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Adult Health I Test II > Class Day III > Flashcards

Class Day III Flashcards

1
Q

what are the three types of transfusions?

A
  • standard donation
  • autologous donation
  • intraoperative blood salvage
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2
Q

explain the difference b/w a standard donation and an autologous donation

A
  • Standard donation: transfusion from compatible donor blood
  • Autologous transfusions: client’s blood is collected in anticipation of future transfusions (elective surgery)
    • Blood is designated for and used only by the client
    • Clients can donate up to 6 weeks prior to surgery
    • If the client’s HgB and HCT remain stable, donation can occur weekly to arrive at desired amount of blood for anticipated transfusion
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3
Q

what is an intraoperative blood salvage?

A
  • blood loss during some surgeries (trauma-related, liver transplantation) is recycled through a device that filters blood into a transfusion bag for transfusion intraoperatively or postoperatively
    • Reinfusion must occur w/in 6 hours of salvaged blood collection
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4
Q

what type of blood product for excessive blood loss?

A

packed RBCs

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5
Q

what type of blood product for anemia?

A

packed RBCs

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6
Q

what type of blood product for kidney failure?

A

packed RBCs

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7
Q

what type of blood product for coagulation factor deficiency?

A
  • example is hemophilia
  • fresh frozen plasma
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8
Q

what type of blood product for thrombocytopenia/platelet dysfunction?

A
  • when platelets less than 20,000 or platelets less than 50,000 and actively bleeding
    • give platelets
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9
Q

what type of blood product for hemophilia A?

A

cryoprecipitate

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10
Q

what type of blood product for burns and hypoproteinemia?

A

albumin

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11
Q

what type of blood can people with A blood receive?

A

A, O

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12
Q

what type of blood can people with B blood receive?

A

B, O

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13
Q

what type of blood can people with AB blood receive?

A

A, B, AB, O

AB+ is universal recipient

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14
Q

what type of blood can people with O blood receive?

A

O

O- is the universal donor

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15
Q

Rh factor

A
  • If Rh negative: born w/o Rh antigen in RBCs
    • As a result, they do not develop Ab unless sensitization occurs
    • Once sensitization occurs, any transfusion w/ Rh positive blood will cause a rxn
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16
Q

what are important nursing actions to remember when doing a blood transfusion?

A
  • assess V/S and temp prior to transfusion
  • remain w/ client during initial 15-30 min of transfusion
  • initiate large bore IV access w/ 18-20 G
  • 2 RNs must identify correct blood product and client by comparing ID numbers
  • prime administration set with NS only!
    • never add meds
    • Y tubing used
  • initiate transfusion w/in 30 min of obtaining blood product
    • must complete w/in 4 hours
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17
Q

important nursing considerations for older adults receiving a blood transfusion

A
  • No larger than 19 G needle
  • Assess kidney function, fluid status, and circulation prior to blood product administration.
    • They are at inc risk for fluid overload
  • Use blood products less than 1 week old
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18
Q

blood transfusion: intraprocedure nursing considerations

A
  • Remain w/ client for first 15-30 min of transfusion and monitor V/S
  • Older adults:
    • Assess V/S every 15 min during transfusion
    • Changes in pulse, BP and RR can indicate fluid overload
    • If they have a hx of cardiac or renal dysfunction, they are at inc risk for HF or fluid volume excess when receiving a transfusion.
    • Administer transfusion over 2-4 hours for older adults
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19
Q

blood transfusion: postprocedure nursing considerations

A
  • Obtain V/S on completion of transfusion
  • Dispose of blood administration set according to policy
  • Complete paperwork and file
  • Document client’s response
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20
Q

onset and findings for acute hemolytic reaction

A
  • Onset: immediate or can manifest during subsequent transfusions
  • Findings:
    • Results from transfusion of blood products that are incompatible w/ the client’s blood type or Rh factor
    • Can occur with transfusion of as few as 10 mL
    • Can be mild or life threatening, resulting in DIC or circulatory collapse
    • S/S: chills, fever, low back pain, tachycardia, flushing, hypoTN, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, impending sense of doom
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21
Q

nursing actions for an acute hemolytic rxn

A
  • Stop transfusion
  • Remove blood tubing from IV access
  • Initiate infusion of NS using new tubing
  • Monitor V/S and fluid status
  • Send blood bag and administration set to the lab for testing
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22
Q

onset and findings of a febrile rxn

A
  • Onset: occurs w/in 2 hours of starting transfusion
  • Findings:
    • Results from development of anti WBC antibodies
      • Can be seen when client has received multiple transfusions
    • S/S: chills, inc of 1 deg F or greater from pretransfusion temp, hypoTN, tachycardia
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23
Q

nursing actions for a febrile rxn

A
  • Use WBC filter for administration to prevent this rxn
  • Stop transfusion and administer antipyretics
  • Initiate an infusion of NS using new tubing
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24
Q

onset and findings for an allergic rxn (with blood transfusion)

A
  • Onset: during or up to 24 hour after transfusion
  • Findings:
    • Results from a sensitivity rxn to a component of transfused blood
    • Findings are usually mild and include itching, urticaria, and flushing
    • Client can develop an anaphylactic transfusion rxn resulting in bronchospasm, laryngeal edema, and shock
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25
nursing actions w/ a mild allergic rxn to blood
* Stop transfusion * Initiate NS using new tubing * Administer antihistamine (diphenhydramine) * If provider prescribes to restart transfusion, do so slowly
26
nursing actions with an anaphylactic rxn to blood
* Stop transfusion * Administer epinephrine, oxygen, or CPR * Remove blood tubing * Initiate NS using new tubing
27
onset and findings with bacterial rxn to blood transfusion
* Onset: during or up to several hours after transfusion * Findings: * Results from transfusion of contaminated blood products * S/S: wheezing, dyspnea, chest tightness, cyanosis, hypoTN, shock
28
nursing actions with a bacterial rxn to blood
* Stop transfusion * Administer antibiotics and IV infusion of NS using new tubing * Send blood culture to lab
29
onset and findings with circulatory overload from blood transfusion
* Onset: can occur any time during transfusion * Findings: * Results from transfusion rate that is too rapid * Higher risk in older adults * S/S: crackles, dyspnea, cough, anxiety, JVD, tachycardia * Can progress to pulmonary edema
30
nursing actions with circulatory overload from blood transfusion
* Slow or stop transfusion depending on severity * Position client upright w/ feet lower than heart * Administer oxygen, diuretics, and morphine
31
what are the causes of anemia?
* Blood loss * Inadequate RBC production (hypoproliferative) * Inc RBC destruction (hemolytic) * Deficiency of necessary components such as folic acid, iron, erythropoietin, and/or vit B12
32
health promotion and dz prevention for anemia
* Women who are pregnant or menstruating should ensure that their diet contains adequate amount of iron rich foods * If iron deficient and have elevated cholesterol levels should integrate iron rich foods that are not red or organ meats * Clients should consume foods high in folate (spinach, lentils, bananas) and folic acid fortified grains and juices
33
what are the major risk factors for anemia?
* acute or chronic blood loss * inc hemolysis * inadequate dietary intake or malabsorption * bone marrow suppression * age
34
explain how inadequate dietary intake/malabsorption can occur to cause anemia
* Iron deficiency * Vit B12 deficiency: pernicious anemia due to deficiency of intrinsic factor produced by gastric mucosa which is necessary for absorption of vitamin B12 * Folic acid deficiency * PICA
35
explain how age can cause anemia
* Older adult clients are at risk for nutrition deficient anemias (iron, vit B12, folate) * Anemia can be misdiagnosed as depression or debilitation in older adults * GI bleed is common in older adults: check for occult blood
36
subjective expected findings of anemia
* Possibly asymptomatic * Pallor * Fatigue * Irritbility * Numbness and tingling of extremities * Dyspnea on exertion * Sensitivity to cold * Pain and hypoxia w/ sickle cell crisis
37
objective findings of anemia
* SOB/fatigue, especially on exertion * Tachycardia * Dizziness or syncope on standing or with exertion * Pallor with pale nail beds and mucous membranes * Nail bed deformities (spoon shaped) * Smooth, sore, bright red tongue (vitamin B12 deficiency)
38
CBC to test for anemia
* RBCs are major carriers of HgB * HgB transports O2 and CO2 to and from cells and can be used as index of oxygen carrying capacity * Hct is percent of RBCs in relation to total blood volume
39
iron studies to test for anemia
* Total iron binding capacity (TIBC): reflects an indirect measurement of serum transferrin, a protein that binds with iron and transports it for storage * Serum ferritin: indicator of total iron stores in body * Serum iron: amount of iron in blood * **Iron deficiency anemia: low serum iron and elevated TIBC**
40
HgB electrophoresis to test for anemia
* Separates normal HgB from abnormal * Used to detect thalassemia and sickle cell dz
41
Sickle cell test for anemia
* Evaluates sickling of RBCs in presence of dec oxygen tension
42
Schilling test for anemia
* Measures vitamin B12 absorption w/ and w/o intrinsic factor * Used to differentiate malabsorption and pernicious anemia
43
nursing care for anemia
* Encourage dietary intake of deficient nutrient * Monitor O2 sats * Administer meds * Teach client and family about energy conservation
44
medications used for anemia
* iron supplements * erythropoietin: epoetin alfa * vitamin B12 * folic acid
45
iron supplements to tx anemia
* ferrous sulfate, ferrous fumarate, ferrous gluconate * Oral iron supplements: used to replenish serum iron and iron stores * Iron: essential component of HgB, and subsequently, oxygen transport * Parenteral only given for severe anemia * Nursing considerations: administer parenteral iron using Z track
46
client education for iron supplements
* Have HgB checked Q4-6 weeks * Vitamin C can inc oral iron absorption * Take iron supplements b/w meals * Tell client stools can be green or black
47
epoetin alfa to tx anemia
* Hematopoietic growth factor used to increase production of RBCs * Nursing considerations: * Monitor for inc in BP * Monitor HgB and HCT 2x per week * Monitor for CV event if HgB inc too rapidly * Client Edu: * Reinforce importance of having Hgb and Hct evaluated 2 times a week
48
vitamin B12 to tx anemia
* Vit B12: necessary to convert folic acid from its inactive form to its active form * All cells rely on folic acid for DNA production * Vit B12 supplementation can be given orally if the deficit is due to inadequate dietary intake * If deficiency is due to lack of intrinsic factor being produced by parietal cells of stomach, it must be administered parenterally or intranasally to be absorbed
49
nursing considerations and client edu for vitamin B12
* Nursing considerations: * Administer according to route related to cause of anemia * Administer parenteral forms via IM or deep subQ to dec irritation * Do not mix other meds in syringe * Client edu: * Clients who lack intrinsic factor or have irreversible malabsorption syndrome should be informed this therapy will be for rest of their life * Should receive B12 injections on monthly basis
50
folic acid supplements to tx anemia
* Folic acid is a water soluble, B complex vitamin * It is necessary to for the production of new RBCs * Nursing considerations: * Folic acid can be given orally or parenterally * Client edu: * Large doses of folic acid can mask vit B12 deficiency * Large doses will turn the client’s urine dark yellow
51
therapeutic procedures to help with anemia
* Blood transfusions: * Blood transfusions lead to immediate improvement in blood cell counts and manifestations of anemia * Typically only used when client has significant manifestations of anemia, b/c of the risk of blood borne infections
52
complications from anemia
* Heart Failure: can develop due to inc demand on the heart to provide O2 to tissues * A low Hct dec amount of O2 carried to tissues in the body, which makes the heart work harder and beat faster * Nursing actions: * Administer O2 and monitor O2 sats * Monitor cardiac rhythm * Obtain daily weight * Administer blood transfusion * Administer cardiac meds (diuretics) * Administer antianemia medications
53
Sickle Cell
* Defective Hgb * RBCs become malformed during periods of hypoxia and obstruct capillaries in joints and organs * Test evaluates the sickling of RBC in the presence of decreased oxygen tension
54
Complications from Sickle Cell
* kidney failure: b/c RBC shape * infection: b/c take out spleen so don't have WBC reserve
55
therapeutic procedures for Sickle Cell
* Stem Cell transplant: will cause normal RBC production * will cure the pt pretty much, but don't want to do this until you are at the end of the line
56
Sickle Cell: priority interventions
* oxygen: want to oversaturate pts on O2, so get them on as much as possible * fluids * pain control * Morphine is the best * rest
57
Sickle Cell Dz: Discharge Instructions
* b/c on PO meds, should continue a stool softener * inc fluids and stay hydrated * infection prevention: b/c don't have their spleen with WBC reserve * how to stay out of exacerbations, what is their triggers * teach them how to take meds properly to avoid dependence
58
thrombocytopenia/anemia: nursing considerations
* Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds and occult or frank blood in stools, urine or vomit * Institute bleeding precautions * Avoid IV and injections * Apply pressure for 10 minutes after blood obtained * Handle client gently and avoid trauma * Administer thrombopoietic medications to stimulate platelet production * Monitor platelet count and may need to administer platelets
59
thrombocytopenia/anemia: client edu
* Instruct how to manage active bleeding * Instruct client about measures to prevent bleeding * Avoid use of NSAID * Prevent injury when ambulating and apply cold if injury occurs
60
neutropenia
* immunosuppression occurs * Due to bone marrow suppression by cytotoxic medications * The most significant adverse effect of chemotherapy * Neutropenic Precautions * Pt remain in the room unless he needs to leave for a diagnostic procedure or therapy - mask on pt during transport * Protect client from possible sources of infection * Frequent hand hygiene * Avoid invasive procedures that could break tissue unless necessary * Keep dedicated equipment in clients rom * Administer colony-stimulating factors as prescribed to stimulate WBC production
61
Neutropenia: priority interventions
* reverse isolation b/c don't have ability to fight infection * no fruits, veggies, flowers in the room * won't have normal signs of infection (redness, swelling, purulent drainage), so ANY slight inc in temperature, you will do a culture
62
what is ITP?
* Coagulopathy that is an autoimmune disorder in which the lifespan of platelets is decreased by antiplatelet antibodies although platelet production is normal * Can result in severe hemorrhage following a C-section or lacerations
63
what are the risk factors for ITP?
* Female age 20-40 * Autoimmune disorder * Recent virus (children only)
64
what are the meds and therapeutic procedures for ITP?
* Meds * Corticosteroids and immunosuppressants * Therapeutic procedures * Splenectomy can be performed if the client does not respond to medical management
65
what is HIT?
* An immunity- mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin
66
what are the risk factors for HIT?
* Female * Receiving heparin longer than 1 week * Exposure to unfractionated heparin * Postsurgical thromboprophylaxis
67
what are the meds for HIT?
Anticoagulants with direct thrombin inhibitor
68
what is DIC?
* A life threatening coagulopathy in which clotting and anticlotting mechanisms occur at the same time * At risk for both internal and external bleeding as well as damage to organs resulting from ischemia caused by microclots
69
what are the risk factors for DIC?
* Septicemia * Cardiopulmonary arrest * Trauma * Obstetric complications * Cancer
70
what are the nursing considerations and meds for DIC?
* Nursing care * Focus on assessing for and correcting the underlying cause * Prevent organ damage * Monitor for s/s of microemboli (cyanotic nail beds and pain) * Meds * Anticoags (heparin) can be used to decrease microclots from forming and using up clotting factors
71
DIC: interventions
* fluids * administer blood/plasma * must keep pt stable until rapid response team responds * send to ICU
72
what expected findings with coagulation disorders?
* Usual spontaneous bleeding from gums and nose * Oozing, trickling or flow of blood from incisions or lacerations * Petechiae and ecchymoses * Hematuria * Excessive bleeding from venipuncture, injection site, or slight traumas hypotension, diaphoresis * Organ failure secondary to microemboli * Respiratory distress * Redness, pain, warmth and swelling of lower extremities (HIT)
73
what are the lab tests for coagulation disorders?
* Hemoglobin decreased with DIC and ITP * Platelet level * Tachycardia, increase with HIT and ITP, Decrease with DIC * Fibrinogen level decrease with DIC * PT time increase with DiC * PTT increase with DIC * Thrombin time increase with DIC * Fibrin split product levels/ fibrin degradation products increase with DIC * D-dimer increase with DIC
74
nursing care with coagulation disorders
* Regularly assess V/S and hemodynamic status * Monitor s/s organ failure or intracranial bleed * Monitor labs for clotting factors * Admin fluid vol replacement * Transfuse blood, platelets and other clotting products * Monitor for complications from admin of blood and blood products * Avoid NSAIDS * Admin supplemental oxygen * Provide protection from injury * Instruct client to avoid valsalva maneuver * Implement bleeding precautions
75
Sepsis: interventions
* fluids * antibiotics and culture

Adult Health I Test II (3 decks)

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