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Summary UPNS 232 HESI Final Exam Study Guide $16.99   Add to cart

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Summary UPNS 232 HESI Final Exam Study Guide

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A great HESI Final Exam Study Guide for UPNS 232. A study guide you can't afford to miss!! Enjoy!!

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  • September 12, 2024
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  • 2021/2022
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1
Blood Administration
Preparation for Blood Transfusion
 Patient History
o Have they ever had previous complications?
 Type and cross match
 Consent
o One per hospital stay
o EVERY sing time they have a hospital stay (only need to ask per each stay)
 Very important to make sure that you match the correct blood type
Type and Cross Match
 2 blood samples taken 5 minutes apart with two RN signature
 Universal donor O negative
 Universal recipient is AB positive
 Donor and recipient is very important
 Have to test 2 (2 different times) and 2 RN signatures on the blood tube that gets sent to the lab and
taken 5 minutes apart
 If you get the wrong blood, they attack itself so it affects the heart  kills the heart  patient is dead
Types of Blood Components
 Packed Red Blood Cells
o Infusion 1 unit per 2 hours
o Given for low Hematocrit and Hemoglobin or to replace fluid loss
 Platelets
o Given rapidly over 15 to 30 minutes
o Given for low platelets
 Fresh-frozen plasma
o Given rapidly over 15 to 30 minutes
o Improve clotting factors and improves volume expansion
 White Blood Cells
o Used to treat sepsis and neutropenia – when unresponsive to antibiotics
o One unit per one hour
 Blood can only be given on certain amount of time
 “getting blood”  top one and its normal (packed red blood cells)
 anything else is abnormal
 blood can only be hung for 4 hours  after 4 hours it will clot (you have 30 minutes to hang the blood
that is not included in the 4 hours)
 blood hanging needs to RNs to hang it
Getting ready for Administration
 ONLY one unit at a time should be received from the blood bank
 Initiate transfusion within 30 minutes of receiving blood
 2 RN need to identify Blood Products:
o ABO group and Rh Type
o Donor number
o Expiration Date
o Patient and Patient ID# (MRN)
Blood Product Set Up  Picture to the right
 Only thing that gets hung with blood is normal saline
 Not normal saline and meds JUST NORMAL SALINE
 MEDS DO NOT GET PUT UP WITH BLOOD!!!

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Monitoring Patient during Blood Product Administration
 Baseline Vital Signs
o Prior to transfusion
o Including temperature
 1st set of Vital Signs:
o 15 minutes after initiation
o Including temperature
 Continuous
o Every hour (usual 4 hours)
 TEMPERATURE IS SO IMPORTANT
 Example: Starts at 9 (baseline starts now), then 9:15 is the first set; then 10, 11, 12, 1.
 Temperature is the most important vital because if they spike a fever, it is called a Febrile Reaction
Blood Administration
 ABSOLUTELY NO MEDICATION ADMINISTRATION WITH BLOOD TRANSFUSION
 Normal Saline Solution is the only thing that is allowed to be pushed with transfusion
Complications 2
 If a reaction occurs during transfusion: IMMEDIATELY STOP BLOOD  even as a student nurse
because it’s a life saving measure
 Call physician
 Obtain vitals
 Collect blood product/IV tubing – send to blood bank
 Administer isotonic solution at a maintenance rate  NS and lactitated ringers
 If get a fever during transfusion STOP INFUSION immediately
 If complications send everything  tubing bag, everything!!
Reactions
 Transfusion reaction is an adverse reaction that happens as a result of receiving a blood transfusion
 Types: hemolytic, allergic, febrile, septicemia, transfusion-associated graft vs. host disease
 S/S: restlessness, Hives, anxiety, chills, flushing, fever, chest/lumbar pain, tachycardia, tachypnea,
nausea, shock
Finished?
 Document date/time and volume given
 Obtain vital signs
 Patient’s status  never be sleep at end of transfusion you have to wake them up
 Check orders for Labs?
 Dispose in contaminated waste-red bag
Acid- Base Imbalances
The arterial blood gas provides the following values:
 pH: measurement of acidity or alkalinity, based on the hydrogen (H+) ions present.
o The normal range is 7.35 to 7.45
o pH > 7.45 = alkalosis
o pH <7.35 = acidosis
 paO2: the partial pressure of oxygen that is dissolved in arterial blood.
o The normal range is 80 to 100 mmHg.
 SaO2: the arterial oxygen saturation
o The normal range is 95% to 100%.
 pCO2: the amount of carbon dioxide dissolved in arterial blood.
o The normal range is 35 to 45 mmHg.
o pCO2 > 45 = acidosis

, 3
o pCO2 < 35 = alkalosis
o CO2  what you breathe out
o Shouldn’t be a lot in arterial because its oxygen rich  deoxygenated blood is higher in CO2
o Acidosis is higher for CO2; alkalosis is lower for CO2
 HCO3: the calculated value of the amount of bicarbonate in the bloodstream
o The normal range is 22 to 26 mEq/liter
o HCO3 > 26 = Alkalosis
o HCO3 < 22 = Acidosis
o How much waste/bad things are in the blood
Acid-base imbalances
 Not a disease: a disorder or pathologic process
 Caused by: metabolic problems, respiratory problems, or both
 Something outside is causing an inside problem
 Metabolic center  kidneys
o Doesn’t work, going to all go back up
o Flushed too much, going to flush everything out
o Respiratory issues = lungs
Patient History
 Risk factors: Kidney Disease and Pulmonary Disease
 Drugs: diuretics and antacids
 Urinations? Dehydration? Respiratory Distress?
 Diuretics  help flush out system (kidneys process faster)
o Easier for a metabolic problem to occur
 Antacid – like tums
 Respiratory distress?  having difficulty breathing
Patient Assessment
 Vital Signs:
o RR and depth
o HR and Rhythm
o Oxygen Saturation of 95% or higher
 Physical Assessment
o Able to speak a sentence of 12 words without stopping for a breath
o Able to walk and talk without stopping for breath
o No cyanosis
o Rapid capillary refill
o Muscle strength consistent
o Urine output equal to fluid intake
 Psychological assessment:
o Alert and oriented x3
o Energy level
o Can engage in desired work, recreational, and personal activities
 Laboratory assessment:
o ABG
o Electrolytes (especially K and Ca)
 Physical assessment  what a health patient should be able to do if they are okay
Acidosis
 Blood pH below 7.35
 Pathophysiology: excess of hydrogen ions (H+)

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 Amount of acids present is greater than normal compared with the amount of strengths of bases
Alkalosis
 Blood pH above 7.45
 Pathophysiology: more base components
 Decrease in the free hydrogen ion level of the blood
Respiratory Acidosis = pH less than 7.35 and PaCO2 greater than 45 mmHg
 Any condition that results in hypoventilation can cause respiratory acidosis. These conditions include:
o Central nervous system depression related to head injury and/or medications such as narcotics,
sedatives, or anesthesia (especially opioids)
o Impaired respiratory muscle function related to spinal cord injury, neuromuscular diseases, or
neuromuscular blocking drugs
o Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema, or
bronchial obstruction
o Massive pulmonary embolus
o Hypoventilation due to pain, chest wall injury/deformity, or abdominal distention
o Hypoventilation  not getting enough O2 and have too much CO2
 Signs and Symptoms
o Dyspnea, respiratory distress, shallow respirations, headache, restlessness, confusion,
tachycardia, dysthymias
o Increasing ventilation will correct respiratory acidosis
o If the patient is unstable, manual ventilation with a bag-mask is indicated until the underlying
problem can be addressed. After stabilization, rapidly resolvable causes are addressed
immediately. Causes that can be treated rapidly include pneumothorax, pain, and CNS
depression related medication. If the cause cannot be readily resolved, the patients with
hypoventilation often require supplemental oxygen, it is important to remember that oxygen
alone will not correct the problem.
o Confusion is a sign because then they have low oxygen – breathing is not working properly
causes confusion
o Treatment: pulse Ox then give them O2
o Always assess before you treat
Respiratory Alkalosis = pH greater than 7.45 and PaCO2 less than 35 mmHg
 Any condition that causes hyperventilation can result in respiratory alkalosis. These conditions include:
o Psychological responses, such as anxiety or fear
o Pain
o Increased metabolic demands, such as fever, sepsis, pregnancy, or thyrotoxicosis
o Medications, such as respiratory stimulants
o Central nervous system lesions
o Hyperventilation  too much O2 not enough CO2
 Signs and Symptoms
o Neurological, light-headedness numbness and tingling, confusion, inability to concentrate,
blurred vision, cardiovascular, dysrhythmias palpitations diaphoresis, dry mouth, tetanic spasms
of the arms and legs
o If the CO2 beccomes extremely high, drowsiness and unresponsiveness may be noted.
o Treatment of respiratory alkalosis centers on resolving the underlying problem. Patients
presenting with respiratory alkalosis have dramatically increased work of breathing and must be
monitored closely for respiratory muscle fatigue. When the respiratory muscles become
exhausted, acute respiratory failure may ensue.

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