predisposing factors to DVT
previous DVT smoking contraceptive age cardiovascular disorder weight gender
what is are the 3 stages of Virchow’s Tried
stasis of blood
vessel wall injury
altered coagulation
Nursing assessment for DVT
edema-bilateral baseline limb girth skin temperature-warm pain color pyrexia pulse
therapeutic intervention for DVT
increase fluids early mobilization ROM bed rest planter and dorsiflexion ambulate meals
Elastic compression stockings (TED hose)
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
what is the antidote for warfarin (coumadin)
Vitamin K
hgb
12-18
HCT
38-54%
RBC
4-6
platelet count
150,000-400,000
WBC
5-10
if neutrophils increase and lymphocytes decrease…
shift to the left
bacterial infection
if lymphocytes increase and neutrophils decrease
shift to the right
viral infection
dehiscence and evisceration can happen POD
5-6
wound infection
abdominal distention
edges part slowly with extravasation of pink serous fluid
Interventions for evisceration
cover with saline
increase IV
monitor for shock-stay with patient
call Dr
what is the antidote for heparin
protamine sulfate
anticoagulant therapy for DVT
heparin
LMWH - fragmin, lovenox
xarelto (rivaroxaban)
what are the site for heparin and LMWH
abdomen
iliac crest
subcutaneous injection of LMWH-Fragmin, Lovenox
keep air bubble sites abdomen or iliac crest DO NOT aspirate hold skin fold during injection DO NOT rub site
when giving heparin subcutaneously
abdomen or iliac crest rotate sites DO NOT aspirate hold skin fold during injection DO NOT rub site
what is are the therapeutic effects of LMWH
no lab measurements required
fixed doses per weight (1 mg/kg)
therapeutic effects of heparin
PTT normal 24-36 sec, therapeutic 46-70 sec
ACT normal 80-135 sec, therapeutic 3 min
what are the therapeutic effects of warfarin (Coumadin)
INR daily
normal .75-1.25, therapeutic 2-3
levels take 48-72 hours (3-5 days)
drug interactions with warfarin
barbiturates (phenobarb) NSAIDS dilantin herbal supplements food-green leafy vegetables
defining characteristics of pulmonary emboli
sudden sharp chest pain extreme apprehension intense hyperventilation intense dyspnea cough hemoptysis decrease PO2 increase CO2
Packed RBCs (PRBC)
prepared from whole blood
1 unit =250-300 ml
less risk of fluid overload
increase RBC mass
for anemia, platelets not functional
Frozen RBCs
prepared from RBCs
Can be stored for 10 years
after thawing use within 24 hrs
used in autotransfusion
Platelets
prepared from whole blood
1 unit =30-60 ml
used for bleeding disorders
Fresh Frozen plasma
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
Albumin
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
S&S of transfusion reaction
itching hives swelling SOB fever chills
S&S of adverse reaction to transfusion
restlessness hives nausea vomiting torso or back pain chills fever hematuria SOB flushing
Stop transfusion immediately, notify physician
When should the nurse change the blooding during transfusion
after every 2 units transfused to decrease chance of bacterial contamination.
when should the blood be spiked
30 min of arriving on the floor
should be infused within 4 hrs
blood transfusion reactions acute hemolytic
chills fever low back pain tachycardia dyspnea hypotension dark urine shock
Tx: Stop transfusion
Febrile transfusion reactions
sensitization from donor sudden chills increase temp headache anxiety muscle pain
Tx. Stop transfusion
mild allergic reaction during a blood transfusion
sensitivity to foreign plasma proteins
flushing
hives (urticaria)
Tx: antihistamines (Benadryl) and continue with transfusion slowly
Blood transfusion reactions-anaphylactic
sensitivity to donor plasma proteins Anxiety urticaria (hives) dyspnea wheezing
Tx: stop transfusion and treat symptoms (epinephrine)
blood transfusion reaction-circulatory overload
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
blood transfusion reaction - sepsis
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
what is the leading cause of trans-related death
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.
If acute reaction is suspected for blood transfusion
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
Should the RN pre medicate the patient before a blood transfusion?
No
premedication can mask the beginning of a more serious transfusion reaction.
what precaution should the RN take to prevent acute hemolytic transfusion
meticulous attention to detail
labeling blood samples and blood components
accurately identifying the recipient
when does fever R/T febrile during blood transfusion begun
within 2 hours of transfusion
Can antipyretics be given to prevent fever before blood transfusion
yes
