Caring Interventions Flashcards
What gauge needle is used to deliver blood?
20 - 18
Premedications ordered for giving blood
Benadryl
Diuretic
Tylenol
Monitoring blood administration
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
What if you suspect a transfusion reaction?
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
Blood transfusion
Febrile reaction
Chills Fever Headache Flushing Tachycardia Anxiety
Blood transfusion
Allergic reaction
Mild- hives
Pruritus
Facial flushing
Severe - severe SOB
Bronchospasm
Anxiety
Hemolytic transfusion reactions
Low back pain Hypotension Tachycardia Fever and chills Chest pain Tachypnea Hemoglobinuria (Immediate or delayed onset)
What to do when hemolytic reaction occurs
Obtain 2 blood samples distal to infusion site
Obtain first UA test for hemoglobinuria
Monitor fluid/electrolytes balance
Evaluate serum calcium levels
What to look for in TRALI
Hypixemia Respiratory failure Hypotension Fever bL pulmonary edema
What to look for in TACO
Dyspnea Orthopnea Cough Cyanosis Tachycardia Hypertension Headache
Nursing interventions for TACO
Upright posture
Oxygen
IV diuretic
Phlebotomy
IV medications nursing considerations
Verify completeness
Review order for appropriateness of therapy
Check the infusate
Verify patients id
Step to administer direct IV push
- Verify order
- Identify patient
- Verify allergy
- Hand hygiene
- Disinfect connector
- Attach syringe, aspirate, flush, disconnect
- Disinfect connector
- Attach med syringe, inject, disconnect
- Disinfect connector
- Assess patient, hand hygiene, document
PCA: nursing interventions
Assess baseline Validate with second clinician Monitor sedation, respiratory Maintain SaO2 >90% Use sedation scale
When is Central Access Vascular Device (CVAD) used
Long term antibiotics
Chemotherapy
Multi-drug therapy
Important info CVAD flushing and locking
Attach syringe Open clamp Aspirate Irrigate with push-pause method Apply pressure to barrel while closing clamp
Care and maintenance for CVAD
Assess for infection: erythema Drainage Swelling Induration Tenderness Pain Edema Assess patency, fluid leakage Assess dressing and stabilization device Assess for outward migration VS
CLABSI : signs and symptoms
Pus Odor Erythema Edema Tenderness/pain Warm skin Increased WBC Malaise Chills
What is a cheat tube used for
Draining pleural space and reestablish negative pressure allowing for proper lung expansion
What space is a cheat tube inserted into
Mediastinal space
What tube is used to drain blood and where is it placed
Large 35-40F
5th - 6th intercostal space
What tube is used to drain Fluid and where is it placed
Medium 24-36F
Mid axillary 5-6th intercostal space
What tube is used to drain air and where is it placed
Small 10-14F
2-3rd intercostal
What position is used to evacuate air
Semi-Fowler’s
What position is used to drain fluid
High Fowler
Cheat tube observations
Air fluctuations (tidaling) Reduced or absent breath sounds Significant bleeding Infection Encourage deep breathing Range of motion exercises
Trach assess need
Coarse crackles over lrg airways Moist cough Restlessness Agitation with decreased O2 Increase peak inspiratory pressure on vent
What is subcutaneous emphysema
Air collecting under the skin resulting from inadequate seal or air leak at the chest tube insertion site
Who is at highest risk with PCA?
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
PCA medications
Morphine
Hydromorphone
Fentanyl
What is extravasation
IV fluid or medication infiltrates and causes localized ischemia and necrosis of the tissue surrounding the vein
What is infiltration
IV becomes displaced from inside the vein or vein ruptures and causes IV fluids and medications to leak into tissue surrounding the vein
