NURS 321 Final Study

what consists of the thoracic cavity

lungs

mediastinum (heart, aorta, great vessels, esophagus and trachea)

what happens during inhalation

diaphragm contracts → increases thoracic cavity volume → pressure inside decreases (negative pressure)

what is the pressure inside lungs called

intrapulmonary pressure

what happens during exhalation

phrenic nerve stimulus stops → diaphragm relaxes and moves up the chest → reduced volume in thoracic cavity → volume decreases (intrapulmonary pressure increases) → air flow out of lungs to the lower atmospheric pressure (generates positive pressure)

Closed pneumothorax

chest wall intact

rupture of lung and visceral pleura allowing air into pleural space

if left unattended pressure increases and lung can fully collapse

tension pneumothorax

can be deadly

chest wall intact

air enters pleural space and has no way to leave

what is a sign of a tension pneumothorax

tracheal deviation

open pneumothorax

opening in chest wall, allowing atmospheric air to enter pleural space

pressure changes in chest, the air moves in and out via opening

hemothorax

blood in the pleural space

usually in lower lung fields

hemothorax/pleural effusion assessment findings

SOB, pain, absent/decreased breath sounds, pain

pleural effusion

buildup of fluids in the lungs

TX of pneumo/hemo/chlyo thoraxes and pleural effusions

remove fluid or air asap

prevent drained air and fluid from being returned into pleural space

restore negative pressure in the pleural space

chest tube equipment

thoracic chest tube, drainage unit, wall suction, tubing, connections

what are bigger chest tube for

blood/fluid

what are smaller chest tubes for

air

important things while taking care of someone with a chest tube

monitor for air leak

keep drainage unit below chest

PaTCH assessment for chest tubes

Pa: patient assessment

T: tubing

C: Collection chamber

Complications with chest tubes

Catheter falls out

Clot in tubing

Tachypnea/tachycardia with SOB

Vigorous bubbling in air leak meter

Increase in bloody drainage

Removal of chest tubes

Analgesics 30 mins prior

Valsalva manuever

Dr. or NP removes

Purse string sutures/occlusive dressing

Sutures out in 7-10 days

Dispose in biohazard container

Monitor VS/LOC/Resp effort

What is a heimlich valve

Small valve attached to catheter for small pneumothoraxes

Direct IV

Bolus of med through med port given in mL/min

Intermittent IV

AKA piggyback, solution containing meds using secondary tubing through an existing IV line

common

what is the pleural space

space between the visceral and parietal pleura of the lungs

indications for a chest tube

pneumothorax, hemothorax, empyema, pleural effusions, thoracotomy, bronchopleural fistula, penetrating wound, chlythorax

advantages of IV medications

rapid onset of medication effect

useful & establishes therapeutic blood levels

less discomfort for patient

disadvantages for IV meds

rapid onset of med can lead to possible speed shock

can have dangerous complications

what is phlebitis and the interventions

• redness, swelling, warmth, tenderness

Stop IV, discontinue IV site

Warm compress, elevate, analgesic, new IV site

allergic reactions and interventions for IV meds

stops meds immediately, assess and report

contact PHCP

document

prevent by knowing pt allergies, and knowing cross-allergy/sensitivites

infiltration and the interventions with IV meds

most common, looks like blisters (swelling, discomfort, tightness, burning, cool skin, blanching, decreased/stopped flow rate)

@ risk = elderly, pediatrics, chronic illness, obesity

Stop/remove infusion, warm compress, elevate limb, check pulse and cap refill, new IV site, document

Prevention = frequent IV site assessment, and pick appropriate IV sites

Extravasation and interventions for IV meds

• Accidental infiltration of a vesicant of chemotherapeutic drug into surrounding IV site (same as infiltration, + swelling, blistering and skin sloughing)

Discontinue immediately, estimate fluid amount, notify prescriber, give antidote, elevate, perform frequent sensation and motor fx assessments, CSMT, and document

When would you use a COLD compress

medication needs to stay put and not spread (vasconstriction)

when would you use a WARM compress

isotonic solutions

Important factors of IV meds

Knowledge, assessment, parenteral manual, proper equipment, 3 checks and 10 rights, proper calculations, maintain asepsis

Important factors for premixed IV meds

check doses are correct, check expiry

Important factors for self mixing IV med in minibags

ADD label, ensure compatible, know final concentration of medication bag

Equipment needed for IV meds

Pump, primary bag and line, secondary line, PT ID label, appropriate size bag

Signs of fluid overload

crackles in lungs, peripheral pitting edema, CSMT (cold temp, pale skin, weak, shiny)

3 steps when giving IV meds as taught by ALINA

1. PT assessment - VS, assessment, allergies, lab work, patent IV

2. Pump and lines - change continuos q4D, intermittent q24hrs

3. Product - medication (pharm class/therapeutic class, MOA, lab vals affected, order)

what are the components of blood

RBC

Plasma

Platelets

Cyroprecipitate

What is cyroprecipitate made from

FFP via the freeze thaw cycle

Blood group O = what ABO for RC and plasma

ABO Antigens Red Cells - none

ABO antibodies plasma - anti-a & anti-b

Blood group A = what ABO group for RC and plasma

ABO red cells - A

ABO antibodies in plasma - anti-b

Blood group B = what ABO groups for RC and plasma

ABO Red cells - B

ABO Antibodies in plasma - anti-a

Blood group AB = what ABO groups for red cells and plasma

Red cells = A and B

Plasma = none

Compatible RBC for O negative

O neg

Compatible plasma for O neg

ALL ABO groups

Compatable RBC for O pos

O pos

O neg

compatible plasma for O pos

ALL ABO groups !

Compatible RBC for A neg

A neg

O neg

Compatible plasma for A neg

A

AB

Compatible RBC for A pos

A pos

A neg

O pos

O neg

Compatible plasma for A pos

A

AB

Compatible RBC B neg

B neg

O neg

Compatible plasma for B neg

B

AB

Compatible RBC for B pos

B pos

B neg

O pos

O neg

Compatible plasma for B pos

B

AB

Compatible RBC for AB neg

AB neg

A neg

B neg

O neg

Compatible plasma for AB neg

AB

Compatible RBC for ABC pos

ALL ABO and RH groups

Compatible plasma AB pos

AB

Indications for packed RBC’s

Chronic symptomatic anemia

Restoration of blood volumes

Administration guidelines for PRBC

Catheter size: 22-14g

Use only NS as primer

170 Micron filter

Administer within 4 hrs

Indications for platelets

Control bleeding in platelet deficieny

Thrombocytopenia

Hemorrhage with platelets less than 50,00

Surgery with platelet count less than 100,000

Nonbleeding patient w rapidly dropping platelets less than 15000

RH: plt given to RH- ABO group

Key admin guidelines for platelets

Admin 1U (30-50mLs) over 5-10 mins

Y site IV line

ABO compatibility **

1 U raises plt counts by 5-10,000

Usually admin 6-8U at once

Indications for plasma and FPP

Procoagulant deficiencies

DIC

Massive transfusion in trauma

What is plasma

liquid portion of blood

does not contain RBC

What is FFP (Fresh frozen plasma)

prepared from whole blood seperation and freezing plasma within 8 hours of collection

may be stored up to 1 year

does not provide platelets

typical vol is 200-500mL

describe cyroprecipitate

prepared by slowly thawing FFP and centrifuging it to seperate preciptiate from plasma

has high fibrinogen content

same ABO types as patient is always the first choice

what are some blood products

• Albumin

• Factor VII Concentrate

• Factor VIII Concentrate

• Factor IX Concentrate

• Antithrombin III (ATIII) Concentrate

• Intravenous Immune Globulin Immunoglobulins - Rh Immune Globulin (RhIG)

• Hep B immune globulin (HBIG)

• Varicella Zoster Immune Globulin (VZIG)

• Prothrombin Complex Complex Concentrates (PCCs)

What should the prior assessment of a transfusion include

• baseline vitals, lung and kidney assessment, lab values, pt history of transfusions

  • Adverse event more likely if have had many prior transfusions, and watch for first time transfusion

Steps in the transfusion process

1. Confirm informed written consent was obtained - document, obtained by MRHP

2. Confirm TSIN - REQUIRED

3. Check order: type/amount, rate/duration, sequence, pre/post transfusion meds, lab testing requirements, indication

4. Gather equipment: gloves, bag of NS, Y tubing w 170 micron filter

5. Obtain and verify blood component or product: one unit @ a time, name/ID # of pt, expiry date, ABO and RH compatibility

6. Have 2nd HCP verify pt ID and blood product

7. Pre-transfusion assessment

8. Advise/educate pt on reporting any side effects

9. Administer blood component or product

10. report any adverse reactions

11. Complete required doc.

What should you confirm prior to blood transfusion assessment

• Pt ID on order matches pt ID on component

• Blood component is consistent

• Component # on container matches # on tag

• ABO/RH on label matches tag

• ABO/RH is comptaible w pt

• any special requirements

what do you confirm at bedside for patients recieving blood transfusion

PT ID - matches transfusion tag

TSIN # on tag matches the one on the band

Patient assessment for blood transfusion

• MUST do pre-transfusion vitals

• MANDATORY For first 5 mins to stay at pts bedside

• Must have pt in view for first 15 mins

• Education on s/s: hives, fever, chills, difficulty breathing, back pain, pain at infusion site

Administering PRBC steps

1. Prime line with NS

2. Hang blood

3. Ensure NS turned off

4. Infuse slowly - follow 15 min rule (start the transfusion at 50 mL/h for the first 15 min (12.5mL of blood) after this set to the rate requested and minus 12.5 mLs. Max time is 4 hours. MUST infuse 30 minutes after receiving blood.

Steps for discontinuing a transfusion

• Flush line to ensure all blood is cleared

• VS

• Documentation tag

• Bag and tubing are discarded into biohazard container

• If another unit is to be transfused, keep vein open (KVO) by infusing NS

• Equipment change

Most common s&s of a transfusion reaction

chills, rigor, fever, dyspnea, lightheadedness, urticaria, itchiness, flank pain.

Interventions for transfusion reactions

• KVO with NS

• notify physician

Emergency equipment to predict needing for blood transfusion

• Pre-primed IV line of NS

• NC or mask

• Suction

• Epinephrine: Adult or pediatric 1mg/mL, neonate 0.1mg/mL

• diphenhydramine : 50mg/mL

• Hydrocortisone, injectable

Acute hemolytic transfusion reactions

• Abrupt onset

• Can lead to DIC or death

• Happens bc given wrong blood to the wrong patient

• Occurs within 5-15 mins of transfusion intitiation

S&S of acute hemolytic transfusion reactions

• Discomfort

• anxiety

• fever,

• chills,

• pain,

• facial flushing,

• pain,

• shock

• Rapid pulse,

• cool,

• clammy,

• lower pressure,

• N&V

interventions for acute hemolytic transfusion reaction

Give lasix - want to promote urine output of 100mLs/hr for 24 hrs

non-hemolytic transfusion reaction: febrile

• happens when baseline increases by 1 degree

• d/t reaction to antibodies in blood bc of leukocytes

non-hemolytic transfusion reaction: febrile s&s

fever

chills

headache

non-hemolytic transfusion reaction: febrile interventions

stop immediately

call physician

treat with antipyretic medications

non-hemolytic transfusion reaction: allergic

• happens d/t antibody formation against plasma protiens

non-hemolytic transfusion reaction: allergic s&s

hives

itching

respiratory distress

non-hemolytic transfusion reaction: allergic treatment

stop blood

notify physician

antihistamines

transfusion related acute lung injury toxicity

• happens within hours

• patient presents with resp. distress, hypoxia, pulmonary edema, hypotension, fever

  • interventions = O2 support and mechanical ventilation

transfusion related circulatory overload

• happens bc there is high osmotic load of blood products and draws volume into the intravascular space - can be d/t transfusing blood to quickly

• risk of cardiac or renal insufficiency

• Presents with signs of HF: dyspnea, crackles

  • Consider lasix use

what is citrate toxicity with blood transfusions

• happens when citrate in blood begins to bind to calcium in the patients body

• can lead to hypoglycemia and hypomagnesemia

what is transfusion associated graft versus host disease

• is fatal

• lymphocytes from the blood attack recipients tissues

what is delayed hemolytic transfusion reaftion

• can present as asymptomatic and can occur up to 4 weeks after transfusion

• sensititzed to RB antigen

• watch for slight fever

Infection related complications for blood transfusions

• Viruses: Cytomegalovirus

• Bacteria

• Prions

• Infections transmitted by insects: West Nile Virus, Parasite Infections

what is TPN

the IV infusion of nutrients in order to sustain nutritional balance when the GI tract cannot be assessed, or absorption is inadequate or hazardous

• cannot be given in conjunction with enteral feeding

what should you never add to TPN

MEDICATIONS → pharmacy will do it

how is the formulation of TPN created

based on the needs of each patient

what are the main components of TPN

carbs: dextrose - easily metabolized and stimulates secretion of insulin. Well tolerated in large quantities. Amount is based on metabolic needs. Amino acids used for protein synthesis

• Goal is protein creation

Lipids: long chain fatty acids from soybean, veggie oils, egg yolks. Provides 9kc/g. Important for maintaining connective tissue integrity. Available as 10/20/30% formulas. Watch lab vals, increased risk for pancreatitis

Amino acids: to facilitate in wound healing and maintain structure. If decreased protein intake, the body will take proteins from muscles and organs

what meds can be added into TPN

insulin, heparin, histamine agonists

goals of TPN

• Meet caloric needs until patient can transition to enteral nutrition

• Transition to enteral nutrition to prevent villous atrophy and cell shrinkage

• Preventing complications: GI cell shrinkage can lead to translocation of bacteria leading to septicemia