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355 test 1
| Question | Answer |
|---|---|
| homeostasis can be disrupted by | Illness / Disease Colonoscopy Prep Diuretics Fluid Restrictions Blood Loss |
| what is homeostasis | What the body is all about! The body’s ability to maintain a stable environment Right amount & location of fluid & electrolytes |
| Intracellular Space (inside the cells) | Interstitial fluid [ICF] : Fluid inside the cells |
| Extracellular Space (outside the cells) | Interstitial Space The “in-between space” between cells & outside vessels Intravascular (plasma) Veins, arteries, capillaries Transcellular Can’t access ex- Urine, digestive secretions, sweat, CSF |
| cations | Positively charged ions (cations) Na +, K +, Ca2+ , Mg2+ |
| anions | Negatively charged ions (anions) Cl -, HCO3 - , PO43- |
| electrolytes are essential for | Maintain fluid balance between spaces Regulate acid-base balance |
| diffusion | What moves? Solutes High to low Natural movement (no energy source needed) Walking through an open door |
| facilitated diffusion | What moves? Bigger Particles / Solutes What’s different? Requires help! Protein Carrier High to low Natural movement (no energy source needed) |
| Osmosis | What moves? Water Low to high Natural movement (no energy source needed) Osmosis = Only water movement |
| Active Transport | What moves? Low to high Active = Against the gradient (energy source IS needed! ATP) |
| Osmotic Pressure | Force created by solutes that pulls water toward them across a semipermeable membrane More solutes there are, greater the pull “Salt Sucks” |
| Osmolality | Number of solute particles per kilogram mOsm/kg More precise / preferred |
| Osmolarity | Number of solute particles per liter mOsm/L |
| Hypotonic Solution | Solutes are less concentrated than in cells Hypoosmolar Water moves into cell, causes swelling / potential bursting |
| Isotonic Solution | Same as cell interior No major fluid shifts |
| Hypertonic Solution | Solutes are more concentrated than in cells Hyperosmolar Water moves out of cell, causes shrinkage / potential cell death |
| Renal regulation | Kidneys filter & secrete Intake & Output Intake: Oral & IV Output: excretion & insensible losses GI Tract regulation: Diarrhea & Vomiting |
| Hypothalamic-Pituitary regulation | Hypothalamus Sensor + Thirst Center If you’re thirsty, you drink water Hypothalamus signals the Posterior Pituitary to release ADH *Think: ADH means you don’t PP* Purpose of ADH is to increase water reabsorption |
| Adrenal Cortical regulation | RAAS [Renin-Angiotensin-Aldosterone System] triggers release of Aldosterone when: Low BP / Low Blood Volume [think dehydration] Low Sodium levels High Potassium levels |
| Aldosterone | Hormone that helps the body reabsorb sodium and water and excrete potassium “Aldosterone makes you HOLD ON to sodium and water and excrete potassium" |
| ANP | Released in response to increased pressure within heart chambers to stimulate the ELIMINIATION of water & sodium in urine INHIBITS ADH & RAAS Patient excretes more urine |
| Hypovolemia | Decreased circulating blood volume Affects fluid within the blood vessels Loss of water & electrolytes in equal proportions |
| Hypervolemia | Increased circulating blood volume Affects fluid within the bloodstream Too much water & electrolytes |
| hypovolemia manifestations | high hr, low bp, low CVP, low O2 sat, thready pulse, decr cap refill, flat neck veins, dizzy, syncope, cool clammy skin, anorexia, sunken eyes |
| hypervolemia manifestations | ↑HR, ↑ BP, ↑ CVP, ↑ RR, Bounding pulse, distended neck veins , crackles, cough, dyspnea, visual changes, seizures, liver enlargment, weight gain, cool will pallor, periphreal edema |
| When would we use IV Therapy? | Unable to take substances orally Replace water, electrolytes, and nutrients more rapidly Provides immediate access to vascular system |
| Crystalloids | Contain no proteins or colloids Low cost Short half-life Fewer side effects Hypotonic, isotonic, hypertonic |
| colloids | Stay in vascular space & increase oncotic pressure Large insoluble molecules. Do not diffuse through membranes easily. All colloids affect blood coagulation, by interfering with coagulation factor VII, (albumin, fresh frozen plasma, blood) |
| Isotonic Solutions are ideal to replace | replace ECF volume deficit due to acute loss, such as diarrhea, blood loss |
| NS | isotonic, 0.9% Sodium Chloride [Normal Saline, NS, Saline] Used when both fluid and sodium are lost Only solution used with blood |
| LR | isotonic,sodium, potassium, chloride, calcium & lactate Expands ECF – ideal for surgery, trauma, burns & GI losses if ECF volume is too low, your body faces risks like low BP, organ injury, etc. |
| LR CAUTION | Caution with liver disease since it contains lactate |
| Hypotonic Solutions | 0.45%NS, D5W More dilute solutions & have a lower osmolality than body fluid movement of water into cells by osmosis – Dilutes ECF because more solvent than solute Replace deficits of total body water Hydrate cells but can deplete circulatory system |
| Hypotonic Solutions usual choice for | maintenance fluids but should be administered slowly to prevent cellular edema Monitor for changes in mentation because of cellular edema |
| dont give hypotonic solutions to | Patient’s at risk for increased ICP Extensive burn or trauma – they are already hypovolemic – will worsen |
| Hypotonic D5W – 5% Dextrose | Behaves differently in the bag vs. in the body! 5 grams of dextrose per 100mL Technically isotonic in the bag, but hypotonic in the body The body rapidly metabolizes the dextrose This “free water” moves into the cells, causing them to swell |
| Hypertonic Solutions examples | D5W in NS (D5NS) or D5W in 0.45% NS (D5 ½ NS) D5W in LR (D5LR) D10W or D20W or D50W 3% or 5% NS |
| Hypertonic Solution | Higher osmolality compared with plasma Draws water out of cells into ECF Electrolyte replacement & shift fluid from cells to vascular space Requires frequent monitoring of BP, lung sounds, serum sodium levels bc its in ecf |
| dextran | COLLOID, Volume expander Monitor for circulatory overload / increased bleeding No electrolytes included Increases plasma volume by 1 to 2 times Increases urine output |
| dextran treats | Treatment for severe hypovolemic shock, burn-related shock, hemorrhage, surgery, trauma |
| Hetastarch [Hespan] | Synthetic colloid volume expander Lasts 24-36 hours Treatment & prevention of dangerously low BP / hypovolemia *Monitor for fatal anaphylactic reactions |
| Albumin | Equivalent to plasma Pulls fluid back in bloodstream to prevent hypotension Available is 5% and 25% solutions Used to treat hypoproteinemia in burns and hypoalbuminemia in shock and ARDs support blood pressure in dialysis and acute liver failure |
| Mannitol | Osmotic Diuretic Makes water move to extracellular & vascular spaces Comes in 5%, 15%, 20%, 25% solutions No dilution required All crystals must be dissolved to infuse |
| Mannitol treats | Treatment of ARF, cerebral edema (decreases ICP), generalized edema |
| what to monitor on mannitol | Monitor electrolytes May induce dehydration with hyperkalemia, hypokalemia, or hyponatremia 20% & 25% solutions are vesicants |
| Sodium | 135-145 mEq/dL, ECF cation Diffusion through active transport that is controlled by the sodium-potassium pump Fluid balance, muscle contraction, nerve signaling |
| Potassium | 3.5-5.0 mEq/dL Major ICF cation Regulated by the kidneys |
| sodium is regulated in | the kidneys |
| causes of Na imbalance hypernatremia | Too much sodium; not enough water •Water loss • •Hyperventilation • •Heat stroke • •Insufficient ADH - Diabetes insipidus • •Loss of thirst mechanism • •Inadequate water intake |
| causes of Na imbalance hyponatremia | Too much water; not enough sodium •Drinking water for fluid replacement •Inadequate sodium intake Loss of sodium-containing fluids •Psychogenic polydipsia •D5W •Hormonal imbalances - insufficient aldosterone, adrenal insufficiency, SIADH |
| Manifestations of Sodium Imbalance hypernatremia | CONCENTRATED, Fluid shift out of the cells due to increased osmotic pressure of interstitial or extracellular fluid Thirst; tongue and mucosa dry and sticky Weakness, lethargy, agitation Edema Elevated BP, tachycardic Decreased urine output |
| hyponatremia manifestations DILUTE | poor nerve conduction.cramps,N/V, anorexia, lethargy, weak Late - bad resp movement R/T skeletal muscle Decr osmo. pressure in extracell: fluid shift into cells results in hypovolemia & low BP Swell in brain - confusion, headache, seizures; late – coma |
| treat hypernatremia | Restrict sodium Dilute with sodium-free fluids to make sodium go down Daily weights I & O Recheck labs |
| treat hyponatremia | Fluid restriction Needs sodium Hypertonic saline if having neuro problems 3% or 5% NS |
| Severe Hyponatremia | Sodium [Na] <120 mEq/L Severe symptoms such as seizures, coma Give small amount of IV hypertonic saline solution (3% NaCl) |
| monitor what for severe hyponatremia | At risk for osmotic demyelination injury if hyponatremia is corrected too quickly Monitor for lithium toxicity because hyponatremia slows lithium excretion Monitor frequent VS, strict I & O, serial sodium levels |
| why dont we rehydrate hyponatremia pts quick | bc it can cause ODS causes damage to myelin sheath |
| potassium necessary for | Resting membrane potential of nerve and muscle cells Regulates intracellular osmolality Promotes cellular growth Maintenance of cardiac rhythms Acid-base balance |
| hyperkalemia causes | Renal failure Deficit of aldosterone Potassium-sparing diuretics – spironolactone Massive cell destruction Metabolic acidosis |
| hypokalemia causes | Abnormal losses from kidneys or GI tract Excessive aldosterone or glucocorticoids (Cushing’s syndrome) Decreased dietary intake - alcoholism, eating disorders, starvation Treatment of diabetic ketoacidosis with insulin |
| hyperkalemia manifestations | Cardiac dysrhythmias & conduction Bradycardia Prolonged PR interval, flat or absent P waves Widened QRS complex Depressed ST segment Tall & peaked T waves Conduction blocks, ventricular fibrillation |
| hypokalemia manifestations | Cardiac dysrhythmias - prolonged repolarization and eventual arrest Slightly prolonged PR interval, peaked P wave ST depression Shallow T wave Lethal ventricular - PVCs, ventricular tachycardia |
| hyperkalemia treat | Sodium polystyrene sulfonate kayexalate Dialysis |
| hypokalemia treat | PO or IV potassium chloride Causes GI upset - give with food Assess output before & during administration Increase dietary potassium |
| Potassium-Containing Foods | Spinach, Fennel, Kale, Mustard greens, Parsley Brussels sprouts Cabbage Broccoli, Cauliflower Banana Potatoes (white or sweet) |
| what to stabilize and monitor for hyperkalemia | Stabilize cardiac cell membrane by administering calcium chloride or calcium gluconate IV Force Force K+ from ECF to ICF by IV regular insulin with dextrose Monitor Use continuous ECG monitoring |
| potassium admin | NEVER give IV Push, IM injection, or SQ injection! Always dilute IV KCl (10mEq in 100 mL) Never give by gravity – need an infusion pump Should not exceed 10 mEq/hr unless in critical care with cardiac monitoring |
| calcium | 9.0-10.5 mg/dL ECF cation Formation of teeth and bone Blood clotting Transmission of nerve impulses, muscle contractions |
| calcium ingested and stored in | Ingested in food, stored in bone, and excreted from the body in the urine and feces Controlled by parathyroid hormone (PTH) and calcitonin Also influenced by vitamin D and phosphate ion levels |
| causes of hypercalcemia | Uncontrolled release of calcium ions from the bones Hyperparathyroidism causes ⅔ of the cases Cancer - hematologic, breast, or lung Thiazide diuretics immobile Increased intake of calcium due either to excessive vitamin D or excess dietary calcium |
| causes of hypocalcemia | Decrease in the production of parathyroid hormone Radical neck surgery Malabsorption syndrome Deficient serum albumin Alkalosis Renal failure |
| hypercalcemia manifestations | Depress neuromuscular activity Interferes with ADH in the kidneys Less water Polyuria, thirst Cardiac Contractions increase in strength Dysrhythmias Incr BP May contribute to the formation of kidney stones in the urinary system |
| hypocalcemia manifestations | Incr in the permeability and excitability of nerve membranes muscle twitching, carpopedal spasm, and hyperactive reflexes, larynospasm Paresthesia, cramps confusion, irritability Heart contractions weak, delayed conduction, arrhythmias, & BP drops |
| tests for hypocalcemia | Chvostek's sign: Contraction of facial muscles in response to a light tap over the facial nerve in front of the ear Trousseau's sign: Carpal spasm induced by inflating a BP cuff above the systolic pressure for a few minutes |
| treat hypercalcemia | Restricting dietary calcium Promoting urinary calcium excretion with loop diuretics Hydrating the patient with isotonic saline infusions Move! Safety precautions |
| Medications that decrease serum Ca: | Bisphosphonates Calcitonin |
| hypocalcemia treat | Oral or IV calcium supplementation Vitamin D Phosphate binders to excrete phosphate & ↑ Ca Sevelamer hydrochloride Calcium acetate |
| Calcium Imbalance Medications | IV 10% calcium gluconate Warm injection solution to body temperature, administer slow, monitor ECG, observe infiltration |
| Medications that increase calcium absorption | aluminum hydroxide reduces phosphorus levels, causing the countereffect of increasing calcium levels Vitamin D aids in the absorption of calcium from the intestinal tract |
| Hypocalcemia Safety | Provide a quiet environment to reduce environmental stimuli Initiate seizure precautions Move the client carefully, and monitor for signs of pathologic fracture |
| Phosphate | 3.0-4.5 mg/dL Primary anion in ICF Essential to function of cell membrane regulation, muscle, RBC, nervous system Involved in acid-base buffering system, ATP production, cellular uptake of glucose, and metabolism of carbohydrates, proteins, and fats |
| phosphate found in | bones and teeth, reciprocal relationship to calcium |
| causes of hyperphosphatemia | Acute kidney injury or chronic kidney disease Tissue damage or cancer chemotherapy Hypoparathyroidism |
| causes of hypophosphatemia | Malabsorption syndromes Diarrhea Excessive use of antacids Alkalosis Hyperparathyroidism |
| hyperphosphatemia manifestations | Neuromuscular irritability & tetany Calcified deposits in soft tissues Same as those of hypocalcemia |
| hypophosphatemia manifestations | Tremors Weak reflexes Paresthesia Confusion Anorexia Dysphagia |
| treat hyperphosphatemia | Correct any hypocalcemia Limit foods and fluids containing phosphorus Oral phosphate-binding agents that promote excretion of phosphorus – sevelamer (Renagel), calcium acetate (Phos-Lo) Take with meals or immediately after meals Hemodialysis |
| treat hypophosphatemia | Increase oral intake of phosphorus-containing foods Avoid foods high in calcium IV administration of sodium or potassium phosphate when levels fall below 1 mg/dL Move client carefully & monitor for pathologic fracture |
| Phosphorous-Containing Foods | dairy, nuts, seeds, pb, beans, peas, bran cereals, whole grains, cocoa bevs, ale, beer, choco drinks |
| magnesium | 1.8-2.6 mEq/L 2nd major ICF cation Cofactor in enzyme for metabolism of carbohydrates |
| magnesium functions | Required for DNA and protein synthesis Blood glucose control BP regulation Needed for ATP production Acts directly on myoneural junction Important for normal cardiac function |
| hypermagnesemia causes | Renal insufficiency or failure with increased magnesium intake Antacids & laxatives that are magnesium-based |
| hypomagnesemia causes | Hypomagnesemia results from malabsorption or malnutrition, often associated with chronic alcoholism Diabetic ketoacidosis Hyperparathyroidism Hyperaldosteronism Increased GI or kidney losses |
| Hypomagnesemia | relation to low potassium Correct the magnesium before the potassium Low magnesium prevents potassium from being reabsorbed Oral supplements to treat may cause diarrhea Can cause torsades de pointes and ventricular fibrillation |
| hypermagnesemia manifestations | sedating, Depressed neuromuscular function Initially, hypotension, facial flushing, lethargy, and nausea and vomiting With rising levels, decreased or absent deep tendon reflexes > somnolence > respiratory and cardiac arrest |
| Hypomagnesemia manifestations | Neuromuscular & CNS hyperirritability Tremors or chorea (involuntary repetitive movements) Insomnia Confusion & personality changes Increased heart rate with arrhythmias Hyperactive deep tendon reflexes Seizures |
| hypermagnesemia treat | Avoiding magnesium-containing medications and foods Diuresis IV calcium gluconate - very slowly, stabilizes potassium Ventilator if respiratory rate < 12 Dialysis |
| Hypomagnesemia treat | Oral or IV supplements Check kidney function before & during administration Seizure precautions |
| IV magnesium when severe | No IM Causes pain & tissue damage Initiate seizure precautions Monitor serum magnesium levels frequently Monitor for decreased DTR suggesting hypermagnesemia during administration |
| Too much magnesium too fast can cause: | Flushing, sweating, hypotension, circulatory collapse and depression of cardiac & central nervous system function… stop medication if you see any of these! |
| Peripheral IV (PIV) Catheters | Inserted peripherally into a vein Final tip resides in a location that is appropriate for the pH and osmolarity of the solution or medication |
| PIV Catheter Sizes | At least size 20g Maintenance fluids Blood administration |
| Midline Peripheral Intravenous Catheters | Over-the-needle catheter Inserted through peripheral vein Tip resides in peripheral vein Longer Catheter Longer placement |
| what veins to avoid for iv | Inner aspect of wrist Bend of wrist Elbow |
| Applying a Tourniquet | 3 – 4 inches above site Don’t leave on longer than one minute Excess should point away from insertion site |
| Site Preparation | Do not shave with a razor May use clippers Solutions used to clean: Chlorhexidine Gluconate (recommended) Iodophor (Povidone – iodine) 70% isopropyl alcohol |
| Intermittent Flush Procedure: SAS Method | Check for patency-vein is open Flush with 0.9% NS per hospital policy Administer medication (if indicated) Flush with 0.9% NS using push – pause technique after medication is administered |
| Complication IV: Air Embolism | Tachycardia, chest pain, dyspnea, hypotension, cyanosis, decreased LOC Prevention: Prime tubing with fluid before use & monitor for air bubbles Secure all connections Replace the IV fluid before bag is empty |
| Complication IV: Air Embolism interventions | Clamp tubing Turn client on left side in Trendelenburg position Notify provider |
| Complication: Catheter Embolism s/s | Hypotension Pain along vein Weak, rapid pulse Cyanosis of nail beds Loss of consciousness |
| Complication: Catheter Embolism prevention | Insert & remove catheter carefully Inspect catheter when removed Interventions, if suspected: Place a tourniquet as proximally as possible to IV site Notify provider Prepare to get an X-Ray |
| Complication: Circulatory Overload | Fluid overload from administering fluids too rapidly Signs & Symptoms: Hypertension Distended neck veins Rapid breathing Dyspnea Moist cough Crackles |
| Complication: Circulatory Overload prevention/interventions | Identify clients at risk Calculate flow rate Use an IV pump & monitor flow rate Interventions, if suspected: Decrease flow rate to a KVO rate Elevate HOB Notify provider |
| Complication: Hematoma | Collection of blood in the tissues after unsuccessful venipuncture or after catheter removal & blood continues to ooze into the tissue |
| Complication: Hematoma s/s | Ecchymosis Immediate swelling & leakage of blood at the site Hard & painful lumps at the site |
| Complication: Hematoma prevention | IV Start: Avoid piercing the posterior wall of the vein, and do not apply a tourniquet to the extremity immediately after unsuccessful venipuncture IV Removal: Apply pressure for 2-3 minutes & elevate the extremity |
| Complication: Hematoma interventions | Elevate the extremity Apply pressure & ice |
| Complication: Infection | Entry & proliferation of microorganisms at the venipuncture site Risk is increased the longer therapy continues Can occur locally or systemically |
| Complication: Infection s/s | Local: Redness Swelling Drainage at the site Systemic: Chills + Fever Malaise Headache Nausea / Vomiting Backache Tachycardia |
| Complication: Infection prevention | Maintain strict asepsis Monitor WBC count Check fluid containers for cracks, leaks, cloudiness, contamination |
| Irritant | Causes discomfort or pain along the internal lumen of the vein Examples: Amiodarone Numerous Antibiotics Diazepam |
| Vesicant: | Causes blistering, tissue sloughing, necrosis if escapes the vein Examples: Numerous Chemotherapeutic medications Promethazine TPN Vancomycin |
| Complication: Infiltration | Seepage of the IV fluid out of the vein and into the surrounding interstitial spaces Signs & Symptoms: Edema Pain Numbness & Coolness at site Pallor May or may not have blood return |
| infiltration prevention | Avoid venipuncture over an area of flexion Anchor the catheter and extension securely, use an arm board if restless or active Monitor IV flow rate for decreased or cessation of flow Evaluate IV site for infiltration |
| Interventions, if suspected infiltration: | Move infusion to another IV site Remove the infiltrated IV device immediately Elevate the extremity & apply a compress Compress temperature will depend on type of fluid Do not rub the infiltrated area Can cause a hematoma |
| Phlebitis | most common Inflammation of the vein that can occur from mechanical or chemical (medication) trauma or from a local infection Heat, redness, tenderness at the site; not swollen or hard; IV infusion sluggish |
| Thrombophlebitis | If a clot forms, Hard & cord-like vein, heat; redness; tenderness at site; IV infusion sluggish |
| Complication: Phlebitis & Thrombophlebitis prevention | Use a catheter smaller than the vein Avoid using very small veins when administering irritants Avoid using the lower extremities Avoid areas of flexion Anchor catheter & extension; use an arm board if needed Change site per hospital policy |
| Interventions, if suspected phlebitis | Remove IV device immediately & restart in opposite extremity Notify provider Apply warm, moist compress If thrombophlebitis, do not flush the catheter |
| Complication: Tissue Damage & Extravasation | Most commonly damaged tissue includes skin, veins, & subcutaneous tissue Signs & Symptoms: Skin tears Skin color changes Sloughing of skin |
| Complication: Tissue Damage & Extravasation prevention | gentle approach when applying a tourniquet Avoid taping the skin over the vein when starting IV Monitor for ecchymosis when penetrating the skin with the cannula Assess for allergies to tape or adhesives Monitor site for color change |
| Complication: Tissue Damage & Extravasation interventions | Stop infusion immediately Apply cool compress Notify provider Administer antidote when appropriate |
| AUTOLOGOUS transfusion | •Client’s own blood •Before a scheduled procedure •5 weeks before procedure •Reduces risk of disease transmission & transfusion complications |
| BLOOD SALVAGE | •Client’s own blood •During surgery / trauma • Needs to be “washed” to remove tissue debris •Immediate availability, decreases blood waste, lowers risk of transfusion reaction |
| DESIGNATED DONOR | •Compatible family or friend selected by client •Before transfusion •Does not reduce risk of disease transmission, but gives comfort in knowing where the blood comes from |
| ALLOGENIC | •Unknown volunteer donor •Before transfusion •Blood Bank •Widely available + Lifesaving •Rigorously screened and tested |
| Compatibility | Type and crossmatch sample Drawn from client Recipient ABO type & Rh type are identified Antibody screen Determines presence of antibodies other than anti-A and anti-B |
| Crossmatching | Using recipient serum & Coomb’s serum to ensure no RBC agglutination Coomb’s Serum: Solution used to detect antibodies attached to RBCs Agglutination: Antibodies attach to antigens on RBCs, causing the cells to clump together |
| Blood Types | Type A: A antigens and B antibodies Type B: B antigens and A antibodies Type AB: A and B antigens and NO antibodies Type O: No antigens and both A and B antibodies |
| universal donor | O- is universal donor bc nothing for recipient antibodies to attack |
| universal recipent | AB + universal recipient bc it has no antibodies |
| Rh System | D-Antigen D antigen present? Rh-positive D antigen absent? Rh-negative |
| Human leukocyte antigen (HLA) system | Genes and protein products located on surface of WBC Involved in immune regulation If HLA is found on WBC, can lead to hypersensitivity & even organ failure, so we give irradiated RBCs Self vs nonself |
| Who Gets What? | A negative can “fit” into a positive A positive cannot “fit” into a negative Negative gets negative Positive gets both |
| Packed Red Blood Cells [PRBC] | Used to replace erythrocytes Infuse within 4 hours of initiation Starts when you leave the blood bank Each unit increases the hemoglobin by 1 g/dL and hematocrit by 3% Change in lab values takes at least one hour after completion |
| Leukocyte-poor or reduced PRBC | Leukocytes, proteins, plasma are removed or reduced Used to restore oxygen-carrying capacity & intravascular volume Replaces RBCs while preventing febrile, nonhemolytic transfusion reactions |
| Washed PRBC | Depleted of plasma, platelets, leukocytes Given to those with history of transfusion reactions or hematopoietic stem cell transplants |
| Irradiated Packed Red Blood Cells [PRBC] | Replaces RBCs while preventing transfusion-associated graft-versus-host disease (TA-GvHD) PRBCs exposed to a special dose of gamma radiation Radiation inactivates donor lymphocytes Makes the donor’s immune cells unable to divide or attack |
| Irradiated Packed Red Blood Cells [PRBC] uses | Used in immunodeficient patients Bone marrow transplants Hematologic malignancy Any blood component can be irradiated |
| Whole Blood | Replaces red cell mass and plasma volume When you need COMPLETE replacement Massive acute hemorrhage Massive transfusion protocol Limited-resource or emergency settings Infuse within 4 hours of initiation |
| Platelets | Used to treat thrombocytopenia & platelet dysfunctions Requires type but not cross-match since there are no RBCs Usually done anyway Administer rapidly within 6 hours of pooling – over 15-30 minutes |
| Fresh Frozen Plasma [FFP] | Used to replace all clotting factors without RBC or platelets & control bleeding when replacement of coagulation factors is needed (e.g., DIC). Patient is actively bleeding / about to bleed / clotting factors are low Contains no platelets |
| Fresh Frozen Plasma [FFP] infuse within | 2 hours of thawing, while clotting factors are still viable Infuse over 15-30 minutes Evaluate effectiveness by coagulation studies (PT, PTT) & resolution of hypovolemia Requires type & cross-match |
| Cryoprecipitate | Prepared from FFP Used to replace only certain clotting factors Given often with Factor VIII & low fibrinogen (r/t massive bleeding) Can be stored for 1 year but once thawed must be used Infuse over 15-30 minutes |
| blood transfusions precautions | No solution other than normal saline! Never add medications into a blood transfusion 1 unit over 4 hours at a time to prevent complications Never exceed 4 hours Administer within 20-30 minutes of receiving from Blood Bank Have the client void |
| Client Identity & Compatibility blood | CRITICAL STEP: Confirm product compatibility, client identity, expiration data on product Two licensed nurses (according to policy) to check blood products & client identity at the bedside Scan barcodes Read armband + blood label |
| Transfusion Administration | Maintain standard & transmission-based precautions 20 gauge or larger peripheral IV (18 gauge is preferred) Check the volume on the bag Pre-medicate the client 30 minutes before with PO acetaminophen or diphenhydramine ONLY if / as prescribed |
| Transfusion Reactions | Stop the transfusion – DO NOT THROW ANYTHING AWAY Change the IV tubing down to the site Keep the IV open with a new bag of normal saline Notify the provider Do not leave the client alone Monitor vital signs q5 minutes |
| Circulatory Overload | Caused by the infusion of blood at a rate too rapid for the client to tolerate Assessment Cough, dyspnea, chest pain, wheezing Headache Hypertension, tachycardia, bounding pulse, distended neck veins |
| Circulatory Overload interventions | Place client in upright position with feet in dependent position Notify provider Administer oxygen, diuretics, morphine sulfate as prescribed Monitor for dysrhythmias |
| Septicemia | Occurs with the transfusion of microorganism-contaminated blood Assessment Rapid onset of chills & high fever Vomiting, diarrhea Hypotension, shock |
| Septicemia interventions | Notify the provider Obtain blood cultures & cultures of blood product Administer oxygen, IV fluids, antibiotics, vasopressors, and corticosteroids as prescribed |
| Iron Overload | A delayed transfusion complication that occurs in clients who receive multiple blood transfusions Anemia & Thrombocytopenia Assessment Vomiting, diarrhea Hypotension Altered hematological values |
| Iron Overload interventions | Deferoxamine IV or subcutaneously – removes accumulated iron via the kidneys Turns urine red as iron is excreted Continue until serum iron levels return to normal |
| Hypocalcemia blood | Citrate in transfused blood binds with calcium & is excreted Assess serum calcium before & after transfusion Monitor for signs of hypocalcemia Slow transfusion & notify provider if signs of hypocalcemia occur |
| Hyperkalemia | Stored blood releases potassium through hemolysis older the blood, the greater the risk Administer fresh blood in presence of renal insufficiency or renal failure Assess date on blood & serum potassium before & after transfusion,Monitor potassium |
| Febrile Non-Hemolytic Transfusion Reaction [FNHTR] | Most common type Occurs in first 30 minutes up to 2 hours post-transfusion Antibodies attack donor WBC’s Fever 1°C or 2°F above baseline |
| Acute Hemolytic Transfusion Reaction [AHTR] | ABO incompatibility Severe flank pain, blood in urine, flushing of face, burning sensation along a vein, headache, chills, fever, lumbar pain, abdominal pain, chest pain, N/V, blood in urine, hypotension, ↑HR, dyspnea Occurs in first 15 minutes |
| Transfusion Reactions in an Unconscious Client | Weak pulse Fever Tachycardia or bradycardia Hypotension Visible hemoglobinuria Oliguria or anuria |
| Transfusion-Associated Graft-versus-Host Disease | Donor cells attack recipient tissue-organ failure Can occur days to years after a transfusion Fever, mild jaundice, decreased hematocrit level Highest risk in immunocompromised clients Death due to bleeding or infection |
| Mild Allergic Reaction blood | Antibodies react against donor proteins Urticaria, itching, wheezing, angioedema, hives, facial flushing Can occur anytime during up to one hour after |
| Anaphylactic Reaction blood | Severe Recipient antibodies interact with allergenic proteins Severe hypotension, ↑HR, flushed skin, urticaria, chills, loss of consciousness, shock state, bronchospasm |
| citrate is a | calcium magnet |
| balance of water and electrolytes | thirst-hypothalamus senses bodies fluid volume ADH from posterior pituitary-release leads to reabsorption of water from the kidney tubles so you PP less |
| hydrostatic pressure | PUSHES fluid |
| osmosis | pulls fluid to higher concentration |
| major cation in ecf | sodium |
| major icf cation | potassium |
| what cells react the quickest when there is fluid change | neuro cells |
| thiazide diuretics increase | sodium excretion |
| CVAD | Catheters placed in large blood vessels Subclavian-[preferred site], Jugular-secretions could get in, or Femoral Veins-urine/sweat could seep in Tip of catheter resides in the superior vena cava or inferior vena cava [femoral] |
| reasons for cvad use | Peripheral veins are no longer adequate Vesicant-worse/irritant drug or solution administration Hyperosmolar solutions-Serum osmolarity > 600 mOsm/L pH <5.0 or > 9.0 Parenteral Nutrition with dextrose concentration >10% IV longer than a week |
| CVAD advantages | Immediate access Decreased venipunctures Risk of extravasation decr Vesicant, blood, parenteral nutrition administration Hemodynamic monitoring Long-term placement can draw blood from them, emergencies |
| CVAD disadvantage | Increased risk of infection Invasive insertion |
| CVAD Assessment for Device Selection: | Lymph node dissection Lymphedema Subclavian stenting Presence of A/V graft and hemodialysis fistulas Thrombocytopenia Anticoagulation therapy |
| Non-Tunneled: | Goes directly from skin into vein Short-term duration Critically-ill patients Temporary dialysis access Short term IV therapy |
| Tunneled | Goes under the skin then into vein Long-term duration Long-term chemotherapy Long-term antibiotics Long-term parenteral nutrition Long-term dialysis |
| IHI Central Line Bundle | Institute for Healthcare Improvement (IHI) Central Line Bundle Hand hygiene Maximal sterile barrier precautions upon insertion Chlorhexidine skin antisepsis Optimal catheter site selection with avoidance of the femoral vein, review daily |
| Maximum Sterile Barrier Precautions | Use Maximal Sterile Barrier Precautions Cap Mask Sterile gown Sterile gloves Sterile full body drape All for the insertion of CVCs, PICCs, or guidewire exchange [14, 75, 76, 80]. Category IB |
| Non-Tunneled Devices sites of insertion | Internal Jugular Vein, Subclavian Vein, Femoral vein Placement must be verified with CXR prior to use Sutured in place RNs dont insert |
| Non-Tunneled: Quinton Catheter | Temporary Central Line for Dialysis Use Only Dialysis RNs should flush and care for Quinton No anesthesia required for insertion Can be used as central line only in DIRE circumstances |
| Non-Tunneled: Triple Lumen Catheter | Used for medication and fluid administration, CVP monitoring, blood sampling, blood administration Multiple lumens allows for incompatible meds to infuse through separate lumens Remain in place < 2-3 weeks No anesthesia required for insertion |
| Non-Tunneled: Swan Ganz Catheter | Measures pressures in the heart, medication and fluid administration, blood sampling, blood administration Sterile Sleeve to cover portion outside of body |
| Peripherally Inserted Central Catheter (PICC) | Therapy duration >1 week to 1 year Maximum Sterile Barrier Precautions Inserted & removed by RN’s with specialized training Site of Insertion Upper arm-basilic (most common), brachial, cephalic veins not sutured in place, no anesthesia |
| PICC | Medication & fluid administration Blood sampling Blood administration |
| PICC advantages | Eliminates insertion complication of a pneumothorax or hemothorax Decreased risk of air embolus Cost-effective At-home use |
| PICC disadvantages | Daily flushes and weekly dressing changes Can be difficult to draw blood from Increased risk of venous thrombosis than other CVADs Why? Longer distance to travel |
| Care & Maintenance of Short Term Devices | Hand hygiene Before and after any use of catheter Sterile dressing change q7 days If not wet or soiled If chlorhexidine pad is over insertion site No topical ointments Removal of catheter when no longer needed Flush with saline and heparin |
| Removal of short-term devices | Gently withdraw while patient performs the Valsalva maneuver bc air embolism, left Trendelenburg if we suspect embolism Apply pressure Catheter tip must be intact Apply occlusive dressing |
| Tunneled Catheter cuff | inhibits migration of organisms into catheter tract & keeps catheter in place in SQ tissue Less risk of infection |
| Hickman/Broviac: | Long-term therapy of hypertonic solutions, obtaining blood samples, administering blood, medications and fluid administration Requires heparin! |
| Groshong | Long-term therapy of hypertonic solutions, obtaining blood samples, administering blood, medications and fluid administration Three-way pressure activated valve at distal tip No heparin needed! |
| Tunneled Catheter Advantages | Decreased risk of blood stream infections Can remain in place for years May not require dressing after tunnel track is healed |
| Tunneled Catheter disadvantages | More costly surgical placement and removal than short term devices Require maintenance Body image concerns |
| Implanted Port | Type: Port-a-Cath Used for therapy in duration > 1 month to > 1 year Maximum Sterile Barrier Precautions Inserted by MD Patient receives local or general anesthesia for insertion Completely implanted under skin Least risk of infection long term |
| Implanted Port Advantages | Decreased risk of blood stream infections Can remain in place for years No dressing unless in use Minimal maintenance – monthly flushes Improved body image |
| Implanted Port disadvantages | More costly surgical placement & removal than short term devices Requires use of non-coring needle for access Risk of extravasation if needle is not placed in port on insertion |
| Implanted Port Accessing | Subclavian vein Tip in superior vena cava Is Accessed with non-coring Huber needle |
| Dressing Care long term catheters | No dressing if not accessed; no dressing on external tunneled once healed Transparent dressing over Huber needle when accessed Sterile technique; change per hospital policy Cleanse with chlorhexidine; NO topical ointments |
| Factors To Consider When Flushing CVADs | Flush at established intervals Volume & concentration of heparin flush SASH & positive pressure methods Syringe size Adhere to manufacturers guidelines Use of positive-pressure flushing technique. 10ml syringe |
| SASHY | saline, administer, saline, heparin, why is heparin needed |
| If continuous fluids are infusing | DO NOT flush with heparin!* *This will only become a bolus of heparin* |
| CVAD Complications insertion | Pneumothorax Hemothorax Malposition Hematoma |
| CVAD Complications indwelling | Central Line Associated Bloodstream Infection (CLABSI) Air embolism Thrombosis Fibrin Sleeve-sleeve develops around line creates inability to draw blood Occlusion |
| PICC line | bypasses lungs and highest risk for clots |
| Parenteral Nutrition | Administration of nutrition by route other than the GI tract (enteral) |
| Central Parenteral Nutrition (CPN) or Total Parenteral Nutrition (TPN) | Administration of nutrition through a central line |
| Peripheral Parenteral Nutrition (PPN) | Administration of nutrition through a peripheral line |
| Peripheral Parenteral Nutrition: PPN pt 2 | Used when not a candidate for enteral feeding <10% Dextrose; requires more fluid to dilute Given through peripheral vein High risk of phlebitis due to increased tonicity of fluids Treatment of malnourished or potential-to-be-malnourished patient |
| Total Parenteral Nutrition (TPN) pt 2 | Used also when not a candidate for enteral feeding; malnourished; support possibly needed for longer period 20-70% dextrose concentration; less fluid for dilution Must be given through central line |
| Total Parenteral Nutrition (TPN) nutrition | Provides calories, protein, electrolytes, vitamins, minerals Nutritionally complete Lipids can be given with (3 in 1) –fat, sugar, amino acids or in addition (2 in 1)-no fat Runs continuously |
| TPN disadvantages | Must have a central line May cause metabolic complications including hyperglycemia, hypoglycemia Must be weaned Hypoglycemia prevention Risk for Infection High glucose content Bugs love sugar Risk for Fluid volume overload Hyperglycemia |
| Renal Formula | Think renal diet Restricted electrolytes _____? Low protein Ex: NephrAmine |
| Hepatic Formula | Contains Branch-chained amino acids (BCAA) Ex: BranchAmine, HepatAmine |
| stress formula | high protein |
| Nursing Management assess feedings | Daily weights Glucose monitoring Sliding scale Daily electrolytes Infection assessment Check label and ingredients WEAN Dressing and tubing changes |
| TPN & PPN: filter | Filter with 0.22 micron filter Helps catch bacteria, tiny particles, etc. |
| lipids | Administered BELOW the filter THINK: Lipids are too BIG – will clog the filter |
| solutes | What is being dissolved |
| Lactated Ringer’s Solution prefered for | surgery… helps maintain better / normal pH than NS because of the lactate • Watch for liver disease! |
| IV Colors | 22? Blue. 18? Green. 20? Pink. • Remember: The bigger the number, the smaller the size. So… a 22g is a bigger number, but it’s a smaller size than a 20g. • Safe, “go-to” size? You typically want to have at least a 20g! |
| If the starter kit has both alcohol and chlorhexidine, what do you use first? | Alcohol first, then chlorhexidine last! What’s stronger as an antimicrobial? Chlorhexidine |
| f you suspect a catheter embolism, what should you do? | Think about what has happened… a catheter tip is not floating in the blood stream, so we want to stop that traveling. So, we place a tourniquet as proximal as possible to the IV site. Call the MD. |
| If you suspect circulatory overload | decrease that flow rate to KVO (keep vein open), and since the patient will be short of breath, raise the head of the bed so they can breathe easier |
| Blood Tubing | Make sure it is specific with the filter. You don’t use regular tubing here! • Always administer blood on an infusion pump |
| What’s the starting rate for blood administration? | 2mL/min o Can increase the rate after the first 15 minutes if everything is “normal” o Make sure to remember that the blood has to be administered within that four-hour mark… so, adjust the timing after the first 15 minutes accordingly |
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cwehner125