Question

A teenage patient was rushed to the emergency department due to wrist laceration from a suicide attempt. The patient is lethargic and have the following findings upon assessment:

• BP –80/50 mm Hg
• HR –110 bpm
• RR –25 bpm

The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the remaining fluid to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was ordered to be transfused immediately after proper cross-matching. The patient was hooked to oxygen 8 liters per minute via face mask.

1. What parameters will the nurse check while the patient is undergoing rapid fluid resuscitation?

2. For a patient who will undergo blood transfusion, enumerate the steps that the nurse should prudently undertake while performing the procedure.
3. List down three (3) priority nursing diagnoses for the patient

Answer 1

The teenage patient with suicidal attempt had lacerated wound over the wrist,he is lethargic and vital parameters indicates he is having tachycardia,tachypnea and low blood pressure.

The parameters to be checked before rapid fluid infusion:

Check for the IV cannulation.Its always better to cannulate with large bore IV cannula.

Select prominent veins for IV cannulation.

Frequently monitoring of Vital signs.

Monitor urine output.

Be aware of complications of rapid fuild infusion such as hypothermia,acid base imbalance and alergic reaction.

Check for respiratory sound to rule out fluid overload.

Steps needed to be taken by the nurse while blood transfusion:

Check basal vital signs before blood transfusion.

IV cannulation of prominent veins with large bore IV cannula.

Cross checking of blood bag details and patient details.

Ask for previous history of blood transfusion and any history of allergic reaction to it.

Check whether the procedure is explained and consent is obtained or not.

Initially start the transfusion very slowly and be near patient side to early identification of allergic reaction.

If any allergic reaction,stop blood transfusion immediately and treat the transfusional reactions as per the institutional policy.

Three priority nursing diagnosis are as following

1)Fluid volume deficit realted to bleeding wound,as evidenced by increased heart rate,low blood pressure.

2)Acute pain realted to lacerated wound as evidenced by increased heart rate ,increased respiratory rate.

3)Fatigue realted to loss of body fluids as evidenced by facial expression,low blood pressure.