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Nursing 130 Perioperative > Exam 1 chapter 20 > Flashcards

Exam 1 chapter 20 Flashcards

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1
Q

predisposing factors to DVT

A 
previous DVT
smoking
contraceptive 
age
cardiovascular disorder
weight 
gender
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2
Q

what is are the 3 stages of Virchow’s Tried

A

stasis of blood
vessel wall injury
altered coagulation

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3
Q

Nursing assessment for DVT

A 
edema-bilateral baseline limb girth
skin temperature-warm
pain
color
pyrexia
pulse
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4
Q

therapeutic intervention for DVT

A 
increase fluids
early mobilization
ROM
bed rest
planter and dorsiflexion 
ambulate
meals
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5
Q

Elastic compression stockings (TED hose)

A

increase venous return
risk-low
mod/high with anticoagulants
apply correctly with band, wrinkles, size

Patient teaching: don’t roll down, don’t cut
off for an 1 per shift

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6
Q

what is the antidote for warfarin (coumadin)

A

Vitamin K

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7
Q

hgb

A

12-18

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8
Q

HCT

A

38-54%

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9
Q

RBC

A

4-6

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10
Q

platelet count

A

150,000-400,000

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11
Q

WBC

A

5-10

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12
Q

if neutrophils increase and lymphocytes decrease…

A

shift to the left

bacterial infection

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13
Q

if lymphocytes increase and neutrophils decrease

A

shift to the right

viral infection

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14
Q

dehiscence and evisceration can happen POD

A

5-6
wound infection
abdominal distention
edges part slowly with extravasation of pink serous fluid

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15
Q

Interventions for evisceration

A

cover with saline
increase IV
monitor for shock-stay with patient
call Dr

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16
Q

what is the antidote for heparin

A

protamine sulfate

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17
Q

anticoagulant therapy for DVT

A

heparin
LMWH - fragmin, lovenox
xarelto (rivaroxaban)

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18
Q

what are the site for heparin and LMWH

A

abdomen

iliac crest

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19
Q

subcutaneous injection of LMWH-Fragmin, Lovenox

A 
keep air bubble
sites abdomen or iliac crest
DO NOT aspirate
hold skin fold during injection 
DO NOT rub site
20
Q

when giving heparin subcutaneously

A 
abdomen or iliac crest
rotate sites
DO NOT aspirate
hold skin fold during injection
DO NOT rub site
21
Q

what is are the therapeutic effects of LMWH

A

no lab measurements required

fixed doses per weight (1 mg/kg)

22
Q

therapeutic effects of heparin

A

PTT normal 24-36 sec, therapeutic 46-70 sec

ACT normal 80-135 sec, therapeutic 3 min

23
Q

what are the therapeutic effects of warfarin (Coumadin)

A

INR daily
normal .75-1.25, therapeutic 2-3

levels take 48-72 hours (3-5 days)

24
Q

drug interactions with warfarin

A 
barbiturates (phenobarb)
NSAIDS
dilantin 
herbal supplements
food-green leafy vegetables
25
Q

defining characteristics of pulmonary emboli

A 
sudden sharp chest pain
extreme apprehension 
intense hyperventilation 
intense dyspnea
cough
hemoptysis 
decrease PO2 
increase CO2
26
Q

Packed RBCs (PRBC)

A

prepared from whole blood
1 unit =250-300 ml
less risk of fluid overload
increase RBC mass

for anemia, platelets not functional

27
Q

Frozen RBCs

A

prepared from RBCs
Can be stored for 10 years
after thawing use within 24 hrs
used in autotransfusion

28
Q

Platelets

A

prepared from whole blood
1 unit =30-60 ml
used for bleeding disorders

29
Q

Fresh Frozen plasma

A 
liquid portion of whole blood
1 L = 200-250 ml
rich in clotting factors
no platelets 
used for bleeding disorders, low Vit K
use 2 hrs after thawing
30
Q

Albumin

A 
prepared from plasma
cause water shift from extravascular to intravascular space
used to tx hypovolemic shock 
used for someone with low BP and edema
increase BP and decrease edema 
hypoalbuminemia
31
Q

S&S of transfusion reaction

A 
itching
hives 
swelling
SOB
fever 
chills
32
Q

S&S of adverse reaction to transfusion

A 
restlessness
hives
nausea
vomiting
torso or back pain
chills
fever
hematuria
SOB
flushing

Stop transfusion immediately, notify physician

33
Q

When should the nurse change the blooding during transfusion

A

after every 2 units transfused to decrease chance of bacterial contamination.

34
Q

when should the blood be spiked

A

30 min of arriving on the floor

should be infused within 4 hrs

35
Q

blood transfusion reactions acute hemolytic

A 
chills
fever
low back pain
tachycardia
dyspnea
hypotension
dark urine
shock

Tx: Stop transfusion

36
Q

Febrile transfusion reactions

A 
sensitization from donor 
sudden chills
increase temp
headache
anxiety
muscle pain

Tx. Stop transfusion

37
Q

mild allergic reaction during a blood transfusion

A

sensitivity to foreign plasma proteins
flushing
hives (urticaria)

Tx: antihistamines (Benadryl) and continue with transfusion slowly

38
Q

Blood transfusion reactions-anaphylactic

A 
sensitivity to donor plasma proteins
Anxiety
urticaria (hives)
dyspnea
wheezing

Tx: stop transfusion and treat symptoms (epinephrine)

39
Q

blood transfusion reaction-circulatory overload

A 
cough
SOB
dyspnea
headache 
pulmonary congestion
hypertension
tachycardia
distended neck veins (first sign)

Tx: adjust flow rate
increase HOB
give diuretics and O2 as ordered

40
Q

blood transfusion reaction - sepsis

A 
bacterially infected blood
rapid onset of chills 
fever
vomiting
diarrhea 
hypotension 
shock

Tx: stop transfusion, draw blood cultures, and send to lab with remaining transfusion
treat symptoms

41
Q

what is the leading cause of trans-related death

A 
reaction B/w transfusion and pt's blood causes pulmonary inflammation
fever
hypotension
tachypnea
decrease O2

Tx: stop transfusion, send blood samples
chest x-ray
O2 and steroid
notify Dr.

42
Q

If acute reaction is suspected for blood transfusion

A 
stop transfusion
infuse saline
notify blood bank and MD
recheck blood
monitor V/S and U.O
treat symptoms
send blood bag and tubing to blood bank
collect required specimens per policy
document per policy
43
Q

Should the RN pre medicate the patient before a blood transfusion?

A

No

premedication can mask the beginning of a more serious transfusion reaction.

44
Q

what precaution should the RN take to prevent acute hemolytic transfusion

A

meticulous attention to detail
labeling blood samples and blood components
accurately identifying the recipient

45
Q

when does fever R/T febrile during blood transfusion begun

A

within 2 hours of transfusion

46
Q

Can antipyretics be given to prevent fever before blood transfusion

A

yes

Nursing 130 Perioperative (12 decks)

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