Exam 1 Flashcards
What are nursing implications for the administration of all blood components, including donation, processing, and administration, and complications?
DONATION
American Red Cross donation requirements
Type and Cross
A, B, O, AB
Rh+ & Rh –
FFP requires ABO but not Rh compatibility
Platelets are not typically cross-matched for ABO compatibility
Testing
Autologous donation
Intraoperative blood salvage- cannot be stored
TRANSFUSION
Blood Administration
Only with NS, Never medications or other fluids through blood tubing
Never medications or other fluids through blood tubing
Only through appropriate filter tubing, change tubing after 2 units (check hospital policy)
Administration time per unit should not exceed 3 ½ hours
Platelets or FFP:
Infuse each unit over 30-60 minutes
FFP requires ABO but not Rh compatibility testing
Platelets typically not cross-matched
steps:
verify Dr order- hgb of 10- anemic, below 8- needs blood transfusion
Obtain consent
Assess IV site & patency
Obtain blood from blood bank
Check accuracy of blood label and pts ID
Baseline VS & assessment
Start the infusion
VS & assessment recheck
Monitor transfusion reactions
complications: occurs in the first 10-15 minutes or first 50cc of blood
Febrile nonhemolytic reaction- chills, fever, HA, flushing tachycardia, anxiety
Acute hemolytic reaction- low back pain, hypotension, tachycardia, fever & chills, chest pain, tachypnea, hemoglobinuria, can be immediate
Allergic reaction- hives, pruritus, facial flushing, SOA, brochospasm, anxiety
Circulation overload-
Bacterial contamination-
Disease acquisition- Hepatitis, AIDS
implications
stop transfusion (maintain line with normal NS) & notify DR
change IV tubing
treat symptoms
recheck crossmatch record with unit
hemolytic reactions-
obtain 2 blood samples distal to infusion site
obtain first UA- test for hemoglobinuria
monitor F & E
serum calcium levels
bleeding disorders
Thrombocythemia- high platelet count resulting from stem cell disorder within BM
Thrombocytopenia- low platelet due to decreased production in BM, increased destruction and increased consumption
Immune Thrombocytopenic Purpura (ITP)- a decreased number of circulating platelets manifests as a bleeding tendency, easy bruising (purpura), or extravasation of blood from capillaries into skin and mucous membranes (petechiae).
Acquired Coagulation Disorders- including vitamin K deficiency and warfarin therapy, liver disease, Disseminated Intravascular Coagulation, platelet disorders and vascular disorders
Most important Labs-rhythm disturbances
Potassium: Normal: 3.5-5. mEq/L
Hypokalemia: irregular rate/rhythm, increased ectopy, PVC’s/V. Tach/ V Fib
<2.5
Hyperkalemia: peaked T wave/wide QRS, irregular rate/rhythm, increased ectopy, PVC’s/ V. Tach/heart block, asystole, v tach
>6
Magnesium: Normal: 1.8-3 mg/dL
Hypomagnesemia: tachycardia, atrial or ventricular
<1.2
Hypermagnesemia: bradycardia, decreases contractility, heart blck, asystole
>6.1
Calcium: Normal: 8.5-10.5 mg/dL
Hypocalcemia: dysrhythmias
<7
Hypercalcemia: dysrhythmias
>12
Atrial fibrillation/Atrial flutter
Thyroid, hepatic, and renal function
hyper
Clinical Manifestations-Rhythm Disturbances
Atrial fibrillation May be asymptomatic Palpitations, SOA, hypotension, dyspnea with exertion, fatigue Pulse deficit Angina
Atrial flutter
Chest pain, SOA, hypotension
Ventricular tachycardia (V. tach) Nearly always unresponsive/pulseless
Ventricular fibrillation (V. fib)
Absence of audible heartbeat
No palpable pulse
No respirations
Medical management/Medications- rhythm disturbances
Atrial fibrillation
Anticoagulants/antiplatelets, Class II and IV antiarrhythmics; Pharmacologic cardioversion
Electrical cardioversion, catheter ablation therapy, Maze/Mini-Maze Procedures
blood pools in atrial, beta blockers & calcium channel blockers (rate control),
Inititate anticoagulants prior to restoring sinus rhythm
Atrial flutter
Adenosine
Antithrombotic drugs, rate and rhythm control similar to atrial fibrillation
Electrical cardioversion
Ventricular Tachycardia
Immediate defibrillation for pulseless VT!
CPR
Cardioversion, antiarrhythmic medications, antitachycardia pacing
ICD
Catheter ablation
Torsades de pointes: polymorphic, prolonged QT interval
Correct magnesium imbalance
Ventricular fibrillation
CPR
Defibrillation
Amiodarone, epinephrine
Defibrillate v fib and v flutter
Assess pt
Call code
Initiate cpr
Sinus brady- not a big deal unless they have symtoms
A fib- blood pools- anticoagulants first
A flutter- rare, same as a fib
Most Important lab values for CAD
Total Cholesterol <200 mg/dL
LDL (bad) Cholesterol <100 mg/dL
HDL (good) Cholesterol > 40 mg/dL (males) >50 mg/dL (females)
Triglycerides <150 mg/dL
increased = increased risk for coronary artery disease
most important labs for Acute Coronary Syndrome (ACS)/MI
Cardiac enzymes/biomarkers
Troponin <0.05 ng/mL- q6h x3
Creatine Kinase (total) Males 50-204 units/L;
Females 36-160 units/L
Creatine Kinase CK-MB 0-5 ng/mL
Myogobin Males 28-72 ng/mL Females 25-58 ng/mL
CORONARY VASCULAR DISORDERS CM, PRIORITY ASSESSMENTS, DIAGNOSTIC TESTS
CLINICAL MANIFESTATIONS
Angina
Chest pain, indigestion, choking or heavy sensation
Feeling of impending death/apprehension
MI
Often cannot be distinguished from unstable angina
PRIORITY ASSESSMENTS Pain Difficulty breathing Palpitations Unusual fatigue Syncope
DIAGNOSTIC TEST
12-lead ECG
Echocardiogram
Lab Tests (see previous slide)
medical management/medications for coronary vascular diseases
CAD Diet Physical activity Medications Tobacco cessation HTN management Diabetes control
Angina
Medications
Oxygen therapy
PCIs/CABG
Medications: Dual antiplatelet therapy: aspirin, clopidogrel (Plavix) or other antiplatelets STEMI-Emergent PCI Thrombolytics Inpatient management CICU with invasive monitoring Continuous cardiac monitoring ASA, beta-blocker, ACE Inhibitor BP, Urine output, Na, K, Creatinine Cardiac Rehab
percutaneous coronary interventions/complications
Percutaneous transluminal coronary angioplasty (PCTA)
Coronary artery stent
Coronary artery bypass graft (CABG) Blood vessel is grafted to an occluded coronary artery so blood can flow beyond the occlusion Indications Traditional CABG Alternative Techniques
priorities Pain management-Oxygen, morphine Bed rest with elevated HOB Fluid volume status Adequate tissue perfusion Anxiety Monitor for complications
complications hypovolemia bleeding cardiac tamponade fluid overload hypothermia hypertension tachydysrhythmias bradycardia cardiac failure MI
PCI Coronary artery dissection, perforation, abrupt closure, vasospasm Acute MI Dysrhythmias Cardiac arrest
education Prevention Non-modifiable/Modifiable risk factors Medication education Post-procedure education
structural, infectious, and inflammatory cardiac disorders
medications Antidysrhythmics CCB, Beta-blockers ACE Inhibitors, ARBs Anticoagulation Valvuloplasty Valve Replacement
priorities Assess for s/s heart failure and emboli Heart sounds Hemodynamic stability post valve replacement Neuro, resp, CV are priority assessments Wound care
complications
Heart failure
Infective endocarditis with mechanical valve prosthesis
education Prevention Medication education Infection prophylaxis Diet, activity, self-care
cardiomyopathy
diagnostic testing 12-lead ECG Echocardiogram Pulmonary artery systolic pressure, pulmonary artery wedge pressure Central venous pressure Cardiovascular MRI
clinical manifestations May be asymptomatic for years S/S of heart failure Cough Orthopnea Peripheral edema Nausea Chest pain, palpitations, dizziness, syncope
priority assessment Physical assessment focuses on s/s of heart failure VS Pulses Weight PMI palpation (shifted to left?) Murmurs, S3/S4 Crackles JVD Edema
medications Antidysrhythmics Anticoagulation Beta-blockers Pacemaker/ICD Alcohol septal ablation Surgical Management Left ventricular outflow surgery Heart transplantation Ventricular Assist Devices (VAD) Total artificial heart
priorities Improve CO and Peripheral blood flow Increase activity tolerance Improve gas exchange Reduce anxiety Decrease sense of powerlessness
complications
Severe heart failure
Lethal dysrhythmias
Death
education
aneurism
clinical manifestations Pain most prominent symptom Dyspnea Cough Hoarseness, stridor Feel heart beating in abdomen Low back pain
assessment
Dilated veins of chest, neck, arms
Edematous areas on chest wall and cyanosis
Pulsatile mass in middle and upper abdomen
Systolic bruit
tests Chest X-ray CTA MRA TEE Duplex ultrasonography
medications
Blood pressure control
Beta-blockers, ACEs, ARBs, diuretics, CCBs
Endovascular repair with graft
priorities
Assessments of baseline prior to surgical repair
Functional capacity of all organ systems
Post operative considerations
complications Hemorrhage Shock Arterial occlusion Infection Ischemic bowel Kidney injury Impotence
education
Medications
Diet/activity
Fluid intake
dissecting aorta
Poorly controlled HTN
Blunt chest trauma
Cocaine use
Sudden and severe Persistent pain-tearing or ripping Pale Sweating Tachycardia Elevated BP/may vary greatly from one arm to the other
diagnostics/management
Pericardial Effusion & Tamponade
Accumulation of fluid in the pericardial sac Heart failure, pericarditis, metastatic carcinoma, surgery/trauma Acute (cardiac tamponade) vs chronic S/S: Tamponade Chest pain Tachypnea SOA JVD Low CO/hypotension Tachycardia Pulsus Paradoxus
management Pericardiocentesis Peri and post procedure monitoring Possible complications Puncture, dysrhythmias, plural laceration, gastric puncture Reaccumulating Pericardial window
steps in blood transfusion
verify Dr order- hgb of 10- anemic, below 8- needs blood transfusion Obtain consent Assess IV site & patency Obtain blood from blood bank Check accuracy of blood label and pts ID Baseline VS & assessment Start the infusion VS & assessment recheck Monitor transfusion reactions
Get a new set of tubing and start NS after a reaction – document & notify Dr.
