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Blood Transfusion

Priority: cross matching

Do not leave the patient within the first 30 minutes

Reactions occur within 15 minutesWhen reaction happened: STOP and REFER!

ConsiderNSS at KVO rate

Drop factor: 10 gtts/min (first 30 minutes)

Needle: 18GDuration: packed RBC not less than 4 hours

Plasma and platelets- not more than 20 minutes

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Common reactions:

Hemolytic - back pain

Pyrogenic -headache and fever Anaphylactic - hives and rashes

Cardiogenic -dyspnea

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NGTPosition: high-Fowlers position(hyperextension followed by flexion)

Length of tube to be inserted: measure from

the tip of the nose to earlobe down to xiphoidprocess (NEX)Lubricate tip with water soluble jelly ( not fat-

soluble: can cause lipid pneumonia)

Bend head forward and drink or swallow astube advances If tube meets resistance, withdraw, relubricate

and insert to other nostril

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If client cant talk, is coughing or cyanotic: STOP

and REMOVEAdvance until taped mark is reached; secure

when placement has been checkedCheck placement

X-ray Aspirate gastric contents Insert 5 to 10 ml of air and listening to the rush of air

Assessing residual: aspirate all and measureamount then reinstill gastric contents unless, itappears abnormal.

Removal: instruct client to take and hold a deepbreath. Remove gently and coil the tube aroundthe hand as it is being removed.

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URINARY CATHETERIZATION

Prone to UTI

Provide privacyWhen unfilling the drainage bag, do not allow

the drainage spout to touch collection

receptacleDo not allow catheter bag to lie on the floor

Provide for gravity drainage

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Client should void within 4-6 hours after

an indwelling catheter is removed

Prevent pooling of urine in the drainage

tubing

Acidify urine (eggs, plums, prunes and

prunes, meat and whole grains)

Increase fluid intake

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Common materials used:

plastic

latex or rubber

PVC

Silicone

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INFORMED CONSENT

Client must be mentally competent

Client must be of legal age

Minors can sign when: indicated for STD treatment

married

emancipated

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Client must be fully informed regarding:

treatment/ procedures

other possible options

possible complications if not done

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RESTRAINTSto limit or immobilize a client or extremity

TYPES: chemical and physicalPhysicians order should:

Specify type of restraint

Behavior that caused the order Time limitation

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Restraints are not to be ordered PRN

Assess for every 30 minutes Skin integrity

CirculationNeurovascular status

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Documentation

ReasonMethod

Date and time of application

Duration of restraint with periodic assessment Assessment of continued need

Evaluation of clients response

Alternatives

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Artificial Airways

Purposes:

to administer oxygen

to suction secretions

to bypass upper airway obstruction

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Endotracheal tube- inserted through the

nose or the mouth into the tracheaTracheostomy tube- artificial aperture

made through the neck into the trachea of

patients needing long term airwaymaintenance. Inserted using a laryngoscope as a guide

Can be temporary or permanent

Avoid mucosal and vocal chord damage that mayoccur with ET

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PARTS:

Outer cannula (main shaft)- inserted into the

trachea. It has a flange at the opening of the

tracheostomy stoma. Cloth or tape is tied through

the flange around the of the patient to keep it inplace

Inner cannula- fits into the outer cannula to

facilitate airway removed when being cleansed.

Obturator- guides the outer cannula during initial

placement and reinsertion if dislodged

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PRINCIPLES:

Position: Fowlers position

Communication: sign language orpicture boards

Safety: don sterile gloves

Tube: avoid movement and maintaincleanliness.

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Tie: should not be too tight; might

compress jugular veinsEmergency care: obturator and suction

apparatus must be available at clients

bedside

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CPRAdult:

15:2 (compressions to ventilations, 2 secondsper breath)

1.5 to 2 inches depth at 100 times per minute

check pulse after first four cycles

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Child:

5:1

1 to 1.5 inches depth at 100 times per minute 1 year and older: check carotid pulse

Below 1 year old: check brachial pulse