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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
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Management of graft-versus- host disease
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-administer methotrexate, corticosteroids as ordered
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circulatory overload onset
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any time during or within 1-2 hours after transfusion
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In management of a mild acute transfusion reaction, if the s/s worsen within 15 minutes, treat:
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as a severe reaction (anaphylaxis)
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Suspect a blood transfusion reaction?
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- 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 |
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transfusion reaction actions:
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-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 |
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Mild s/s of a transfusion reaction
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-fever
-urticaria -rash - pruritus |
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severe s/s of a transfusion reaction
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-pyrexia
- hypotension -back pain - increasing anxiety - pain at infusion site - respiratory distress - dark urine - severe tachycardia - unexpected bleeding |
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Be prepared for these orders from a physician in case of a transfusion rxn:
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- 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 |
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Electrolyte changes when giving blood
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-hyperkalemia
-hypocalcemia |
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Documentation for transfusion
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- 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 |
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What is the only component of blood transfusion that can be delegated?
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- picking up of blood from the blood bank
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Extravasation/infiltration
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- occurs when a medication or fluid inadvertently bypasses the vein and infuses into the interstitial tissue
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Whether tissue injury occurs depends on:
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-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. |
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Initial symptoms of tissue extravasation
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-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 |
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Patients at risk for extravasation
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- 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 |
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Most injuries associated with IV extravasation are caused by these 3 agents:
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- hyperosmolar solutions
-vasopressors - chemtherapy agents |
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Frequent labs that need to be done for blood transfusions
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CBC:
-hemoglobin -hematocrit - RBC, WBC -differential WBC Bleeding: -PT -PTT -Platelet count Other: -fasting blood glucose, Hgb A1c - Serum K, Mg, Na -BUN -Creatinine |
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When drawing blood from PICC, CVL, etc, flush with:
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20 ml NS aterwards
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Red blood cell normal range for men
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4.7-6.1 million/mcg/L
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Red blood cell normal range for women
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4.2-5.4 million/mcg/L
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Red blood cell increased value means
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-polycythemia
- high altitude - intense physical training |
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Red blood cell decreased value means
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- loss or destruction of RBCs
- decreased production of RBC's - bone marrow suppression |
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Hemoglobin normal values for men
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14-18 g/dL
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Hemoglobin normal values for women
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12-16 g/dL
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Hemoglobin increased level means
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-some genetic anemias such as thalassemia are hyperchromic (too much Hgb)
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Hemoglobin decreased level means
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-anemia
-blood loss -bone marrow suppression -abnormal Hgb diseases such as sickle cell anemia |
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Hematocrit normal values for men
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42-52%
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Hematocrit normal values for women
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37-47%
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Hematocrit increased values mean
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-loss of body fluids causes relative
-polycythemia causes actual |
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Hematocrit decreased levels means
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-overhydration causes relative
- decrease in # of RBC's causes actual (ex. hemorrhage) -pregnancy |
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Hematocrit levels measure:
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-the percentage of RBC's in the plasma
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Mean Corpuscular Hgb (MCH) levels measure:
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average hemaglobin content of each RBC
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White blood cell count measures:
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the total WBCs per cubic millimeter of blood
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WBC normal values
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5000-10,000 mcg/L
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WBC increased values mean
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infection
*Leukocytosis |
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WBC decreased values mean
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bone marrow depression from drugs (i.e. chemotherapy), radiation, or disease.
*Leukopenia |
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Erythrocyte sedimentation rate (ESR)measures:
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Aggregated RBCs
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Erythrocyte sedimentation rate (ESR) normal values:
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<20 mm/hr
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Erythrocyte sedimentation rate (ESR) increased level means:
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tissue destruction
inflammation |