Medsurg Exam 1: blood transfusions, anemias, bleeding disorders, the surgical client, delegation, aplastic anemia, neutropenia, leukemia, lymphoma, polycythermia

how many nurses are required to be present during a blood transfusion?

2

minimal requirements for blood donors:

at least 110 lbs

17 or younger, must have parental consent

temp less than 99.6

hemoglobin lvls 12.5 g/dL

directed blood donation

when family and friends donate blood for the exclusive use of the patient

standard blood donation

transfusion from compatible donor blood

think donating blood on the red bus

autologous blood donation

donation of the pt own blood to use later

intraoperative blood salvage

Sterile blood lost during a procedure is saved or retrieved into a device that filters and drains the blood into a bag for transfusion intraoperatively or postoperatively. Reinfusion must occur within 6 hr of salvaged blood collection.

hemodilution

reducing the concentration of blood by increasing the plasma volume

what is the most common complication of blood donation?

excessive bleeding from venipuncture site

other complications of blood donation

fainting

anginal pain (rare)

seizures (rare)

blood processing

used to cure and modify and separate blood to prepare it for medical transfusions or treatments.

now tests for organisms not just antibodies

Pretransfusion Assessment

- pt history

-allergies

- any reaction to previous transfusion

- vitals

- 16, 18, or 20 guage only

- any history of pulmonary, cardiac, or vascular diseases

if a pt has cardiac disease how should a blood transfusion go?

slowly over 4 hours

what are the key points to giving a blood transfusion?

- stay with pt for the first 15 min

- check flow to watch for fluid overload

signs and symptoms of a transfusion reaction:

fever

chills

low back pain

pain at IV site

anything "unusual"

if the nurse suspects a problem while a pt is receiving a transfusion they should...?

stop blood transfusion and notify the provider immediately

which IV is given with a blood transfusion?

normal saline

febrile non hemolytic rx (moderate reaction)

- one of the most common type of transfusion reactions, high risk in pt who have had a blood transfusion before.

- pt develops fever

- no destruction of RBC (hemolysis)

- symptoms: tachycardia, tachypnea, redness, vomiting

- prevention: remove WBC in transfused blood

acute hemolytic RX

- life threatening bc the immune system rapidly destroys transfused RBC

- donor blood incompatible with recipient (type 2 hypersensitivity)

- symptoms: low back pain, angina, dyspnea

what can result from acute hemolytic RX

hypotension

bronchospasm

vascular collapse

arterial renal failure

allergic RX to transfusion (mild reaction)

- hypersensitivity rx to plasma protein of transfused blood ranging from mild to severe

- symptoms: itching, redness, rash

- mild rx treat with diphenhydramine

- severe rx treat with epinephrine, vasopressors or corticosteroids

** can wash plasma proteins from blood and premedicate with benadryl**

Transfusion Associated Circulatory Overload (TACO)

- volume of transfused blood exceeds the circulatory's ability to handle it

- leads to fluid overload and pulmonary edema

- common in pt with renal failure (fluid retention), the elderly, and the young

- causes: venous pressure and pulmonary edema

treatment: diuretics to reduce fluid overload, slow infusion rate, O2

TACO

hypertensive

stops fluid

bacterial contamination of blood transfusion:

- low risk

- clean IV site with alcohol

- most common in platelets

- to prevent transfuse blood within 4 hrs

- signs: fever, chills, hypotension

treatment: antibiotics and fluids

Transfusion Related Acute Lung Injury (TRALI)

- rare but severe

- occurs within 6 hours of transfusion

- immune mediated damage to the lungs (donor plasma reaction with recipients WBC)

- hypoxia, pulmonary edema

- treatment: use O2 intubation and fluids

when a reaction occurs the nurse should...

1. stop transfusion immediately (both NS attached and blood)

2. set up a new NS IV with new lines

3. check vitals

4. Notify the HCP

5. notify the blood bank

6. send blood with tubing back to bank

7. collect serum/ urine specimen if needed

TRALI

hypotensive

needs fluids

RANDI: bleeding precautions

no razors

no aspirin

no needles

decreased needle sticks

protect from injury

DO: stool softners and soft bristle toothbrush

DONT: use enemas, tampons, play contact sports

possible bleeding platelet count

less than 50,000 platelets

petechiae, menstrual bleeding, postop, nasal/gingival bleeding platelet count:

less than 20,000 platelets

spontaneous, fatal, CNS bleeding or GI hemorrhage platelet count:

less than 5,000 platelets

thrombocytopenia:

low platelet levels within the bone marrow

test with a bone marrow biopsy, genetic test, CBC or hepatitis screening

Immune Thrombocytopenic Purpura (ITP)

- immune system antibodies IgG mistakenly destroying its own platelets, increasing the risk of bleeding (purpura/petechiae

- primary or secondary

- IgG develops-> IgG binds to platelets-> platelets are destroyed-> bone marrow produces more platelets to compensate but is not effective-> production diminished

clinical manifestations and treatment of immune thrombocytopenic purpura (ITP)

easy bruising

heavy menses

petechiae

purpura

nose bleeds

- use immunosuppresive agents and corticosteroids

qualitative defects of platelets:

- number of platelets are normal but they do not function properly

- causes: aspirin, NSAIDS, MDS, ESRD, herbal therapy, multiple myeloma, cardiopulmonary bypass

if a pt has a vitamin K deficiency the nurse should

give them vitamin A

aquired coagulation disorders:

liver disease

vitamin K deficiency

anticoagulant therapy complications

why is vitamin K so important in the coagulation process?

- involved in the synthesis of proteins called clotting factors that take part in coagulation which stop bleeding

- common in malnourished pts

- vitamin K administration (PO or SQ)

- anticdote for warfarin toxicity

anemia:

deficit in red blood cells

low hemoglobin concentration

low # of erythrocytes

decreased O2 to tissues

hypoproliferation

failure or reduced production of red blood cells in bone marrow

- causes: iron, B12, folate deficiency

chronic or inflammatory disease

aplastic anemia:

bone marrow fails to produce enough RBC, WBC, and platelets

hypochromic anemia:

red blood cells that have less hemoglobin (protein that carries O2) resulting in pale RBC. This is done by either less production or iron deficiency

secondary anemia:

bleeding, leukemia, cancer, or chronic kidney disease

B12 anemia:

Pernicious anemia- results when people cannot make intrinsic factor

causes: vegan diet (no animal products)

or gastic bypass surgery

erythroblastosis fetalis anemia:

hemolytic disease of a newborn or fetus via immune incompatibility between mother and fetus blood due to Rh and ABO incompatibility

general diagnostic studies

24hr concern of pain

more than 24hr concern of infection

general complications of anemia:

heart failure

paresthesias: numbness/ tingling

delirium: not enough O2 to brain

dyspnea

angina

main causes of anemia:

lacking vitamins

vegan

gastric bypass

when assessing for general anemia what should a nurse check?

capillary refill

pulse ox

when educating a pt on taking iron supplements the nurse should...

- inform the pt to take them on an empty stomach

- use a stool softener to reduce constipation risk

- possible dark stool

shilling test:

measures the absorption of B12 used when deficiency is suspected.

determines if its due to lack of intrinsic factor or other causes like intestinal disease of bacterial overgrowth

sickle cell anemia:

- severe hemolytic anemia from inheritance of abnormal sickle hemoglobin (HbS) gene and exposed to low oxygen tension, that results in obstruction of blood flow

- causes severe pain

- the nurse should apply oxygen, give hydration, and manage pain

clinical manifestations of sickle cell anemia:

chronic anemia: occlude flow of blood

jaundice

ischemia

pain in chest, abdomen, fever

sickle cell crisis AKA vasoocclusive crisis

episode of pain or complications that occur with sickle cell disease with the entrapment of erythrocytes in microcirculation

- causing hypoxia, inflammation, and necrosis to region, disfunctional endothelium, or perfusion creating free radicals damaging vessels

Acute Chest syndrome

- life threatening complication of sickle cell disease, requires intervention

- blocks blood vessels of lungs causing pulmonary infarction and inflammation

- symptoms: angina, cough, shortness of breath)

- mimic infection

- can cause death

pulmonary HTN

- pulse ox may be normal

- lung assessment normal

- pulmonary artery pressure elevated

- elevated beta naturetic peptide

reproductive problems associated with sickle cell anemia:

low testosterone

low libido

erectile dysfunction

infertility

priapism (long erection without stimulation)

diagnostic findings and prognosis of sickle cell anemia:

- low hematocrit on blood smear

- confirmed by hemoglobin electrophoresis

- diagnosed in infancy

- death common due to disease

management of sickle cell anemia:

IV narcotics

promoting coping

pain management

preventing infections

HOP sickle cell crisis

- hydration and electrolytes

- oxygen and bedrest to decrease O2 needs

- pain relief

nursing interventions to optimize pt outcomes post operation...

1. immediate ambulation to prevent clots and ulcers

2. focus on lung function (incentive spirometer)

3. compression devices post op

perioperative:

- begins with decision to have surgery

- ends when the client is transferred to operating room or procedural bed

intraoperative:

- begins when client is transferred to the OR bed

- ends with the transfer to post anesthesia care unit

postoperative:

- begins with admission to the PACU or recovery area

- ends with complete recovery from surgery and follow up with MD

palliative procedures:

Intended to provide the patient with symptom relief

anesthesia states:

1. Loss of conciousness

2. amnesia: temporary memory loss after given anesthesia

3. analgesia: relief of pain without causing the loss of consiousness

4: relaxed skeletal muscles

5. depressed reflexes

general anesthesia:

administration of drugs by inhalation or intravenous route

moderate sedation/ analgesia:

used for short-term and minimally invasive procedures

regional anesthesia:

anesthesia injected to a limb or an entire section of the body around a nerve pathway

EX: knee surgery

topical and local anesthesia:

used on mucous membranes, open skin, wounds, burns

phases of general anesthesia:

induction: administration to incision

maintenance: incision to near completion

emergence: pt emerges from anesthesia and ready to leave room

types of regional anesthesia:

nerve blocks: bone replacements

spinal anesthesia: back surgery

epidural anesthesia: giving birth

nursing process in pre operative care:

assess to gather baselines

check for allergies

health history

determine risk for infection

get any samples for the lab

remove all jewelry, dentures, contacts, hearing aids

client risk factors in surgery...

meds: hold blood thinners 7 days before surgery

nutrition: affects healing process

alc use: affects heart and tolerance to meds

sociocultural needs: can the pt afford meds, care, etc?

surgical risks with meds:

anticoagulants: interfere with clotting

diuretics: electrolyte imbalances resulting in arrhythmias

tranquilizers: enhance sedative effects with anesthesia and can cause hyperventilation, hypoxia, and respiratory arrest

adrenal steroids: abrupt withdrawal can cause cardio vascular collapse (always withdrawal slowly)

antibiotics in mycin group: respiratory paralysis when paired with some muscle relaxers

what screening tests are done before surgery

electrocardiography (EKG)

chest Xray

complete WBC count (CDC)

electrolyte levels (DMP/CMP)

urinalysis

females: pregnancy test

what increases venous return

immediate ambulation as tolerated

to prepare a pt for surgery the nurse should?

1. perform a chlorahexadine shower twice before to eliminate bacteria

2. allow the pt to eliminate or empty catheters and drains

3. nutrition and fluids (diabetic = NS + dextrose and NPO)

4. rest

vital protocols post op

every 15 min for the first hour

every 30 min for the second hour

every hour for the next four hours

**if something seems wrong increase vital checks on pt**

once a pt has returned to consciousness post op the nurse should...

check urinary output to ensure kidney function

test gag reflex using a small amount of liquid

always assess airway, breathing, circulation

notify if drainage is excessive

how to prevent DVT?

ambulation

compressions

pharmacologic : heparin&lovanox

TED hose

signs of hemorrhaging:

bruising

pallor

low bp

tachycardia

signs of shock:

weak

faint or dizzy

nauseous

thirsty

pale or gray skin

restless

agitated or confused

cold & clammy skin

increase WBC count

signs of pulmonary embolism:

shortness of breath

pleuritic chest pain

low-grade fever

blood-tinged sputum

tachycardia

discharge planning:

No lifting over 5lbs

educate

if on narcotics no driving

take home incentive spirometer

nurses cannot delegate ? (TAPE)

teaching

assessment

predictability

evaluation

priority levels:

1. ABC, cardiac arrest

2. mental status change, acute pain

3. health problems (coping, education)

LPN delegation guidlines:

piggback meds

wound care

foley insertion

UAP delegation guidlines:

basics like bed making

what does "pan" stand for in pancytopenia?

bone marrow is not functioning resulting in low WBC, RBC, and platelets

what type of precautions should aplastic anemia pts be on?

fall precautions

neutropenic precautions

thrombocytopenic precautions

what are neutropenic precautions?

- strict hand hygiene

- no lab coats when with pts

- no plants in room

- no fresh fruits and vegetables

- reverse isolation

- pt should wear surgical mask

- limit interaction with young kids

causes of aplastic anemia:

- main cause: idiopathic

- congenital or inherited

- exposure to chemicals or radiation

- drug induced

- viral infection

pathophysiology of aplastic anemia:

bone marrow is suppressed or destroyed-> failure to produce stem cells-> insufficient amounts of erythrocyted(RBC), leukocytes(WBC), and platelets-> pancytopenia

clinical manifestations of aplastic anemia:

- anemia: pallor, fatigue, dyspnea

- leukopenia: multiple infections

- thrombocytopenia: purpura, petechiae, ecchymosis

diagnostic findings of aplastic anemia:

- hematology: pancytopenia (decreased granulocytes, thrombocytes, and RBC's)-> do a bone marrow biopsy to identify if RBC, WBC, and platelets are replaced with fat

- hematopoietic stem cell transplant done-> pt prescribed immunosuppressants so the body does not attack new stem cells

- transfusion therapy-> PRBC's and platelets are on call so pt doesnt bleed out during procedure

management of aplastic anemia:

- transfusion therapy

- O2 administration

- monitor and record vitals, I&O, lab values, and blood in stool, emesis, and urine

- monitor for any signs of infection, bleeding and bruising

what should a nurse avoid with a pt diagnosed with aplastic anemia?

intramuscular injections

If a pt has spontaneous bleeding the nurse should?

- avoid IM injections

- monitor bleeding and bruising

neutropenia:

- neutrophil count below 2,000/mm3

- decreased production or increased destruction of neutrophils making a pt susceptible to infection

- caused by aplastic anemia, lymphoma, leukemia, chemo, radiation, drug induced, infection

diagnosing neutropenia:

- absolute neutrophil count (ANC)

- significant risk: below 1000/mm3

- high risk: below 500/mm3

- definite risk: below 100/mm3