic ketoacidosis.
Blood tests
• monitor blood glucose levels;
• monitor electrolytes;
• monitor therapeutic ranges for medications.
Various blood tests have corresponding ‘blood bottles’, vials with different coloured tops to indicate the test. These vials contain different substances, such as an anticoagulant to prevent the blood from clotting (if this is a test requirement), or vials without an anticoagulant or a serum separator when blood samples need to be put in a centrifuge and separated.
You may not normally take blood unless you have undergone specific phlebotomy training and are deemed competent in undertaking this role. Blood samples are usually taken by a phlebotomist or a doctor. However, it is important for practitioners to have the background knowledge of what the blood is getting tested for and what this might mean for the MHSU’s physical and mental health.
There are many different blood tests but here we examine some of those that may be described as routine in mental health care. However, MHSUs may require different tests than those out- lined here depending on their individual presentation. This section will be split whereas in reality the tests will probably be components of the full blood count (FBC). It should also be remembered that normal ranges vary slightly from laboratory to laboratory.
Full blood count
The FBC is a general analysis of a sample of blood that includes red blood cells (RBCs), iron levels, white blood cells (WBCs), platelets, electrolytes, and hormones. This test can be very inclusive or specific aspects can be requested, depending on the presenting complaint.
Biochemistry
Biochemistry testing is used to examine electrolyte balance. Having stable electrolyte levels is important for physical health; for example, monitoring sodium levels is important for car- diovascular health. When blood is taken and sent to the laboratory, the tests requested may include those shown in Tables 4.23 and 4.24.
Arterial blood gas
Measurements of blood pH, oxygen, and carbon dioxide levels can be obtained from an arterial blood sample. Arterial blood gases perform an important diagnostic and monitoring function for MHSUs with respiratory problems. Arterial blood gases assess lung function by illustrating how well the lungs supply oxygen and eliminate carbon dioxide. This helps in diagnosing a
Table 4.23 Blood tests and normal values
Blood test Normal levels
Haemoglobin 14–17.4 g/day (males), 12.3–15.3 g/day (females) rBC count 4.5–5.9 × 106/µL (males), 4.5–5.1 × 106/µL (females) Erythrocyte sedimentation rate adults <50 years: males 0–15 mm/h, females 0–20 mm/h
adult >50 years 0–30 mm/hr Platelet count* 150,000–400,000 cells/µL Source: adapted from Malarkey and McMorrow (2005)
*Platelets are also called thrombocytes. thrombocytopenia is a reduction in platelets, which is also a side-effect of antipsychotic medications such as clozapine.
Note: µL= microlitre.
physical disorder or monitoring effectiveness of treatment by comparing a range of results to determine how a condition is progressing. Maintaining a stable body pH is also important. An ABG sample may indicate acidosis. If the blood plasma is acidic, respirations will increase in rate and depth to correct this imbalance (see Chapter 6 on respiration).
Causes of abnormal respiratory values include (Allibone and Nation 2006):
• respiratory acidosis or alkalosis;
• inadequate alveolar ventilation;
• excess carbon dioxide production;
• lung disease, e.g. Chronic obstructive pulmonary disease (COPD), pneumonia or asthma;
• central nervous system (CNS) depression due to medication or brain stem injury;
• impaired respiratory muscle function due to chest wall injury or deformity;
• airway obstruction;
• pulmonary oedema;
• cardiac arrest;
• hysteria or anxiety;
• hypoxia.
As blood is taken directly from an artery, practitioners should have the appropriate compe- tence to undertake this procedure. Your role in this procedure may be as an assistant. Fol- lowing the procedure, the arm should be elevated and the puncture site compressed until the bleeding stops; this can take up to 3 minutes (Hastings 2009). Practitioners should support MHSUs, allowing them to express feelings and offer reassurance about the need for and impor- tance of the tests. Educating and preparing the MHSU if a series of ABGs is required may lessen their reluctance to undergo the tests.
Cardiac enzymes
When cell tissue becomes damaged, it releases enzymes into the blood stream. These act as markers, which can be identified in blood tests. In myocarditis, the damaged heart tissue releases its marker, in this case an enzyme called troponin, into the blood stream. This can be identified in a cardiac enzyme blood test. This is an important blood test in MHSUs taking clozapine (see Chapter 8 for ADRs of medication).
Blood cultures
Testing blood for cultures is a test to determine the presence of infection. This type of test will also indicate the type of antibiotic treatment that may be required to treat the infection.
Hormone levels
Blood tests can also be used to monitor the presence and levels of hormones in the cir- culation; for example, blood glucose levels may indicate problems with insulin tolerance.
Other common hormone tests include the thyroid function test, which tests for levels of Table 4.24 Some ranges for biochemistry blood tests
Electrolyte Normal range Sodium 135–145 mmol/L Potassium 3.5–5.5 mmol/L
Creatinine 60–125 µmol/L (males), 55–110 µmoL (females) Calcium 2.15–2.65 mmol/L
Note: mmol = millimole, µmol = micromole.
thyroid stimulating hormone (thyrotropin) in the blood. This test serves to differentiate between a poorly functioning thyroid gland and depression (see Table 4.25). The normal level of thyroid stimulating hormone for adults is 0.4–4.2 mL/U/L (Malarkey and McMor- row 2005).
Prolactin is another hormone that is usually tested for in response to ADRs (see Chapter 8). The normal values for prolactin are <25 µg/L for females and <20 µg/L for males. Breast enlargement and lactation are natural responses in pregnancy, and so pregnancy can elevate the levels of prolactin. In pregnant women, the normal range of prolactin is 20–400 µg/L.
Fighting infection
Monitoring WBC count is important in determining the presence and severity of infection. In mental health, it is also an important means of monitoring ADRs, such as neutropenia with antipsychotics (see Table 4.26).
Monitoring levels of medication
Some medications require monitoring to ensure that they are within a set therapeutic range.
Lithium, which is used to treat bipolar disorder, is probably the most frequent drug test. How- ever, MHSUs with epilepsy also require medication levels checked to monitor therapeutic effi- cacy and compliance. Examples of medications and therapeutic ranges include the following (Taylor et al. 2012):
• Lithium carbonate: 0.6–1.0 mmol/L
• Carbamazepine: >7 mg/L
• Olanzapine: 20–40 µg/L
• Clozapine: 350–500 µg/L
Table 4.25 Comparing some signs and symptoms of hypothyroidism and depression
Hypothyroidism Depression
Fatigue Fatigue
Lack of energy Lack of energy Decreased libido Decreased libido
Low mood Low mood
Poor concentration Poor concentration Poor memory Poor memory
Table 4.26 White blood cell tests and normal values
Blood test Normal range
WBC count 4.5–11 × 103 cells/µL
Differential WBC count Neutrophils Lymphocytes Monocytes
1800–7800 cells/µL 1000–4800 cells/µL 0–800 cells/µL Source: adapted from Malarkey and McMorrow (2005)
Summary of key points
• Practitioners are required to have the skills and knowledge to undertake a range of clinical observations.
• Clinical governance issues are very important in ensuring clinical observations are under- taken in a safe and effective manner.
• Clear documentation and communication of results is important for continuity of care.
• Practitioners should undertake regular training updates to ensure their skills base and com- petency is up to date.
Quick quiz
1 What is the therapeutic range for lithium?
2 What is the normal temperature range for an adult?
3 Define homeostasis.
4 What are the Korotkoff sounds? How many phases are there?
5 List the factors that might affect pulse oximetry readings.