Week Three Flashcards
(158 cards)
1
Q
What is family centred care?
A
- Recognises family as constant in child’s life
- Systems must support, respect, encourage and enhance the family’s strength and competence
- Needs of family must be addressed
2
Q
What are stressors of hospitalisation?
A
Separation anxiety:
- Protest phase (Crying and screaming; clinging to the parent)
- Despair phase (Crying stops; evidence of depression)
- Detachment (denial) phase (Resignation but not contentment; superficial adjustment;
May seriously affect attachment to the parent after separation)
3
Q
What are infants needs when there is a loss of control?
A
- Trust
- Consistent living caregivers
- Daily routines
4
Q
What are preschoolers needs when there is a loss of control?
A
- Egocentric and magical thinking is typical of this age
- May view illness or hospitalisation as punishment for misdeeds
- Preoperational thought
5
Q
What are school-age children’s needs when there is a loss of control?
A
- Striving for independence and productivity
- Fears of death, abandonment, permanent injury
- Boredom
6
Q
What are adolescents needs when there is a loss of control?
A
- Struggle for independence and liberation
- Separation from the peer group
- May respond with anger and frustration
- Need for information about their condition
7
Q
How to normalise the hospital environment?
A
- Maintain the child’s routine, if possible
- Time structuring
- Self-care (age appropriate)
- Schoolwork
- Friends and visitors
8
Q
What are normal values of a child from birth to one week?
A
Respiratory rate - 30-60
Pulse rate - 100-160
Systolic BP - 50-70
9
Q
What are normal values of a child from one week to six weeks?
A
Respiratory rate - 30-60
Pulse rate - 100-160
Systolic BP - 70-95
10
Q
What are normal values of a child at six months?
A
Respiratory rate - 25-40
Pulse rate - 90-120
Systolic BP - 80-100
11
Q
What are normal values of a child at one year?
A
Respiratory rate - 20-30
Pulse rate - 90-120
Systolic BP - 80-100
12
Q
What are normal values of a child at three years?
A
Respiratory rate - 20-30
Pulse rate - 80-120
Systolic BP - 80-110
13
Q
What are normal values of a child at six years?
A
Respiratory rate - 18-25
Pulse rate - 70-110
Systolic BP - 80-110
14
Q
What are normal values of a child at ten years?
A
Respiratory rate - 15-20
Pulse rate - 60-90
Systolic BP - 90-120
15
Q
What should you consider for vital sign values for children?
A
- Patients normal should always be considered
- HR, BP and RR will increase during fever and stress
- RR on infants count for 60 seconds
- In clinically decompensating child BP last to change
- Bradycardia in children ominous sign, usually from hypoxia - act quickly
16
Q
How to communicate with children and their families?
A
- Listening to the parent - are they concerned
- Parental involvement
- Developmental age of language development
17
Q
How to prepare for procedures?
A
- Goal is to decrease anxiety, promote cooperation, and support coping skills
- Psychological preparation (Age-specific guidelines for preparation; Based on developmental characteristics)
- Establish trust and provide support
- Parental presence and support
- Explanation to the child
18
Q
How to perform procedures?
A
- Use of the treatment room for procedures
- Expect success
- Involve the child
- Provide distraction
- Encourage expression of feelings
- Provide positive support
- Use of play in procedures
- Prepare the family
19
Q
What immunity do infants younger than 3 months have?
A
Maternal antibodies offer protection
20
Q
What infection rate do infants age 3 to 6 months have?
A
An increasing rate of infection
21
Q
What is there a high rate of in toddlers and preschoolers?
A
High rate of viral infections
22
Q
What is there an increase of in children older than 5 years?
A
An increase in GABHS and Mycoplasma pneumoniae infections
23
Q
How does immunity change as children grow older?
A
- Immunity increases with age
24
Q
How is size different in children?
A
- Diameter of airways is smaller
- Distance between structures is shorter, allowing organisms to rapidly move down
- Short and open eustachian tubes
25
What are types of respiratory dysfunction in children?
- Croup syndromes
- Bronchitis
- Bronchiolitis
- Asthma
- Epiglottitis
26
What are clinical manifestations of respiratory infections in children?
- Vary with age
| - Generalised signs and symptoms and local manifestations differ in young children
27
What are clinical signs of respiratory infections?
- Fever
- Anorexia, vomiting, diarrhea, abdominal pain
- Cough, sore throat, nasal blockage or discharge
- Respiratory sounds
28
What are nursing interventions for respiratory infections?
- Ease the respiratory effort
- Manage fever
- Promote rest and comfort
- Control infection
- Promote hydration and nutrition
- Provide family support and teaching
29
What is croup syndromes characterised by?
- Hoarseness
- Barking cough
- Inspiratory stridor
- Varying degrees of respiratory distress
30
What does croup syndromes affect?
- Larynx
- Trachea
- Bronchi
31
What is croup syndromes particularly problematic for infants and small children?
Due to smaller diameter of airways
32
What are principles of nursing care for a child with croup?
- Observe from a distance
- Reassure parents
- Minimal interaction
- Minimal intervention
- Adrenaline nebuliser if severe
- Stay calm
- Hydrate
33
What are clinical manifestations of acute epiglottitis?
- Sore throat
- Pain
- Tripod positioning
- Retractions
- Inspiratory stridor
- Mild hypoxia
- Distress
34
What is therapeutic management for acute epiglottitis?
- Potential for respiratory obstruction
- A presumptive diagnosis of epiglottitis constitutes an emergency
- Should not be examined until anaesthetist present as immediate intubation or tracheostomy may be indicated for airway obstruction
- Keep patient calm, comfortable and minimise any distress
35
How to prevent acute epiglottitis?
Haemophilus influenzae type b (Hib) vaccine
36
What are characteristics of bronchiolitis?
- Acute viral infection - bronchiolar level
- Rare in children over 2 years
- Respiratory syncytial virus (RSV)
- Spread by hand to eye, nose and other mucus membranes
- Causes childhood pneumonia as well
37
What are characteristics of a mild disease in children?
Behaviour - Normal
Respiratory rate - Normal-mild tachypnoea
Use of accessory muscles - Nil to mild chest retraction
Oxygen saturation/oxygen requirement - O2 saturations greater than 92% (room air)
Apnoeic episodes - None
Feeding - Normal
38
What do children need to have when having IV fluids administered?
Burette
39
What are characteristics of a moderate disease in children?
Behaviour - Some intermittent irritability
Respiratory rate - Increased
Use of accessory muscles - Moderate chest wall retractions, tracheal tug, nasal flaring
Oxygen saturation/oxygen requirement - O2 saturations 90-92% (room air)
Apnoeic episodes - May have brief apnoea
Feeding - May have difficulty or reduced feeding
40
What are characteristics of a severe disease in children?
Behaviour - Increased irritability and/or lethargy; fatigue
Respiratory rate - Marked increase or decrease
Use of accessory muscles - Marked chest wall retractions, marked tracheal tug, marked nasal flaring
Oxygen saturation/oxygen requirement - O2 saturations less than 90% (room air); hypoxemia may not be corrected by O2
Apnoeic episodes - May have increasingly frequent or prolong apnoea
Feeding - Reluctant or unable to feed
41
What are characteristics of febrile convulsions/seizures in children?
- Affects 4% of children
- Most occurs 6 months to 3 year
- Boys affected twice as often as girls
- Most febrile seizures generalised, last < 5 minutes
- 30% to 30% of children have one occurrence
- Cause uncertain
- >38.8c and occurs during temperature rise
- Accompany illness: otitis media, respiratory infections
42
What is nursing management for children having febrile convulsions/seizures?
- Stay calm
- Think safety
- Call for help
- If lasting > 5 minutes - Dr consultation
- Observe and examine for origin of fever
- Parental support and education
43
How to ease respiratory effort?
- Positioning
- Oxygen
- Hydration
44
What age group is croup common in?
6 months to 3 years
45
What to inspect in children's appearance ?
- Abnormal tone
- Decreased interactiveness
- Decreased consolability
- Abnormal look/gaze
- Abnormal speech/cry
46
What are key assessments when caring for children?
- Health history
- Nutrition
- Family structure
- Physical
- Developmental
47
What to inspect in children's work of breathing ?
- Abnormal sounds
- Abnormal position
- Retractions
- Flaring
- Apnea/gasping
48
What to inspect in children's circulation to skin?
- Pallor
- Mottling
- Cyanosis
49
What are ABCs of critical paediatric illnesses?
Absent airway, breathing or circulation
50
What are ABCs of unstable paediatric illnesses?
Compromised airway, breathing or circulation
51
What are ABCs of potentially unstable paediatric illnesses?
Normal airway, breathing, and circulation but significant mechanism of injury or illness
52
What are ABCs of stable paediatric illnesses?
Normal airway, breathing and circulation. No significant mechanism of injury or illness
53
What does CUPS stand for for paediatric illnesses?
Critical
Unstable
Potentially unstable
Stable
54
What to assess for the paediatric assessment triangle?
- Appearance
- Work of breathing
- Circulation
55
What does AVPU stand for?
Alert
Verbal
Pain
Unresponsive
56
What can increase HR and RR?
- Compensated shock
- Infection
- Stress
57
What can decrease RR?
- Medications (e.g. racemic)
| - Exhaustion
58
What can cause decreased HR?
- Hypoxia
| - End stage shock
59
What is angina?
- Symptom of coronary artery disease
- Chest pain due to lack of blood supply and oxygen to the heart
- Pain often spreads to shoulders, arm, neck and jaw
60
What does angina feel like?
- Squeezing
- Pressure
- Heaviness
- Tightness
- Pain in the chest
- Can be sudden or recur over time
61
How can angina be treated?
Depending on severity, can be treated by lifestyle changes, medication, angioplasty or surgery
62
What is atherosclerosis?
Build up of plaque
63
What is arteriosclerosis?
Thickening of walls of arteries
64
What is chronic stable angina?
- Same pattern of onset, duration, intensity of symptoms
- Pain lasts 5-15 mins
- Usually predictable - provoked by exertion
- Relieved by rest or GTN
65
What is unstable angina?
- New in onset, occurs at rest (or with minimal exertion), has a worsening pattern
- Other symptoms: SOB, fatigue, indigestion, anxiety
- Not relived with GTN
- Unpredictable
- Associated with plaque rupture exposing a thrombus
- Medical emergency
66
What is acute coronary syndrome (ACS)?
The name given to three types of CAD that are associated with sudden plaque rupture:
- UA
- N-STEMI
- STEMI
67
What are modifiable risk factors of CAD?
- Elevated serum lipids
- HTM
- Tobacco use
- Sedentary lifestyle
- Obesity
- DM
- Metabolic syndrome
- Stress
- Homocysteine levels
68
What are non-modifiable risk factors of CAD?
- Age
- Gender
- Ethnicity
- Family history and genetics
69
How does the patient with acute coronary syndrome present?
- Collapse
- Sweating
- Pallor
- Chest pain
- Dyspnoea
- Nausea and vomiting
- Pale and clammy
- Pulmonary oedema
- Hypotension
- Bradycardia/tachycardia
70
Which acute coronary syndrome has a elevated ST segment?
STEMI
71
Which acute coronary syndrome doesn't have a elevated ST segment but has elevated cardiac enzymes?
NSTEMI
72
Which acute coronary syndrome doesn't have a elevated ST segment and doesn't have elevated cardiac enzymes?
Unstable angina pectoris
73
What are complications of MI?
- Arrythmias (AF – atrial fibrillations, ectopic beats)
- Cardiac arrest
- Heart failure
- Cardiogenic shock
- Pulmonary oedema
- Acute respiratory failure
74
What are diagnostic studies for MI?
```
Lab Tests:
- Lipid profile
- Serum cardiac markers (Trop T)
Medical Imaging:
- 12-lead ECG
- Cardiac catheterisation + coronary angiography
- Chest x-ray
- Echocardiogram
- Exercise stress testing
```
75
What are acute nursing interventions for cardiac problems?
- Pain
- Ongoing monitoring an assessment
- Rest and comfort
- Anxiety
- Emotional and behavioural reactions
76
What is multidisciplinary care for cardiac problems?
- Rapid diagnosis and treatment extremely important
| - Best practice treatment
77
How to reperfuse STEMIs with thrombolysis?
- Stop the infarction process by dissolving thrombus and reperfusing myocardium
- Treatment if no PCI available in timely manner (ie within 120 mins; goal within 30mins of arrival to facility without cardiac catheterisation facility)
- Within 6 hours ideally otherwise mortality reduced by 25%
78
What is surgical revascularisation - CABG?
The restoration of perfusion to a body part or organ that has suffered ischemia mainly by vascular bypass and angioplasty
79
What are nursing interventions for acute heart failure:pulmonary oedema?
- C-XRAY
- Monitoring
- Treat cause
- Positioning
- Oxygen therapy
- Drug therapy (cardiac Mx and anxiety Mx; intravenous)
- Daily weight
- Rest
- Regular assessment
- Combine physical, psychosocial and relational needs with each care encounter
80
How to provide patient education for cardiac problems?
- Needs to occur at every stage of the hospitalisation and recovery
- Patient must be aware of the need to learn
- Timing important - initially in crisis - shock, disbelief
- Simple, brief language
- Learning what to expect provides sense of control
- Use evidence-based teaching guides
81
What are nursing assessments for cardiac pain?
- Pain assessment
- Vital signs
- Precipitating factors
- Skin
- ECG
- Blood work
- Medication
- Pt history/cardiac history
- Perfusion
- Auscultation
82
What is a MI?
- Occlusion of coronary artery for greater than 4-6 hours
| - Irreversible cell death
83
What are characteristics of unstable angina?
- No change in ECG but possible ST depression and T wave depression
- No change in biomarkers
84
What are characteristics of a NSTEMI?
- No ST elevation or Q waves
- Can have ST depression or T wave inversion
- Change in biomarkers
85
What are characteristics of a STEMI?
- ST elevation and presence of Q wave
| - Change in biomarkers
86
What is emergency care for MI (MONATAS)?
- Morphine
- Oxygen
- Nitrates
- Aspirin
- Thrombolytics
- Anticoagulants
- Stool softener
87
How to administer nitrates?
- 1-2 sprays at 0 min
- Check blood pressure
- 1-2 sprays five minutes later
- Check blood pressure
- 1-2 sprays five minutes
88
When should you not give GTN?
If systolic blood pressure is below 100
89
What are manifestations of heart failure?
- Breathlessness
- Tachycardia
- Hypotension
- Anxiety
- Fatigue
90
What is heart failure?
- Linked to cardiovascular disease (HTN, CAD, and MI)
- A chronic condition that worsens over time
- No predictable course
91
What are the types of heart failure?
- LVF (left sided heart failure)
- RVF (right sided heart failure)
- Bilateral heart failure
92
What is normal ejection fraction?
55%-70%
93
When if heart failure end stage?
- Confirmed diagnosis
- Ejection fraction less than 20%
- Not a candidate for device therapy or surgery
- BNP greater than maximal therapy
- Persistent NYHA class III-IV symptoms
- Multiple comorbidities which influence initiating heart failure
- Inability to optimise
94
If a patient is complaining of chest pain what should you do as a nurse?
- Get help
- Pain assessment
- Vital signs
- ECG
- Skin
95
What is DKA?
- Absent of insulin
| - Leads to disorders of metabolism of carbohydrate, protein and fat
96
What are the three clinical features of DKA?
- Hyperglycaemia
- Dehydration and electrolyte loss
- Acidosis
97
What is HHNS (Hyperglycaemic hyperosmolar non-ketotic syndrome)?
Lack of effective insulin leads to hyperosmolarity and hyperglycaemia which causes osmotic diuresis, resulting in water and electrolyte losses
98
What are characteristics of DKA?
- Patients affected - Type 1 diabetes
- Precipitating event
- Omission of insulin; physiological stress
- Onset - Rapid (<24h)
- BGL - >13.9 mmol/L
- Arterial pH - <7.3
- Serum and urine ketones - Present
- Serum Osmolality - 300 -350 mmol/L
- Plasma bicarbonate - <15 mmol/L
- Urea and Creatinine level - Elevated
- Mortality rate - <5%
99
What are characteristics of HHNS?
- Patients affected - Type 2 diabetes
- Precipitating event
- Physiological stress
- Onset - Slower (several days)
- BGL - >33.3 mmol/L
- Arterial pH - Normal
- Serum and urine ketones - Absent
- Serum Osmolality - >350mmol
- Plasma bicarbonate - Normal
- Urea and Creatinine level - Elevated
- Mortality rate - 10%-40%
100
What are precipitating factors of DKA?
- Increased amounts of stress hormone
- New diabetics
- Management errors in insulin doses
- Deliberate omission of insulin by patient
- Erratic compliance with insulin and eating
- Recreational drug use/ alcohol binges
101
What are signs and symptoms of DKA?
- Fatigue, headache
- Polyurina
- Polydipsia
- Polyhagia
- Nausea and vomiting
- Abdominal pain
- Dehydration
- Kussmaul respirations
- Acetone on breath
- Decreased LOC
102
What are nursing assessments and interventions for DKA?
- Rapid ABC and determine LOC
- Number 18 IV leur
- Venous ABGs, FBC, U and E's
- CBG and CBK
- Dehydration assessment
- Signs of hypokalemia
- Potential for hypovolemic shock
- Signs of infection
- ECG, SPo2, urine output
103
What are signs of hypokalaemia?
- Fatigue
- Muscle weakness, leg cramps, soft, flabby muscles
- Nausea and vomiting, paralytic ileus
- Paraesthesia, decreased reflexes
- Weak, irregular pulse
- Polyuria
- Hyperglycaemia
- ECG changes: inverted T wave
104
What is collaborative management for DKA?
- Treating hyperglycaemia
- Correcting dehydration and hypovolemia
- Correcting electrolyte loss
- Correcting acidosis
- Identify and correct the precipitating cause
105
What are nursing interventions for DKA?
Monitoring of:
- Vital signs
- LOC
- ECG
- O2 saturations
- Urine output – 1/24
- FBC 1/24
- Serum glucose and potassium
106
How to provide rehydration therapy for DKA patients?
- 1L 0.9% saline over 1 hour
- 1L over 1-2 hours
- 2 L over 4 hours
- 1L every 4-6 hours
- Switch to 5-10% glucose over next 8 hours once BGL <15mmol/L
- Continue with saline in addition to glucose if patient remains volume depleted
107
How to administer insulin for fluid management of patients with DKA?
- 50 units actrapid in 50ml NaCl in syringe driver for IV infusion
- Start 6 unit/hour
- Laboratory venous BGL should be checked 2/24
108
How to replace potassium in patients with DKA?
- Do not add to the first litre of fluid infused
- Establish K+ level
- Monitor K+ every 2 hours
109
What is the rate of potassium chloride to be added to each litre of fluid for different serum potassium levels?
- >5.5 - Nil recheck in 2 hours
- 3.5-5.5 - 20 mmol/L
- 3.0 -3.4 - 40 mmol/L
- <3.0 - Higher rates of potassium should be administered in ICU
110
How to prevent DKA and what are sick day rules?
- Sugar free cough mixtures
- Seek prompt medical treatment – antibotics/ paracetamol
- If unable to eat normally – carbohydrates should be replaced with cereals, soups or liquid carbs
- Drink plenty of sugar-free liquids
- If vomiting – seek medical attention
- Insulin should be continues even if not eating
- It is likely that insulin doses will need to increased during illness
- BGL should be checked more regularly (4x/day)
111
What are characteristics of AKI?
- Rapid onset and loss of kidney function
- Accompanied by rise in serum creatinine and/or reduction in urine output
- Potentially reversible
- High mortality rate
- Usually affects people with life threatening conditions
- Commonly follows severe, prolonged hypotension or hypovolaemia or exposure to nephrotoxic agent
112
What is the process of DKA?
- No glucose in cells to be used as source of energy
- Liver starts converting glycogen to glucose
- Body starts breaking down fat (lypolysis)
- Ketones (acid by products) produced
- Increased ketones and glucose in blood and ketones in urine (ketonuria)
- Metabolic acidosis
- Osmotic diuresis
113
What are the three categories of AKI causes?
- Prerenal
- Intrarenal
- Postrenal
114
What are prerenal causes of AKI?
- Hypovolaemia
- Decreased cardiac output
- Acute haemorrhage
- Decreased peripheral vascular resistance
- Decreased renovascular blood flow
115
What are intrarenal causes of AKI?
- Nephrotoxic injury
- Interstitial nephritis
- Other – acute tubular necrosis
- SLE and myoglobin
116
What are postrenal causes of AKI?
- Benign prostatic hyperplasia
- Bladder cancer
- Calculi formation
- Neuromuscular disorders
- Prostate cancer
- Spinal cord disease
- Strictures
- Trauma
117
What is acute tubular necrosis (intrarenal)?
- Nephrotoxic or ischemic injury that damages renal tubular epithelium
- ATN most common cause of intrarenal failure especially in hospitalized patients.
- Damage to cellular structure
118
What can damage to cellular structure in acute tubular necrosis cause?
- Prevents normal concentration of urine
- Filtration of wastes
- Regulation of acid-base, electrolyte and water balance
119
What does RIFLE mean?
- Risk
- Injury
- Failure
- Loss
- ESRD
120
What is criteria for risk in RIFLE?
Increased creatine x 1.5 or GFR decrease > 25%
121
What is criteria for injury in RIFLE?
Increased creatine x 2 or GFR decrease > 50%
122
What is criteria for failure in RIFLE?
Increased creatine x 3 or GFR decrease > 75% or creatine > 4mg per 100ml (acute rise of > 0.5 mg per 100 ml dl)
123
What is criteria for loss in RIFLE?
Persistent ARF = complete loss of renal function > 4 weeks
124
What is criteria for ESRD in RIFLE?
End stage renal disease
125
What is multidisciplinary care for AKI?
- Treat precipitating cause
- Fluid restriction (600 mls + previous 24 hours loss)
- Nutritional therapy (enteral nutrition)
- Measures to lower potassium
- Calcium supplements
- Dialysis
126
What is nursing management for AKI?
- Monitor vital signs
- Fluid and electrolyte balance
- Urine assessment
- Respiratory assessment
- Skin assessment
- Prevent infection
- Monitor fatigue and potential anxiety
- Monitor of complications - arrhythmias, infection
127
What are the general principles of dialysis?
- Diffusion
- Osmosis
- Ultrafiltration
128
What lab monitoring do you complete on a DKA patient as a baseline?
- Glucose
- NA+, KCL and urea
- Creatine
- Bicarbonate
- Arterial gas
129
What lab monitoring do you complete on a DKA patient after 2 hours?
- Glucose
- NA+, KCL and urea
- Bicarbonate
- Arterial gas
130
What lab monitoring do you complete on a DKA patient after 6 hours?
- Glucose
- NA+, KCL and urea
- Bicarbonate
131
What lab monitoring do you complete on a DKA patient after 12 hours?
- Glucose
- NA+, KCL and urea
- Creatine
- Bicarbonate
132
What lab monitoring do you complete on a DKA patient after 24 hours?
- Glucose
- NA+, KCL and urea
- Creatine
- Bicarbonate
133
What are signs of hyperkalaemia?
- Elevated T wave
| - Blood work
134
What is the rate of insulin infusion?
Start 0.1 units/kg/hour intravenous insulin infusion
135
When should insulin infusion be stopped?
When insulin and ketone levels are normal
136
How do you stop insulin infuson?
Lower infusion and administer sub cut injection of insulin. Titrate this slowly and continue hourly monitoring
137
What is the range for normal potassium?
3.5-5.2 mmol/L
138
What are risk factors for AKI?
- Diabetes
- Over 75 years
- Hypertension
- Heart and liver failure
- Sepsis
- Nephrotoxic drugs
139
What are examples of nephrotoxic drugs?
- Gentamicin
- Vancomycin
- MI contrast
140
What are the phases of AKI?
- Initial or onset phase
- Oliguric or maintenance phase
- Diuretic
- Recovery
141
What is TPN mean?
Total parental nutrition
142
What is PPN mean?
Peripheral parental nutrition
143
What does TPN and PPN do?
They directly administer nutrients into the circulatory system
144
What are the different types of dialysis?
- Peritoneal dialysis
- Haemodialysis dialysis
- Continuous renal replacement therapy (CRRT)
145
What are the phases of peritoneal dialysis?
- Instill (glucose fluid administered)
- Dwell (from 30 minutes to 8 hours)
- Drain (ideally straw colour and translucent)
146
What do you look for in a drained bag of peritoneal dialysate?
- Colour
- Clarity
- Mucous shreds
- Weight
147
What is RH factor?
- The D antigen
| - A protein found on RBC's surface
148
What does "-"ve D antigen mean?
Negative
149
What does "+"ve D antigen mean?
Present
150
What are the different types of blood products?
- Whole blood
- Red blood cells
- Platelets
- Fresh frozen plasma (FFP)
- Albumin
151
What does prothrombinex do?
Reserve blood thinners
152
What is a group and hold?
- Check patient details
- Check historical information on patient such as previous blood group, previous transfusion and obstetric history
- ABO and RhD typing of recipient's red cells
- Antibody screen to detect antibodies in recipient's plasma
- Identification of red cell antibodies (performed if positive antibody) screen detected
153
What is a cross match?
- Serological crossmatch of the patient’s plasma versus donor red cells
- Once pre-transfusion testing is completed blood can be issued to the ward or operating theatre
- Detects incompatibility between a patient and donor blood chosen for transfusion
- The units compatible are labelled specifically for the patient
- The blood bank holds the units and releases them immediately upon request
154
How to manage blood transfusion before the blood arrives?
- Know why your patient requires a transfusion
- Prepare and talk to your patient
- Ensure that the patient has a valid sample for “group and screen” in the Blood Bank
- Ensure written, informed consent has been obtained
- Ensure blood is prescribed and prescription signed by the Medical Practitioner
- Prepare your equipment
- IV line primed with 0.9%NaCL only
- Min 20G leur, 18G preferable
- Send for the blood (using appropriate forms and systems)
155
How to manage blood transfusion when the blood arrives?
- Take the unit, prescription and consent to the bedside, and check all of this with another RN - 2 person check
- Ask the patient to identify themselves – full name and DOB while checking the patients wristband and details on swing label on the blood bag
- Both nurses check the unit number, component, unit group that has been provided by the blood bank with details on swing label on the blood bag
- Check expiry date on unit
- Spike the unit and prime the line - always use a line with a 170-200micron filter or add a 170-200 micron filter onto the giving set
- Set up line - you may use an infusion pump
- You have 30 minutes in which to begin the infusion
156
What are observations necessary for a blood transfusion?
- Baseline temp, pulse, respiration and manual blood pressure - document
- Remain with your patient for the first 15mins of the transfusion
- Repeat all vital signs within 15 min of commencement - document
- Depending on patients condition and hospital policy, vital signs are monitored and recorded every 30mins, 1 hourly or 2 hourly
- Always take and document observations at the end of every unit
- Read and be familiar with the hospital blood policies prior to transfusing the patient
157
What are adverse effects of blood transfusions?
- Febrile Non-Haemolytic Transfusion Reaction
- Allergic reaction
- Anaphylactic reaction
- Hypotensive reaction
- Acute Haemolytic Transfusion Reaction
- Bacterial sepsis
- T.A.C.O. – Transfusion Associated Circulatory Overload
158
What are the rights for blood transfusions?
- Right patient
- Right component
- Right time
