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10 Cards in this Set

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  • Back
What are signs of hypoglycemia Blood glucose <70 mg/dl
Shaking
tachycardia
sweating
anxious
dizziness
hunger
impaired vision
weakness
fatigue
headache
irritability
What are the signs of hyperglycemia
Blood glucose >200 mg/dl
Extreme thirst
frequent urination
dry skin
hunger
blurred vision
drowsiness
nausea
What are the signs of a stroke?
Sudden neurological deficits such as muscle weakness (hemiplegia) of face, arm, or leg (especially if confined to one side of the body); confusion or trouble speaking or understanding speech; trouble seeing in one or both eyes; trouble walking; dizziness; loss of balance or coordination; and severe headache
What are nursing interventions for patient with a seizure?
Turn to left side; note time seizure starts and stops, note incontinence
What are the signs of a blood transfusion reaction?
abnormal bleeding, chest or back pain, coughing, cyanosis, dyspnea, facial flushing
Interventions for transfusion reaction
STOP THE BLOOD infusion immediately and infuse normal saline to keep the vein open. Then, notify the MD and blood bank with signs and symptoms of the reaction; take vitals every 15 min. until patient is stable; be prepared to begin resuscitative measures if needed; draw an EDTA (lavender top) tube and label appropriately; send the sample along with the complete transfusion reaction form and the remainder of the blood with the entire administration set still attached to the blood bank; collect the first voided or obtain a catheter urine sample immediately afterward; send to the lab for urinalysis record on transfusion record in reaction and comments columns
Blood products must be infused within...
within 30 min from the time the component left the blood bank.
Rate of infusion should be set at...
Begin infusion slowly for first 15 min to observe for any sign of reaction. If no reaction, increase infusion rate to couple within 2-4 hours.
What do you need to verify before beginning blood transfusion?
Patient name and number on hospital bracelet; name and number on unit requisition; patients own verbal response when asked to give name and date of birth
How do you treat a pt who is not NPO and has a glucose between 50-70?
Treat with 15 grams of fast acting carbs; recheck 15 min after carbs given; then again in 1 hour