nursing 120 final – Flashcards
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obtain blood component from bank, Blood transfusion must be initiated within?
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30 minutes after release from laboratory or blood bank
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check appearance of blood products for leaks, bubbles, clots, and purplish color.
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Do not transfuse blood if integrity is compromised. Air bubbles, clots, or discoloration indicate bacterial contamination or inadequate anticoagulation of the stored component and are contraindications for transfusion of that products. Blood serves as a medium for bacterial growth.
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Verbally compare and correctly verify patient and blood product. Blood is double checked with another person considered qualified by your agency.
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Strict adherence to verification procedures before administration of blood or blood components reduces the risk for administering the wrong blood to patient.
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Step 1. transfusion record number and patients identification number match
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prevents accidental administration of wrong components.
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Step 2. patients name is correct on all documents. Check patients identification number and date of birth on ID band and patient record.
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prevents accidental administration of wrong components.
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Step 3. check unit number on blood container with blood bank form to ensure they are the same.
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Prevents accidental administration of wrong components.
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Step 4. Blood type matches on transfusion record and blood bag. Verify that component received from blood bank is the same component physician or health care provider ordered
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Ensures patient receives correct therapy. One of the most common causes of the patients receiving the incorrect transfusion is obtaining the wrong blood components from the blood bank.
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Step 5. Check the patients blood type and RH type are compatible with donor blood type and Rh type
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Verifies accurate donor blood type and compatibility
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Step 6. Check expiration date and time on unit of blood.
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Never use expired blood, because the cell components deteriorate and may contain excess citrate ions
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Step 7. Check patients first and last names by having patient state name, if able. identify patient using at least 2 identifiers. when you notice a discrepancy during verification procedure. Notify blood bank and appropriate personnel as indicated by agency policy. Return blood to blood bank until discrepancy resolved.
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At least 2 identifiers are required to administer blood.
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Step 8. At the point of initiation, check the patients identification information with the blood unit label information. Do not administer blood to a patient without an identification bracelet
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Serves as the last point of patient and blood confirmation and is the most important step in the verification process.
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Step 9. Both individuals verifying the patient and unit identification record verification process as directed by agency policy.
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Documentation is the legal medical record.
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Review purpose of the transfusion, and ask patient to report any changes he or she may feel during the transfusion.
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SS of transfusion reactions include chills, low back pain, shortness of breath, rash, hives, or itching
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Empty urine drainage collection container, or have patient void.
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if a transfusion reaction occurs, a urine specimen containing urine produced after initiation of the transfusion will be sent to the laboratory.
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Blood Administration: Perform hand hygiene, apply clean gloves and appropriate attire.
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reduces risk for transmission of microorganisms.
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Open Y- tubing blood administration set.
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Y - tubing facilitates maintenance of IV access in case a patient will need more than 1 unit of blood. Both a unit of blood and a container of normal saline are connected to the system.
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Set all clamps to "OFF" position
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setting clamps to off position prevents accidental spilling and wasting of products.
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Spike 0.9% normal saline IV bag with one of Y - tubing spikes. Hang the bag on an IV pole, and prime tubing. Open the upper clamp on normal saline side of tubing, and squeeze the drip chamber until fluid covers the filter and 1/3 to 1/2 of the drip chamber.
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Primes tubing with fluid to eliminate air in Y- tubing. Closing the clamp prevents spillage and waste of fluid.
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Maintain clamp on blood products side of Y- tubing in off position. Open common tubing clamp to finish priming the clamp when tubing is filled with saline. All three tubing clamps should be closed. Maintain protective sterile cap on tubing connector.
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this will completely prime the tubing with saline, and the IV line is ready to be connected to the patients vascular access device. Some patient conditions contraindicate the infusion of normal saline, and it is necessary to connect the blood component to prime the common tubing.
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Prepare blood component for administration. Genlty agitate blood unit bag. Remove protective covering from access port. Spike blood component unit with other Y connection. Close normal saline clamp above filter and open clamp above filter to blood unit, and prime tubing with blood. Blood will flow into the drip chamber. Tap the filter chamber to ensure residual air is removed. Allow saline in tubing to flow into receptacle, being careful to ensure any blood spillage is contained in blood precaution container.
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Gentle agitation suspends the red blood cells in the anticoagulant. A protective barrier drape may be used to catch any potential blood spillage. The tubing is primed with the blood unit and ready for transfusion in the patient.
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Maintaining asepsis, attach primed tubing to patients VAD. Open common tubing clamp, and regulate blood infusion to allow only 2 mL/min to infuse in the initial 15 minutes.
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This initiates infusion of blood products into patients vein.
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Remain with the patient during the first 15 minutes of a transfusion. Initial flow rate during this time should be 2mL/min, or 20gtt/min
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Most transfusion reactions occur within the first 15 minutes od a transfusion. Infusing a small amount of blood component initially minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction.
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If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the VAD at keep vein open rate, and notify the health care provider immediately.
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Monitor patients vital signs at 5 minutes, 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy.
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frequent monitoring of vital signs will help to quickly alert you to a transfusion reaction.
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If there is no transfusion reaction, regulate rate of transfusion according to health care provider orders. Check the drop factor for the blood tubing.
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Maintaining the prescribed rate of flow decreases risk for fluid volume excess while restoring vascular volume. Drop factor for most blood tubing is 10 gtt/mL.
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Do not let a unit of blood hang for more than 4 hours because of the danger of bacterial growth. Administration sets should be changed every 12 hours or after 4 units to reduce bacterial contamination. Never store blood in a facility's refrigerator.
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Never inject medication into the same IV line with a blood component because of the risk for contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV access must be maintained if the patient requires IV infusion during the transfusion.
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After blood has infused, clear IV with 0.9% normal saline, and discard blood bag according to agency policy. when consecutive units are ordered, maintain IV patency with 0.9% saline at keep open rate and retrieve subsequent unit for administration.
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infusing IV saline solution infuses remainder of blood in IV tubing and keeps IV line patent for supportive measures in case of a transfusion reaction.
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Appropriately dispose of all supplies. Remove gloves, and perform hand hygiene.
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standard precautions during a transfusion reduce transmission of microorganisms.
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Patient displays S/S of a transfusion reaction, which occurs when donor blood is incompatible with recipients blood or when recipient has sensitivity to a plasma protein in the transfused (donor's ) blood.
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Stop transfusion immediately connect normal saline - primed tubing at VAD hub to prevent any subsequent blood from infusing from tubing. Disconnect blood tubing at VAD hub, and cap distal end with sterile connector to maintain sterile system. Keep vein open with slow infusion of normal saline at 10 to 12 gtt/min to ensure venous patency and maintain venous access for medication or to resume transfusion. It is important to regulate flow rate to minimize administration of excess IV fluid, especially in patients who are prone to fluid overload such as patients with cardiac and renal disorders, pediatric patients, and older adults. Notify health care provider
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patient develops infiltration of phlebitis at venipuncture site.
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remove IV, and insert new VAD at different site, restart the product if remainder can be infused within 4 hours in initiation of transfusion. Institute nursing measures to reduce discomfort at infiltrated or infected site.
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Rate of infusion slows in the absence of infiltration
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Verify IV catheter is patent and all clamps are open. Gently flush IV line with normal saline, or use a pressure bag or EID that permits blood transfusion to increase flow rate of product.
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Fluid overload occurs, and / or patient exhibits difficulty breathing or has crackles on auscultation.
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Slow or stop transfusion, elevate HOB, and inform physician of physical findings, KVO venous access. Administer diuretics, morphine, and / or oxygen as ordered by physician. Continue frequent assessments, and closely monitor vital signs, intake and output.
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Patient displays signs and symptoms associated with decrease cardiac output; hypotension, tachycardia, cold skin, decreased urine output.
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Ensure that transfusion is infusing at ordered rate, so that rate of volume replacement is sufficient. If blood loss is too rapid, allogeneic transfusion may be necessary.
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what is the infection rate for hospitals after surgical procedures?
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40%
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how does hyperglycemia affect immediate postoperative patients?
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Hyperglycemia inhibits the body's ability to fight infection. Immediate postoperative glucose control is also correlated with a reduction in surgical infection. Higher the glucose level, the higher the potential for infection.
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If a patient cannot be positioned to use diaphragmatic breathing postoperatively what should the nurse do?
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Instruct patient to ask for pain medication 30 minutes before performing postoperative exercises or use PCA before exercising.
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What percentages of surgical patients develop DVT's?
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Patients who have sustained major trauma or spinal cord injury or are undergoing hip or knee surgery or hip fracture surgery are deemed high risk (40%- 80%) for VTE. Patients at moderate risk (10%-40%) are bed bound medical patients and patients undergoing most general gynecological and urological surgical procedures. Low risk patients (<10%) include minor surgery on physically mobile patients and active medical patients.
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Preoperative preparation that the nurses need to complete prior to surgery.
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1. Orient patient to room or holding area 2. Physician obtains informed consent 3. Check medical record, and review or complete preoperative checklist. 4. provide preoperative teaching, include explanation of postoperative exercises, skin preparation, pain control measures, and postoperative care in recovery room. 5. Assess that any preoperative orders for enemas, douches, and skin preparations have been followed. Insert IV and / or indwelling catheter if ordered 6.Provide for hygiene measures, ensuring patient privacy. instruct patient to remove all clothing, undergarments, and to apply disposable cap and hospital gown.
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Preoperative preparation cont...
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7. instruct patient to remove hairpins, clips, wigs, hairpieces, jewelery, and makeup. Religious medals may be pinned to gown if agency policy permits. 8. Assist patient in removing prosthesis, dentures, oral appliances, glasses, and contact lenses. artificial limbs and eyes, hearing aids. give to family members or lock it up. document list of items and their location. 9. secure all valuables, or give to family member. have release form signed if required by agency. 10. apply antiembolism stockings 11. assess vital signs immediately before going to OR. 12. if patient does not have a catheter, assist patient in voiding before having surgery. 13. Administer preoperative medication as ordered. 14.Patient is placed on bed rest with call light within reach and is told not to get out of bed without assistance.
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What are the Procedures for ambulatory areas.
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Postanesthesia Discharge criteria 1.Patient awake 2.vital signs stable 3.No excess bleeding or drainage 4.No respiratory depression 5.SaO2 greater than 90% 6.pain controlled 7. report given Ambulatory Surgery Discharge Criteria. 1.All postanesthesia care unit discharge criteria met. 2.No intravenous narcotics for last 30 minutes. 3.Minimal nausea and vomiting 4.pain controlled 5.voided 6.able to ambulate if age- appropriate and not contraindicated. 7.Responsible adult present to accompany patient. 8.Discharge instructions given and understood.
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What percentage of surgical patients die from PE?
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10%
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1. vital signs are above or below patients baseline
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ensure patient is fully awake from anesthesia before giving large doses of opioids. Make sure patients family does not medicate patient with PCA. Monitor geriatric patient closely for opiate sensitivity - patient may require use of opiate antagonist such as narcan in presence of bradypnea. Medicate for pain as indicated; titrated analgesics to maximize pain relief; assess patients use of and understanding of PCA device. Notify physician or healthcare provider for symptoms of internal bleeding or shock such as hypotension or tachypnea.
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Patient continues to experience incisional pain. Analgesic dosage may be insufficient.
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initiate different nonpharmacological relief measures. Call physician or health care provider for additional analgesic orders. Perform pain assessment.
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Abnormal or diminished breath sounds are auscultated. This is sometimes due to bronchial constriction, mucous secretions in large airways, or atelectasis.
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Notify physician, request order for incentive spirometer, if not already ordered. change position to promote chest expansion Encourage pt. to turn, deep breath, and cough more often. Investigate history of asthma or allergic response to medication when wheezing or stridor is auscultated.
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Patient exhibits signs of hypovolemia related to hemorrhage.
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elevate legs, but do not lower head past flat position. administer oxygen increase rate of IV fluid, administer blood products as ordered. monitor pulse and blood pressure every 5 to 15 minutes. Apply pressure dressing to external wound if not contraindicated.
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Patient complains of calf tenderness and warmth; may exhibit redness and edema in lower extremity.
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These are signs and symptoms of venous thrombosis or thrombophlebitis. Notify physician, and anticipate orders for bed rest, leg elevation, and Initiation of anticoagulation. DO NOT massage affected leg continue to have patient do leg exercises with unaffected leg.
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Bowel sounds are absent or decreased
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Paralytic ileus can develop as a common complication after bowel surgery. intestinal motility may return slowly depending on anesthetic effects. Keep IV in place. Encourage turning and ambulation. Assess for bowel sounds and flatus every 4 hours. Report findings to physician.
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Patient develops fever, tenderness, and pain at the wound site; increased white blood cell count or purulent drainage is present.
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These are s/s of a wound infection, notify physician and anticipate orders for culture and wound drainage and IV antibiotics.
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Patient reports feeling something in wound "give away". Increased serosangineous drainage occurs.
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possibly indicates wound dehiscence or evisceration. Report findings to physician immediately because it could be life threatening. If evisceration has occurred, cover abdominal contents with sterile gauze saturated with sterile normal saline, and prepare patient for emergency surgery.
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I&O measurements reflect imbalance.
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Indicates possible fluid volume excess or deficit . Continue to monitor strict I&O, and contact physician if 24-hour totals continue to reflect imbalance.
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Patient is unable to discuss discharge plans or has negative view of recovery.
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Discuss discharge plans and instructions with family member Encourage patient to express fears and concerns. Refer patient to support group if appropriate. Notify physician, and request referral for counseling if necessary.
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What is the expected assessment finding for a patient post colostomy or ileostomy?
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stoma is moist and reddish pink. Skin is intact and free of irritation; sutures are intact. Stoma initially is edematous and shrinks over next 4 to 6 weeks.
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A client has returned to the medical surgical unit after having surgery to create an ileostomy. Which goal has the highest priority at this time?
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Maintaining fluid and electrolyte balance.
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what is the most effective way to warm a patient undergoing major surgery?
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offer patient an extra blanket
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Know when IV sets should be changed
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IV containers are changed every 24 hours. changing infusion tubing - no more than every72 hours. Primary intermittent sets every 24 because the IV system becomes interrupted.
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What is the circulating nurses responsibilities?
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reviewing the preoperative assessment, establishing and implementing the intraoperative plan of care, evaluating the care, and providing for continuity of care after surgery. The circulating nurse assists with procedures such as endotracheal intubation and blood administration as needed. positions the patient, monitors sterile technique and a safe OR environment, assist the surgeon and surgical team by operating nonsterile equipment, provides additional supplies, verifies sponge and instrument counts and maintains accurate and complete written records.
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How to care for a patient with multiple stomas
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select a cut to fit pouch that allows multiple stoma openings in skin barrier.
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know how to care for patients of all ages with multiple stomas.
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pediatric pouches designed especially for neonates, infants, and children. these pouches are smaller and have a more skin - sensitive adhesive on the barrier. DO NOT use skin sealants and adhesive removers unless they are approved for preterm infant use. As a baby grows, so does the stoma. Measure the stoma frequently.
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How long can blood products be stored?
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A unit of RBC's can be stored for 4 weeks, or if frozen, for several years.
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Why is moderate sedation used?
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helps improve the patients cooperation with the procedure, allows a rapid return to the pre - procedure status, and minimizes the risk for injury. In addition, it often raises the patients pain threshold and provides amnesia concerning the actual procedure events.
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Different blood types
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A+ = A+, A-, O+,O- A- = A-,O- B+ = B+,B-,O+,O- B- = B-,O-, AB+ = A+,A-,B+,B-,O+,O-, (universal) AB- = A-,B-,O- O+ =O+,O- O- = O- (universal)
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What are the expected outcomes of the operative phase of surgery?
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Patient will have intact skin and show no signs of redness at end of surgery. patient will be free of burns from the grounding pad at end of surgery.
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Process of informed consents
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It is the surgeons responsibility to explain the procedure and obtain the informed consent. After the patient completes the consent form,place it in the medical record. The record goes to the OR with the patient.
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care of urostomy
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empty urostomy if it is 1/3 to 1/2 full. clean peristomal skin gently with warm tap water using washcloth; do not scrub skin. Pat the skin dry.
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how to care for air embolus and how to prevent
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Immediate action= clamp catheter; position patient in left trendelenburg's position; call physician; administer oxygen as needed. Prevention = Make sure all catheter connections are secure; clamp catheter when not in use. Never use a stopcock with a CVC. Instruct patient in valsalva's maneuver for tubing changes.
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How to assess a patient with nerve blocks.
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No loss of consciousness, elevation of the upper body can prevents respiratory paralysis, Some patients have a sudden fall in blood pressure, which requires careful monitoring during and immediately after surgery. It is necessary to frequently observe the position of extremities and the condition of the skin. Ongoing assessment of the patients discomfort and evaluation of pain - relief therapies are essential throughout the postoperative course.
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How to minimize skin breakdown
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Assess and inspect skin daily frequently turn and reposition a patient every 1-2 hours. Proper positioning helps minimizes formation of a pressure ulcer. specialized beds, overlays, and mattresses. clean patients who are incontinent of stool or urine as soon as possible. interventions to minimize friction and shear. adequate nutrition is important in the prevention and treatment of pressure ulcers. If a patient develops an ulcer, routinely assess the ulcer to determine progress toward healing.
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Society of Anesthesiologist classifications
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P1. A normal healthy patient, No physical, biological, organic disturbance. P2. A patient with mild systemic disease, Cardiovascular disease with minimal restriction on activity. P3. A patient with severe systemic disease, Hypertension, obesity, diabetes mellitus. P4. A patient with severe systemic disease that is a constant threat to life, CV or pulmonary disease that limits activity, severe diabetes with systemic complications, history of MI, angina pectoris, or poorly controlled HTN. P5. A moribound patient who is not expected to survive without the operation, Severe cardiac, pulmonary, renal, hepatic, or endocrine dysfunction. P6. A patient declared brain dead whose organs are being removed for donor purpose, Patients may have a wide variety of dysfunctions that are being managed to optimize blood flow to the heart and organs ( aggressive fluid replacement and blood pressure medication )
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What is the timing for prophylactic antibiotic therapy prior to surgical procedures?
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It is recommended that prophylactic antibiotics be given as close to the time of Incision as possible (within 30 to 60 minutes) and not be given for longer than 24 hours post-operatively.
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What puts elderly patients at risk for surgery?
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With advancing age patients have less physical capacity to adapt to the stress of surgery because of deterioration in certain body functions.
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Degenerative change in myocardium and valves. (cardiovascular)
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- decreased cardiac reserve puts older adults at risk for decreased cardiac output, especially during times of stress. Nursing implications - Assess baseline vital signs for tachycardia,fatigue, and arrhythmias. Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation to the heart.
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Rigidity of arterial walls and reduction in sympathetic and parasympathetic innervation to the heart.
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Alterations predispose patient to postoperative hemorrhage and rise in systolic and diastolic blood pressure. Nursing implications - Maintain adequate fluid balance to minimize stress to the heart. Ensure that blood pressure level is adequate to meet circulatory demands.
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Increase in calcium and cholesterol deposits within small arteries; thickened arterial walls.
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Predispose patient to clot formation in lower extremities. Nursing implications - Instruct patient in techniques of leg exercises and proper turning. Apply elastic stockings or intermittent pneumatic compression devices. Administer anticoagulants as ordered by health care provider. Provide education regarding effects, side effects, and dietary considerations.
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Integumentary - decreased subcutaneous tissue and increased fragility of skin.
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Prone to pressure ulcers and skin tears. Nursing implications - Assess skin every 4 hours; pad all bony prominences during surgery. Turn or reposition at least every 2 hours.
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Pulmonary - Decreased respiratory muscle strength and cough reflex
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Increased risk for atelectasis Instruct patient in proper technique for coughing, deep breathing, and use of spirometer. Ensure adequate pain control to allow for participation in exercises.
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Reduced range of movement in diaphragm
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Residual capacity (volume of air is left in lung after normal breath) increased, reduced amount of new air brought into lungs with each inspiration Nursing implications - When possible, have patient ambulate and sit in chair frequently.
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Stiffened lung tissue and enlarged air spaces.
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Blood oxygenation reduced. Nursing implications - Obtain baseline oxygen saturation;measure throughout perioperative period.
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Gastrointestinal - Gastric emptying delayed
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Increases the risk for reflux and indigestion. Nursing implications - Position patient with head of bed elevated at least 45 degrees. Reduced size of meals in accordance with ordered diet.
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Renal - Decreased renal function, with reduced blood flow to kidneys.
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Increased risk of shock when blood loss occurs; increased risk for fluid and electrolyte imbalance. Nursing implications - For patients hospitalized before surgery, determine baseline urinary output for 24 hours.
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Reduced glomerular filtration rate and excretory times
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Limits ability to eliminate drugs or toxic substances. Nursing implications - Assess for adverse response to drugs.
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Decreased bladder capacity
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Increase the risk for urgency, incontinence, and urinary tract infections (Sensations of need to void often does not occur until bladder is filled.) Nursing implications - Instruct patient to notify nurse immediately when sensation of bladder fullness develops. Keep call light and bedpan within easy reach. Toilet every 2 hours or more frequently if indicated.
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What type of care will be needed after a coronary artery bypass procedure?
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Classification for surgical procedures and be to identify examples.
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Seriousness, Major - involves extensive reconstruction or alteration in body parts; poses great risks to well - being (Coronary artery bypass, colon resection, removal of larynx, resection of lung lobe) Minor - Involves minimal alteration in body parts; often designed to correct deformities; involves minimal risks compared with major procedures.(cataract extraction, facial plastic surgery, tooth extraction)
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Urgency
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Elective - Performed on basis of patients choice, is not essential and is not always necessary for health. (bunionectomy, facial plastic surgery, hernia repair, breast reconstruction) Urgent - Necessary for patients health; often prevents additional problems from developing (tissue destruction or impaired organ function);not necessarily emergency. (excision of cancerous tumor, removal of gallbladder for stones, vascular repair for obstructed artery (coronary artery bypass)
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Emergency
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- Must be done immediately to save life or preserve function of body part.(Repair of perforated appendix or traumatic amputation, control of internal hemorrhaging.
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Purpose
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Diagnostic - surgical exploration that allows health care providers to confirm diagnosis; often involves removal of tissue for further diagnostic testing. (exploratory laparotomy (incision into peritoneal cavity to inspect abdominal organs) breast mass biopsy. Ablative - excision or removal of diseased body part.(amputation, removal of appendix, cholecystectomy.)
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Purpose cont.....
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Palliative - relieves or reduces intensity of disease symptoms; does not produce cure. (colostomy, debridement of necrotic tissue, resection of nerve roots) Reconstructive / restorative - Restores function or appearance to traumatized or malfunctioning tissues.( internal fixation of fractures, scar revision) Procurement for transplant - Removal of organs and / or tissues from a person pronounced brain dead for transplantation into another person.(Kidney, heart, or liver transplant) Constructive - Restores function lost or reduced as result of congenital anomalies. (Repair of cleft palate closure of atrial septal defect in heart)
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Purpose cont.....
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Cosmetic - Performed to improve personal appearance. (Blepharoplasty for eyelid deformities; rhinoplasty to reshape nose.)
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Stoma placement and the different types of stool seen with the various placements.
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Output from a colostomy located in the ascending colon will have a semi-liquid consistency, that from a colostomy located in the transverse colon will have a semi-liquid to pasty consistency, and that from a colostomy located in the descending or sigmoid colon will be a more formed stool (McCann, 2002).
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Advantage of dry heat
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less likely to burn skin Does not cause skin maceration. Retains temperature longer because not influenced by evaporation.
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Complications related to blood transfusions.
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Acute hemolytic transfusion reactions Delayed hemolytic transfusion reaction. Febrile nonhemo-lytic. Allergic reaction (mild to moderate) Allergic reaction(severe) Graft - versus - host disease. Circulatory overload Infectious disease transmission Iron overload.
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Acute hemolytic transfusion reactions
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Signs and symptoms: Severe kidney and chest pain, increased temperature, increased heart rate; sensations of heat and pain along vein receiving blood;chills, low back pain, headache, nausea, chest or back pain, chest tightness, dyspnea, bronchospasm, anxiety, hypotension, vascular collapse, disseminated intravascular, possibly death. Prevention: Carefully identify patient and blood sample obtained for blood typing and compatibility screening. When blood released from blood bank, match with patient information. Follow agency's verification procedures at bedside before transfusion. Nursing intervention: Stop transfusion, Remove blood products and tubing. Maintain IV access. Notify physician, monitor vital signs every 15 minutes, Administer ordered therapy to correct arterial blood pressure and coagulopathy. Insert foley catheter, monitor intake and output hourly. Assess for shock. Dialysis may be required. Obtain blood and urine samples, and send to laboratory with unused portion of unit of blood. Document.
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Delayed Hemolytic transfusion reaction
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Signs and symptoms: Unexplained fever, unexplained decrease in Hgb/Hct, increased bilirubin levels, Jaundice. Prevention: Careful crossmatching of donor and recipient blood. Potential to be missed because it may occur several days after transfusion. Nursing Intervention: Monitor lab values for anemia, if detected, notify doctor and blood bank. Most delayed hemolytic reactions require no treatment.
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Febrile, Nonhemolytic reaction
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Signs and symptoms: Fever greater than 1c above baseline, flushing, chills, headache,muscle pain; occurs most frequently in immunosuppressed patients. Prevention: Use leukocyte - reduced blood products in patients who have experienced febrile nonhemolytic reactions in the past. Nursing Interventions: Stop transfusion, administer antipyretics as ordered. Monitor temperature every 4 hrs.
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Allergic reaction (mild to moderate)
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Signs and symptoms: Local erythema, hives and urticaria, itching or pruritus. Prevention: May administer antihistamines before transfusion if prescribed. Nursing Intervention: Stop transfusion, notify doctor and blood bank, Administer antihistamines as ordered, monitor and document vital signs every 15 minutes, Transfusion may be restarted if fever, dyspnea, and wheezing are not present.
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Allergic reaction (severe)
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Signs and symptoms: coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, possible cardiac arrest. Prevention: Transfusion of saline washed or leukocyte depleted RBS's. Nursing Intervention: This is a life threatening reaction; Stop transfusion, maintain IV access, notify doctor and blood bank. Administer antihistamines, corticosteroids, epinephrine, and antipyretics as ordered. Measure and document vital signs until stable. Initiate cardiopulmonary resuscitation if necessary.
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Graft - versus host disease reaction
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Signs and symptoms: skin rash, fever, jaundice due to liver dysfunction, bone marrow suppression. Prevention: Administer irradiated blood and / or leukocyte depleted RBC products as prescribed. Nursing Implication: Administer methotrexate, corticosteroids as ordered.
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Circulatory overload reaction
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Signs and symptoms: Dyspnea, cough, crackles at lung bases, tachypnea, headache, hypertension, tachycardia, increased central venous pressure, distended neck veins. Prevention: Administer blood or components at prescribed rate,usually no greater than 2-4 mL/kg/hr; pay close attention to rate and volume in older adults, young children, and patients with cardiac and renal disorders. Administer PRBC's instead of whole blood. Minimize amount of saline infused with transfusion. Nursing Intervention: Slow or stop transfusion as ordered. Elevate patients head. Notify doctor, administer diuretics as ordered.
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Infectious disease transmission reaction
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Signs and symptoms: high fever, chills, abdominal cramping,vomiting, diarrhea, profound hypotension, flushed skin,back pain. Prevention: Proper care of blood or blood products from time of procurement through end of administration. Complete transfusion within 4 hr. Nursing Intervention: Stop transfusion. Remove blood product and tubing. Maintain IV access. Notify doctor, monitor and document vital signs. Obtain samples for blood culture and gram stain from recipient. Administer IV fluids, broad spectrum antimicrobials, vasopressors, and steroids as ordered.
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Iron overload reaction
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Signs and Symptoms: Cardiac dysfunction, SOB, arrhythmias, congestive heart disorder, increased serum transferrin, increased liver enzymes, jaundice. Prevention: Chelation, phlebotomy, monitor serum Fe levels. Nursing Interventions: Monitor patient for CHF, cardiac disorder, liver disorder, serum transferrin.
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How to decrease risk of venous stasis and formation of thrombus postoperatively?
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Venous thrombosis and venous stasis: early ambulation and leg exercises. When this is not possible, use additional devices to help prevent the formation of DVT. Such as compression stockings, Intermittent pneumatic compression device, this device also decreases venous pooling and stasis. Venous plexus foot pump helps with the prevention of a DVT.
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Surgeons should do what to prevent postoperative infections?
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The use of an antimicrobial preparation for hand antisepsis is and integral part of the presurgical scrubbing procedure for operating room personnel.
