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V.J. 79 y/o female admitted from ED to floor with upper GI bleed (Risk of…
V.J. 79 y/o female admitted from ED to floor with upper GI bleed
Risk of Hypovolemic Shock
Caused by excessive bleeding from a wound, internal bleeding, severe burns, excessive diarrhea or vomiting and prolonged sweating
Diagnosis: Labs for electrolyte and kidney/liver function, CT scan, ultrasound, echocardiogram, endoscopy, urinary catheterization to measure output
Nursing Interventions: Monitor for s/s of transfusion reactions, s/s hypervolemia (JVD, edema, pulmonary edema), weight and I&O, vital signs often and give supplemental oxygen
Assessment: Assess BP, temperature, heart rate, electrolyte levels, kidney and liver function, LOC, I&O
-assess H/H, WBC and platelet counts
Symptoms: headache, fatigue, dizziness, sweating, nausea, cold and clammy skin, pallor, rapid and shallow breathing, tachycardia, confusion, low urine output
Treatments: Fluid bolus, blood transfusion, dopamine, norepinephrine, epinephrine, dobutamine
Risk of Transfusion Reactions
Hemolytic reactions
This type of reaction occurs when the red blood cells given during the transfusion are destroyed by the person's immune system
Symptoms: Back pain, bloody urine, fever, chills, dizziness, flank pain, flushing of skin
Diagnosis: CBC, Coombs test, UA, fibrin degradation products, haptoglobin, urine and serum hemoglobin, bilirubin, BUN, creatinine
Treatment: Stop the blood transfusion, acetaminophen, IV fluids
Nursing Implications and Assessment: Assess status of patient and have patient report feeling anything that is abnormal, monitor vitals at beginning of administration then at 10 minutes, 30 minutes and end of administration
Non-hemolytic reactions
Most common type is febrile non-hemolytic reaction. This is caused by cytokine accumulation in blood units (especially platelets) and the presence of donor antibodies that react with recipient antigens
Symptoms: Fever (increase of 1 degree C or greater), chills, increased respiratory rate, change in BP, anxiety, headache
Diagnosis: Direct antiglobin test, repeat ABO testing, UA, serum IgA levels, anti IgA antibody testing, serum alloantibody screen
Treatment: Stop the transfusion, administer IV fluids, give Benadryl, Epinephrine, Acetaminophen or steroids to treat the symptoms
Nursing Implications and Assessment: Assess status of patient and have patient report feeling anything that is abnormal, monitor vitals at beginning of administration then at 10 minutes, 30 minutes and end of administration