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NUR 102 ECC > Caring Interventions > Flashcards

Caring Interventions Flashcards

1
Q

What gauge needle is used to deliver blood?

A

20 - 18

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2
Q

Premedications ordered for giving blood

A

Benadryl
Diuretic
Tylenol

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3
Q

Monitoring blood administration

A

Start at 5mL/m for the first 15 minutes.
Watch for rash, fever, SOB, lower back pain (hemolytic).
Repeat VS
Increase IV rate if no symptoms (rate 1.5to 2 hr per unit) (2-4 hr no emergent situation)
Record VS at end of transfusion

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4
Q

What if you suspect a transfusion reaction?

A 
STOP transfusion
Notify laboratory, blood bank, Health care provider 
Treat symptoms per orders
Recheck ID tags and numbers
Monitor VS and urine output
Send blood bags and tubing to blood bank
Document
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5
Q

Blood transfusion

Febrile reaction

A 
Chills
Fever
Headache
Flushing
Tachycardia 
Anxiety
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6
Q

Blood transfusion

Allergic reaction

A

Mild- hives
Pruritus
Facial flushing

Severe - severe SOB
Bronchospasm
Anxiety

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7
Q

Hemolytic transfusion reactions

A 
Low back pain
Hypotension 
Tachycardia 
Fever and chills
Chest pain
Tachypnea 
Hemoglobinuria 
(Immediate or delayed onset)
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8
Q

What to do when hemolytic reaction occurs

A

Obtain 2 blood samples distal to infusion site
Obtain first UA test for hemoglobinuria
Monitor fluid/electrolytes balance
Evaluate serum calcium levels

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9
Q

What to look for in TRALI

A 
Hypixemia
Respiratory failure
Hypotension
Fever
bL pulmonary edema
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10
Q

What to look for in TACO

A 
Dyspnea 
Orthopnea
Cough
Cyanosis
Tachycardia 
Hypertension 
Headache
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11
Q

Nursing interventions for TACO

A

Upright posture
Oxygen
IV diuretic
Phlebotomy

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12
Q

IV medications nursing considerations

A

Verify completeness
Review order for appropriateness of therapy
Check the infusate
Verify patients id

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13
Q

Step to administer direct IV push

A
  1. Verify order
  2. Identify patient
  3. Verify allergy
  4. Hand hygiene
  5. Disinfect connector
  6. Attach syringe, aspirate, flush, disconnect
  7. Disinfect connector
  8. Attach med syringe, inject, disconnect
  9. Disinfect connector
  10. Assess patient, hand hygiene, document
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14
Q

PCA: nursing interventions

A 
Assess baseline
Validate with second clinician
Monitor sedation, respiratory 
Maintain SaO2 >90%
Use sedation scale
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15
Q

When is Central Access Vascular Device (CVAD) used

A

Long term antibiotics
Chemotherapy
Multi-drug therapy

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16
Q

Important info CVAD flushing and locking

A 
Attach syringe
Open clamp
Aspirate
Irrigate with push-pause method
Apply pressure to barrel while closing clamp
17
Q

Care and maintenance for CVAD

A 
Assess for infection: erythema
Drainage
Swelling
Induration
Tenderness
Pain
Edema
Assess patency, fluid leakage
Assess dressing and stabilization device
Assess for outward migration
VS
18
Q

CLABSI : signs and symptoms

A 
Pus
Odor
Erythema
Edema
Tenderness/pain
Warm skin
Increased WBC
Malaise
Chills
19
Q

What is a cheat tube used for

A

Draining pleural space and reestablish negative pressure allowing for proper lung expansion

20
Q

What space is a cheat tube inserted into

A

Mediastinal space

21
Q

What tube is used to drain blood and where is it placed

A

Large 35-40F

5th - 6th intercostal space

22
Q

What tube is used to drain Fluid and where is it placed

A

Medium 24-36F

Mid axillary 5-6th intercostal space

23
Q

What tube is used to drain air and where is it placed

A

Small 10-14F

2-3rd intercostal

24
Q

What position is used to evacuate air

A

Semi-Fowler’s

25
Q

What position is used to drain fluid

A

High Fowler

26
Q

Cheat tube observations

A 
Air fluctuations (tidaling)
Reduced or absent breath sounds
Significant bleeding
Infection
Encourage deep breathing
Range of motion exercises
27
Q

Trach assess need

A 
Coarse crackles over lrg airways
Moist cough
Restlessness
Agitation with decreased O2
Increase peak inspiratory pressure on vent
28
Q

What is subcutaneous emphysema

A

Air collecting under the skin resulting from inadequate seal or air leak at the chest tube insertion site

29
Q

Who is at highest risk with PCA?

A 
Older adults >60
Morbid obesity
Snoring
Recent opioid abuse
Postoperative clients (upper abdominal/thoracic)
Long duration anesthesia 
Taking other sedative meds
Preexisting cardiopulmonary disease
Organ failure
Obstructive sleep apnea
30
Q

PCA medications

A

Morphine
Hydromorphone
Fentanyl

31
Q

What is extravasation

A

IV fluid or medication infiltrates and causes localized ischemia and necrosis of the tissue surrounding the vein

32
Q

What is infiltration

A

IV becomes displaced from inside the vein or vein ruptures and causes IV fluids and medications to leak into tissue surrounding the vein

NUR 102 ECC (4 decks)

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