Module 4.pdf

Module 4: Clotting and Comorbidities Hematologic Anatomy + Physiology Review Components of the Hematologic System Blood Is the link between the organ systems Consists of erythrocytes (RBC),...

Module 4: Clotting and Comorbidities Hematologic Anatomy + Physiology Review Components of the Hematologic System Blood Is the link between the organ systems Consists of erythrocytes (RBC), leukocytes (WBC), and thrombocytes (platelets) Functions Circulates through the vascular system carrying oxygen and nutrients to the various cells throughout the body to promote cell growth and function Carries proteins such as hormones, antibodies, and other substances to their sites of action or use Carries waste products produced by cellular metabolism to the lungs, skin, liver, and kidneys for elimination Erythrocytes AKA Red Blood Cells (RBC) Carry hemoglobin to provide oxygen to tissues Mature erythrocytes consist primarily of hemoglobin, which contains iron, and makes up 95% of the cell mass Oxygen readily binds to hemoglobin in the lungs and that is carried out as Cleukemia = MBCs, ↓ RBCs a platelets) oxyhemoglobin in arterial blood , Differentiation of the primitive myeloid stem cell of the bone marrow into a RBC is anemia = Epo stimulated by erythropoietin, a protein primarily produced primarily by the kidney - For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, and folic acid. ↳ needs erythropoietin (EPO) from Kidneys and I Old RBCs are removed from the blood by the reticuloendothelial cells, particularly in the liver and in the spleen. ↓ RES Leukocytes AKA White Blood Cells (WBC) Protect the body against infection and tissue injury Thrombocytes AKA Platelets Are fragments of megakaryocytes Platelet production in the bone marrow is regulated in part by thrombopoietin (hormone), which stimulates the production and differentiation of megakaryocytes from the myeloid stem cell. hemostasis how the body prevents = blood loss Provide the basis for coagulation to occur ↓ When a vessel is from broken !! a nosebleed) Ino dying ↑ BP can Play an essential role in hemostasis (control of bleeding) break clots into ○ When vascular injury occurs, platelets collect at the site and are activated. fragments !! ○ Platelets adhere to the site of injury and to each other, forming a platelet plug that temporarily stops bleeding. aVLATION ↑ ○ Substances released from platelet granules activate coagulation factors in blood PRIMARY plasma and initiate formation of a stable clot composed of fibrin, a filamentous protein SECONDARY HEMOSTASIS: ~ HEMOSTASIS : platelet plug is reinforced by FIBRIN · First of 2 steps needed for hemostasis · (motar between the bricks) - plateleg plug (bricks) fibrinogen e fibrin e protein · mesh spasm (constriction be a factors factor X endothelialinjuryVascular clotting · · , · coagution cascade exposed vonMillbrandsbindtocollag a release collagen e e HARD CLOT few minutes · · e only takes a Plasma Liquid portion that remains after cellular elements are removed from the blood albumin made in liver maintains osmotic pressure /keeps Composition: = , water in bloodstream) transport protein (shuttles fatty acid , ○ 90% water - calcium hormones + meds) , ○ Plasma Proteins (Albumin + Globulins) - globulins label pathogens for destruction ○ Clotting Factors (Fibrinogen) = ↳ Remain in an inactive from in the blood plasma until activated by the clotting cascade ○ Nutrients ○ Enzymes ○ Waste Products Bone Marrow Primary site for hematopoiesis: ○ Hematopoiesis is the formation and production of blood cell ○ The need for blood to replenish its supply of cells is continuous because blood cells have a short lifespan ○ In children, blood formation involves all skeletal bones ○ With aging, bone marrow activity is usually limited to the pelvis, ribs, vertebrae, and sternum Stem Cells: ○ Are primitive cells ○ Have the ability to self-replicate, which ensures a continuous supply of stem cells throughout the lifecycle ○ Will differentiate into myeloid or lymphoid stem cells when stimulated ○ Lymphoid stem cells produce either T or B lymphocytes ○ Myeloid stem cells produce RBCs, nonlymphoid WBCs, and platelets ○ When stem cells are dysfunctional, they may respond inadequately to the need for more cells, or they may respond excessively, sometimes uncontrollably, as in leukemia Cellular Life Span: ○ Under normal conditions, the adult bone marrow produces about 175 billion RBC, 70 billion WBC, and 175 billion platelets every single day. ○ RBC average life span is 120 days ○ WBC average lifespan is 7 days TESTS FOR COAGULATION : prothrombin time (PT) extrinsic pathway · = activated thromboplastin time (aPTT) intrinsic pathway · = Hemostasis: Blood Clotting S Occurs when the endothelial surface of a blood vessel is injured NEED When blood vessels are damaged, hemostasis prevents blood loss from intact vessels functional Platelets and terminates bleeding when blood vessels are damaged Requires adequate numbers of platelets ○ Platelets nurture endothelium; thereby maintain blood vessel structural integrity Primary Homeostasis: Vasoconstriction occurs Von Willebrand factor (vWf) binds to the collagen exposed on the damaged vessel and creates a binding site for the platelets Binded platelets release factors that stimulate other platelets to aggregate at the site, forming an unstable platelet plug. Secondary Homeostasis: ↳!!! Intrinsic or extrinsic clotting pathway and clotting factors are activated Extrinsic Pathway Activated by the release of thromboplastin from the tissue. As the result of a series of reactions, prothrombin is converted to thrombin. EXTRINSIC : Thrombin catalyzes the conversion of fibrinogen to fibrin. prothrombin -due to negatively charged phosphates on surface ↓ 2 Intrinsic Pathway thrombin Activated when the collagen that lines blood vessels is exposed. ↓ fibrinogen Clotting factors are activated sequentially until fibrin is formed. > - ↓ fibrin Thrombus and Antithrombotic Events: calcium As the injured vessel is repaired and again covered with endothelial cells, fibrin clot is no is a longer needed - tissue plasminogen activator cofactor Releases t-PA (Fibrinolysis → Clot Dissolution) ○ Plasminogen is required to lyse (break down) the fibrin. ○ Plasminogen is activated to form plasmin. Plasmin digests fibrinogen and fibrin Releases Thrombomodulin (Blocks Coagulation Technique) Neutrophil and RBC are trapped Blood Transfusions !!! S infused a through VEIN at a time - 1 bag need patient ID  symptoms : · edema · Fenderness/cramping warm, errythematous · Venous Thrombosis Venous Thrombosis bumpy/knot feeling · Venous Thromboembolism (VTE) larger calf diameter · Could be DVT, PE, or both Thrombophlebitis Inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs Deep Vein Thrombosis (DVT) Occurs in legs and arms and deeper within Virchow’s Triad Causative factors of venous thrombosis, thrombophlebitis, DVT, and Venous Thromboembolism Stasis of Blood ○ Immobility: Bed rest, long plane/car/train rides, obesity, constrictive devices, paresis, paresis, recent surgery, varicose veins, pregnancy or severe illness Vessel Wall Injury ○ Trauma (fractures, contusions), Central Venous Catheterization, Vascular Devices (PICC, central lines, pacemaker wires), IV Medications, Cancer Therapy (hormonal, chemotherapy, or radiotherapy) Altered Coagulation Chypercoagulation) ○ Estrogen-Containing Oral Contraception or Hormone Replacement, Cancer (secretes procoagulants), Smoking, Dehydration, Hypercoagulable States, Late Pregnancy, and the Postpartum Period How to prevent / interventions for thrombophlebitis in DVT - physical interventions, such as elastic compression stockings, intermittent pneumatic compression devices, and body positioning and exercise. Medications to prevent thrombosis include anticoagulant therapy, such as subcutaneous or low–molecular weight heparin Who has increased risk? Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury are at high risk. Other patients at high risk include those who are obese, immobile, or elderly, as well as women taking oral contraceptives. narrow vessels dehydration= S Clinical Manifestations Signs and symptoms of DVT are non-specific unless it’s massive depend on If massive, there will be swelling, tension, pain, bluish color, loss of distal pulses sizeand location !! Will have manifestations for a pulmonary embolism before a DVT Low grade fever Tenderness Asymmetry of extremities Assessment Careful assessment is key Compare extremities to see if they’re symmetrical → Measure circumference of each leg Assess for tenderness by gently touching on the legs can be amedical emergency , if it fat , plaque turns into PE clot = , blood or air Assess for Homans sign→ Positive if the pt feels pain after foot is sharply dorsiflexed D Dimer Blood Assay → Marker of coagulation activity Risk Factors = -D-dimer = BAD Varicose Veins & clotting Hypercoagulation Neoplastic Disease, like Cancer Cardiovascular Disease Recent Major injury or disease Medical Management Heparin therapy is effective as a prophylactic, SQ - to prevent development of DVT & Heparin IV - to prevent the extension of a thrombus and the development of new unfractioned with ronal thrombi. - Monitor PTT and platelets -> patients insufficiency heparin Low Molecular Weight Heparin - These agents have longer half-lives than unfractionated heparin so doses can be given in one or two subcutaneous injections each day. Doses are adjusted according to patient weight. LMWH prevents the extension of a thrombus and development of new thrombi, and they are associated with fewer bleeding complications and lower risks of heparin-induced thrombocytopenia (HIT) than is unfractionated heparin. Heparin Antidote - Protamine sulfate term > can be given long - Warfarin Antidote - Vitamin K For extended treatment, warfarin (coumadin) is frequently used - Monitor INR Oral direct factor Xa inhibitors include rivaroxaban, apixaban, and edoxaban. They are at least as effective and safe as warfarin, and their ability to be administered in fixed doses without routine coagulation monitoring has led to an increase in their use. Thrombectomy → Done if anticoagulant or thrombolytic therapy is contraindicated ○ Filter being placed or by balloon angioplasty and a stent placement Nurse Management Monitor PTT and PT/INR Assess for unusual or spontaneous bleeding Use SCDs (Sequential Compression Device) Walk if possible Don't sit for long periods of time Flex + point toes to activate calf muscles Elevate affected extremities/legs Wear compression socks when necessary Take analgesics to help with circulation and comfort Put warm, moist packs on When the patient is on bed rest, the feet and lower legs should be elevated periodically above the level of the heart. Deep breathing exercises Active and passive leg exercises · RAISE LEGS  acidosis causes respiratory O2 administered IMMEDIATELY !!! &Pulmonary Embolism - if I BP give fluids 4 and IV thrombolytics !! clot in a Often a medical emergency PULMONARY Manifestations- tachypnea, crackles, tachycardia, s4 artery flow ↓ blood Medical Management to vein General measures to improve respiratory status should be initiated - Catheter Anticoagulation Therapy inserted into Thrombolytic Therapy Surgical Intervention a pulmonary angiography vena cava can visualize Nursing Management Minimize risk Prevent thrombus formation > use inferior vena Assess for potential or pulmonary embolism Cava - Monitoring thrombolytic therapy Risk Factors filter if anticoagulant if contraindicated Being in bed for prolonged periods of time Fracture of a large bone like a femur or hip therapy Stroke MANIFESTATIONS : Paralyzed Chronic Heart Disease Smoker ↑ HR dBP 202 , , Prevention Stockings SCDs (Sequential Compression Device) - temp infarction of Ambulation Keep the leg muscles moving · hemoptysise lung tissue !! Uncrossed legs · crackles dyspnea cough · No dangling legs over the side of the bed , Change catheters in a timely manner · pleuritic(sharp) chest pain Assessment · disoriented , anxious Family history doom impending · Medical record respiratory hyperventilation = alkalosis · Ask about pain or discomfort daily in extremities Assess one leg sided redness, warmth, and inflammation & blood pH Monitor thrombolytic therapy ○ Can lyse deep vein thrombi and cause pulmonary emboli Assess vital signs every 15 minutes for 2 hours, then every 2 hours for 4 hours Do not do invasive procedures COMPLICATIONS : PTT is required every 6 hours after thrombolytics are started pulmonary HTN · Mange pain, oxygen, and anxiety (“impending sense of doom”) a rightventrical · Emergency Management Oxygen is administered immediately shock · Intravenous infusion lines are established death· & A perfusion scan, hemodynamic measurements, and ABG determinations are ventilation performed. CT angiogram or pulmonary angiography are performed. perfusion scan ↳ CTPAluses dye D-dimer = fibrin breakdown products (blood clot * plasmin F IRST of excessive sign dosage of anticoagulants - BLOOD IN URINE !! and thrombolytics Hypotension treated with fluids ECG is monitored for arrhythmias Glycosides, diuretics and antiarrhythmic agents are administered as appropriate Blood is drawn (D Dimer) Maybe indwelling catheter Sedatives to relieve patient anxiety IV thrombolytic agents Initiate low-molecular weight heparin !!! of PE : other causes of PE : complications · fat from broken femur · pleural effusion infarction tumor pulmonary · · · air embolism · Cardiac arrhythmia pulmonary HIN · · cardiac arrest/death  RNEXPLAINED antigens glycoproteins : BLOOD TYPE COMPATIBILITY only to give Rh +!! Rh + -everybody can receive CAN can "t" to "I' DONATE Blood receive O - TO group DONATING "NEGATIVE" from & "POSITIVE"bad RECEIVING = = good receiver AB+ AB+ Everyone AB NO , be blood = give C antibodies !! has everything AB+, AB- AB- AB-, A-, B-, O- universal RECIPIENT ! A+, AB+ A+ A+, A-, O+, O- A+, A-, AB+, AB- A- A-,O- B+, AB+ B+ B+, B-, O+, O- B+, B-, AB+, AB- B- B-, O- O+, A+, B+, AB+ O+ O+, O- - CANNOT B !! receive A or Everyone O- O- they have A/B antibodies universal DONOR O = good at giving , bad at receiving Universal donor is O- because they can give to the whole world AKA Universal dOner The O+ person can only give to other positive people: AB+, A+, B+, O+ BLOOD TRANSFUSION REACTION COMMON REACTION SYMPTOMS: Allergic: -common in IgA deficiency Fever and/or chills 1. Immediately STOP the infusion and check vital signs Urticaria pruitus a BP , 2. Administer a normal saline bolus through a patent IV Wheezing and/or respiratory distress 3. Notify MD and blood bank Angioedema (facial swelling) Hemolytic: - > RBCs are killed If unstable: call a rapid response & Severe flank pain or low back pain 4. Administer any additional medications + tests ordered Chills, flushing, tachycardia (diuresis, DIC, blood screening, antihistamines, Signs of DIC (like oozing from IV site) anaphylactic medications) Hypotension Urine turning red or brown 14 acute or delayed  RNEXPLAINED RED BLOOD CELL DISORDERS 4.5-5.5 m/mcl 4.5-6.0 m/mcl function of Carry oxygen from the lungs to the rest of the body and tissues. RBC's: Then, they return to the lungs to expel carbon dioxide. Hemoglobin (Hgb): A protein in RBC's that carry oxygen KNOW THIS, TRAIN YOUR Iron: A component of Hgb & also aids in red blood cell production and all of BRAIN: Vitamin B-12: aids in red blood cell production THESE will Formed in the bone marrow with WBC's and platelets make sense! Fatigue, SOB, trouble concentrating (lack of O2 reaching the brain) symptoms of all Muscle weakness & disorders: Tachycardia (body is working hard to distribute healthy RBC's) ANEMIA Iron Deficiency Cause: Lack of mineral iron in the body! common in Anemia Tx: Give iron supplementation pregnant women Cause: The body is unable to absorb enough Vitamin B-12, so we have a decrease Pernicious in RBC production Anemia Tx: Give Vitamin B-12 shots! Cause: Bone marrow stops making enough new blood cells d/t damage (exposure Aplastic to radiation/chemotherapy, toxic chemicals, or present at birth) Anemia Tx: Give blood transfusion or bone marrow transplant Cause: Unusual sickle shape of RBC's make them harder to flow through blood Sickle Cell vessels. They stick together, cause blockage, and transport less oxygen d/t less Anemia surface area. Tx: Give blood transfusion & supportive therapy (hydration, opioids/meds) episodes can be extremely painful Thalassemia A genetic mutation that prevents the normal production of Hgb so, ↓ Hgb = ↓ ability to carry O2 CAUSES: Anemia, enlarged spleen (cells get stuck in spleen d/t shape; works harder to create RBC’s) Tx: Give blood transfusion Small misshapen rbc's polycythemia vera A genetic mutation that causes the bone marrow to make TOO MANY red blood cells. The blood will THICKEN = ↑ risk for blood clots and heart attack/stroke Tx: Removing blood from the veins may have enlarged spleen d/t filtering more blood than usual 97 RNEXPLAINED DISSEMINATED INTRAVASCULAR C O A G U L A T I O N WHAT HAPPENS? DIC occurs when thrombin (an enzyme that facilitates clotting) uncontrollably converts fibrinogen to fibrin (a major component of clots) ↓ The overdrive in clotting uses up platelets and clotting factors → simultaneous bleeding in other parts of the body : ↓ A AK TOO MUCH AND TOO LITTLE CLOTTING! NCLEX WHAT CAUSES DIC? Blood transfusion reaction! Inflammation of the pancreas, liver disease Infection in the blood (sepsis, meningitis) Pregnancy complication: Retained placenta SYMPTOMS NCLEX #1 SIGN: PETECHIAE Bleeding from many sites of the body (petechiae or purpura) PETICHIA PURPUR Blood in stool or urine E A Blood clotting, bruising, pain/redness at clotting sites Drop in blood pressure, change in behavior Shortness of breath: ↓ O2 getting to major organs Confusion, fever SEVERE: HEMORRHAGE & ORGAN DAMAGE!! TREATMENT KEY LABS: PTT, Hgb, PLTs GOAL: Control clotting/bleeding and treat the underlying cause; will go away once treated! 1. Fresh frozen plasma: To provide clotting factors or prevent bleeding 2. Platelet transfusion: To quickly raise platelet levels 3. If actively hemorrhaging: PRBC’s 4. Medications: Anticoagulants (to reduce clotting) 5. Treat underlying cause! (Ex: stop blood transfusion, remove retained placenta) AS THE NURSE... O2 supplementation Watch vital sings (BP/HR/O2) Monitor mental status Bleeding precautions (no IM’s, razors, flossing, soft 104toothbrush, or knives with meals) Blood Product Admin Med Surg: Hematology What is it? PRBC Whole blood, given to increase hemoglobin & hematocrit (H&H) when blood count Packed Red Blood Cells is low from anemia, trauma or surgery. PRBCs MUST be given within 4 hours after being taken out of the refrigerator. HESI PRBC PRBC (Packed Red Blood Cells) Q1: A child involved in a motor vehicle accident has a thready pulse, decreased blood pressure, rapid Hgb 8 - 11 respiration, and clammy skin with pallor. The child Hemoglobin is not responding to secondary fluid bolus. REPORT to HCP & Surgeon Which treatment would the nurse anticipate administering to ensure the safety of the child? (if before surgery) Red blood cells KEY NUMBERS Q2: A nurse is caring for a patient with hemoglobin Hgb below 7 = Heaven! (Hgb) of 8 g/dL and hematocrit (Hct) of 35%, who is Normal 12 - 18 NEED blood transfusion or die (shock) receiving an infusion of 1 unit of packed red blood cells. The nurse anticipates which results on the patient's next lab work? Risky 8 - 11 Top S/S for shock: HgB 9, HcT 38 Low H&H Below 7 1. Pale skin: pallor, dusky skin signs 1 unit 1 Hgb below 7 2. Cool Clammy skin PRBC HEMOGLOBIN 3. Fatigue, Weakness = Heaven What is it? PLT Proteins that help the blood to clot & form scabs to stop bleeding. Given to clients Platelets with low platelets. Low platelet count typically results from cancers, & certain types of anemia. 150,000 or LESS = Thrombocytopenia 150K OR LESS 50k or less 50,000 = DEADLY! Thrombocytopenia Deadly What is it? FFP Clotting factors that act like glue, helping to stick all the platelets together in order to form a clot & stop bleeding. Fresh Frozen Plasma Given to clients with low clotting factors: Hemophilia Fresh Frozen Liver disease (Cirrhosis & Hepatitis) since the liver helps make clotting factors. PLASMA Side Note: It is important to know the difference between low platelets vs. low clotting factors, since giving a bunch of platelets to a client with hemophilia (low clotting factors) is not going to do anything if they lack the glue that holds GLU E it all together. Transfusion Reactions & Priority Interventions Med Surg: Hematology 4 Types of Reactions F FEBRILE REACTION (mild allergic rx) A ANAPHYLACTIC REACTION C CIRCULATORY OVERLOAD H HEMOLYTIC F FEBRILE REACTION (mild allergic rx) A ANAPHYLACTIC REACTION Flushing (redness) Wheezing Itchy Hives Hypotension (low BP) NORMAL HIGH LOW C CIRCULATORY ATI KAPLAN OVERLOAD Difficulty breathing and crackles after The nurse is caring for a patient who is administration of PRBCs … priority actions? receiving a blood transfusion. The client Signs & Symptoms begins to exhibit dyspnea, crackles in lung Select all that apply Lung crackles Crackles bases, and becomes restless. Which action Administer furosemide 40 mg IVP should the nurse anticipate? Restlessness Elevate HOB at least to 45 degrees Dark Urine Slow the infusion rate Monitor for HTN, tachycardia, SOB & Dyspnea tachypnea, hypoxia Notify HCP JVD (jugular vein distention) Risk: HF - Heart Failure HF - Heavy Fluid Action: SLOW the infusion- 4 hours max H O P E NCLEX TIP Wait 2 hrs between infusions PRBC H - HOB Elevated “SIT UP!” STOP O - Oxygen P - Push Diuretics (FurosemIDE) 4hrs MAX FurosemIDE E - End all IV fluids H KEY TERM HEMOLYTIC KAPLAN Hypotension (Low BP) Which of the following indicates a Low back pain hemolytic reaction? Fever Low back pain and apprehension Tachycardia (Fast HR) Urine specimen: “check for hemolyzed RBC” NCLEX TIP Over 5.0 Hemolyzed RBCs PRIORITY Interventions K High Potassium (Hyperkalemia) 1. Slow or STOP the infusion Over 5.0 Potassium Priority Pumps heart 2. Using new tubing 0.9% sodium Peaked T Waves on ECG NCLEX TIP chloride (normal saline) ATI 3. Report to HCP immediately Ordered Response: Reaction to blood transfusion 4. Assess: 1. STOP transfusion Vital signs 2. Hang new IV infusion set 3. Start 0.9% sodium chloride infusion Urine specimen: “check for K K K 4. Call HCP K K K K K K K K K K K hemolyzed RBC” NCLEX TIP K K 5. Assess BP, HR, RR K K K K 6. Obtain blood and urine specimens Blood Transfusion & Autologus Transfusion Med Surg: Hematology 5 Steps of Transfusion HESI PRBC 0.9% Q1: Safe administration of PRBCs? Sodium Chloride 250 mL Select all that apply 1. Prime tubing with 0.9% sodium chloride BEFORE (normal saline) 2. Obtain and document a full set of Vital Signs 1. 2 RNs verify order: 3. Check name and blood product with second nurse Name & blood product (blood type & Rh factor) 4. Administer 0.9% sodium chloride after infusion 2. Vital signs 5. Monitor for s/s of transfusion reaction like volume overload (every 15 minutes for first hour) Q2: A nurse is preparing the transfusion of a unit of 3. Prep: blood to a patient with anemia. The nurse knows which intervention is most important to prevent a transfusion 18 G - IV catheter reaction? 2 Tubings Double-checking the blood product’s type for compatibility with the patient’s blood type 1. Blood tubing with filter 2. 0.9% sodium chloride (normal saline) ONLY KAPLAN DURING NO LR, NO dextrose Q1: The nurse is preparing to administer a blood 4. STAY at bedside 15 minutes transfusion to a client who has anemia. Which action should the nurse take first? AB+ A+ B+ O+ Reaction? (slow / stop infusion) Check for the type and number of units of blood to administer AFTER AB- A- B- O- Q2: A nurse is preparing to administer a unit of PRBCs to a client. Which action should the nurse take? 5. 0.9% sodium chloride (normal saline) Rh factor Remain with the client for the first 15 minutes 18G - IV catheter Autologous Transfusion Jehovah Witness PRBC PRBC Collection of blood from a single patient that is retransfused back into the same patient when needed, typically done for clients with particular religious PRBC views like Jehovah Witnesses who can not have other people's blood. HESI The nurse is teaching about autologous transfusion of blood to a group of student nurses. Which statements should the nurse include in the teaching plan? PRBC 3 years MAX Select all that apply. Blood is stored in frozen conditions PRBC Blood is stored for as long as 3 years Blood may not be rejected by the patient’s immune system OBTAIN BASELINE BEFORE INFUSION !! Top 3 Missed Question Q1: When preparing to administer Q2: Which is the priority nursing Q3: Which is the most a unit of packed red blood cells to action for a patient who develops a appropriate nursing intervention H&H a client with anemia, which nursing high fever and tachycardia during when preparing to administer actions are appropriate? administration of a unit of packed synthetic erythropoietin to a Select all that apply. red blood cells? patient with anemia from chronic renal disease? Highest PRIORITY 1. Ensure that the patient has a 1. Administer 650 mg acetaminophen PO. 1. Give the drug in the patient’s right functioning central venous access 2. Notify the provider. deltoid muscle. NORMAL HIGH LOW catheter. 3. Assess the remainder of the patient’s 2. Hold the dose for a HgB less than 2. Have two licensed nurses verify vital signs. 10 g/dL. the prescription. 4. Stop the infusion. 3. Assess the patient’s blood pressure 3. Assess the patient’s HgB and Hct. prior to administration. STOP 4. Auscultate the patient’s heart and 4. Check the patient’s urine output to lung sounds. ensure an output of at least PRBC 0.9% Sodium Chloride 250 mL 5. Prepare a bag of lactated Ringer’s 30 mL/hr. to administer with the blood. Blood Types & Rh Factor Med Surg: Hematology Blood Types Memory trick A B The main blood types are A, B, AB, O. O AB The most tested key point for donating & DOnor Receiver ABs AB receiving blood: O AB O0-- can be given to everyone. AB O AB AB +- receives blood from everyone. A+ B- B+ O- AB- AB+ O+ A- A+ B- B+ O- AB- AB+ O+ A- Donor Recipient A A HESI Universal DOnor O Q1: A nurse is caring for a patient with type AB blood who requires a blood transfusion. However, the blood B B bank sends up type A blood. Which action should the nurse take first? AB AB AB Infuse blood according to agency protocol Q2: A patient with anemia states... “I'm a universal Universal receiver donor" … patient has which blood type? O O O type * Don’t focus on memorizing this chart, it’s NOT often tested on the NCLEX. Rh Factor (ANTIBODIES) Rh Factors are the positive & negative antibodies on the blood’s surface. An indirect coomb’s test is done to see if the blood is positive or negative + AB+ A+ B+ O+ & make sure blood can be given or received. - AB- A- B- O- SAUNDERS Rh factor A client is donating blood … The nurse tells the client that an indirect Coombs' test will be performed on RhoGAM the blood. The client asks the nurse about the COOMB TEST purpose of the test. Which response should the nurse provide to the client? “The test detects circulating antibodies against red blood cells (RBCs).” Rhogam is given to Rh negative pregnant mothers to protect the baby from a 2ND deadly complication called Hemolytic Disease of the Newborn (HDN). RhoGA M This happens when the mother is Rh - and the baby is Rh +. The Mom’s negative antibodies can attack the babies positive Rh & cause this deadly hemolysis or hemolytic anemia, so this is why we give RhoGAM to shield & protect the baby from this deadly reaction. HDN - Hemolytic Disease of the Newborn 1 ST 2 ND Rh+ Rh+ Rh+ Antibodies Rh+ Antibodies Respiratory Pulmonary Embolism Pathophysiology Deadly PRIORITY medical emergency! PE is a blood clot that obstructs a pulmonary vessel (blood vessel inside the lung), typically the pulmonary artery. This blockage prevents blood flow to the Alveoli where gas exchange is supposed to happen, eventually leading to DEADLY hypoxemia (deadly low oxygen). Highest Priority Impaired gas exchange r/t imbalance of ventilation & perfusion Causes: Typically caused from a DVT blood clot that loosens from another part of the body (typically the leg) & gets sucked into lungs - causing a blockage. Risk Factors Smoking, Obesity, Immobility, & even cardiac issues like Atrial Fibrillation or valve disorders. Memory Trick Estrogen birth control “oral contraceptives” MOST TESTED leads to increased risk for blood clots E - Estrogen SMOKING OBESITY IMMOBILITY E - Emboli (blood clots) Diagnostics: Signs & Symptoms: High D dimer - High risk for blood clots #1 in the body #1 Sign = Hypoxemia 0₂ 0₂ Memory trick: 0₂ 1. Restless 0₂ 2. Agitation D - Dimer (Positive) D - Dime sized clot in body 3. Mental status change Chest pain HESI Question Dyspnea & SOB Indications for pulmonary embolism Tachypnea include... 68- 494 Positive D-Dimer Tachycardia 0₂ 0₂ Normal range 68- 494 ng/dL) ng/dL Anxiety 0₂ 0₂ Pharmacology Treatments Pharmacology Surgery Anticoagulants Embolectomy: surgical removal of Heparin the clot Warfarin Vena Cava filter: acts like a net to catch Thrombolytics any new clots tPA B - Bolytics Thrombolytics B - Clot Busters Alteplase Streptokinase Peripheral Vascular Med Surg: Cardiac NARROW NARROW PVD | VEIN PAD | ARTERY Signs & Symptoms Signs & Symptoms VEINY ARTS V VOLUMPTUOUS PULSES - Warm legs A ABSENT PULSES, E EDEMA (blood pooling) Absent Hair (Shiny) = Cool legs I IRREGULAR SHAPE SORES (Exotic pools) R ROUND, RED SORES (blood pooling) N NO SHARP PAIN (Dull pain) T TOES & FEET PALE or BLACK “Eschar” Y YELLOW & BROWN ANKLES S SHARP CALF PAIN (intermittent Claudication) E - Exercise E-Elevation (recliner chair) Positioning Patient Education Positioning PAD PVD & PAD C–Constriction AVOID PVD C–Cross legs C–Constrictive clothing C–Cigarettes VEINS = ELEVATE C–Caffeine ARTERIES = HANG C–Cold Temperatures (Vacuum) T–Toenails trimmed ONLY by Dr. (Away) NCLEX TIP DVT, RAYNAUD’S & BUERGER’S DVT - Deep Vein Thrombosis Pathophysiology Treatments CLOT in a deep vein DURING CLOT-DV D Don’t Walk (bed rest) V Venous return (eleVate) Signs & Symptoms CHANT COWS AFTER CLOT C Calf Exercise & Isometrics C CALF PAIN & CRAMPING H Hydration O ONE-SIDED SWELLING (Unilateral) A Ambulation NCLEX TIP W WARM & RED (Blood pooling) N NO long sitting (Car, Airplane, Bedrest) S SOB & CHEST PAIN = PE! (Call Doctor) T Ted & SCDs (AFTER CLOT resolved) Raynaud’s & Buerger’s Disease Signs & Symptoms R–RAYNAUD’S R–RING FINGER B–BUERGER’S B–BLACK FINGERS & TOES