EXAM 5--MEDSURGE Flashcards
1
Q
most common type of blood product for transfusion
A
packed RBCs
PRBCs
2
Q
PRBCs are used to increase the ____-____ capacity of blood
A
oxygen-carrying
3
Q
PRBCs help the body get rid of?
A
carbon dioxide and other waste products
4
Q
1 unit of PRBCs = raises hematocrit by?
A
2-3%
5
Q
carry O2
A
RBCs
6
Q
what is given in transfusions?
A
plasma
platelets
packed RBCs
7
Q
liquid component of blood
A
plasma
8
Q
plasma has proteins called?
A
clotting factors
9
Q
expands blood volume and provides clotting factors
contains no RBCs
A
fresh frozen plasma (FFP)
10
Q
1 unit of FFP= increases level of any clotting factor by ?
A
2-3 %
11
Q
platelets aka
A
thrombocytes
12
Q
tiny cell structures necessary in blood clotting process
A
platelets
13
Q
platelets are needed in pts with?
A
bleeding disorders or
platelet deficiency
14
Q
1 unit of platelets increases the average adult client’s platelet count by about ?
A
5,000 platelets/microliter
15
Q
steps for initiating blood transfusion:
A
receive MD order
type and cross match
written consents and teaching
large-bore IV access
16
Q
absolute 1st step in transfusion process
A
receive MD order
17
Q
is done by the lab but will need to be confirmed by the nurse
A
type and cross match
18
Q
which gauge IV is recommended for blood transfusions?
A
20 gauge or larger
19
Q
equipment needed for blood transfusions
A
IV pump Y-filter IV tubing NS vital sign equipment large bore IV
20
Q
what are they looking for when typing and cross matching?
A
blood type & antibodies
21
Q
when to do VS in transfusion process?
A
before, during, & after
22
Q
stay with patient for first ___ min of transfusion
A
15 minutes
23
Q
how many people need to be a part of blood transfusion?
A
2 licensed personnel
24
Q
slow infusion rate and within ___ min of getting blood
A
30
25
inquire about history of previous?
blood product transfusions
26
what to check for in cardiovascular assessment
JVD & edema
27
what to check for in respiratory assessment
auscultation & use of accessory muscles
28
what to check for in integumentary assessment
rashes
petechiae
ecchymoses
29
what do look for in the sclera?
icterus
30
jaundice in sclera is indicative of ?
liver failure
31
worry about what in integumentary system?
current bleeding
32
3 checks with LPN for blood label
contents
expiration date
pt. info
33
transfusion must be complete within ?
4 hours
34
change tubing after every?
2 units
35
how fast to infuse FFP?
infuse over 30-60 minutes
36
infuse as fast as patient can tolerate
platelets
37
if FFP is not given what are they at risk for?
thrombolytic event & hemorrhage
38
adverse reactions to blood components
```
restlessness
hives
N/V
torso, back, flank pain
dyspnea
flushing
hematuria
```
39
how fast to adverse reactions show up?
almost immediately (1st 15 minutes)
40
bloody urine
hematuria
41
lack of O2 in the blood stream can lead to which AE?
restlessness
42
a result of the vasodilating adverse reaction
flushing
43
what happens when RBCs aren't compatable
clump together and sickle.
scrape inside of capillaries and excoriates vasculature
44
most common type of reaction
febrile non-hemolytic reaction
45
febrile non hemolytic reaction occurs mostly in patients with ?
previous transfusions
46
is febrile non hemolytic reaction life threatening ?
NO
47
Febrile non hemolytic reaction symptoms?
chills & fever 1 degree celsius elevation within 2 hours
48
most dangerous reaction
acute hemolytic reaction
49
acute hemolytic reaction can occur when?
immediately within 10 ml infused
50
sx of acute hemolytic reaction
```
fever
chills
low back pain
nausea
chest tightness
dyspnea
anxiety
hemoglobinuria
```
51
occurs because of destruction of erythrocytes releasing hemoglobin from the cells where it is excreted by the kidneys
hemoglobinuria
52
how to prevent acute hemolytic reactions?
careful type & screening of pt & blood
53
what to do if patient has acute hemolytic reaction
STOP & discontinue TRANSFUSION
start rapid admin of NS
get VS
call physician
54
cause of allergic reaction to blood
sensitivity to plasma proteins
55
symptoms of allergic reactions of blood
urticaria
itching
flushing
56
if pt. responds to antihistamines...
they can resume transfusion
57
pre treat with what before blood transfusions?
antihistamines or corticosteroids
58
patient begint to have JVD, crackles in bilateral lung bases, dyspnea, & sudden anxiety.
what is going on with the patient?
FE overload
59
should you stop the infusion?
YES
60
when does transfusion related acute lung injury (TRALI) occur?
2-6 hours of transfusion
61
sx of TRALI
```
acute SOB
hypoxia
hypotension
fever
pulmonary edema
```
62
TRALI is more likely occurs with which types of transfusions?
plasma & platelets
63
why is TRALI more likely with plasma & platelets?
bc they don't go through as much screening
64
pulmonary edema sx
crackles
SOB
JVD
65
delayed hemolytic reaction occurs within?
14 days after transfusion
66
sx of delayed hemolytic reaction
fever
anemia
increased bilirubin level
jaundice
67
management of reactions
```
stop the transfusion
maintain the IV with NS
assess the pt.
notify the MD
notify the blood bank
send blood bag and tubing to blood bank
```
68
a client has an order to receive 2 units of PRBCs for post op bleeding. during the transfusion of the first unit, the client complains of chills. List the actions in the sequence which the nurse should perform them.
```
stop the infusion
notify the charge nurse
start a NS infusion
take the clients VS
send the blood bag to the blood bank
```
69
a client with esophageal varies is admitted with hematemesis, and 2 units of blood are ordered. halfway through the first unit of blood the client complains of flank pain. the nurses first action should be to:
STOP the transfusion
70
a client demonstrates signs and symptoms of a transfusion reaction. the nurse immediately stops the transfusion and next:
hangs a bag of NS with new tubing
71
4 types of hypersensitivites
type 1 anaphylactic hypersensitivity
type 2 cytotoxic hypersensitivity
type 3 immune complex
type 4 delayed type
72
affects multiple organs and can have mild to severe reactions IgE mediated!
anaphylactic
73
the faster the onset of anaphylaxis-- the ?
more severe the reaction
74
mild anaphylaxis
```
peripheral tingling
warmth
nasal congestion
periorbital swelling
pruirits
sneezing watery eyes
```
75
moderate anaphylaxis
flushing
warmth
anxiety
itching
76
abrupt onset
severe anaphylaxis
77
sx of severe anaphylaxis
```
bronchospasms
laryngeal edema
SOB
cyanosis
hypotension
```
78
prevention of anaphylaxis
avoid the allergen
79
pts should carry around what?
auto-injection system for epinephrine
80
common causes of allergic rhinitis
hay fever
seasonal allergies
IgE mediated
81
allergic rhinitis is the most common form of ?
respiratory allergy.
82
when does allergic rhinitis begin?
ingestion or inhaling the antigen
83
is the major mediator of allergic reactions
histamine
84
sx of allergic rhinitis
sneezing
watery eyes and nasal passages
itching
85
type of therapy for allergic rhinitis
avoidance therapy
pharmacologic therapy
immunotherapy
86
skin rashes associated with certain medications
drug reactions
87
appear suddenly, have a vivid color, more intense reactions and disappear rapidly after the medication is withdrawn
drug reactions
88
what to tell pts with drug reactions
stop taking the med immediately and notify the physician
89
IgE mediated except for a newly identified ____ mediated food allergies
T-cell
90
what are the most severe food allergies?
peanuts and tree nuts
91
symptoms of food allergies
classic allergic symptoms and GI upset
92
common symptoms of latex allergies
rhinitis
conjuctivitis
asthma
anaphylaxis
93
an autoimmune disorder affecting the myonureal junction
myasthenia gravis
94
what is myasthenia graves characterized by?
varying degrees of weakness of the voluntary muscles
95
80% of MS patients present with?
diplopia and ptosis
96
weakness of the face and throat muscles results in ?
bland facial expression, impaired voice & dysphagia
97
impaired voice
dysphonia
98
what are MS patients at risk for?
aspiration
99
an autoimmune attack on the peripheral nerve myelin
guillian-barre syndrome
100
guillian-barre syndrome results in ?
ascending weakness
dyskinesia
hyporeflexia
paresthesia
101
guillian barre starts with muscle weakness an diminished reflexes and may progress to ?
tetraplegia
102
should be especially concerned with what in guillian barre ?
neuromuscular respiratory failure
103
an inflammatory, autoimmune disorder that affects nearly EVERY ORGAN in the body
systemic lupus erythematosus
104
begins because of an immune system dysfunction where the immune system inaccurately recognizes one or more of the cell's nucleus as foreign, seeing it as an antigen
lupus
105
a classic identifiable characteristic of lupus is?
butterfly rash!
106
acute or chronic skin inflammation
results from direct skin contact with chemical or allergen
contact dermatitis
107
sx of contact dermatitis
```
itching
burning
erythema
skin lesions
edema
followed by:
weeping
crusting
and drying and peeling of the skin
```
if severe:
hemorrhagic bullae may appear
108
understand that latex allergies are classified as?
abrupt, life-threatening
109
delayed type of latex allergy results in a ?
contact dermatitis reaction
110
assume that all patients are infected with?
microorganisms
111
airborne precautions
neg air pressure in room.
must wear N95 fitted respirator
112
droplet precautions
3-6 feet of a patient you must wear a mask
113
contact precautions
gowns and gloves
| disposable stethescope and tools
114
how does contact spread?
skin to skin
115
positive blood cultures indicating bacteremia is an indicative of ?
sepsis
116
early signs of acute organ dysfunction:
```
systolic BP over 90
RR over 20
decreased renal output
elevated liver function tests
change in LOC
```
117
1st line of defense
skin
digestive tract
respiratory tract
118
act as filters to remove debris and antigens entering the respiratory tract
tonsils and adenoids
119
act as filters to remove debris and antigens and to foster contact with T lymphocytes
lymph nodes
120
contains stem cells for B lymphocytes, which mature and become antibody-producing plasma cells that react to many bacteria, viruses and other antigens; controls humoral immunity
bone marrow
121
contains cells that mature into T lymphocytes and specifically react to viruses, parasites, fungi, foreign tissue, and other antigens; controls cell-mediated immunity
thymus
122
act as a filter to remove debris and antigens and to foster contact with T lymphocytes
spleen & lymph nodes
123
The antibodies (large proteins) that defend against foreign invaders. Induces the clumping effect of specific antigens (agglutination) to clear them from the body.`
immunoglobulins
124
enhances phagocytosis and crosses the placenta, blood borne and tissue infections (75%) (Remember –Greatest)
IgG
125
passed to neonate in breast milk and prevents absorption of antigens from food, appears in body fluids, protects against respiratory, GU and GI infections (15%) (Remember: A is first letter of alphabet, first-line of defense for babies)
IgA
126
activates the complement system and appears as the first produced in response to bacterial and viral infections (10%)
IgM
127
Role is unkown
IgD
128
combats parasitic infections, takes part in allergic and some hypersensitivity reactions. (0.004%) (Remember: IgE=Epi)
IgE
129
humoral immunity
produce antibodies or immunoglobulins
B lymphocytes
130
cellular immunity
Attack invaders directly, secrete cytokines, and stimulate immune system responses
Helper T cells
Cytotoxic T cells
Memory cells
Suppressor T cells (suppress immune response)
T lymphocytes
131
Destroy antigen coated with antibody
null cells
132
Defend against microorganisms and some malignant cells
natural killer cells
133
Circulating plasma proteins made in the liver and activated when antibody connects to antigen playing an important defense against microbes
complement system
134
complement system is activated by 3 pathways:
classic
lectin
alternative
135
Affects the host via direct or indirect effects on one or more components of the immunoregulatory network; help to enhance the immune system
immunomodulators
136
3 types of immunomodulators
interferons
colony stimulating factors
monoclonal antibodies
137
antiviral and antitumor properties used to treat multiple sclerosis and chronic hepatitis
interferons
138
play a key regulatory role in the growth and differentiation of bone marrow cells.
colony-stimulating factors
139
growth and production of targeted antibodies for specific pathologic organisms
Monoclonal antibodies:
140
assessing the cardiovascular system
```
pericardial effusin
anemia
HR
BP
vasculitis
```
141
assessing the GI system
N/V/D
Colitis
splenomegaly
142
myths about HIV
can be transmitted by casual contact.
an immediate death sentence
is only a gay male disease
means a person has AIDS
can be transmitted by mosquitos
143
what is HIV
human immunodeficiency virus
144
HIV is the virus that causes?
AIDS
145
attacks the CD4 T-cells which are some of the primary cells that allow our bodies to fight off infections
HIV
146
lacking resistance to disease
immunodeficiency
147
a sub-microscopic parasite that invades living cells for replication.
virus
148
how is HIV transmitted?
contact with sexual transmitted fluids
contact with infected blood
children born from HIV infected mothers
149
which fluids for HIV?
semen and vaginal secretions
150
how contact with infected blood?
sharing needles, breaks in skin causing blood to blood contact
151
how is HIV transmitted from mother to child
amniotic fluid and breast milk
152
how is HIV NOT transmitted
casual contact
food preparation
biting
insects
153
initial onset of HIV transmission
flu-like symtopms
154
Viral load is Extremely High---Body is developing antibodies and continues to build antibodies for the 1st
2-4 weeks of the virus
155
Primary test such as ? may not detect a virus in the early stages BECAUSE THERE ARE NOT ENOUGH ANTIBODIES BUILT UP IN THE BODY YET, resulting in a False (-).
EIA & ELISA
156
these 2 tests do not test for specific ?
antibodies
157
what to the 2 tests test for?
presence of B cells.
158
it could take up to ___ weeks for enough detectable antibodies to build up
36
159
Client returns to the hospital years later due to illness, ELISA is performed again and Antibodies are THROUGH THE ROOF!!
secondary infection
160
ELISA lead to ___ __ for confirmation of HIV
western blot
161
___ markers are then tested
CD4
162
May test negative on the HIV antibody test
Client is MOST infectious during the initial phase of this stage (Extremely high Viral Load)
Equalization occurs but CD-4 count is lower.
stage 1--primary infection
163
in stage 2 CD4 count falls between __ and then below ___ at which point the client is considered to have AIDS
499-200
then below 200
164
Fungal Infection (oral) occurs in most every AIDS client
candidiasis
165
involuntary weight loss
wasting syndrome
166
stage 2 most common symptoms
kaposi's sarcoma
candidiasis
wasting syndrome
167
no vaccine or cure due to
mutation of the virus
168
how to protect yourself from HIV/AIDS
```
universal precautions
abstinence
monogamy
safer sex
use care with alcohol and drug use
```
