Blood, O2 Therapy, Burns

cdunbar4's version from 2017-10-03 16:21

Blood Administration & Rxns

Question Answer
If transfusion reaction occurs: stop transfusion, restart NS, return blood container & tubing to blood bank, draw blood sample for plasma/hgb/culture/retyping, collect urine sample & send to lab for Hgb determination, monitor voiding for hematuria.
autologous transfusion: donation occurs how long prior to patient's surgery?4-6 weeks, may need iron supplements
CI fo autologous transfusionsacute infection, chronic disease, Hgb <11, hct <33%, cerebrovascular or cv disease
Allergic rxn/hypersensitivity mild symptomsurticaria, itching flushing
Allergic rxn/hypersensitivity anaphylaxis symptomshypoTN, dyspnea, decreased oxygen saturation, flushing
When do allergic rxns occur?Immediately, or within the first 24 hours
NC Allergic rxn/hypersensitivity rxnspremedicate with antihistamines; stop blood; restart NS; notify hcp. Give diphenhydramine, oxygen, corticosteroids
Acute intravascular hemolytic rxns symptomsn/v, chills, pain in LOWER BACK, hypoTN, increase pulse, decrease UO, hematuria
When do Acute intravascular hemolytic rxns occur?Within minutes to 24 hours
Acute intravascular hemolytic rxns NCstop blood; supportive care: o2, diphenhydramine, airway mgmt
Febrile, nonhemolytic rxnMOST COMMON, occurs within minutes to hours
Febrile, nonhemolytic rxn symptomsfever, chills, nausea, h/a, flushing, tachycardia, palpitations
Febrile, nonhemolytic rxn supportive care, NCstop blood, antipyretics (avoid aspirin in thrombocytopenia clients)
Febrile, nonhemolytic rxn usually seen in which clients?after multiple transfusions
Sepsis rxn causecontaminated blood products
Sepsis rxn symptomstachy, hypoTN, fever, chills, shock
Sepsis NCstop blood, obtain blood culture, ABs, IV fluids, vasopressors, steroids
Circulatory overload reaction symptoms dyspnea, crackles, ↑respiratory rate, tachycardia
Circulatory overload NCmonitor clients at high-risk (elderly, heart disease, children); slow or DC transfusion

O2 Therapy Values

Question Answer
Nasal cannula or prongs23-42% at 1-6L/min
Nasal cannula or prongs NCassess patency of nostril; apply water-soluble jelly to nares q3-4h; perform oral care
Face mask 40-60% at 6-8L/min (minimum 5L)
Face mask NC remove mask q1-2hours; wash, dry, apply lotion to skin; emotional support to decrease feeling of claustrophobia
Partial rebreather mask 50-70% at 8-11L/min
Partial rebreather NCadjust o2 flow to keep reservoir bag 2/3 full during inspiration
Non-rebreather80-100% at 12L/min
Nonrebreather NCadjust oxygen flow to keep bag 2/3 full
venturi mask24-80% at 4-8L/min
venturi mask NCprovides high humidity and fixed concentrations; keep tubing free of kinks
Tracheostomy collar or T-piece30-100% at 8-10L/min
trach collar or t-piece NCassess for fine mist; empty condensation from tubing; keep water container full
oxygen hood30-100% at 8-10L/min
When is an o2 hood use?for infants and young children; provides cooled humid air
NC oxygen hoodcheck o2 concentrations with O2 analyzer every 4 hours; refill humidity jar with sterile distilled water; clean humidity jar daily; cover client with light blanket and towel or cap for head; change linen frequently; monitor client's temperature freq.

Burns & rule of nines

Question Answer
superficial similar to 1st degree; skin is pink/red; painful; epidermis/sunburn; heals in 3-5days
superficial partial thicknesssimilar to 2nd degree; skin is pink to red/painful; epidermis & dermis; scalds, flames are cause; heals in 2 weeks
DEEP partial thicknesssimilar to 2nd degree; skin is red to white/painful; epidermis and dermis; caused by scalds, flames, tar, grease; heals in 1 month; possible grafting
FULL Thicknesssimilar to 3rd degree; skin red, white, brown, black; pain is possible; ALL skin layers; due to prolonged contact with hot objects; heals in weeks to months
DEEP FULL thicknesssimilar to 3rd degree; skin black; NO PAIN; ALL SKIN LAYERS & possibly to muscles/tendons; from flames/electricity; heals in weeks to months; escharotomy/grafting
Rule of nines: adults (percentages for 1 side, i.e. anterior only)head- 9%
chest 18 %
each arm 9%
each leg 18%
genital area 1%
Rule of nines: kids (%s for 1 side of body)head 19%
each arm 9.5%
chest 32%
each leg 15%

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