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Complex test 1

Terms in this set (167)

TACO can happen to patient with
-HF (mr. hart) and maybe went into cardiogenic shock and doesn't have good perfusion
-the doctor writes for a replacement of PRBCs because they aren't producing erythropoietin
What can we give instead that won't give TACO reaction?
EPOGEN: subcut, this way we don't have to deal with blood. Taco and trali can be so bad for pts that we decide to switch to epogen
PRBCs
most common cause you want to raise pts hBG
Fresh frozen plasma usually given in
series of transfusions
TRALI reaction
99% will occur with fresh frozen plasma (when have a coagulation deficiencies)
-only take FFP from male pts because females have a certain antibodies that causes pts to have a reaction of TRALI
If you stop transfusion and need to flush the line
ALWAYSSS FLUSH WITH NORMAL SALINE (nothing else)
Ms. Hart presents to the ED with hypovolemic shock after trauma (antler to the abdomen)
VS: 80/55, HR 152, RR 36, O2 Sat 98% on NRB mask
2 peripheral IVs placed in the field: 18 gauge
ED trauma team working to stabilize the patient
...
With blood transfusions
hemoglobin would be low
Blood transfusions
-blood products
Whole blood
PRBC
Platelets
Fresh Frozen Plasma
Albumin
Whole blood
RBC's, plasma, platelets;
usually 500ccs.
For when someone is bleed profusely.
Risk factor for whole blood is
overload of fluid (this is why we don't give it as much)
Packed Red Blood Cells
250ccs. When hemoglobin begins to drop, we want to replace it with PRBC.
Candidates for PRBC
-anemic patients
-sickle cell
-GI bleed
-PP hemorrhage
-kidney patient
(G KAPS)
Platelet
when platelets go below 20,000 (normal is 150,000-400,00)
Fresh Frozen plasma
people with coagulation deficiency
AIDS, cancer patients, unable to clot.
Usually give three to five packs
Albumin
gives blood substance/strength. People with low albumin= liver failure patients
Nursing role and responsibility "Best Practice"
-Check order
-Ensure blood matches patient*** (type & cross screening)
-Obtain consent for blood
-Check with another RN or MD
-Take baseline VS
-Educate patient on signs and symptoms of reaction
-Use special tubing
-Infusion under close observation and monitoring
(CEO CTE UI)
Check with another RN or MD
two people always have to check the blood
Take baseline VS
sometimes patients get a temperature and you need to have a set of vitals to compare to
Make sure you LOOK at blood before you give it
prime tubing with saline first then hand blood
Blood must be infused
30 minutes from getting it from blood bank
-Must be infused within 4 hours into patient
Why?
-clots can form
-bacterial contamination
What needle gauge do you need for blood transfusions?
18!!
Observe and assess patient while infusion blood q15 minutes CANNOT
Delegate checking on patient
Type and cross
Know recipient blood type and the donor
Administration of blood
-Slow for First 15 Minutes
--Closely Monitor Patient
-Vital Signs
--Know Your Protocols!
-Monitor for Transfusion Reaction
Cell saver is when you have a patient that is bleeding a lot in surgery they put
blood into this machine and give it back to patient
Sometimes if patient knows they're having surgery --> come in 6 weeks before and give own blood -->
they'll save it for you
(autologus)
Febrile non-hemolytic reaction
-Occurs mostly in patients who have had previous transfusions
Febrile s/s
chills then fever (within 2 hours of transfusion), muscle stiffness
Febrile nursing interventions
give antipyretics
Acute hemolytic reaction s/s
-fever, chills
-back pain
-nausea
-chest tightness
-SOB
-anxiety
-hypotension
-bronchospasm
-and circulatory collapse;
*decreased renal perfusion = ARF, DIC may also occur
(FLH CNT- SAB CD)
Acute hemolytic reaction interventions
-stop infusion immediately
-notify MD and blood bank
-save blood product for analysis
-patient labs obtained
With acute hemolytic reaction it means
you're giving the wrong blood
--clots start to form
Nursing interventions for acute hemolytic reaction
Stop transfusion --> replace tubing --> run NS
Send blood back to blood bank
Allergic reaction
-sensitivity to a plasma protein
-s/s = rash, itching, flushing
-Nursing = supportive care, antihistamines per order, close observation
-Severe: ??? Anaphylactic shock
Circulatory overload
-Too much infused too fast (esp in those with too much fluid on board - HF); typically happens with whole blood
Circulatory overload s/s
-SOB
-tachycardia
-anxiety!
-crackles at the bases (may proceed to pulmonary edema)
Circulatory overload nursing interventions
-give slow, may give diuretics after transfusion or between units
-HOB elevation
-d/c transfusion and notify MD
-O2
Transfusion-related acute lung injury (TRALI)
-most common transfusion related cause of death
-usually occurs within 6 hours
-Most likely to occur with FFP and Platelets
TRAIL s/s
-SOB
-hypoxia
-hypotension
-fever
-pulmonary edema (non-cardiogenic)
TRAIL interventions
manage s/s within orders and notify MD immediately
TRALI is more common than
TACO
TACO
Problem
Symptoms
BNP lab
CXR
ABG
CVP & PAWP
Diuretic response
IVF
Treatment
Problem Heart- Volume Overload- Backs Up Into Lungs
Symptoms SOB, Anxiety, Tachypnea, HTN, JVD, Crackles @ Bases, Pink & Frothy Sputum
BNP Lab High
CXR White Out, Large Heart,
Vascular Congestion
ABG hypoxemia
CVP & PAWP High
Diuretic response improves
IVF response worsens
Treatment O2, Intubate, Diuretics
TRALI
Problem
Symptoms
BNP lab
CXR
ABG
CVP & PAWP
Diuretic response
IVF
Treatment
Problem Lungs- Capillaries Leaking Fluid & Proteins Into Lungs
Symptoms Fever, Chills, SOB, Anxiety, Tachypnea, HypoTN, Coarse Lung Sounds
BNP Lab low or normal
CXR White Out, Normal Heart, No Vascular Congestion
ABG hypoxemia
CVP & PAWP low to normal
Diuretic response none or worsens
IVF response none or improves
Treatment O2, Intubate, IVF
Post-Administration care
-Properly Dispose of Tubing
-Flush IV
-Resume IVF if Ordered
-Monitor the Patient, VS, & I/O
-Monitor Laboratory Results
-Document!
Only two units of blood can be given thru
one tubing. If patient needs two more units of blood, you gotta change tubing
After transfusion of 2 units of blood, Ms. Hart is suddenly feeling anxious and complains of shortness of breath and chest tightness. She develops a fever of 102.4 and his BP is increasingly unstable and drops to 72/48.
What do you do?
Give NS
Never give PRBC with albumin
*Ms. Hart is awaiting surgery but needs to receive two more units of blood. While experiencing anxiety, she pulled out both of his IVs. The trauma team is unable to obtain peripheral IV access.
The trauma surgeon calls out "Set up for a central line"*
...
Central line is always in a
vein never artery
-Look for large veins: typically jugular vein or subclavian vein (don't do in carotid artery because would kill the patient)
There are
4 types of central lines
1.) Non-tunnled central lines
-Used for short term therapy
-SCL (subclavian), IJ (internal jugular), Femoral
-Single, double, triple or quad lumen
With non-tunneled central lines
clots and infection are main concerns so we don't keep them in for more than a Month
non-tunneled central lines are
done by physical, under sterile procedure (gowned, gloved, and masked)
Central venous right catheter goes
straight into right atrium
Non-tunneled central lines are most often seen because
pts veins are too fragile and this leads to less infection
Most often seen triple lumen
Triple lumen is for 3 things:
-medication
-blood withdrawal/samples for labs
-infusions/blood administration
Sometimes if just a double lumen they
don't need blood administration
Best place to put non-tunneled central lines is in
the neck (femoral is not as good because they move)
If you are assisting with central line placement (non-tunneled central line)
don gown, glove, mask, face shield if you were assisting
Peripherally interred central catheter (PICC)
-Used for intermediate term care (days to months)
-Basilic or cephalic vein accessed and PICC line threaded to the SVC
-No blood pressure or blood sticks from this extremity
PICC is longer than
1st and these are done to send people home (TPN or IV antibiotics)
-family can monitor
-very common just like non-tunneled central line
Peripheral viens have a
long way to travel (as opposed to central-right atrium)
PICC is inserted by
physician
PICC lines are long so measure
before inserted so that when you take it out, you can make sure some didn't break off
How long can picc lines and non-tunneled central lines stay in the patient:
a month, sometimes a little longer (best practice): this is to reduce the infection rate
Sterile dressing change for central line
White markers: bio patches. It's got an antibiotic in them to help insure patient doesn't get infection
We put these patches around the hub of the central line to decrease infection
Patient and nurse wear a mask with
dressing change (insertion will be full guard)
Dressings changed every
7 days or when visibly soiled
Tunnled central lines
Long term use (years)
Single or double lumen
Hickman, Groshong, Permacath
Inserted surgically
Tunnled central lines are usually done for
chemotherapy. Women with ovarian cancer.
Placed sometimes in abdomen
Tunnled central lines are extremely long and end up
going into right atrium but come out usually in the abdominal area
Tunnled central lines are typically for patients with
cancer to give chemotherapy
most see in leukemia patients or long term cancer
Tunnled central lines can stay in
for a year or longer
With tunneled central lines physicians put it in the
operating room: they go into the heart, but they come out in abdominal so that they can manage them
Implanted ports
-Long term IV therapy
-Port A Cath, PAS Port, Mediport
-End of catheter is attached to chamber that sits under the skin on chest or forearm
Implanted ports are done
surgically under general anesthesia; in operating room
implantable port is undertake skin, Must feel for port as a nurse
-has a rubber stopper and this is what you feel underneath the skin
Implanted ports stay in for
years done for chemotherapy
-also for sickle cell patients
Since implanted ports are underneath the skin this decreases
the chance of infection but still use sterile technique
All of the 4 types of central lines need to be flushed w/ either
NS or dilute heparinized saline
--use 10cc syringe: nothing less
When you go to flush you have to
When you go to flush you have to push, stop, push, stop (over time), this decreases the chance of clots, it would go right to the heart.
The issue with flushing
air getting into flush: air embolism: if this happens, immediately clamp the line, turn the patient to the left side and put the patient in tredenelenburg: head below the feet: traps the air in the right atrium
-if air embolism pt will have chest pain
Must do _________ before accessing central line
chest x-ray
Complications of central lines
-infection
-clot
-air emboli, anxiety, feeling funny
-rupture of the vessel to side of heart or side of penumothroax
(I CAR)
IF patient has air embolism (happens frequently in central line) then you
-clamp tubing
-oxygen
-turn them on their left side
-put them in trendelenburg (head lower than feet)
Ms hart needs a central line prior to surgery. What kind would be best?
Non tunneled (because would get triple lumen) when getting blood cultures, the initial flashback is what you use for a culture
Ms hart needs a central line prior to surgery. What site would be best?
Subclavian or jugluar (not brachial or femoral)
What can we use this line for?
-Blood products
-Venous labs
-Meds
-Run fluids
What are the nursing responsibilities?
Look for infections, clots
If you change dressing --> do under sterile conditions
Flush the line, make sure patent
Ms. Hart pulls through surgery and was admitted to the surgical ICU. She has a triple lumen central line in place where she is receiving her medications (including Vasopressors) and blood products as needed.
The physician is concerned about her volume status and therefore orders hemodynamic monitoring (higher level, done in ICU).
What does hemodynamic monitoring mean to you?
Invaisve tools that we look at central venous pressure, internally monitoring of BP, and mean arterial BP (much better indicator), and check for left ventricular function of the patient
Hemodynamic monitoring helps us determine patients
volume status, their BP, and if they have any problems with their left ventricular function
Noninvasive hemodynamic monitoring
BP, HR, Pulse ox, cardiac ultrasound
Invasive hemodynamic monitoring
-Arterial lines
-CVP
-PA Catheters
Arterial lines
-2nd type of monitoring
is invasive blood pressure monitoring
restricted to icu settings
Indications for arterial lines
severe hypertension or severe hypotension
frequent ABGs
cardiac procedures
Arterial line complications
bleeding
air embolism
distal ischemia
pain
infection
(BAD PI)
Arterial line during responsibilities
Monitor BP values
Watch for complications
Site maintenance
Transducer maintenance
With arterial lines physician puts in a line in
Radial artery usually to measure pts BP and mean arterial pressure
-This is much more accurate to check BP than usually BP cuff of even machine
Nurse might be asked to do a test to see if artery is patent to insert the line
Allen Test
which is when you take the patients hand and actually hold it up straight (elevate it), once they have their hand elevated, take their two fingers and press on their arteries until you see no return in the patients hand: hand will go blanch, after 30 sec, take fingers away and pts hand will go completely red: this would mean good perfusion THIS IS BEFORE U PLACE IT (if not good perfusion, don't use the way of arterial line). Only do with patients who are severely hypertension
You can draw ABGS from an
arterial line: you can just draw it from that site (nurse can draw ABGs in ICU setting-provider/resp therapist usually does in some facilities)
Purpose of arterial line
-Invasively monitor someone's BP on a screen (we can actually see it) OR draw arterial lab (ABG's)
-Mean Arterial Pressure (MAP)
-Physicians put these in
Central Venous Pressure (CVP) monitoring indications
-1st type of monitoring
monitor fluid status, preload
Central Venous Pressure (CVP) monitoring is typically seen in
in critical care, progressive care, PACU areas
Central Venous Pressure (CVP) monitoring complications & nursing responsibilities
same for central line
Measure what is in the central vein and what to see the amount of pressure
too much fluid or dehydrated?
Do pateints have too low of CVP, too hgh or normal?
Normal CVP of mercury
2-6mL of mercury is considered normal

If they use a watered device, normal is 5-10mL of water
Heidi hart, initial admission to ER, would you expect her fluid volume to be below 2 if using mercury?
yes
If we started to infuse a whole butt load of saline, is there a chance that her CVP might go above 6 and be overloaded?
yes
If you have a patient with HF you would expect patient to have
over 6 of mercury CVP
If patient has a 0-1 reading they are probably in
shock
How do you measure central venous pressure
transducer
Measurement of 15 mercury you would expect patient to be
hypervolemic: pt will need to receive diuretics (Lasix), might even put them off fluids
With CVP physician threads
through femoral, ij, or subclavian into the right atrium. (monitoring preload)
Would heidi hart be a candidate
yes
CVP is used to
monitor hyper/hypovolemia (volume shifts)
PA Catheters indications
LV function
PA Catheter complications
same as for central line
pulmonary artery rupture
pulmonary thromboembolism
dysrhythmias
(PPD)
PA Catheter nursing responsibilities
monitor critical response and maintain central line standards of care.
Pulmonary artery catheter is same line
used for CVP
PA Catheters are ONLY used to
check left ventricular function
Do this for patients who have potential for
overload such as:
Cardiogenic shock
HF
Cardiomyopathy
Thread same cath for CVP physician pushes it
further from R atrium into pulmonary artery.
Ms. Hart pulls through surgery and was admitted to the surgical ICU. She has a triple lumen central line in place where she is receiving her medications (including Vasopressors) and blood products as needed.
The physician is concerned about her
volume status and therefore orders hemodynamic monitoring.
Drug of choice for hypovolemic shock
dopamine (1st, 2nd, & 3rd dose)
Even after giving highest dose of dopamine it still didn't bring her blood pressure back up to normal

So....
she needs a blood transfusion
Different types of blood transfusions
1.) standard
2.) autologous: from yourself. Donate your own blood for you to receive
3.) intraoperative: reusing blood from trauma surgery
AB positive blood is
universal recipient
O negative blood is
universal donor
Blood products: whole blood
not seen a lot
used in severe trauma or in war zones.
450ml of blood and 50ml of coagulants
Blood products: packed red blood cells (PRBCs)
most common:
anemic pts or excessive blood loss
come in 300 mls
Blood products: platelets
give if pt has less than 20,000 platelets or platelet count is less than 50,000 and they are actively bleeding
Blood products: frozen plasma
give for coagulation deficiencies: seen in liver pts who have coagulation issues or after heart surgery after they get a lot of blood products
Blood products: cryprecipiate
have high coagulation factor: massive bleeding:
effector 8 deficiency:
smaller units: 15-20ml:
fibrogen level low
Prior to transfusion
1.) Check policy
2.) Consent: NO next of kin:
3.) Vital signs: before transfusions!!
4.) Order: physical order: WRITTEN order
5.) Lab work: get any labs that are ordered
6.) Type and cross: check to see what blood you would be compatible with
7.) IV access: large IV: 18 gauge
(CC VOLT I)
Equipment
blood tubing
IV pump
normal saline
Heidi Hart
-33 female
-Large abdomen laceration
-Hemoglobin 5.3 (normal is 12-16): expect her to look pale, VS would be tachycardic and low BP
-AB+ is her type of cross. She could receive ALL types of blood
-18 IV R AC
...
Order: Give 1 unit PRBCS over 2 hours
...
Policy for vital signs
-30 minutes before prior to start of transfusion,
-first hour every 15 minutes, and then every hour during the transfusion
-30-60 minutes after you stop the transfusion
Policy for verification
double check person and blood with second RN/doctor if they are available
check blood bank band, blood expiration date, etc.
*only a nurse can go pick the blood up from the blood bank
Policy for time frame
must be given within 4 hours of picking up the blood, usually are given over 2 hours
Policy for transfusion reaction criteria
a temperature change up or down by 1.8 degrees, BP change up or down by 30
Transfusion reactions: acute hemolytic
Happens immediately due to blood being incompatible
Acute hemolytic symptoms
Fever/chills
low back pain
hypotension
chest tightening
nausea
tachypnea
(FLH CNT)
Acute hemolytic interventions
Stop immediately
check vital signs
send blood and tubing to the lab to see where the problem came from
Transfusion reactions: Febrile
-happens within two hours
-will see more commonly if they receive several blood transfusion.
Febrile symptoms
chills
HTN
increase in temp by 1 degree
tachycardia
(CHIT)
Febrile interventions
stop
give antipyretic (Tylenol)
and give fluid
Transfusion reactions: Allergic
-Either mild or severe reaction
-Happens within 24 hours (longer reaction time frame)
If a patient has a history of allergic reaction
write order prior to start of transfusion
Mild Allergic symptoms
Itching & flushing
Severe Allergic symptoms
anaphylactic
bronchospasm
shock
(ABS)
Allergic interventions
Stop transfusion
-Give antihistamine
-If mild, maybe reorder transfusion
If anaphylactic give
-epinephrine
-oxygen
-disconnect blood
-give IV fluids
Transfusion reaction: Bacterial
-Seen within several hours
Bacterial symptoms
-Wheezing
-dyspnea
-chest tightness
-cyanosis
-hypotension
-shock
(WD CCHS)
Bacterial interventions
-Stop transfusion
-Order antibiotics
-Send blood cultures
-Give IV fluids
Transfusion associated circulatory overload (TACO)
-Seen in CHF
-Fluid overload
-Occurs anytime
TACO happens when transfusion is
going too quickly and body cannot handle
-Could lead to pulmonary edema if we don't react in time
TACO interventions
Definitely call provider: may have you restart at a slower rate
-Sit patient up, give oxygen, give diuretics
TACO symptoms
Hear crackles, SOB, cough
-JVD
-Tachycardia
Transfusion associated acute lung injury (TRALI)
-Non cardiogenic pulmonary edema
-New acute lung injury that happens within 6 hours
-Don't know why: only explanation for this besides the blood transfusion
-Potentially fatal
(NNDP)
TRALI symptoms
Acute onset of SOB
hypoxic
hypotension
fever
pulmonary edema
(AHH FP)
TRALI interventions
Immediately stop transfusion
-Chest x ray: pulmonary infiltrates
-Need aggressive support of therapy: need to be treated aggressively cause it can progress and be fatal
15 minute vitals
-HR 140
-BP 82/62
-RR 28
-O2 96
-Temp 100.4

Pt complains of low back pain and feels flushed:
hemolytic reaction
-Nursing actions: stop transfusion, check VS
Hour vital signs
140
82/62
18
95%
temp 101.2
Complaining of chills:
Febrile reaction
Interventions: stop infusion, give antipyretics, call doctor and let them know
2 hour vitals
135
111/78
24
93%
98.6
JVD
And we hear crackles
TACO reaction
Sit up, give oxygen, and call the doctor
Documentation
-Vitals
-Transfusion start and stop time
-Witness
-Education
*if you didn't document, it didn't happen
Post transfusion
-Continue to monitor patient
-I and Os, vitals, pain
-Dispose of blood tubing properly: send back to blood bank to be disposed
-Check labs as ordered: if you gave transfusion because hGB was low, you will most likely have to check afterward
(CID C)
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