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NEEDS FOR BLOOD TRANSFUSION (Transfusion Reactions (circulatory KNOW THIS,…
NEEDS FOR BLOOD TRANSFUSION
You need:
an order
packed red blood cells (PRBC)
whole blood (WB)
platelets
fresh frozen plasma (FFP)
type and cross match (T&C)
how many units?
consent
the nurse gets the consent
it is the MD's responsibility to explain procedure, risks, and plan for the transfusion
one consent covers hospital stay
with surgery, the risks/benefits change b/c of complications
IV access
18 inch preferred
20 inch is exceptable
22 inch is ok if you cannot access a vein
labs
hemoglobin: 7 or less; unless they are having symptoms
hgb: 12-16%
hct: 36-48%
CBC: you want the WBC as well as RBC and platelets
H&H: only for RBC
BUN/creatinine
pt receiving more than 2 units of blood, furosemide will be adminstered
mg of furosemide is based on comorbidities
equipment
Nursing Care:
pre-transfusion
vital signs
baseline
clarify stability
consent
NS hanging
if pt needs surgery RIGHT NOW the DO will order O-
administration
educate in a positive manner
let pt know there's possibility of blood reaction - i dont expect it to happen, but if you have anything like headache, itching, ect. let me know
350 mL per unit of RBC
vitals are done 5 minutes for first 15 minutes after transfusion starts
FOR TEST PURPOSES: frequent vital signs
VITAL SIGNS CAN NOT BE DELEGATED B/C AN ASSESSMENT IS NEEDED AS WELL
post-transfusion
tubing goes in biohazard
remove label from bag
labs
depends on what looking at
immediately/an hour after infusion gives good value for hgb and hct
physician will specify when to order labs
Transfusion Reactions
hemolytic
allergic
febrile
bacterial
circulatory
KNOW THIS
graft vs. host
happen 0.5-1% of the time
90% chance of death
IMMUNODEFICIENCY
at risk populations
ppl with HIV
immune system is compromised by disease
cancer patients
infants
elderly
malnourished
burn patients
pts on ventilation
ventilator acquired pneumonia
pt with liver disease
anyone w/ immune disease
are MOST at risk when theyre around SICK PPL
they're at RISK FOR:
influenza
measles
INTERVENTIONS:
standard precautions
isolation precautions
clean the equipment
with appropriate wipes
educate:
wash their own hands
avoid ill people
wear mask if necessary
no live vaccines
need to discuss immunizations w/ PCP
no fresh fruit/veggies
cook food properly
avoid eating raw foods
do not share personal products
buy toothbrush every week
wash dishes w/ hot water or in dishwasher
wash after every use
do not drink cold drinks left out for over an hour
dont change kitty litter
do not feed pets raw meat
take temperature daily
practice safe sex
no patient cant be roomed with them
appropriate pt assignments
assess every 4 hrs and PRN
vitals
head to toe q8hr
coughing/deep breathing
no indwelling caths
clean bathroom daily
no live plants/flowers
SECONDARY
acquired some time after birth
congenital
born with it
ASSESSMENT
ANC (actual neutrophil count)
total WBC x 10 (bands + segs)
indicates if pt is immunocompromised
under 500 means pt is immunocompromised
decreased means reserved cells have been used up or damage to bone marrow that produces the cells
used when immune system isnt able to recognize antigens or fails to eliminate antigens
HIV/AIDS
LABS
CBC
WBC <3.5
CB4
function of helper T cells
antibody tests
measure pt response to test
13-60 get tested for HIV
genome
a retrovirus (doesnt have DNA)
binds to CD4 cell
enzyme forces cell to produce DNA by RNA replication
20% affected are unaware they have it
heterosexual sex is the highest cause
mortality rate is 60%
no longer terminal
a chronic disease now
high risk populations can take medications to prevent contraction of HIV
leaves open wound for disease to enter
takes 6 weeks to 6 months to seroconvert
REACTIONS
HEMOLYTIC
caused by blood type of Rh factor incompatibility
prevention:
follow policy and protocols of verification
autologous transfusion
cell saver maching - washing
signs/symptoms:
sense of dread - something's wrong but idk what
lower back pain
chills
increased HR and RR
can lead to cardiac arrest ------ death
treatment:
1.stop the transfusion!
2.change the tubing!!!
keep for testing
place in biohax bag for lab
3.start NS
call BB to pick up blood products
call lab per protocol
send 1st void urine to the lab
if pt cant void - call physician for order to straight cath
call MD ASAP to obtain further orders
MD should be contacted before needing order for straight cath
AUTOIMMUNE DISORDERS