Neonatal Jaundice
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Glasgow Coma Scale ( GCS)
There are a few different systems that medical practioners use to diagnose the symptoms of Traumatic Brain Injury. This section discusses the Glasgow Coma Scale. Click on the link to find out more information about the Ranchos Los Amigos Scale.
The Glasgow Coma Scale is based on a 15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others.
The test measures the motor response, verbal response and eye opening response with these values:
I. Motor Response(M)
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious stimuli
3 - Abnormal flexion, i.e. decorticate posturing
2 - Extensor response, i.e. decerebrate posturing
1 - No response
II. Verbal Response(V)
5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words and jumbled phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds
III. Eye Opening(E)
4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening
The final score is determined by adding the values of (E+V+M = ? score).
This number helps medical practioners categorize the four possible levels for survival, with a lower number indicating a more severe injury and a poorer prognosis:
Mild (13-15):
More in-depth discussion on the Mild TBI Symptoms page.
Moderate Disability (9-12):
Loss of consciousness greater than 30 minutes
Physical or cognitive impairments which may or may resolve
Benefit from Rehabilitation
Loss of consciousness greater than 30 minutes
Physical or cognitive impairments which may or may resolve
Benefit from Rehabilitation
Severe Disability (3-8):
Coma: unconscious state. No meaningful response, no voluntary activities
Vegetative State (Less Than 3):
Sleep wake cycles
Aruosal, but no interaction with environment
No localized response to pain
Coma: unconscious state. No meaningful response, no voluntary activities
Vegetative State (Less Than 3):
Sleep wake cycles
Aruosal, but no interaction with environment
No localized response to pain
Persistent Vegetative State:
Vegetative state lasting longer than one month
Vegetative state lasting longer than one month
Brain Death:
No brain function
Specific criteria needed for making this diagnosis
No brain function
Specific criteria needed for making this diagnosis
Oxygen Delivery Devices
OXYGEN DELIVERY DEVICES
1) Low Oxygen Delivery Devices
i) Nasal cannula
a) Two short plastic nasal prongs
b) Delivers 25-45% FIO2 at 1-6 L/min flow
2) Moderate flow oxygen delivery devices
i) Partial Rebreathing Mask with reservoir
a) Delivers 35-60% Oxygen at 6-10 L/min flow rate
-First third of exhaled gases mix with reservoir
-Exhaled gases from upper airway are oxygen rich
b) Delivers 25-45% FIO2 at 1-6 L/min flow
c) Delivers 4% Oxygen per liter flow
1) Flow 0 liters per minute: 21% (Room Air)
2) Flow 1 liters per minute: 25%
3) Flow 2 liters per minute: 29%
4) Flow 3 liters per minute: 33%
5) Flow 4 liters per minute: 37%
6) Flow 5 liters per minute: 41%
7) Flow 6 liters per minute: 45%
d) Flow rates >4 liters per minute irritates nasopharynx
e) Does not provide humidified oxygen
1) Flow 0 liters per minute: 21% (Room Air)
2) Flow 1 liters per minute: 25%
3) Flow 2 liters per minute: 29%
4) Flow 3 liters per minute: 33%
5) Flow 4 liters per minute: 37%
6) Flow 5 liters per minute: 41%
7) Flow 6 liters per minute: 45%
d) Flow rates >4 liters per minute irritates nasopharynx
e) Does not provide humidified oxygen
ii) Simple Oxygen Mask 
a) In children use the Soft Vinyl Pediatric Mask
b) Poorly tolerated by infants and toddlers
c)Delivers 35-60% Oxygen at 6-10 L/min flow rates
-Room air entrained during inspiration
-Reduced Oxygen Concentration if:
i) High spontaneous inspiratory flow
ii) Mask is loose
iii) Oxygen flow into the mask is low
a) In children use the Soft Vinyl Pediatric Mask
b) Poorly tolerated by infants and toddlers
c)Delivers 35-60% Oxygen at 6-10 L/min flow rates
-Room air entrained during inspiration
-Reduced Oxygen Concentration if:
i) High spontaneous inspiratory flow
ii) Mask is loose
iii) Oxygen flow into the mask is low
2) Moderate flow oxygen delivery devices
i) Partial Rebreathing Mask with reservoira) Delivers 35-60% Oxygen at 6-10 L/min flow rate
-First third of exhaled gases mix with reservoir
-Exhaled gases from upper airway are oxygen rich
ii)Venturi Maska) Allows provider to dial in oxygen concentration
b) Delivers 25-60% oxygen at 4-8 L/min flow rate
3) High oxygen delivery devices
i) Non-Rebreathing Mask with reservoir
a) Delivers 95% Oxygen at 10-12 L/min
b) Two valves added to rebreathing mask prevents:
-Entrainment of room air during inspiration
-Retention of exhaled gases during expiration
a) Delivers 95% Oxygen at 10-12 L/min
b) Two valves added to rebreathing mask prevents:
-Entrainment of room air during inspiration
-Retention of exhaled gases during expiration
ii)Oxygen Hood
a) Clear plastic shell encompasses the baby's head
b) Well tolerated by infants
c) Size of hood limits use to younger than age 1 year
d) Allows easy access to chest, trunk, and extremities
e) Allows control of Oxygen Delivery
-Oxygen concentration
-Inspired oxygen temperature and humidity
f) Delivers 80-90% oxygen at 10-15 liter per minute
a) Clear plastic shell encompasses the baby's head
b) Well tolerated by infants
c) Size of hood limits use to younger than age 1 year
d) Allows easy access to chest, trunk, and extremities
e) Allows control of Oxygen Delivery
-Oxygen concentration
-Inspired oxygen temperature and humidity
f) Delivers 80-90% oxygen at 10-15 liter per minute
Hand Washing
Despite the proven health benefits of hand washing, many people don't practice this habit as often as they should — even after using the toilet. Throughout the day you accumulate germs on your hands from a variety of sources, such as direct contact with people, contaminated surfaces, foods, even animals and animal waste. If you don't wash your hands frequently enough, you can infect yourself with these germs by touching your eyes, nose or mouth. And you can spread these germs to others by touching them or by touching surfaces that they also touch, such as doorknobs. Infectious diseases that are commonly spread through hand-to-hand contact include the common cold, flu and several gastrointestinal disorders, such as infectious diarrhea. While most people will get over a cold, the flu can be much more serious. Some people with the flu, particularly older adults and people with chronic medical problems, can develop pneumonia. The combination of the flu and pneumonia, in fact, is the eighth-leading cause of death among Americans. Inadequate hand hygiene also contributes to food-related illnesses, such as salmonella and E. coli infection. According to the Centers for Disease Control and Prevention (CDC), as many as 76 million Americans get a food-borne illness each year. Of these, about 5,000 die as a result of their illness. Others experience the annoying signs and symptoms of nausea, vomiting and diarrhea. Good hand-washing techniques include washing your hands with soap and water or using an alcohol-based hand sanitizer. Antimicrobial wipes or towelettes are just as effective as soap and water in cleaning your hands but aren't as good as alcohol-based sanitizers. Antibacterial soaps have become increasingly popular in recent years. However, these soaps are no more effective at killing germs than is regular soap. Using antibacterial soaps may lead to the development of bacteria that are resistant to the products' antimicrobial agents — making it even harder to kill these germs in the future. In general, regular soap is fine. The combination of scrubbing your hands with soap — antibacterial or not — and rinsing them with water loosens and removes bacteria from your hands. Area that frequent missing Proper hand washing with soap and water Proper use of an alcohol-based hand sanitizer Alcohol-based hand sanitizers — which don't require water — are an excellent alternative to hand washing, particularly when soap and water aren't available. They're actually more effective than soap and water in killing bacteria and viruses that cause disease. Commercially prepared hand sanitizers contain ingredients that help prevent skin dryness. Using these products can result in less skin dryness and irritation than hand washing. Not all hand sanitizers are created equal, though. Some "waterless" hand sanitizers don't contain alcohol. Use only the alcohol-based products. The CDC recommends choosing products that contain at least 60 percent alcohol. To use an alcohol-based hand sanitizer: If your hands are visibly dirty, however, wash with soap and water, if available, rather than a sanitizer.
Hand washing is a simple habit, something most people do without thinking. Yet hand washing, when done properly, is one of the best ways to avoid getting sick. This simple habit requires only soap and warm water or an alcohol-based hand sanitizer — a cleanser that doesn't require water. Do you know the benefits of good hand hygiene and when and how to wash your hands properly?The dangers of not washing your hands
Proper hand-washing techniques
Follow these instructions for washing with soap and water:
IV Therapy and Cannualtion
DEFINITION:
Intravenous therapy or IV therapy is the administration of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. The word intravenous simply means "within a vein", but is most commonly used to refer to IV therapy.
1. Establish or maintain a fluid or electrolyte balance
2. Administer continuous or intermittent medication
3. Administer bolus medication
4. Administer fluid to keep vein open
5. Administer blood or blood components
6. Administer intravenous anesthetics
7. Maintain or correct a patient's nutritional state
8. Administer diagnostic reagents
9. Monitor hemodynamic functions
B. IV Devices :
i. Steel Needles :
Example: Butterfly catheter. They are named after the wing-like plastic
tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles
ii. Over the Needle Catheters
Example: peripheral IV catheter. This is the kind of catheter you will primarily be using. Also see the close up view of the catheter/needle tip in the next section ("inside the needle catheters"). Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.
C. IV Fluids :
Intravenous fluids are usually provided to:
- Provide volume replacement
- Administer medications, including electrolytes- Monitor cardiac functions
For example, a patient comes into the ED with gastroenteritis and is dehydrated from vomiting and diarrhea. Acutely, she receives a fluid bolus to expand her intravascular volume. Her blood chemistry shows that her electrolytes are a bit
- Administer medications, including electrolytes- Monitor cardiac functions
For example, a patient comes into the ED with gastroenteritis and is dehydrated from vomiting and diarrhea. Acutely, she receives a fluid bolus to expand her intravascular volume. Her blood chemistry shows that her electrolytes are a bit
off, so the IV fluid is adjusted to bring them within normal parameters. She is also given medication for nausea via her IV. She will remain on maintenance IV fluids until she is able to drink adequate amounts of fluids.
There are three main types of fluids:
1) Isotonic fluids:
Can be helpful in hypotensive or hypovolemic patients.
Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension.
Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water
2) Hypotonic fluids:
Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water
2) Hypotonic fluids:
Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients.Example: .45% NaCl, 2.5% dextrose
3) Hypertonic fluids :
Can help stabilize blood pressure, increase urine output, and reduce edema.
Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration.Examples: D5% .45% NaCl, D5% LR, D5% NS, blood products, and albumin.
Flow Rates :
Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration.Examples: D5% .45% NaCl, D5% LR, D5% NS, blood products, and albumin.
Flow Rates :
You will often need to calculate IV flow rates. The administration sets come in two basic sizes:
1.Microdrip sets, Allow 60 drops (gtts) / mL through a small needle into the drip
chamber (Good for medication administration or pediatric fluid delivery).
chamber (Good for medication administration or pediatric fluid delivery).
2.Macrodrip sets, Allow 10 to 15 drops / mL into the drip chamber (Great for rapid
fluid delivery. Also used for routine fluid delivery).
3.Fluid may be ordered at a KVO rate. This means to Keep the Vein Open, or run in fluids very slowly, enough to keep the vein open, but not really deliver much
volume.At times, you may desire a faster flow rate. This is usually expressed in
mLs / hour. In other words, how much fluid do you want your patient to receive
each hour? A common "maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient would receive 125 mL of fluid every hour.
This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute. To do this, you must know what size administration set you are using (micro or macrodrip). Plug the numbers into the following formula and you've got it
mLs / hour. In other words, how much fluid do you want your patient to receive
each hour? A common "maintenance" amount, for instance, would be "run it in at 125 an hour". Your patient would receive 125 mL of fluid every hour.
This is usually done by counting the number of drops that fall into the clear drip chamber on the IV administration set in one minute. To do this, you must know what size administration set you are using (micro or macrodrip). Plug the numbers into the following formula and you've got it
(volume in mL) x (drip set) gtts
------------------------------------ = ------
(time in minutes) min
3. Dorsal venous network
4. Cephalic vein
5. Basilic vein
4. Cephalic vein
5. Basilic vein
2) Veins of the Forearm1. Cephalic vein
2. Median Cubital vein
3. Accessory Cephalic vein
4. Basilic vein
5. Cephalic vein
6. Median antebrachial vein
5. Cephalic vein
6. Median antebrachial vein
E. Technique:
Remember the four rights:
1) Do I have the right patient?
2) Do I have the right solution?
3) Do I have the right drug?
4) Do I have the right route?.
Preparation:
It is important to gather all the necessary supplies before you begin. You will need:
1 alcohol prep pad,
Tourniquet,
IV catheter,
IV tubing,
Bag of IV fluid.
Tegaderm (secure the canula)
Prepare the IV fluid administration set.
1) Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking, and the bag is not expired.
2) Select either a mini or macro drip administration set and uncoil the tubing. Do not let the ends of the tubing become contaminated.
3) Close the flow regulator (roll the wheel away from the end you will attach to the fluid bag).
4) Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set.
5) Insert the spike of the administration set into the port of the fluid bag with a quick twist. Do this carefully. Be especially careful to not puncture yourself.
6) Hold the fluid bag higher than the drip chamber of the administration set.
7) Squeeze the drip chamber once or twice to start the flow.
8) Fill the drip chamber to the marker line (approximately one-third full). If you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag.
9) Open the flow regulator and allow the fluid to flush all the air from the tubing. Let it run into a trash can or kidney dish. You may need to loosen or remove the cap at the end of the tubing to get the fluid to flow although most sets now allow flow without removal. Take care not to let the tip of the administration set become contaminated.
10) Turn off the flow and place the sterile cap back on the end of the administration set (if you've had to remove it). Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein.
10) Turn off the flow and place the sterile cap back on the end of the administration set (if you've had to remove it). Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein.
Perform the venipuncture
1) introduced yourself to your patient and explained the procedure.
2) Apply a tourniquet high on the upper arm. It should be tight enough to visibly indent the skin, but not cause the patient discomfort. Have the patient make a fist several times in order to maximize venous engorgement. Lower the arm to increase vein engorgement.
3) Select the appropriate vein. If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb) The vein will feel like an elastic tube that "gives" under pressure.
4) Tapping on the veins, by gently "slapping" them with the pads of two or three fingers may help dilate them. If you still cannot find any veins, then it might be helpful to cover the arm in a warm, moist compress to help with peripheral vasodilatation. If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand. If still no suitable veins are found, then you will have to move to the other arm. Be careful to stay away from arteries, which are pulsatile.
5) Don disposable gloves.
6) Clean the entry site carefully with the alcohol prep pad. Allow it to dry. Use both in a circular motion starting with the entry site and extending outward about 2 inches.
7) To puncture the vein, hold the catheter in your dominant hand. With the bevel up, enter the skin at about a 30 degree angle and in the direction of the vein. Use a quick, short, jabbing motion.
8) After entering the skin, reduce the angle of the catheter until it is nearly parallel to the skin. If the vein appears to "roll" (move around freely under the skin), begin your venipuncture by apply counter tension against the skin just below the entry site using your nondominant hand. Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing. Be carefully not to press too hard which will compress blood flow in the vein and cause the vein to collapse. Then pierce the skin and enter the vein as above.
9)Advance the catheter to enter the vein until blood is seen in the "flash chamber" of the catheter.
***If you are unsuccessful in entering the vein and there is no flashback, then slowly withdraw the catheter, without pulling all the way out, and carefully watch for the flashback to occur. If you are still not within the vein, then advance it again in a 2nd attempt to enter the vein. While withdrawing always stop before pulling all the way out to avoid repeating the painful initial skin puncture. If after several manipulations the vein is not entered, then release the tourniquet, place a gauze over the skin puncture site, withdraw the catheter and tape down the gauze. Try again in the other arm.
Otherwise,After entering the vein, advance the plastic catheter (which is over the needle) on into the vein while leaving the needle stationary. The hub of the catheter should be all the way to the skin puncture site. The plastic catheter should slide forward easily. Do not force it.
10) Apply gentle pressure over the vein just proximal to the entry site to prevent blood flow. Remove the needle from within the plastic catheter. Dispose of the needle in an appropriate sharps container. NEVER reinsert the needle into the plastic catheter while it is in the patient's arm! Reinserting the needle can shear off the tip of the plastic catheter causing an embolus. Remove the protective cap from the end of the administration set and connect it to the plastic catheter.
11) Adjust the flow rate as desired.
12) Tape the catheter in place using tegaderm.
13) Label the IV site with the date, time, and your initials.
14) Monitor the infusion for proper flow into the vein (in other words, watch for infiltration).
***Occasionally, you may inadvertently enter an artery. You'll recognize this because bright red blood is quickly seen in the IV tubing and the IV bag because of the high pressure that exists. If this occurs, stop the fluid flow, remove the catheter, and put pressure on the site for at least 5 minutes.
To discontinue an IV
Remember to observe universal precautions.
1) Start by clamping off the flow of fluids.
2) Then gently peel the tape back toward the IV site.
3) As you get closer to the site and the catheter, stabilize the catheter and remove the rest of the tape from the patient's skin.
4) Then place a 4 x 4 gauze over the site and gently slide the plastic catheter out of the patient's arm.
5) Use direct pressure for a few minutes to control any bleeding. Finally, place a band aide over the site.
Complications:
2) Cellulitis,
3) Infiltrate,
5) Phlebitis,
Blood Transfusion
Blood transfusion is the process of transferring blood or blood-based products from one person into the circulatory system of another.
Blood transfusions can be life-saving in some situations, such as massive blood loss due to trauma, or can be used to replace blood lost during surgery. Blood transfusions may also be used to treat a severe anaemia orthrombocytopenia caused by a blood disease. People suffering from hemophilia or sickle-cell disease may require frequent blood transfusions. Early transfusions used whole blood, but modern medical practice commonly uses only components of the blood.
a) group A blood contain type A agglutinogen,
b)group B blood contain type B agglutinogen,
c) group AB contain both A & B agglutinogens,
d) group O blood containe neither agglutinogen.
a) group A blood does not contain agglutinin A but does contain agglutinin B.
b) Group B blood does not contain agglutinin B but does contain agglutinin A.
c) Group AB blood contain neither agglutinin
d) group O contain both anti A and anti B agglutinin.
Blood transfusion must be match to the patient blood type in term of compatible agglutinogen mismatch blood will cause hemolytic reaction.
Rhesus (Rh) and other factors
Rh antigen also on the surface of erythrocytes are present in about 85% of the population are can be a mayor cause of hemolyt
ic reaction. Persons who possess the Rh factor are referred to as Rh positive those who do not are referred to as Rh negative. Unlike the A and B agglitinogen, the Rh factor cannot cause a hemolytic reaction on the first exposure to mismatched blood, because the Rh antibody is not normally present in the plasma of Rh negative person.
3. Types of blood transfusions
Blood is transfused either as whole blood (with all its parts) or, more often, as individual parts. The type of blood transfusion you need depends on your situation. For example, if you have an illness that stops your body from properly making a part of your blood, you may need only that part to treat the illness.
Red blood cell transfusions
Red blood cells are the most commonly transfused part of the blood. These cells carry oxygen from the lungs to your body's organs and tissues. They also help your body get rid of carbon dioxide and other waste products. You may need a transfusion of red blood cells if you've lost blood due to an injury or surgery.
You also may need this type of transfusion if you have severe anemia due to disease or blood loss. Anemia is a condition in which your blood has a lower than normal number of red blood cells, or the red blood cells don't have enough hemoglobin. Hemoglobin – an iron-rich protein that gives blood its red color – carries oxygen from thelungs to the rest of the body.
Platelets and clotting factor transfusions
Platelets and clotting factors help stop bleeding, including internal bleeding that you can't see. Some illnesses may cause your body to not make enough platelets or other clotting factors. You may need regular transfusions of these parts of your blood to stay healthy. For example, if you have hemophilia A, you may need a special clotting factor to replace the clotting factor you're lacking. Hemophilia is a rare, inherited bleeding disorder in which your blood doesn't clot normally.
If you have hemophilia, you may bleed for a longer time than others after an injury or accident. You also may bleed internally, especially in the joints (knees, ankles, and elbows).
Plasma transfusions
Plasma is the liquid part of your blood. It's mainly water, but also contains proteins, clotting factors, hormones, vitamins, cholesterol, sugar, sodium, potassium, calcium, and more. If you have been badly burned or have liver failure or a severe infection, you may need a plasma transfusion.
Who needs a transfusion?
Plasma is the liquid part of your blood. It's mainly water, but also contains proteins, clotting factors, hormones, vitamins, cholesterol, sugar, sodium, potassium, calcium, and more. If you have been badly burned or have liver failure or a severe infection, you may need a plasma transfusion.
Who needs a transfusion?
Some people need blood or parts of the blood because of illnesses. You may need a blood transfusion if you have:
- A severe infection or liver disease that stops your body from properly making blood or some parts of blood.
- An illness that causes anemia, such as kidney disease or cancer. Medicines or radiation used to treat a medical condition also can cause anemia. There are many different types of anemia, including aplastic,Fanconi, hemolytic, iron-deficiency, and sickle cell anemias and thalassemia.
- A bleeding disorder, such as hemophilia or thrombocytopenia.
4.Transfusion reaction
Transfusion reaction can be categorized as hemolytic, febrile, circulatory over load and allergic. The nurse must asses a client closely for reactions. Sign of an acute reaction include;
a) sudden chills or fever,
b) low back pain,
c) drop in blood pressure,
d) nausea,
e) flushing agitation
f) respiratory disorders.
Sign of less severe allergic reaction include;
a) hives and itching but no fever.
Nursing management for transfusion reaction:
•Stop the transfusion. Maintain the intravenous line with normal saline solution
through new intravenous tubing, administered at a slow rate.
•Asses the patient carefully, compare the vital sign with those from the base line assessment.
•Notify the physician of the assessment findings and implement any order obtained.
•Notify the blood bank that a suspected transfusion reaction has occurred.
•Send the blood container and tubing to the blood bank for repeat typing and
culture, the identifying tag and number are verified.
Before commencing a blood transfusion determine:
1.Base line data regarding blood pressure, temperature, pulse and respiration.
2.Any previous reaction to a blood transfusion.
3.The request for blood transfusion form has been completed and send specimen for typing and cross matching
4.Purpose
1.Restore blood volume after hemorrhage
1.Restore blood volume after hemorrhage
2.Maintain hemoglobin levels in severe anemia
3.Replace specific blood component.
5. Assessment focus
Clinical signs of reaction (e.g. sudden chills, nausea, itching rash, dyspnea) status of infusion, site, any unusual symptoms.
Equipment
1.Unit of whole blood
2.Blood administration set either a straight line or a Y set ( Y set is preferred)
3.Normal saline solution
4.IV dressing (tegaderm)
5.Vena puncture set containing a 18 needle or catheter, or if blood is to be
administered quickly no 16 needle or a larger.
6.Alcohol swab
7.Tape
8.Disposable gloves (non Sterile)
6.Initiating, Maintaining and Terminating a Blood Transfusion
***Nursing Intervention
a.Pre Procedure
1.Obtain patient’s base line data before the transfusion.
•Asses base line data: Temp, Pulse, Respiration and Blood Pressure.
•Determine any known allergies or previous adverse reaction to blood.
Note specific signs related to the client's pathology and reason for transfusion
(e.g. an anemic client, note the hemoglobin level less than 10g/L).
2.Obtain the correct blood component for the patient.
•Check the physician's order with the requisition. See that doctor check and write
to start.
•Check the requisition form and the blood bag label with a specially check the
patient name, identification number, blood type and Rh group the blood donor
number, and the expiration date of blood.
•Ensure that doctor’s counter check and sign
•With another nurse (RN) compare the laboratory blood type round with :
•The client's name and identification number. Ask the patient to state the full name as a double check.
•The number on the blood bag label
•The patient’s blood group and label, amount of blood, calculate and adjust.
•Check blood for any abnormalities, gas bubles dark color or cloudiness, clots and excess air
•Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. Agencies may designate different times at which the blood must be returned to the blood bank if it has not been started. As blood component warm, the risk of bacterial growth also increases.
Rational :
If the patient’s Clinical status permits, delay transfusion if baseline temperature is greater than 38.50 C
b.Procedure
1.Wash and dry hands
2.If any pre medication order, give before transfusion
3.Prepare the patient
•Identify the patient and explain the procedure and its purpose to the patient such as blood product to be transfused, approximate length of time, and desired outcome of transfusion.
4.Assemble the equipment and bring to the patient
5.Wear gloves.
6.Positioning the patient comfortably
7.Prime the tubing with saline solution.( 50cc)
Establish the saline infusion See that the set used in appropriate, as sometimes
attached filter is not suitable for some product
8.If the patient has an intravenous solution infusing check whether the needle and solution are appropriate to administer blood. The needle should be no. 18 gauge or larger and the solution must be saline. If solution is not compatible remove it and dispose of it according to hospital policy. Dextrose which causes lysis of RBCs, Ringer's Solution, medication and other additives and hyper alimentation solution are incompatible.
9.If patient does not have an intravenous solution infusing, in the case you will
need to perform veni puncture on a suitable vein. Select a large vein that allows
patient some degree of mobility and place bed protector under the site. Start the
prescribed intravenous infusion
10.Establish the blood transfusion. Invert the blood bag gently several times to mix the cell within the plasma
11.Start infusion slowly at 2 ml/mnt. Remain at bed side for 5-30 minutes. If there are not sign of circulatory overloading, the infusion rate may be increased
12.Observe the patient closely for chilling, nausea, vomiting, skin rashes
tachycardia as they early sign and symptom reaction
13. check vital sign
a) 1st hour - every 15 minutes
a) 1st hour - every 15 minutes
b) 2nd hours- every 30 minutes
c) 3rd hours - every 60 munites
14) Report sign and symptoms of reaction immediately to physician to minimize consequences. Acute reaction may occur at anytime during the transfusion.
**If any reaction:
1) close clamp & run normal saline,
2) report to doctor,
3) Send urine FEME, FBC to lab.
4) complete blood form and send to blood bank together with unfinish blood bag.
5) continue observation.
Rational :
Rational :
The majority of acute fatal transfusion reaction are caused by clerical errors. Patient and product verification is the single most important fucntion of the nurse. It is strongly recommended that two qualified individuals perform this task. Do not proceed with the transfusion if there is any discrepancy. Contact the blood bank immediately
c. Post procedure
1) Give IV Lasix 20mg according doctor's order before complete transfusion.
2) Obtain vital sign and compare with base line assessment.
3) Document procedure in patient's medical record including:
•Product , blood type Rh, volume transfused, rate, site infused.
•Product identification number
•Name of individual verifying, patient ID, name of person starting and ending
transfusion.
•Patient assessment findings and tolerance to procedure.
•Monitor patient for response to and effectiveness of the procedure.
4) Flush with Normal saline about 50cc after finish transfusion
5) Terminate the transfusion
Discard administration set according to policy procedure.
(i.e. If any reaction, save the set for further investigations)
Rational :
Rationale it must be possible to trace each transfusion product to the originalDiscard administration set according to policy procedure.
(i.e. If any reaction, save the set for further investigations)
Rational :
blood donor
