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205 Cards in this Set

  • Front
  • Back
Reasons for IV therapy

(4)
1. Maintain body requirements of H2O, electrolytes, vitamins, proteins, and calories
2. Restore acid-base balance
3. Replenish blood volume
4. provide access for IV medications
Types of IV solutions

(3)
1.Isotonic
2. Hypotonic
3. Hypertonic
Isontonic IV solutions
-Solution with the same osmotic pressure as blood
- Used for extracellular replacement
-expands the body's blood volume without a fluid shift
-Expands the body's blood volume without a fluid shift
-
HypotonicIV solutions
- Solution with LESS osmotic pressure than blood
- Causes cells to EXPAND
- Used in dehydration
Hypertonic IV solutions
- Solution with HIGHER osmotic pressure than blood
-Causes cells to SHRINK
- used in cellular overhydration
Isotonic IV solution types
- 0.9% NS (0.9% normal saline)
- D5W (5% dextrose in water)
- LR (lactated ringers)
Hypotonic IV solution types
- 0.45% NS (half normal saline)
- 0.25 NS (1/4 normal saline)
Hypertonic IV solution types
- D5NS (5% dextrose in normal saline)
- D10NS (10% dextrose in normal saline)
- D10W (10% dextrose in water)
-D5 1/2NS (5 and a half% dextrose in normal saline)
- D20W
-D5LR
D5W composition/use
-Isotonic
-278 mOsm/L
-50 g/L glucose
- provides free water necessary for renal excretion of solutes
-provides 170 calories/L
-Does not provide any electrolytes
D10W composition/use
- hypertonic
- 556 mOsm/L
-100 g/L glucose
- Provides free water only, no electrolytes
-Provides 340 calories/L
0.45% NS composition/use
- Hypotonic
- 154 mOsm/L
- 0 g/L glucose
- Provides free water, Na, and Cl
- used to replace hypotonic fluid losses
- used as maintenance solution although it does not replace daily losses of other electrolytes
- provides no calories
0.9% NS composition/use
- isotonic
- 308 mOsm/L
- 0 g/L glucose
- used to expand intravascular volume and replace extracellular fluid losses
-only solution that may be administered with blood products
- contains Na and Cl in excess of plasma levels
-does not provide free water, calories, or other electrolytes
- may cause intravascular overload or hyperchloremic acidosis
3.0-5.0% NS composition/use
- hypertonic
- 1026 mOsm/L
- 0 g/L glucose
- used to treat symptomatic hyponatremia
-must be administered slowly and with extreme caution because it may cause dangerous intravascular volume overload and pulmonary edema
5% dexcrose in 0.225% saline
composition/use
-isotonic
-355 mOsm/L
- 50 g/L glucose
- provides Na, Cl, and free water
-used to replace hypotonic losses and treat hypernatremia
- provides 170 calories/L
5% dextrose in 0.45% saline
- hypertonic
-432 mOsm/L-
-50 g/L glucose
-same as 0.45% NaCl except provides 170 cal/L
5% dextrose in 0.9% saline
composition/use
- hypertonic
- 586 mOsm/L
- 50 g/L glucose
- same as 0.9% NaCl but provides 170 cal/L
Lactated ringer's composition/use
- isotonic
- 309 mOsm/L
- 0 g/L glucose
- similar in composition to plasma except that it has excess Cl, Mg, and no HCO3
-does not provide free water or calories
- used to expand the intravascular volume and replace extracellular fluid losses
Hartmann's solution composition/use
-isotonic
-274 mOsm/L
-0 g/L glucose
- similar in composition to normal plasma except does not contain Mg
-used to treat losses from burns and lower GI tract
-may be used to treat mild metabolic acidosis but should not be used to treat lactic acidosis
- does not provide free water or calories
whole blood- single donor:allogenic or autologus

uses
-replaces red cell mass and plasma volume
-expected to raise hgb 1g/100ml and hct by 3% in non hemorrhaging adult
Pacted RBC's- single donor: allogenic or autologous

uses
- preferred method of replacing red blood cell mass
-expected to raise hgb/hct level same as whole blood
Leukocyte-poor RBCs-- single donor:allogenic or directed

uses
replaces RBCs while preventing febrile, nonhemolytic transfusion reactions.
-reduces risk of CMV (cytomegaloviris) transmission
Irradiated RBCs--single donor:allogenic or directed

uses
- replaces RBCs while preventing transcusion-associated graft-versus-host disease; used in immunodeficient clients (any blood component can be irradiated)
Fresh frozen plasma--single donor

uses
- replaces plasema without RBCs or platelets; contains most coagulation factors and complement; used in the control of bleeding where replacement of coagulation factores is needed
Cryoprecipitate-- multiple donors, pooled

uses
-replaces factors VIII, XIII, von Willebrand's factor, and fibrinogen
Platelets--multiple/random donor, pooled

uses
- used in cluentw with thrombocytopenia.
-certain microaggregate filters are not to be used with platelets
Platelets-- single donor

uses
- most useful in immunologically refractory clients when given as HLA matched with recipient.
-each unit expected to raise platelet count by 5,000-10,000/ml in a 70 kg client
Colloid components--albumin 25% pooled

uses
-oncotically equivalent to plasma, used to treat hypoproteinemia in burns and hypoalbuminemia in shock and ARDs; used to support blood pressure in dialysis and acute liver failure
Colloid components--albumin 25% pooled

uses
- increased circulating bloodvolume by increasing intravascular oncotic pressure
Which blood products can transmit HIV/HBV?

(8)
-whole blood- single donor:allogenic or autologus
-Pacted RBC's- single donor: allogenic or autologous
-Leukocyte-poor RBCs-- single donor:allogenic or directed
-Irradiated RBCs--single donor:allogenic or directed
-Fresh frozen plasma--single donor
-Cryoprecipitate-- multiple donors, pooled
-Platelets--multiple/random donor, pooled
-Platelets-- single donor
Which blood products need ABO testing?

(7)
-whole blood- single donor:allogenic or autologus
-Pacted RBC's- single donor: allogenic or autologous
-Leukocyte-poor RBCs-- single donor:allogenic or directed
-Irradiated RBCs--single donor:allogenic or directed
-Fresh frozen plasma--single donor
-Platelets--multiple/random donor, pooled
-Platelets-- single donor
Which blood products need Rh Testing?

(6)
-whole blood- single donor:allogenic or autologus
-Pacted RBC's- single donor: allogenic or autologous
-Leukocyte-poor RBCs-- single donor:allogenic or directed
-Irradiated RBCs--single donor:allogenic or directed
-Platelets--multiple/random donor, pooled
-Platelets-- single donor
Which blood products cannot transmit HIV/HBV?

(2)
- colloid components-albumin 5% pooled
-colloid components-albumin 25% pooled
Which blood products do not need ABO testing?
-cryoprecipitate-multiple donors,pooled
- colloid components-albumin 5% pooled
-colloid components-albumin 25% pooled
Which blood products do not need Rh testing?
-fresh frozen plasma-single donor
-cryoprecipitate-multiple donors,pooled
- colloid components-albumin 5% pooled
-colloid components-albumin 25% pooled
Who can use the scalp veins site for IV?
infants only
Possible IV sites:

(9)
1. scalp veins (infants)
2. hand veins
3. veins in radial area of wrist
4. forearm veins
5. antevubital fossa veins
6. jugular
7. leg
8. foot
9. sternum
Hand veins:
1.indications for use
2. advantages
3. disadvantages
4. other
1. short-term therapy: meds for surgery/sedation
2. -good b/c should alway try to start IV most distally. Is most distal site, so other veins can be used if long-term therapy is needed.
- easy to palpate and people normally don't have hair on their hands
3. small size, near bones, painful, veins vary positionally, easily dislodged, pt. moves hands alot. Veins tend to roll.
4. try to put in non-dominant hand
Total Parenteral nutrition (TPN)
1. AKA
2. indications
3. especially important for...
1. Hyperalimentation (HA)
2. for example, they have a block in GI tract, had GI surgery, in coma, not able to eat b/c of LOC, etc.
3. if they have wounds for healing proces
Forearm veins
1. indication
2. advantages
3. disadvantages
1. longer-term therapy
2. larger veins, can accomodate larger fluid rates and IV catheters. Tend to not impede activities/movement. can use dominant or nondominant.
3. harder to find, especially in fat people. Harder for tape to stick or take off.
Antecubital veins
1. indication
2. advantages
3. disadvantages
4. other
1. diagnostic tests, rapid administration of med, giving blood, adenocart is ex- give very fast over 1-2 minutes or even faster
2. easily palpable and seen. Can use large-guage IVs
3. pt. bends arms. IV here limits mobility. this is used for drawing blood, so limits use of distal sites
4. used sometimes for surgery
Lower extremety veins
1. indication
2. Advantages
3.disadvantages
1. mostly used in children
2. children don't focus on them as much, easier than hand veins to stick because more superficial
3. rarely used in adults b.c of potential for blood clots
Circulatory overload

symptoms
-HA
-flushed skin
-increased P,BP,and R
-cough
-SOB & dyspnea
- Syncope
-Pulmonary edema
Circulatory overload


preventive nursing prescriptions
-assess client for heart condition
- monitor IV flow rate
-closely monitor elderly and very young clients
-Accurate I and O's
Circulatory overload

nursing interventions
- stop infusion
-call MD
Thrombophlebitis

s/s
- tender vein
- inflammation
- redness
- warmth
- hard cord-like vein, swelling
- phlebitis, may lead to clot formation
Thrombophlebitis

preventive nursing prescriptions
- change IV site as per hospital protocol
- Dilute IV meds accordingly
- Assess IV site and surrounding venous areas frequently
Thrombophlebitis

nursing interventions
- D/C IV and restart elsewhere
-cold compress (Decrease inflammation
- MD may order antithrombolytic agent if client has clot
Air Embolism

s/s
- decreased BP
- tachycardia
-chest pain
- loss of consciousness
Air embolism

nursing prescriptions
- replace IV bags before empty
-prime tubing carefully
Air embolism

Nursing interventions
- trendelenberg on left side
(air goes into right ventricle, allows blood to go into lungs and dissipate)
IV Equipment failure

s/s
-infiltration
-kinked tubing
- solution not infusing
IV equipment failure

preventive nursing prescriptions
- frequentyl check tubing for kinks
- avoid IV site at vein junction
- don't flush if not patent
- check for pump functioning
IV equipment failure

nursing interventions
- increase height of solution
- change position of arm
-D/C IV and restart
IV Pyrogenic reaction
contaminated soln
IV Pyrogenic reaction

s/s
-onset: 30-60 minutes after soln started
- increased temp
-chills, flushing
- HA
-NV
- decreased BP
IV Pyrogenic reaction

preventive nursing prescriptions
-assess soln appearance
-change bag and tubing as per pilicy (usually every 2-3 days
- change site as per policy (usually every 2-3 days)
- use IV only when necessary
IV Pyrogenic reaction

nursing interventions
- stop infusion, call MD
- check VS
- Treat symptoms:
*give tylenol/benadryl
*possible volume replacement to increase BP
*stay with client
* save solution and tubing for lab analysis
IV infiltration
needle dislodges from vein into SQ tissue
IV infiltration

s/s
-swelling
- skin blanching
-decrease flow/flow stops
-discomfort/pain
- coolness at site
IV infiltration

preventive nursing prescriptions
- secure angiocath
-limit arm movement
IV infiltration

nursing interventions
- stop infusion
- notify MD
- D/C IV and restart elsewhere
-warm compress (increase fluid reabsorption)

* make sure IV med is not necrosis-causing before giving warm compress.
IV pumps are programmed in __
ml/hr
Most ped patients receive meds via ___
pumps
strong medications are often given via ____
pumps
Factors affecting IV flow rate for gravity drips

(5)
1. pressure gradient
2. friction
3. diameter/length of tubing
4. height of column of fluid
5. fluid viscosity
Piggybacks (IVPB)

*based on____1___ theory, where the ___2____ bag/medication will empty first. Then the ____3_____ bag will kick in when the "piggyback" bag is empty
1. physics of gravity
2. higher
3.lower
Can piggybacks work via pump or gravity drip?
both
IV bolus/IV push info
-inject med into rubber port in the tubing
- must be dilute BEFORE giving
- given slowly: check med book
-very dangerous route, be precice and check 6 rights several times
PCA
-patinet controlled analgesia
-client as IV solution with piggyback PCA to deliver periodic pain medication.
-RN programs pump with parameters as ordered by MD
- need keys to access PCA pumps
-risk of addiction almost nonexistant
- emergency equipment at bedside
-family can NEVER push for pt.
-it keeps up with amout patient is pushing, being denied, etc.
Saline lock/heparin lock
-an IV site that is not being used, so it is kept "plugged" with a male adapter.
-IV is flushed with saline or heparin flush, according to hospital policy, to keep site patent in case it is needed.
Hickman/Broviac devices
- central catheter that is tunneled (going under the skin) into superior vena cava
Port-A-Cath
-catheters for long-term use
- under the skin
-can't see it
PICC line
-centrally inserted
-delivers to superior vena cava from arm area
Subclavian central venous lines
-for long term use when peripheral veins are no longer an available site
IV head to toe assessment
- proceed from IV bag to IV site
- bag: clear? particles? correct/expired IVF?
- pump/gravity drip: set correctly?
- tubing: kinks? air? precipitates? tangled? catheter secure at site? piggyback secure? Clamps on or off?
-IV site: c/o swelling? redness? pain? tenderness? patent? catheter size? When inserted? infusing or to HL/SL? leaking?
Band-aid dressing is changed
q 24 hrs
transparent dressing are changed
q 72 hrs
only use __ or ___ over IV site. NEver use tape
bandaids or transparent dressings
An RN/LPN must check site ______ on rounds for signs of infection and infiltration.
q 2hrs
Change site and tubing, etc...
q 72 hrs
Site selection:
- use non-dominant hand
- avoid areas of extremity flexion
- hand veins generally first choice in adults for long term therapy
- avoid areas of skin breakdown, hematomas, etc
- large deep veins are best for thick fluids/irritating drugs
-do not use lower extreities without MD order
- avoid veins in inner askect of arm and wrist if possible
- do not start IV in an arm with arteriovenous shunt or fistula
IV cannulas/catheters should be what size?

what if it's a deeper vein?
3/4" to 1 1/4"

2" for deep vein
To reduce risk of phlebitis, the catheter should be as ____1_____ in diameter as pissoble so it takes up ___2__ space in the vein. this allows______3____
1. small
2. more
3.better blood flow around the catheter, lessening the risk of phlebitis
What guage catheter should you use in infants, children, and possibly elderly with extremely small veins?
24 guage
what guage catheter should you use for stable medical patients?
22-20
If patient is bordering on unstable, what guage catheter would you use IV?
20 or larger if blood administration is anticipated
what guage IV catheter should be used for surgical patients and blood administration?
18
What guage catheter should be used in trauma patients or patients in hypovolemic shock?
16
advantages of butterfly catheters
-come in a variety of guages and lengths
-very sharp and less painful
-easy to use
- less prone to infection
-good in very small fragile veins such as elderly
disadvantages to butterfly catheters
- associated with frequent infiltration/being dislodged from the vein.
-patient must be restricted
-short-term only
large bore IV tubing
- delivers fluid at a faster rate and takes fewer drops to equal 1 ml of fluid.
Why would you need to use a larger vein?
thick fluids such as blood, TPA, or fats.
Why would you use digital veins? How?
In patients who have had alot of IV therapy and can't use arm veins. Use veins around thumb and knuckles, using a tongue blade to stabilize.

Also, the only veins that are available for use in obese patients may be in the hand
Why use large deep veins?
if giving irritatine drugs/solutions, because it is less prone to phlebitis.
If therapy is likely to continue for more than a few days, start _____ and work your way ______
distally
up
If the patient is dehydrated, it makes it ________ to find their veins
harder
Last resort veins:
-veins on inner aspect of arm and wrist b/c thin walled and smaller than cephalic or basilic veins and associated with bruising, phlebitis, and infiltration
- veins of legs, feet, and akles can only be utilized with a doctor's order because cannulating them may compromise circulation in legs and cause thrombophlemitis or embolism. Dorsum or saphenous vein are sites of choice if you must use
-veins below a phlebitic area
-clerosed and thrombosed vein
- areas of skin inflammation, disease, bruising, breakdown
- arm affeted by radical mastectomy, edema, blood clot or infection
-DO NOT Attempt to start an IV in an arm with an arteriovenous shunt or fistula
What should veins feel like?
-round
-firm
-elastic
-engorged

not hardened, bumpy, or flat
What guage do most IV infusions for a pediatric patient require?
22-24 guage
What guage should you use for IV for geriatric patient?
smallest guage possible

*is less traumatic to the vein and allows better blood flow to provide increased hemodilution of the IV fluids or medications
In elderly adults with fragile skin and veins, how much tourniquet pressure should you use?
little or none
What angle of insertion should you use on an IV for an elderly patient?
5-15 degrees
Insert IV catheter bevil side _______ in infants
down
Pediatric extremety sites
Upper extremity
-cephalic vein
-median cubital vein
- basilic vein
Lower extremity
- great saphenous vein
-dorsal venous arch
EMLA cream must be applied at least ______ minutes before the procedure, but can be left in place up to ______ hours
60

3
what angle should you insert the cannula for IV?
15-25 degrees depending on depth
Why are blood products given?

(4 reasons)
1. to restore volume
2. restore oxygen carrying capacity
3. replace clotting factors
4. replace WBC's in a neutropenic patient
Blood is regulated by the_________.
FDA

* so you need written MD order, consent, and 2 nurses to check before giving
What is the universal recipient?
AB

*because they have neither antibody but both antigens
What is the universal donor?
O

* because they have both antibodies and neither antigen
85% of population is Rh __
positive
15% of the population is Rh
negative
What happens if a Rh negative person is exposed to Rh positive blodd?
-thye will make antibodies against the Rh factor and the result will be hemolysis upon any subsequent exposure to Rh positive blood
Risk of contracting a blood bourne disease (AIDS, hepatitis, etc.)
1:34,000
95% of transfusion fatalities are from:
ABO incompatibility due to patient ID/clerical error or specimen labeling error
Packed red blood cells
used for oxygen carrying capacity
fresh frozen plasma
provides clotting factors
cryoprecipitate
factor VIII, fibrinogen, von Willebrand factor
Pre- transfusion assessment consists of:
1. question the patient- get hx and reason for transfusion
2. explain the procedure
options to avoid anonymous donor:
-store own blood before a planned procedure
-have friend or relative donate for you (but statistically not any better than anonymous donor)
-autologous transfusion
Transfusion procedure:
1. begin slow to allow for early detection of problems
2. transfuse within 4 hours max
3. monitor for side effects
4. record findings
rapid blood administration can result in :
cardiac dysrhythmias
what is the maximum time period blood can be transfused over?

Why?
4 hours (whole blood or packed RBCs usually transfuse within 2 hours)

if longer, at risk for contamination
Before initiating blood therapy:
1. crossmatch
2. place IV catheter/ get supplies
3. obtain baseline vital signs
4. blood transfusion form consent
5. identifying date to be checked
6. have patient void or empty catheter bag
Supplies needed to transfuse:
blood
Y type blood infusion set
bag of normal saline
gloves
alcohol wipes
18 guage IV access
VS equipment
Signd consent form
while the blood transfusion is taking place, when/ how often should you assess vital signs?
every 5 minutes for 15 minutes, then 15 minutes after that
most transfusion reactions occur within the first:
15 minutes
what is the only fluid that can be infused with blood transfusions?
normal saline
Procedure to administer blood immediately before giving:
1. check your order (name of pt., physician, blood bank number, appearance of blood)
2. get signed consent
3. obtain blood from blood bank- 2 RNs need to make sure it is the right blood for the pt.
4. observe the blood for clots, discoloration
5. gently rotate the blood bag to mix the blood
6. spike the NS and purge the Y set of air
7. spike the blood
8. take baseline VS
Begin blood transfusions at what rate?

Then how do you increase the rate?
2ml/min (drip rate is 10gtt/ml)

gradually increase to ordered rate (b/c must infuse within 4 hours)
Signs of a transfusion reaction:

1. first signs
2. other signs
1. fever, tachycardia, hypotension
2. chill, back pain, HA, nausea, chest tightness, anxiety, dyspnea, pruritus, urticaria
What are some systemic responses by the body to incompatible blood?
-red cell incompatibility
- allergic sensitivity to blood components
-acute reaction
-transmission of infectious disease (Malaria, hepatitis, AIDS)
Acute Hemolytic reaction cause
-infusion of ABO-incompatible whole blood, RBCs, or components containing 10ml or more of RBCs
-antibodies in the recipient's plasma attach to antigens on transfused RBCs, causing RBC destruction
Acute hemolytic rection clinical manifestations
-chills
-fever
-low back pain
-flushing
-tachycardia
-tachypnea
-hypotension
-vascular collapse
-hemoglobinuria
-leeding
-hemoglobinemia
-acute renal failure
-shock
-cardiac arrest
-death
Acute hemolytic reaction management
-stop transfusion
-treat shock
-draw blood samples for serological testing slowly to avoid hemolysis from the procedure
-send urine specemin to lab
-maintain BP with IV colloid solution
-give diuretics as prescribed to maintain urine flow
-insert indwelling catheter or measure voided maounts to monitor hourly urine output
-dialysis may be required
-do not transfuse additional RBC-containinc components until transfusion service has provided newly crossmatched uints
prevention of acute hemolytic reaction
-meticulously verify and document client identification from sample collection to component infusion
febrile, noonhemolytic reaction
most common reaction
cause of febrile, nonhemolytic reaction
-reaction to leukocytes or platelets
-sensitization to donor whit blood cells, platelets, or plasma proteins
febrile, nonhemolytic reaction s/s
- sudden chills and fever (greater than 1 degree celcius rise)
- HA
-flushing
-anxiety
- muscle pain
Management of febrile, nonhemolytic reaction
-give antipyretics as prescribed- avoid aspirin in thrombocytopenic patients
-do not restart transfusion
Prevention of febrile, nonhemolytic reaction
- consider leukocyte-poor blood products (filtered, washed, or frozen)
causes of mild allergic reation
sensitivity to foreign (donor's) plasma proteins
s/s of mild allergic reaction
-flushing
-itching
-urticaria (hives)
management of mild allergic reaction
- give antihistamine as directed.
- if symptoms are mild and transient, transfusion may be restarted slowly
- do not restart transfusion if fever or pulmonary symptoms develop
prevention of mild allergic reaction
treat prophylactically with antihistamines
Acute hemolytic reaction
- ABO or Rh incompatibility, occrs within first 5-15 minutes
Delayed hemolytic reaction
-caused by a non-ABO donor antigen
-onset is 2-14 days
Causes of an anyphylactic transfusion reaction
- infusion of IgA proteins to IgA deficient recipient who has developed IgA antibody
s/s of anaphylactic transfusion reaction
- anxiety
- urticaria
- wheezing
- progressing to cyanosis
- shock
- possible cardiac arrest
management of Anaphylactic reaction
-initiate CPR, if indicated
- have epinephrine ready for injection
-do not restart transfusion
prevention of anaphylactic transfusion reaction
- transfuse extensively washed RBC products, from which all plasma has been removed
-alternately, use blood from IgA deficient donor
causes of Circulatory overload transfusion reaction
- fluid administration faster than the circulation can accomodate
s/s of circulatory overload
-cough
-dyspnea
-pulmonary congestion
- HA
- hypertension
- tachycardia
- distended neck veins
Management of circulatory overload
- place client upright with feet in dependent position
-administer prescribed diuretics, oxygen, morphine
-phlebotomy may be indicated
prevention of circulatory overload
- adjust transfusion volume and flow rate based on client size and clinical status
Causes of sepsis transfusion reaction
- transfusion of contaminated blood components
s/s of sepsis transfusion reaction
- rapid onset of chills
- high fever
- vomitin
- diarrhea
- marked hypotension and shock
management of sepsis
- obtain culture of client's blood and send bag with remaining blood to transfusion service for further study
-treat septicemia as directed- antibiotics, IV fluids, vasopressors, steroids
prevention of sepsis
- collect, process, store, and transfuse blood products according to blood banking standards and infuse wihtin 4 hours of starting time
Febrile, nonhemolytic reaction onset
30 minutes after initiation to 6 hours after completion
Allergic reaction (mild) onset
- during transfusion to 1 hour after transfusion
Anaphylactic reaction onset
within 5-15 minutes to onset of transfusion
Graft-versus host diesase
reproduction of donor lymphocytes, usually in an immunocompromised recipient, which attack recipient's RBCs as if they were foreign proteins
Graft-versus host onset
days to weeks
Graft-versus host s/s
- rash
-fever
- jaundice
- bone marrow suppression
Graft veruss host prevention
- administer irradiated blood products as prescribed
Management of graft-versus- host disease
-administer methotrexate, corticosteroids as ordered
circulatory overload onset
any time during or within 1-2 hours after transfusion
In management of a mild acute transfusion reaction, if the s/s worsen within 15 minutes, treat:
as a severe reaction (anaphylaxis)
Suspect a blood transfusion reaction?
- keep IV line open- piggyback 0.9%NS
-do not just turn blood off and turn on NS
-hang new tubing
-notify MD immediately
- remain with patient/assess/ Vital signs
-prepare for emergency
- CPR
-specimens to lab as indicated
- remember all blood containers, tubing, copy of transfusion record to lab
transfusion reaction actions:
-stop product and keep IV open
- notify MD and blood band STAT
- may need blood and urine samples sent to lab
- blood and tubing returned to the blood bank
Mild s/s of a transfusion reaction
-fever
-urticaria
-rash
- pruritus
severe s/s of a transfusion reaction
-pyrexia
- hypotension
-back pain
- increasing anxiety
- pain at infusion site
- respiratory distress
- dark urine
- severe tachycardia
- unexpected bleeding
Be prepared for these orders from a physician in case of a transfusion rxn:
- draw blood sample for free hgb, bilirubin, and check the type and crossmatch of the patient and blood
- collect a urine sample for hemoglobinuria. If positive you may need to give diuretics and alkalinize the urine
- administer epinephrine
-administer diphenhydramine to block some aspects of allergic response
- administer antibiotics if septic rxn
-administer corticosteroids to suppress immune response to blood,stabilize cell membranes and decrease histamine release
- administer IV fluids for shock
- administer diuretics and morphine to treat circulatory overload reaction to blood
Electrolyte changes when giving blood
-hyperkalemia
-hypocalcemia
Documentation for transfusion
- transfusion form
- vital signs section chart
- nursing notes (record how pt. reacted, outcomes of assessments)
-I and O sheet (blood is intake)
- MAR
- patient education
What is the only component of blood transfusion that can be delegated?
- picking up of blood from the blood bank
Extravasation/infiltration
- occurs when a medication or fluid inadvertently bypasses the vein and infuses into the interstitial tissue
Whether tissue injury occurs depends on:
-if drug is irritating
-volume infused into tissue
- whether there is an early recognition that it has occured

*it can result in tissue necrosis w/ resultant loss of motor and sensory function and potential amputation of the affected limb.
Initial symptoms of tissue extravasation
-patient complaint of burning
-erythema
-swelling at site of injury

*these symptoms may occur over several hours and it is necessary to continually assess an extravasation for ongoing damage. In severe extravasation damage may bot be apparent for several weeks
Patients at risk for extravasation
- patient unable to communicate pain/discomfort (children or sedated patients)
- peripheral vascular disease
- those who hav eIV line that has been placed in a superficial vein (dorsum of hand or forearm)
- those who underwent multiple attempts at venipumcture
-those receiving high-risk irritant meds
Most injuries associated with IV extravasation are caused by these 3 agents:
- hyperosmolar solutions
-vasopressors
- chemtherapy agents
Frequent labs that need to be done for blood transfusions
CBC:
-hemoglobin
-hematocrit
- RBC, WBC
-differential WBC

Bleeding:
-PT
-PTT
-Platelet count

Other:
-fasting blood glucose, Hgb A1c
- Serum K, Mg, Na
-BUN
-Creatinine
When drawing blood from PICC, CVL, etc, flush with:
20 ml NS aterwards

-
Red blood cell normal range for men
4.7-6.1 million/mcg/L
Red blood cell normal range for women
4.2-5.4 million/mcg/L
Red blood cell increased value means
-polycythemia
- high altitude
- intense physical training
Red blood cell decreased value means
- loss or destruction of RBCs
- decreased production of RBC's
- bone marrow suppression
Hemoglobin normal values for men
14-18 g/dL
Hemoglobin normal values for women
12-16 g/dL
Hemoglobin increased level means
-some genetic anemias such as thalassemia are hyperchromic (too much Hgb)
Hemoglobin decreased level means
-anemia
-blood loss
-bone marrow suppression
-abnormal Hgb diseases such as sickle cell anemia
Hematocrit normal values for men
42-52%
Hematocrit normal values for women
37-47%
Hematocrit increased values mean
-loss of body fluids causes relative
-polycythemia causes actual
Hematocrit decreased levels means
-overhydration causes relative
- decrease in # of RBC's causes actual (ex. hemorrhage)
-pregnancy
Hematocrit levels measure:
-the percentage of RBC's in the plasma
Mean Corpuscular Hgb (MCH) levels measure:
average hemaglobin content of each RBC
White blood cell count measures:
the total WBCs per cubic millimeter of blood
WBC normal values
5000-10,000 mcg/L
WBC increased values mean
infection

*Leukocytosis
WBC decreased values mean
bone marrow depression from drugs (i.e. chemotherapy), radiation, or disease.

*Leukopenia
Erythrocyte sedimentation rate (ESR)measures:
Aggregated RBCs
Erythrocyte sedimentation rate (ESR) normal values:
<20 mm/hr
Erythrocyte sedimentation rate (ESR) increased level means:
tissue destruction

inflammation