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.

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

For a patient who will undergo blood transfusion, enumerate the steps that the nurse should prudently undertake while performing the procedure.

List down three (3) priority nursing diagnoses for the patient and create a hypothetical FDAR.

Answer 1

Answer;

The nurse has to check the following parameters to ensure the complication of fluid volume over load .

It include;

Blood pressure

Central venous pressure

The fluid overloading the circulatory system with excessiveIV fluids causes increased blood pressure and central venous pressure.

The signs and symptoms of fluid overload include moist crackles on auscultation of the lungs, edema, weight gain, dyspnea, and respirations that are shallow and have an increased rate.

And also causes include rapid infusion of an IV solution or hepatic, cardiac, or renal disease.

The risk for fluid overload and subsequent pul-monary edema is especially increased in elderly patients with car-diac disease,this is referred to as circulatory overload.

For a patient who will undergo blood transfusion, enumerate the steps that the nurse should prudently undertake while performing the procedure.

1.The 1st step to verify doctor’s order.

2.To inform the client and explain the purpose of the procedure.

3.To Check for cross matching and typing.

4. To ensure compatibility.

5.To obtain and record baseline vital signs

Practice strict asepsis

6.The 2 licensed nurse check the label of the blood transfusion.

7.Check the following:

Serial number

Blood component

Blood type

Rh factor

Expiration date

8.To undergo screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.

9.To warm blood at room temperature before transfusion to prevent chills.

10.To identify client properly. Two Nurses check the client’s identification.

11.To ensure the use needle gauge 18 to 19 to allow easy flow of blood.

12.To ensure the use BT set with special micron mesh filter to prevent administration of blood clots and particles.

13.To start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.

14.To monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)

15.Do not mix medications with blood transfusion to prevent adverse effects.

16. Do not incorporate medication into the blood transfusion.

17. Do not use blood transfusion lines for IV push of medication.

18.To administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose based IV fluids cause hemolysis.

19.To Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.

20.To observe for potential complications. Notify physician.

Nursing Diagnosis

1.Deficient fluid volume related to wrist laceration as evidenced by lethargy.

2.Ineffective cardiac tissue perfusion related to active fluid volume loss as evidenced by decreased blood pressure.

3.Self care deficit related to physical weakness as manifested by getting assistance to perform activities

Hypothetical FDAR

Example;

Date &Time;

2/9/2020

Focuse;

Hemorrhage

Data,Action&Response;

D.I feel like lethargy

  A;Monitor the signs of Hemorrhage and shock Starts to treat with blood transfusion.  

R;I understand the purpose of blood transfusion.