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sed rateErythrocyte sedimentation rate, see there.
Erythrocyte Sedimentation Rate
Synonym/acronym: Sed rate, ESR.
To assist in diagnosing acute infection in diseases such as tissue necrosis, chronic infection, and acute inflammation.
SpecimenWhole blood (5 mL) collected in a lavender-top (EDTA) tube for the modified Westergren method or a gray-top (3.8% sodium citrate) tube for the original Westergren method.
(Method: Westergren or modified Westergren)
|Newborn||0–2 mm/hr||0–2 mm/hr|
|Less than 50 yr||0–15 mm/hr||0–25 mm/hr|
|50 yr and older||0–20 mm/hr||0–30 mm/hr|
The erythrocyte sedimentation rate (ESR) is a measure of the rate of sedimentation of red blood cells (RBCs) in an anticoagulated whole blood sample over a specified period of time. The basis of the ESR test is the alteration of blood proteins by inflammatory and necrotic processes that cause the RBCs to stick together, become heavier, and rapidly settle at the bottom of a vertically held, calibrated tube over time. The most common promoter of rouleaux is an increase in circulating fibrinogen levels. In general, relatively little settling occurs in normal blood because normal RBCs do not form rouleaux and would not stack together. The sedimentation rate is proportional to the size or mass of the falling RBCs and is inversely proportional to plasma viscosity. The test is a nonspecific indicator of disease but is fairly sensitive and is frequently the earliest indicator of widespread inflammatory reaction due to infection or autoimmune disorders. Prolonged elevations are also present in malignant disease. The ESR can also be used to monitor the course of a disease and the effectiveness of therapy. The most commonly used method to measure the ESR is the Westergren (or modified Westergren) method.
This procedure is contraindicated for
- Assist in the diagnosis of acute infection, such as tuberculosis or tissue necrosis
- Assist in the diagnosis of acute inflammatory processes
- Assist in the diagnosis of chronic infections
- Assist in the diagnosis of rheumatoid or autoimmune disorders
- Assist in the diagnosis of temporal arthritis and polymyalgia rheumatica
- Monitor inflammatory and malignant disease
- Increased rouleaux formation is associated with increased levels of fibrinogen and/or production of cytokines and other acute-phase reactant proteins in response to inflammation. Anemia of chronic disease as well as acute anemia influence the ESR because the decreased number of RBCs falls faster with the relatively increased plasma volume.
- Acute myocardial infarction
- Anemia (RBCs fall faster with increased plasma volume)
- Cat scratch fever (Bartonella henselae)
- Collagen diseases, including systemic lupus erythematosus (SLE)
- Crohn’s disease (due to anemia or related to acute-phase reactant proteins)
- Elevated blood glucose (hyperglycemia in older patients can induce production of cytokines responsible for the inflammatory response; hyperglycemia related to insulin resistance can cause hepatocytes to shift protein synthesis from albumin to production of acute-phase reactant proteins)
- Heavy metal poisoning (related to anemia affecting size and shape of RBCs)
- Increased plasma protein level (RBCs fall faster with increased plasma viscosity)
- Infections (e.g., pneumonia, syphilis)
- Inflammatory diseases
- Multiple myeloma (RBCs fall faster with increased plasma viscosity)
- Pregnancy (related to anemia)
- Pulmonary embolism
- Rheumatic fever
- Rheumatoid arthritis
- Subacute bacterial endocarditis
- Temporal arteritis
- Waldenström’s macroglobulinemia (RBCs fall faster with increased plasma viscosity)
- Conditions resulting in high hemoglobin and RBC count
- Some drugs cause an SLE-like syndrome that results in a physiological increase in ESR. These include anticonvulsants, hydrazine derivatives, nitrofurantoin, procainamide, and quinidine. Other drugs that may cause an increased ESR include acetylsalicylic acid, cephalothin, cephapirin, cyclosporin A, dextran, and oral contraceptives.
- Drugs that may cause a decrease in ESR include aurothiomalate, corticotropin, cortisone, dexamethasone, methotrexate, minocycline, NSAIDs, penicillamine, prednisolone, prednisone, quinine, sulfasalazine, tamoxifen, and trimethoprim.
- Menstruation may cause falsely increased test results.
- Prolonged tourniquet constriction around the arm may cause hemoconcentration and falsely low values.
- The Westergren and modified Westergren methods are affected by heparin, which causes a false elevation in values.
- Bubbles in the Westergren tube or pipette, or tilting the measurement column more than 3° from vertical, will falsely increase the values.
- Movement or vibration of the surface on which the test is being conducted will affect the results.
- Inaccurate timing or a delay in performing the test once the specimen has been collected will invalidate test results.
- Specimens that are clotted, hemolyzed, or insufficient in volume should be rejected for analysis.
- The test should be performed within 4 hr of collection when the specimen has been stored at room temperature; delays in testing may result in decreased values. If a delay in testing is anticipated, refrigerate the sample at 2°C to 4°C; stability at refrigerated temperature is reported to be extended up to 12 hr. Refrigerated specimens should be brought to room temperature before testing.
Nursing Implications and Procedure
Potential nursing problems
|Problem||Signs & Symptoms||Interventions|
|Infection (Related to inadequate defense mechanism; insufficient nutrition; chronic disease; IV access devices; pathogen exposure; indwelling urinary catheter; compromised immune system; mechanical intubation)||Fever; increased heart rate; increased blood pressure; shaking; chills; mottled skin; lethargy; fatigue; swelling; edema; pain; localized pressure; diaphoresis; night sweats; confusion; vomiting; nausea; headache; cloudy, foul smelling urine with sediment; elevated WBC; elevated ESR||Promote good hygiene; assist with hygiene as needed; administer prescribed antibiotics, antipyretics; provide cooling measures; administer prescribed IV fluids; monitor vital signs and trend temperatures; encourage oral fluids; adhere to standard or universal precautions; isolate as appropriate; obtain cultures as ordered; encourage use of lightweight clothing and bedding; assess nutritional status and provide supplements as needed; assess for exposure to infections; monitor sputum color and viscosity; assess urine characteristics (color, clarity); monitor and trend WBC and ESR rate; monitor for symptoms of infection (redness, swelling, purulent drainage, pain from wound or incisions); provide asceptic tracheal care; perform dressing changes with sterile or asceptic technique; perform vigilant hand hygiene|
|Tissue integrity (Related to infection)||Area on the skin that is warm or tender to touch; skin that turns red, purple, or black; localized pain; swelling of affected area; elevated WBC; elevated ESR||Perform baseline skin assessment and frequent re-assessment using a standardized scale (Braden); monitor and note the presence of herpes lesions; encourage the use of hypoallergenic soap and lanolin products, pat rather than rub skin dry; avoid bed wrinkles; ensure sheets are soft and gentle on skin; encourage adequate nutrition; administer prescribed vitamin supplements; encourage and assist range of motion; assess the characteristics of a wound (color, size, length, width, depth, drainage, and odor); monitor for fever; identify the cause of the tissue damage; monitor and trend WBC and ESR|
|Nutrition (Related to nutrition, to inability to digest foods, metabolize foods, ingest foods; refusal to eat; increased metabolic needs associated with disease process; lack of understanding)||Unintended weight loss; current weight is 20% below ideal weight; pale dry skin; dry mucous membranes; documented inadequate caloric intake; subcutaneous tissue loss; hair pulls out easily; paresthesis||Record accurate daily weight at the same time each day with the same scale; obtain an accurate nutritional history; assess attitude toward eating; promote a dietary consult to evaluate current eating habits and best method of nutritional supplementation; develop short-term and long-term eating strategies; monitor nutritional laboratory values such as albumin; assess swallowing ability; encourage cultural home foods; provide a pleasant environment for eating; alter food seasoning to enhance flavor; provide parenteral or enteral nutrition as prescribed|
|Activity (Related to inflammation; infection; altered tissue perfusion; deconditioned state)||Weakness; verbal report of fatigue; altered sleep pattern; altered blood pressure, heart rate, or respiratory rate in response to activity; oxygen desaturation with activity||Assess current level of activity and weakness; identify the patient’s perception of the cause of weakness; assess the need for the use of assistive devices; observe and document the patient’s tolerance to activity; provide ordered oxygen; limit energy expenditure to necessary activities|
- Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
- Patient Teaching: Inform the patient this test can assist in identification of inflammation.
- Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to latex.
- Obtain a history of infectious, autoimmune, or neoplastic diseases.
- Obtain a history of the patient’s cardiovascular, hematopoietic, immune, and respiratory systems; symptoms; and results of previously performed laboratory tests and diagnostic and surgical procedures.
- Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
- Review the procedure with the patient. Inform the patient that specimen collection takes approximately 5 to 10 min. Address concerns about pain and explain that there may be some discomfort during the venipuncture.
- Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
- Note that there are no food, fluid, or medication restrictions unless by medical direction.
- Potential complications: N/A
- Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
- Instruct the patient to cooperate fully and to follow directions. Direct the patient to breathe normally and to avoid unnecessary movement.
- Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate tubes with the corresponding patient demographics, date, and time of collection. Perform a venipuncture; collect the specimen in a 5-mL gray-top (sodium citrate) tube if the Westergren method will be used. Collect the specimen in a 5-mL purple-top (EDTA) tube if the modified Westergren method will be used.
- Remove the needle and apply direct pressure with dry gauze to stop bleeding. Observe/assess venipuncture site for bleeding or hematoma formation and secure gauze with adhesive bandage.
- Promptly transport the specimen to the laboratory for processing and analysis.
- Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
- Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
- Provide teaching and information regarding the clinical implications of the test results, as appropriate.
- Educate the patient regarding access to counseling services, as appropriate.
- Provide contact information, if desired, for the American College of Rheumatology (www.rheumatology.org) or for the Arthritis Foundation (www.arthritis.org).
- Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
- Answer any questions or address any concerns voiced by the patient or family.
Expected Patient Outcomes
- States understanding of the signs and symptoms of infection including what to report and when to report concerns
- States understanding of follow-up ESR to monitor the effectiveness of therapeutic interventions
- Effectively paces activities to manage energy expenditures and increase participation in activities of daily living
- Increases dietary intake by 50% and is validated with increased weight
- Complies with the request to perform vigilant hand hygiene to decrease infection risk
- Complies with the request to monitor temperature and report elevation to the HCP
- Related tests include antibodies, anticyclic citrullinated peptide, ANA, arthroscopy, arthrogram, blood pool imaging, BMD, bone scan, CBC, CBC hematocrit, CBC hemoglobin, CBC RBC indices, CBC RBC morphology, CT cardiac scoring, copper, CRP, d-dimer, exercise stress test, fibrinogen, glucose, iron, lead, MRI musculoskeletal, MRI venography, microorganism-specific serologies and related cultures, myocardial perfusion heart scan, procalcitonin, radiography bone, RF, synovial fluid analysis, and troponin.
- Refer to the Cardiovascular, Hematopoietic, Immune, and Respiratory systems tables at the end of the book for related tests by body system.