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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
Q

nursing actions w/ a mild allergic rxn to blood

A
  • Stop transfusion
  • Initiate NS using new tubing
  • Administer antihistamine (diphenhydramine)
  • If provider prescribes to restart transfusion, do so slowly
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26
Q

nursing actions with an anaphylactic rxn to blood

A
  • Stop transfusion
  • Administer epinephrine, oxygen, or CPR
  • Remove blood tubing
  • Initiate NS using new tubing
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27
Q

onset and findings with bacterial rxn to blood transfusion

A
  • 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
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28
Q

nursing actions with a bacterial rxn to blood

A
  • Stop transfusion
  • Administer antibiotics and IV infusion of NS using new tubing
  • Send blood culture to lab
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29
Q

onset and findings with circulatory overload from blood transfusion

A
  • 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
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30
Q

nursing actions with circulatory overload from blood transfusion

A
  • Slow or stop transfusion depending on severity
  • Position client upright w/ feet lower than heart
  • Administer oxygen, diuretics, and morphine
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31
Q

what are the causes of anemia?

A
  • 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
Q

health promotion and dz prevention for anemia

A
  • 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
Q

what are the major risk factors for anemia?

A
  • acute or chronic blood loss
  • inc hemolysis
  • inadequate dietary intake or malabsorption
  • bone marrow suppression
  • age
34
Q

explain how inadequate dietary intake/malabsorption can occur to cause anemia

A
  • 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
Q

explain how age can cause anemia

A
  • 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
Q

subjective expected findings of anemia

A
  • Possibly asymptomatic
  • Pallor
  • Fatigue
  • Irritbility
  • Numbness and tingling of extremities
  • Dyspnea on exertion
  • Sensitivity to cold
  • Pain and hypoxia w/ sickle cell crisis
37
Q

objective findings of anemia

A
  • 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
Q

CBC to test for anemia

A
  • 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
Q

iron studies to test for anemia

A
  • 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
Q

HgB electrophoresis to test for anemia

A
  • Separates normal HgB from abnormal
  • Used to detect thalassemia and sickle cell dz
41
Q

Sickle cell test for anemia

A
  • Evaluates sickling of RBCs in presence of dec oxygen tension
42
Q

Schilling test for anemia

A
  • Measures vitamin B12 absorption w/ and w/o intrinsic factor
  • Used to differentiate malabsorption and pernicious anemia
43
Q

nursing care for anemia

A
  • Encourage dietary intake of deficient nutrient
  • Monitor O2 sats
  • Administer meds
  • Teach client and family about energy conservation
44
Q

medications used for anemia

A
  • iron supplements
  • erythropoietin: epoetin alfa
  • vitamin B12
  • folic acid
45
Q

iron supplements to tx anemia

A
  • 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
Q

client education for iron supplements

A
  • 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
Q

epoetin alfa to tx anemia

A
  • 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
Q

vitamin B12 to tx anemia

A
  • 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
Q

nursing considerations and client edu for vitamin B12

A
  • 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
Q

folic acid supplements to tx anemia

A
  • 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
Q

therapeutic procedures to help with anemia

A
  • 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
Q

complications from anemia

A
  • 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
Q

Sickle Cell

A
  • 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
Q

Complications from Sickle Cell

A
  • kidney failure: b/c RBC shape
  • infection: b/c take out spleen so don’t have WBC reserve
55
Q

therapeutic procedures for Sickle Cell

A
  • 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
Q

Sickle Cell: priority interventions

A
  • oxygen: want to oversaturate pts on O2, so get them on as much as possible
  • fluids
  • pain control
    • Morphine is the best
  • rest
57
Q

Sickle Cell Dz: Discharge Instructions

A
  • 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
Q

thrombocytopenia/anemia: nursing considerations

A
  • 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
Q

thrombocytopenia/anemia: client edu

A
  • 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
Q

neutropenia

A
  • 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
Q

Neutropenia: priority interventions

A
  • 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
Q

what is ITP?

A
  • 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
Q

what are the risk factors for ITP?

A
  • Female age 20-40
  • Autoimmune disorder
  • Recent virus (children only)
64
Q

what are the meds and therapeutic procedures for ITP?

A
  • Meds
    • Corticosteroids and immunosuppressants
  • Therapeutic procedures
    • Splenectomy can be performed if the client does not respond to medical management
65
Q

what is HIT?

A
  • An immunity- mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin
66
Q

what are the risk factors for HIT?

A
  • Female
  • Receiving heparin longer than 1 week
  • Exposure to unfractionated heparin
  • Postsurgical thromboprophylaxis
67
Q

what are the meds for HIT?

A

Anticoagulants with direct thrombin inhibitor

68
Q

what is DIC?

A
  • 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
Q

what are the risk factors for DIC?

A
  • Septicemia
  • Cardiopulmonary arrest
  • Trauma
  • Obstetric complications
  • Cancer
70
Q

what are the nursing considerations and meds for DIC?

A
  • 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
Q

DIC: interventions

A
  • fluids
  • administer blood/plasma
    • must keep pt stable until rapid response team responds
  • send to ICU
72
Q

what expected findings with coagulation disorders?

A
  • 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
Q

what are the lab tests for coagulation disorders?

A
  • 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
Q

nursing care with coagulation disorders

A
  • 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
Q

Sepsis: interventions

A
  • fluids
  • antibiotics and culture

Adult Health I Test II (3 decks)

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