NUR 314 Final Exam Study Guide
NUR 314 Final Exam Study Guide NUR 314
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This 154 page Study Guide was uploaded by Katelyn Paccione on Thursday December 10, 2015. The Study Guide belongs to NUR 314 at Purdue University taught by Becky Walters in Fall. Since its upload, it has received 123 views. For similar materials see Med Surg I in Nursing and Health Sciences at Purdue University.
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Date Created: 12/10/15
NUR 314 Final Exam Study Guide Please read the following information about the Final Exam: Focus on the nursing care and role of the nurse. Exam 1: Peri-op, Pain, Shock, & Sensory: Comprehensive Review Lecture 1: Peri-Operative Care o Preoperative Phase Nursing care Assessment o Pay attention to these things that creates an increased risk in the patient for intraoperative complications Allergies Bleeding tendencies Cortisone Diabetes Emboli o What are some risk factors for peri-operative complications? Elderly Obese Co-morbid conditions, very ill Disabled Patients where emergency surgery is needed o Medication Considerations Anticoagulants: should stop taking 5 days before surgery: can create bleeding tendencies Herbals are dangerous for the patient to take peri-operatively NUR 314 Final Exam Study Guide All other medications need to be assessed Informed consent forms signed o Written document o Discloses information about the diagnosis and surgical procedure o Ensure that patient has full understanding o A consent is voluntary A patient may withdraw from their consent at any time Must be witnessed and signed by a witness The witness should be the nurse The patient signing the document must be at least 18 years of age The form should then be obtained by the MD What if the patient is incompetent? Next of kin or 2 physicians may grant consent for the incompetent patient o Other forms that may be reviewed with the patient Advance Directive Living will o Patient is full code 24 hours following surgery o States the patient wishes Power of Attorney o Respects the patient’s wishes in their healthcare NUR 314 Final Exam Study Guide Appointed by the patient Ensure that the correct surgical site is marked Preventative measures of possible complications Complete pre-operative teaching o TCDB, IS o Early ambulation, leg exercises, turning in bed o Pain management o Lines, drains o Coping strategies o Plans for discharge, discharge planning is started upon admittance Address anxiety or concerns in the patient o Nursing intervention: offer the patient a sleep aid the night before surgery to help them relax and sleep o Let the patient verbalize feelings and offer therapeutic touch Pre-operative Interventions that should be performed right before OR o ID the patient o ID and verify surgical site o Verify that the patient has been NPO o Empty bladder and bowels prior o Sedative should be administered 30-60 min prior o Apply gown and cap o Apply SCDs if indicated o Remove undergarments o Remove makeup and nail polish NUR 314 Final Exam Study Guide More accurate depiction of the color of the skin More accurate O2 sat readings o Remove jewelry, dentures, hearing aids, and lenses o Promote patient safety o Administer IV fluids o Prep skin: clean and shaven o Obtain baseline vitals o Obtain all consents Surgery Sedation (anesthesia) Blood transfer o Intraoperative Phase (OR) Infection Control Zones o Restricted: surgical room o Semi-restricted: hallway o Unrestricted: nurse’s station Environmental Control of the OR o Attire: scrubs, gloves, hair cover, shoe covers, mask o Low room temperature o Patient is draped o Doors are closed o Traffic in and out of room is limited Surgical Asepsis o Front chest are is sterile and elbow to cuff NUR 314 Final Exam Study Guide o Sterile fields are sterile, instruments are sterile, must be dispensed aseptically o Stay at least 1 foot away from sterile fields at all times Medications administered General Anesthesia o Can be given as an inhalant or IV o Advantages Promotes LOC Amnesia Analgesic: pain management Muscle relaxant Rapidly excreted Regional Anesthesia o –caines o Injected near the nerve blocks o Examples: spinal, epidural o On-Q Pump Continuous infusion Lasts for a few days Decreases the need for narcotics Ropivacaine and Bupivacaine Muscle Relaxants o Muscle paralysis Conscious Sedation o There is no artificial airway o Still have responses to stimuli o Combination of opioids and sedatives NUR 314 Final Exam Study Guide Complications Intraoperatively Malignant Hyperthermia o Life-threatening: EMERGENCY o Triggered by anesthesia o What happens? Early sign: tachycardia Tachypnea = hypoxia Muscle rigidity BP is unstable Rising in temperature Increased potassium and calcium levels Cardiac arrhythmias Acidosis Possible renal failure and cerebral damage o What to do when this happens? Stop surgery immediately Supply O2 to the patient Place a cooling blanket on the patient Administer fluids Administer Dantrolene The nurse is the patient’s advocate: How can we prevent injury of the patient during surgery? TIME OUT o Correct: patient, procedure, site and side o Consents signed o All healthcare professionals in agreement with procedure NUR 314 Final Exam Study Guide o Allergies have been identified o Antibiotics were administered o Special equipment is in the OR Monitoring o Vitals Nursing responsibilities for end of the intraoperative phase Documentation o Times o Counts: sponges, sharps, and instruments o Postoperative Phase PACU: Post Anesthesia Care Unit In this unit postoperatively for about 1 hour Continuous monitoring o Vitals are monitored every 15 minutes Nursing Care/Assessment o ABCs o Pain o Nausea o LOC o Muscle strength and sensation o Drains and dressings Lateral recovery position o Patient is place left lateral with pillow under right arm and leg Why this position? If patient is nauseous then the use of this position decreases the risk for aspiration NUR 314 Final Exam Study Guide Remember patient may also have decreased LOC The following should be established before the patient can be transferred to a different unit o Motor and Sensory function resumes o Vital signs are stable o Alert and Oriented o No hemorrhage o Patient should score at least an 8/10 on the aldrete score Post-Op orders after transfer from the PACU Vitals are assessed every 15 minutes for an hour, when stable, assess every 30 minutes for 2 hours, then every hour for 4 hours, then every 4 hours till discharge o Physician should be called when… Systolic BP: less than 90, or greater than 160 HR: less than 60, or greater than 120 I & O TCDB, IS, activity Diet Medications Assessment o ABC o Neuro o Surgical site Dressing and drains Elimination o Assess abdomen and I&O NUR 314 Final Exam Study Guide o Important that the patient is able to void before discharge Comfort o Pain and activity o Review Study Aides in Blackboard folders Lecture 2: Pain & Shock o Pain Pain is subjective: What is the patient’s rating of their pain? How to objectively assess pain Behavioral signals o Crying, moaning, wincing, grimacing, guarding o Agitated, restless, irritable o Social withdrawal o Decreased sex drive, appetite, sleep (more fatigue) Physiological signs o Increased BP, HR, and RR o Pale skin color o Sweating o Pupils are dilated o Muscle tension Medications Non-opioids o We will try this FIRST o Use for mild to moderate pain o Types of medications Acetaminophen MAX 4,000 mg per day NUR 314 Final Exam Study Guide NSAIDS Ibuprofen and Aleve Toradol: IV Aspirin RISK: bleeding Opioids o Orals Hydrocodone, Oxycodone, Codeine, Methadone, Morphine o Other routes for persistent severe pain Morphine: IV route 1-2 mg Onset is within minutes Hydromorphone (Dilaudid): IV Fentanyl: transdermal patch o PCA: Patient Controlled Analgesia Lessens side effects of opiates Also helps to manage pain more affectively for acute reasons Only the patient can control o Opioid Adverse Effects Constipation Respiratory depression Itching Nausea and vomiting Constricted pupils Sedation and drowsiness o Considerations with the Elderly and Opioid use NUR 314 Final Exam Study Guide Start low and go slow Monitor closely Polypharmacy Adjuvant Therapy o Antidepressants, antiseizure, local anesthetics (-caine), muscle relaxants, sedatives, steroids o Benzodiazepines Xanax and valium Sedation and anti-anxiety ADVERSE EFFECT: drop BP o Overdose signs and symptoms Cold and clammy Confused and drowsy Respiratory depression Pinpoint pupils o Antidote Narcan 0.4 mg every 2-3 minutes until back to baseline condition, MAX dose 4 mg ABCDE o Ask about the pain regularly o Believe the patient, remember that pain is subjective o Choose appropriate pain control options o Deliver the intervention in a timely manner Administer the medication before pain becomes uncomfortable for the patient NUR 314 Final Exam Study Guide o Evaluate the effectiveness of the pain medication Nonpharmacological interventions Comfortable positioning Massage therapy Relaxation, meditation Music or guided imagery Cold or hot compresses o Shock Decreased perfusion Caused by decreased cardiac output which in turns causes tissues of the body to become hypoxic Also less blood is returning to the heart due to decreased blood volume Shock syndromes Hypovolemic: “empty tank” o VOLUME problem o Common causes Blood loss: hemorrhage d/t surgery or trauma Fluid loss: dehydration d/t nausea and rd vomiting, sweating, burns, 3 spacing o Nursing Interventions O2 Shock position Foot end of the bed raised above head level Call rapid response team VOLUME REPLACEMENT NUR 314 Final Exam Study Guide NS, LR, blood or blood products Control the source of fluid loss Distributive (septic, anaphylactic, neurogenic) o VESSEL problem o Septic Shock Signs and symptoms Increase in temperature: antipyretics Increased HR Decreased BP: vasopressors Abnormal WBCs Response to an infection Nursing Interventions O2 Shock position Call rapid response team OBTAIN CULTURE o Give a broad spectrum antibiotic until strain of bacteria has been identified o Anaphylactic Shock Signs and symptoms Wheezing Difficulty breathing Angioedema Hives and itching Increased HR Decreased BP NUR 314 Final Exam Study Guide Nursing Interventions O2 Shock position Call rapid response team ABC o Adrenalin IV: EPI-PEN o Benadryl o Corticosteroid Bronchodilators to open airways Important to obtain allergy hx Cardiogenic o PUMP problem NUR 314 Final Exam Study Guide Signs and symptoms of shock Increased HR with a weak pulse pale and cool and clammy skin Increased RR Decreased BP Urine output less than 30 ml/hr Changes in LOC Stages of shock Compensatory o Increased HR, tissue perfusion is maintained, vasoconstriction NUR 314 Final Exam Study Guide Progressive o Decreased CO, changes in LOC, increased RR, edema Irreversible: patient does not survive o Tissue damage, MODS, death Assessment Airway, maintain Breathing, control work of Circulation, optimize Delivery, adequate oxygen Expansion, volume o LR and NS: crystalloids Lecture 3: Postoperative Complications o Respiratory complications Who is at greater risk? Patients who underwent abdominal surgery These patients won’t be doing a lot of abdominal breathing because of related pain Atelectasis Alveolar collapse d/t mucus plugs d/t retained secretions in the lungs or decreased lung expansion Nursing Interventions o Lung sounds are diminished at the bases o Position HOB elevated o TCDB, q1-2h, encouraging coughing to loosen and get rid of secretions, IS 10 breaths q1h while awake o Early ambulation post-op, 3-4 times per day o Assess vitals and keep hydrated NUR 314 Final Exam Study Guide o Pain management: vitals to look for indications of pain: increased HR and BP o Cardiovascular Complications VTE: Venous Thromboembolism = blood clots Risk factors: o Dehydration o Decreased physical mobility o Smoking o Increased age o History of blood clots o A-fib o Obesity Types of VTE o DVT: Deep Vein Thrombosis Unilateral calf pain Edema Increased temperature Nursing management Bed rest Elevate the leg Monitor labs o PE: Pulmonary Embolism Difficulty breathing Increased HR Coughing Sweating NUR 314 Final Exam Study Guide Nursing management Monitor labs, d-dimer Monitor ABG’s O2 Keep HOB elevated Prevention o Pharmacological LMWH- enoxaparin (lovenox) o Non-pharmacological Early ambulation and leg exercises SCDs o GI Complications Paralytic ileus “post-op ileus” Signs and symptoms o Nausea and vomiting Prevention management NGT Pantoprazole, Zofran o Abdominal distention o Absent bowel sounds o No bm or flatus noted Nursing intervention o Give medications to increase peristalsis o Keep the patient NPO until BS return Nutrition will be through IV or NGT NUR 314 Final Exam Study Guide Once there is the return of BS, diet may progress Sips and chips o Well tolerated? Advance to Clear and full liquids o Well tolerated? Advance to Soft or solids o Ambulate early and often Reasons: Decrease gas pain Promote motility of the intestinal tract o Skin Integrity Who is most at risk for impaired skin integrity? DM Obese Malnourished Steroid therapy Dehiscence Separation of the incision Evisceration Separation of all wound layers and protrusion of internal organs Nursing intervention o Cover the exposed organs with sterile moistened saline dressing Prevention: Splinting: hold pillow to abdomen NUR 314 Final Exam Study Guide Abdominal binder o Surgical site infection (SSI) Signs and symptoms Fever and chills At the surgical site: hot, redness, swelling, tender, purulence, malodor Labs: elevated WBC o Changes in mental status AMS: Altered Mental Status: delirium Treat the underlying condition Common cause: overuse/overdose of narcotics Nursing intervention: Keep patient safe! o GU complications Urinary retention (POUR) Voiding should happen 8 hours postop Interventions: o Stand and run water Lecture 4: Sensory Disorders o Eye Cataracts “cloudy lens” Causes o Congenital o Aging (MOST COMMON) o Toxicity: steriods o Accidents o Radiation (sunlight) NUR 314 Final Exam Study Guide o Altered metabolism (DM) o Cigarette smoking Treatment o Nonsurgical Improve acuity Glasses Magnifiers Better lightening NO NIGHT DRIVING o Surgical ONLY cure Post-op Eye drops Protective eyewear from sunlight Restrict activities that can an increase in eye pressure o No heavy lifting o No rubbing eyes Glaucoma “tunnel vision” “silent thief of sight” : usually no symptoms d/t a problem with fluid drainage in the eye, pressing against the optic nerve risk factors o greater than 60 o family hx of glaucoma o increased IOP o African descent NUR 314 Final Exam Study Guide types o open-angle MOST common 22-32 IOP Gradual Chronic No symptoms o angle-closure greater than 50 IOP sudden and immediate s/s: painful, halos MEDICAL EMERGENCY Treatment o Medical Eye drops: decrease production of fluid or increase drainage of fluid o Surgical Laser: want to turn off the faucet, unclog the blockage, and create a new channel Post-op Avoid activities that increase eye pressure Prevention o See your eye doctor! Annual eye exams! Retinal Disorders Retina: senses light and color: produces images Diabetic retinopathy o #1 cause of blindness NUR 314 Final Exam Study Guide o Dot and blot hemorrhages due to eye vessel leakage due to hyperglycemia o Management Photocoagulation: laser Vitrectomy: drain blood Control blood sugars Annual eye exams Retinal detachment o Retinal layers split: medical emergency o Warning signs! Light flashes Floaters Shadows in peripheral field Curtain moving across field of vision o Management Laser or cryotherapy Vitrectomy: drain fluid Scleral buckling Avoid straining activities Age related macular degeneration o Hole in the vision o Risk factors AGE: older than 50 Family history Poor nutrition Dry (drusen) or wet (leaky blood vessels) SERIOUS o Management NUR 314 Final Exam Study Guide Laser therapy: there is no cure, this can only slow progression Eye Disorders Conjunctivitis, “pink eye” o Bacterial Most dangerous: contagious o Viral Most common: contagious Prevent with proper hygiene o Allergic Not contagious o Tx: Cool compresses Blepharitis o Irritation of the eyelids o Tx: antibiotic ointment, baby shampoo and warm compress Hordeolum (Sty) o uocompress Keratitis o Eyelash follicle that causes scarring o Tx: antibacterial or viral drops Corneal Injury o Abrasion of the cornea that is caused by something sharp #1 cause: poor care of contact lenses o Signs and symptoms Redness Pain NUR 314 Final Exam Study Guide Gritty sensation Tearing o Fluorescein dye stains green o Tx: antibiotics and pain medications Eye Trauma Prevention o Wear eye protection Management o Penetrating: do not remove the object, want to stabilize the object and prep for surgery o Foreign body: use wet q-tip to remove o Chemical/burn: irrigate the eyes Nursing care for eye disorders Prevention o Protect vision Hand hygiene Eyewear Contact lens care Discard old makeup Vitamins Annual eye exams Post-op eye care o Avoid rubbing or putting pressure on the eyes This includes avoiding those activities that increase IOP o Use protective eyewear o Administer eye drops as prescribed Eye drops NUR 314 Final Exam Study Guide o Administering Lay the patient down Have the patient close their eyes Place the drops in the inner canthus Have the patient open their eyes and blink Wait 3-5 minutes between drops The visually impaired o Speak as you enter the room and before you touch the patient o Always explain what you are doing o Give the patient orientation to the environment o Ear Hearing Disorders #1 cause: loud noises Hearing loss o Conductive Involves the middle and outer ear Otosclerosis Stiffening of the stapes Often shows up in pregnancy Tx: hearing aids or removal of the stapes o Sensorineural Involves the inner ear Meniere’s Disease o “dizzy terror” o Excess fluid in the inner ear NUR 314 Final Exam Study Guide o Vertigo and tinnitus o Tx: Bed rest Avoid rapid head movements Low sodium diet and NO alcohol IV fluids, antiemetics, antihistamines, antivertigo, sedative Ototoxicity o Permanent damage to the inner ear due to medications o Prevention Use ear protection TURN DOWN volume Keep ears dry Avoid cotton tip applicators, use a wash cloth instead Ear drops o Administering Med should be room temperature Position head to the side Apply drops into canal Gently push the ear lobe inward Maintain with head to the side for 2 minutes The hearing impaired o Speak normally and slowly o Face the patient NUR 314 Final Exam Study Guide o Limit distracting noises o Use written words or sign language o Skin Skin cancer Diagnostics: excisional biopsy preferred AK: Actinic Keratoses: pre-cancer o Cause: sun o Characteristics: thick and scaly skin, sand paper texture o Risk factors: Fair skinned Sun exposure o Treatment Liquid nitrogen and topical cream (5-FU) Basal Cell Carcinoma o Most common o Slow growing o Causes: UV or sun exposure o Characteristics: pearly papules, painless o Treatment Remove the malignant tissue: excision, moh’s, curettage: 90% success rate Squamous Cell Carcinoma o Causes: UV, sun exposure, lips of smokers o Characteristics: non-healing, crusts and bleeds o Treatment Remove the malignant tissue: excision, moh’s, curettage: 90% success rate NUR 314 Final Exam Study Guide Malignant Melanoma o mole = nevi o melanoma = cancerous growth of the moles o causes: genetic, UV, sun, fair skinned o MOST DEADLY o Treatment Wide surgical excision, chemotherapy, radiation, biologic therapy Burns 1 degree o Involves: superficial thickness: epidermis o i.e. sunburn o Characteristics: painful, red, blanches o Interventions Soak in cold water Apply with antibiotic ointment Cover with a dry dressing NSAIDS for pain prn nd 2degree o Involves: dermis Can be partial and deep partial o Characteristics: red, blanches, blisters, edema, moist, very painful o Interventions ABC assessments Analgesics for pain Wound care rd 3 degree NUR 314 Final Exam Study Guide o Involves: SQ: full thickness o Characteristics: white and waxy, leathery, no blanching, edema, insensitive to pain o Interventions ABC assessments Surgery and grafts Assessing burns o Rule of 9’s o Assessment in light of complications associated with burns Assess vitals Administer O2 prn and assess airway patency IV lines and fluids Elevate extremities Keep the patient warm Maintain NPO status Skin Infections Bacterial o Impetigo Staph or strep Honey crusts, on the face Treatment: topical antibiotic o Folliculitis Staph Redness around the hair follicles Due to shaving Treatment: topical antibiotic NUR 314 Final Exam Study Guide o Furuncles and Carbuncles MRSA Infection at the hair follicle but deeper Boils Treatment: warm compress, drain, oral antibiotic o Cellulitis Involves the SQ tissue and is caused by staph or strep Red, hot, tender, and swollen can cause fever and fatigue treatment: oral/IV antibiotic, elevate, apply moist heat Viral o Shingles: herpes zoster o At risk populations Elderly Immunocompromised o Characteristics: painful vesicles and crusts o Treatment: antiviral: acyclovir, analgesics for pain o Prevention: zostavax vaccine Fungal o Tinea or candida o Most commonly found in the skin folds of the body due to moisture o Treatment: antifungals: -azole, dry the skinfolds with drying agents, wear cotton clothing, use powder and alternate shoes and socks Inflammatory skin conditions NUR 314 Final Exam Study Guide Contact dermatitis o Most common o Rash o Due to skin irritants o Want to avoid the causative agent which can be tested through a patch test o Treatment: corticosteroids, itching can be treated with cool compress, burrows solution, calamine, Benadryl Urticarial: aka hives o Treatment: antihistamines, corticosteroids, cool compress, calamine Psoriasis o Autoimmune disorder o Causes: sun, stress, season changes, hormones and meds o Most commonly on elbows, knees, and scalp o Silvery white scales o Management No cure Topical cream: coal tar Light therapy Oral meds Skin Ulcers Types o Diabetic On the feet o Pressure On bony prominences NUR 314 Final Exam Study Guide o Arterial Cannot heal until restored Smoking is a causative factor o Venous Need SCDs Wound should always be covered Caring for patients with skin disorders Be sun aware! o Avoid unprotected sun exposure o Wear protective clothing o Apply sunscreen o Routinely check skin o Educate How to prevent skin breakdown o Hygiene o Good nutrition o Promote mobility o Avoid hot water o Moisturize skin o Avoid tanning beds How to promote wound healing o Keep clean and covered Wound should be moist Skin around wound should be dry o debride necrotic tissue o pack deep wounds loosely o monitor albumin and pre-albumin labs, nutrition NUR 314 Final Exam Study Guide o monitor for signs of infection, antibiotics o diabetics: manage blood sugars AVOID Neosporin because it can cause allergic dermatitis NUR 314 Final Exam Study Guide Exam 2 Review: Oncology and Hematology Lecture 1: Anemia o Decrease in the number of red blood cells which puts the body’s tissues at risk for hypoxia o This is not a disease, this is a CONDITION o Causes of anemia Major loss of red blood cells through bleeding Decreased red blood cell production Increase in red blood cell destruction, hemolysis Hemodilution: increase in fluids that dilutes the blood o Severe anemia is a RBC count below 6 o Symptoms Pallor, jaundice Dyspnea Tachycardia, palpitations Fatigue, weakness, activity intolerance o General appearance of a patient with anemia Skin Hair and nails are dry and brittle Poor skin turgor Skin pale or jaundiced Mucous membranes bluish tint Respiratory Tachypnea Cardiovascular Tachycardia, palpitations ANKLE EDEMA NUR 314 Final Exam Study Guide Neurological Headache Tinnitus Confused and irritable o Normal LABS WBC: 5-10 RBC: 5 million Hgb: 12-18% Hct: 45% Platelets: 150-400 o Types of anemia Normocytic MCV 80-100 d/t blood loss Microcytic MCV less than 80 IRON DEFICIENCY o Labs: Decreased Fe Decreased Ferretin Increased TIBC o Symptoms: Glossitis, cheilitis, pallor, ha, paresthesia, spooning of the nails o Nursing intervention Medications Ferrous sulfate: iron supplements NUR 314 Final Exam Study Guide o Take with VITAMIN C: enhances absorption o Avoid antacids 2 hours before and after administration o #1 cause of constipation Administer with stool softeners o Other side effects: black stools, liquid causes staining of the teeth Diet: iron rich Dark leafy green vegetables, liver, red meats, eggs, dried fruit, whole grains Macrocytic MCV greater than 100 FOLATE DEFICIENCY o Symptoms: glossitis o Labs: decrease in folate o Nursing intervention Folic acid supplements Diet Dark green leafy vegetables, liver, red meat, fish, legumes, whole grains B12 DEFICIENCY o Pernicious anemia Lack of IF in the GI system, cannot absorb vitamin B12 o Labs: decrease in vitamin B12 or cobalamin NUR 314 Final Exam Study Guide o Symptoms: paresthesia, neurological impairment o Nursing intervention Medications B12 IM injection Anemia of Chronic Disease Etiology: chronic inflammation and a decrease in RBC production We have to treat the underlying disorder Nursing intervention o Epogen: erythropoietin supplement o Blood transfusion Aplastic Anemia “lazy bone marrow” Pantocytopenia: decrease in all blood cell types This causes risk for INFECTION and BLEEDING Nursing intervention o Treat the cause o Prevent bleeding and infection o Erythropoietin supplements, blood transfusion, iron supplements o Bone marrow and hematopoietic stem cell transport Blood Loss Anemia Acute o Due to sudden hemorrhage o Nursing management Replace fluid loss Stop the blood loss NUR 314 Final Exam Study Guide Transfuse red blood cells Treat shock Give supplemental iron Chronic o Due to gradual blood loss o Nursing management Give supplemental iron Stop the bleeding Hemolytic anemia Red blood cell destruction Symptoms: jaundice, hepatomegaly, splenomegaly Nursing management o Splenectomy o Nursing assessment for a person with anemia O2 sat Vitals Nutrition Labs Blood Administration o PRBC: packed red blood cells Hang blood with normal saline Use the bag of blood no later than 30 minutes after retrieving the bag of blood Should be infused over 2-4 hours o Transfusion responsibilities Before the transfusion Need to obtain consent NUR 314 Final Exam Study Guide Inspect the blood color and clarity VERIFY o Need 2 nurses o Compare blood label obtained to patient’s wristband identification o Patient’s full name and MRN o Blood bank number, unit number o ABO/Rh compatibility o Expiration date During the transfusion Assess initial vitals and lung sounds o After the first 15 minutes of the infusion, then… o Every hour while infusing o Last time at completion of infusion Begin the infusion slowly Stay with the patient for the first 15 min of the infusion o Transfusion reactions General signs of a reaction to a blood transfusion Increased temperature Chills Hypotension Back, chest pain Dyspnea, wheezing Bloody urine Nausea and vomiting Decreased urine output NUR 314 Final Exam Study Guide Types Febrile o Most common o Fever, chills, flushing, and nausea Hemolytic o Triad: chills, flank pain, blood stained urine Anaphylaxis o Anxiety, urticaria, SOB, wheezing, shock o Along with all other treatments, don’t forget to administer epinephrine Circulatory overload o Transfusion was administered faster than it should have been o Cough, SOB, crackles, hypertension, tachycardia, distended neck veins o Along with traditional shock treatment: Administer O2 Raise the HOB Administer Lasix Decrease infusion rate of NS
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