Course Task CU 7

Course Task CU 7 2. HYPOVOLEMIA A teenage patient was rushed to the emergency department due to wrist laceration from a suicide attempt. The patient is lethargic and have the following findings upon assessment: ● BP –80/50 mm Hg ● HR –110 bpm ● RR –25 bpm The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the remaining fluid to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was ordered to be transfused immediately after proper cross-matching. The patient was hooked to oxygen 8 liters per minute via face mask.

1. What parameters will the nurse check while the patient is undergoing rapid fluid resuscitation? ● ● ● ● ●

Regularly monitor the vital signs Temperature Pulse Respiration Blood pressure

-Fluid management is an important feature of patient care, particularly in the inpatient medical setting. Fluid management is both tough and exciting because each patient's fluid needs must be carefully considered. Unfortunately, there is no way to apply a single, precise recipe to all patients. However, one fundamental guideline that applies to all patient settings is to restore whatever fluid is lost as precisely as feasible. These fluid losses can vary in amount and composition depending on the medical circumstances of the individuals. The following are some signs that can indicate if a patient is fluid-depleted or volumeoverloaded: Weight: Body weight is one of the most sensitive indicators of changes in patient volume status. To measure fluid status, patient weight fluctuations are used to approach a gold standard. Heart rate: Tachycardia can be a compensatory physiological response to maintain perfusion in the presence of hypovolemia. Blood pressure: Falling blood pressure is a concerning result in the presence of tachycardia, indicating that the cardiovascular system can no longer sufficiently adjust for hypovolemia. Hypervolemia, on the other hand, can cause high blood pressures. Respiratory rate: Increased respiratory rate implies a compensatory reaction to metabolic acidosis caused by lactic acidosis due to inadequate tissue perfusion.

2. For a patient who will undergo blood transfusion, enumerate the steps that the nurse should prudently undertake while performing the procedure.

Ensure that the correct preparation of the patient and the care procedure is done. a. Double-check the order for transfusion and correlate this with the clinical diagnosis and care plan of the patient. b. Verify the blood type of the patient on the chart. If needed, obtain a request for blood typing. c. Once blood to be transfused or a donor is available, request for crossmatching to be done. A sample will be obtained from the patient and from the donor/blood pack and tested. d. After cross matching is done, a request for the number of units to be transfused should be made. e. NOTE: Universal donor is blood type O-, while type AB+ is the universal recipient. Obtain consent. The consent must be obtained prior to starting any invasive procedure or therapy. NOTE: The physician is the one explaining the procedure and asks the patient to sign the form. The role of the nurse is to witness the signing. f. Assess for any allergies the client may have. g. Ask the client for any previous blood transfusion and their reaction to it. i. If the patient has had a BT before, the physician may need to prescribe premedication to prevent a febrile non-hemolytic reaction, common with patients who have had several blood transfusions done. ii. Usual premedication given is Benadryl (diphenhydramine) and acetaminophen, 30 minutes to 1 hour before transfusion. h. Verify the BT order. Check the patient record and the order of the physician. The following are verified: i. Patient identification and the information about the patient from the blood bank; ii. Results of typing and crossmatching;

iii. Expiration date of the blood product to be administered. i. Warm the blood products. j. Determine the correct gauges of IV needles. Usual IV needles from a blood transfusion are gauge 18 0r 16. Larger bore needles are needed for BT because it allows the passage of RBCs. k. Ensure proper IV tubing and access site. Y-tubing with an in-line filter is typically used for BT. If the patient needs any other IV fluids, this is administered on another line. l. Prime the line. The BT line is primed prior to the administration of BT. 0.9% NaCl is used to prime the line and is the only compatible IV fluid with blood transfusions. NOTE: Once the line is primed, the BT can be started. m. Obtain vital signs. These vital signs are taken prior to the start of the BT and several times during the BT. Blood pressure, temperature and pulse rate can be used as indicators of potential adverse reactions to transfusion. n. Start the transfusion. Ensure that the patient is positioned comfortably since the BT may last for anytime between 30 minutes to 4 hours. o. Monitor patient response to the therapy. Apart from vital signs, the patient may be assessed for the following: i. Rashes. This is an indication of an allergic reaction either to the blood type or the additives in the blood products. ii. Chills. A sign of a pyrogenic reaction, especially when this is seen in the patient with an increase in temperature. iii. Shortness of breath. This is a sign of hemolytic reaction and necessitates the stopping of the transfusion. iv. Headache, back pain, nausea and vomiting. p. NOTE: If using an infusion pump, set the pump at 2mL/min for the first 15 to 30 minutes of transfusion and monitor the patient’s response. Vital signs must be monitored as per the following schedule: i. At the first 5 minutes after starting the transfusion; ii. 15 minutes after transfusion started;

iii. On the 30th minute; iv. Every hour until the transfusion is done; v. 1 hour after the transfusion is over. q. Once transfusion is done, the line should be flushed with normal saline solution. If there are no more succeeding transfusions, the line is discontinued, and the BT set is disposed of properly.

3. List down three (3) priority nursing diagnosis for the patient and create a hypothetical FDAR. Three Nursing Diagnosis: · Fluid imbalance- decreased blood volume patient with laceration in wrist after suicide attempt, blood pressure of 80/50 mmHg, heart rate of 110 bpm, and respiratory rate of 25 bpm. · Decreased cardiac output- The patient has a blood pressure of 80/50 mmHg and has a decreased cardiac output blood loss. · Risk for hopelessness- A laceration on the wrist of a suicidal attempt. FDAR: FOCUS Enhance the patient's condition. Improve the patient's mental state

DATA Subjective: Suicide attempt

Objective: l BP-80/50 mmHg l HR - 110 bpm l RR - 25 bpm

ACTION l Administer 1L of PNSS to a fast-drip 200c, then run the remaining fluid for 6 hours as directed by the doctor for fluid resuscitation. l Administer three units of whole blood, which should be transfused

RESPONSE After performing and administering procedures , patient condition is alleviated. Patient undergo psychological assessments , interventions and treatments to improved mental and cognitive condition.

promptly following adequate crossmatching. l

Check the patients' oxygen levels. Provide the patient with a psychologica l evaluation and intervention.

3.THIRD SPACE EDEMA A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in the surgical ward. The patient presented with emaciated body build, distended abdomen with prominent veins, and jaundice. The doctor ordered paracentesis and the following laboratory tests prior to the procedure: Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT), Total Protein, Albumin-Globulin ratio, AST, ALT.

1. List down two (2) nursing diagnoses and create a hypothetical FDAR for the patient. Two Nursing Diagnosis: · Increased cardiac output- ) increased pressure within the portal vein · Imbalanced nutrition / improper diet- patient presented with emaciated body build, distended abdomen with prominent veins, and jaundice.

FDAR: FOCUS

DATA

ACTION

RESPONSE

Improve the patient's condition. Alleviate

Subjective: Suicide attempt

Objective: l Emaciated body build. l Distended abdome n w/ promine nt veins. l Jaundice.

Discuss arrangements for paracentesis. Prior to the procedure, assist the patient with the following blood tests: Prothrombin time (PT), Activated Partial Thromboplastin Time (APTT), Total Protein, AlbuminGlobulin ratio, AST, ALT. Keep an eye on the patients' vital signs and overall health. Provide health education on correct diet and living a healthy lifestyle.

After completing the action, the patient's condition improved, and he informed the nurse of his awareness of health lifestyle and food.

2. Why is there a need to check the PT and APTT levels of the patient prior paracentesis? PTT and APTT levels are measured to determine or assist doctors in assessing the body's potential to develop blood clots. Bleeding sets off a chain of events known as the coagulation cascade. Coagulation is the mechanism through which your body stops bleeding. The thromboplastin time (TPT) measures the integrity of the intrinsic system as well as factors common to both systems. This is followed by Prothrombin Time (PT) which measures the internal structure of the blood clotting fluid. The partial thromboplastin time (PTT) is a screening test that helps evaluate a person's ability to form blood clots. It measures the number of seconds it takes for a clot to form in a sample of blood after substances are added.

3. What is the rationale behind the order of checking the Total Protein, Albumin-Globulin ratio? Proteins are essential components of all cells and organs. They are necessary for physical growth, development, and health. They are structural components of most organs, as well as

enzymes and hormones that govern physiological activities. This test determines the level of protein in your blood. Total protein and albumin-globulin levels are measured to determine the body's ability to fight infection and carry nutrients. The total serum protein test determines the concentration of all proteins in your blood. It can also determine the quantity of albumin you have in comparison to globulin, or your "A/G ratio." The blood contains two types of proteins: albumin and globulin: l Albumin is produced by the liver and accounts for approximately 60% of total protein. Albumin prevents fluid from escaping from blood arteries, nourishes tissues, and carries hormones, vitamins, medicines, and calcium throughout the body. l The remaining 40% of proteins in the blood are globulins. Globulins are a diverse group of proteins, some of which are produced by the liver and others by the immune system. They aid in the fight against infection and the transfer of nutrients. The test also compares the amounts of albumin and globulin and computes the A/G ratio. A shift in this ratio can help your doctor figure out what's causing the protein levels to fluctuate. Total protein levels in the blood may grow or decrease to varying degrees depending on the circumstance.

4. Enumerate the following regarding the nursing role in assisting with paracentesis: ● Position of choice: To reduce the danger of perforation during paracentesis, the patient is laid supine and slightly rotated to the side of the procedure. The left-lateral technique is most usually utilized since the cecum is relatively fixed on the right side

● Site of insertion: Insertion locations may be in the midline or through the oblique transversus muscle, which is lateral to the thicker rectus abdominus muscles.

● At least three (3) nursing considerations: 1. During the procedure, reassure the patient. Check blood pressure, heart rate, respiration rate, and temperature, and look for indicators of problems such as ascetic fluid leakage, infection, bladder and intestine perforation, and bleeding. 2. Take note of the characteristic as well as the amount of fluid aspirated. 3. Compare his or her abdominal girth to the baseline measurement.