8.3: Chapter 3
- Page ID
- 92860
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)Case Study #1
1. Indications for a blood transfusion for Helen:
- Anemia (Hgb of 6.5 g/dL)
- Fatigue and exhaustion
- Pale appearance
2) Considerations for starting an IV for the blood transfusion:
- Client assessment: Check Helen’s vital signs, hydration status, and any underlying medical conditions.
- Site selection: Choose the best IV site, taking into consideration the age of the client, access, and current skin condition. Consider the size of catheter, optimally a 20-gauge catheter or larger for blood administration.
- Equipment and supplies: Ensure you have all necessary equipment, such as an IV catheter, blood tubing, sterile dressing, and saline.
- Safety measures: Follow standard infection control procedures to prevent transmission of infectious diseases.
- Client comfort: Explain the procedure to Helen.
3) Steps to prepare for the administration of blood for Helen:
- Ensure Helen has signed the consent for blood transfusion
- Verify the correct patient with 2 identifiers, blood type, and cross-match
- Check the compatibility of the blood with the client’s blood type and cross-match
- Check for any allergies or sensitivities to components of the blood
- Ensure that the blood is labeled
4) Precautions or nursing considerations:
- Monitor for adverse reactions, such as fever, chills, itching, or hives
- Observe for signs of anaphylaxis
- Check the IV site regularly for any signs of infiltration or infection
- Monitor vital signs and fluid status
- Monitor for signs of fluid volume overload; administer transfusion at an appropriate rate to not overload the client
5) Assessments to be completed prior to the blood transfusion:
- Vital signs
- Lung sounds
- Allergies or sensitivities to components of the blood
- Blood type and cross-match
Assessments to be completed during the blood transfusion:
- Vital signs
- Lung sounds
- Fluid status
- IV site
- Any adverse reactions
6) Blood type O- is compatible with O- and O+ blood types.
7) Steps to ensure safety for the client during blood transfusion:
- Verify the correct client and blood type
- Check the compatibility of the blood with the clent
- Check for any allergies or sensitivities to components of the blood
- Monitor vital signs, lung sounds, and fluid status
- Observe for signs of adverse reactions
8) Steps for the procedure of administering the blood transfusion:
- Administer furosemide 20 mg IV as ordered
- Complete checks with a second RN
- Attach the transfusion set to the IV tubing
- Begin the transfusion at a slow rate and monitor vital signs
- Observe the client for adverse reactions and adjust the rate as needed
- Document the transfusion, including the amount and rate of transfusion, any adverse reactions, and any changes in the client’s condition
- Administer furosemide 20 mg IV between units
- Administer second unit of PRBCs
- Discontinue the transfusion and remove the IV catheter once the transfusion is complete
All of the answers to the interactive element are found within the element.