Professional Nursing 2 Exam 2 Rasmussen

Nursing Responsibilities with blood transfusion - -verify client consent -obtain baseline vital signs -ensure suitable vein for 18 to 20 ga. needle -set up Y set with blood filter -with 2nd nurse compare client's ID bracelet against tag on unit of blood, number on blood ID, ABO group, Rh type -immediately hand the blood within 30 minutes from bank -begin transfusion at 2ml/min checking vitals q5-q15 minutes -increase infusion rate after 15 minutes -whole unit must be transfused within 4 hours Acute Transfusion Reactions Clinical FIndings - chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening, tachypnea, nausea, anxiety, hemoglobinuria Acute hemolytic reaction - Immediately occurring transfusion reaction. Can lead to cardiovascular collapse, kidney failure, intravascular coagulation, shock, and death Infective endocarditis - Aka bacterial endocarditis, an infection of the endocardial tissue due to strep or staph bacteria. Most common in IV drug users who have cardiac malformations Signs and symptoms of endocarditis - fever, flu-like symptoms, murmur, petechiae, on trunk and mucous membranes, positive culture, splinter hemmorhages in nail beds Pericarditis - inflammation of the pericardium, commonly follows a respiratory infection but can occur after an MI Signs and symptoms of pericarditis - chest pressure, pain, friction rub ausculataed, shortness of breath relieved by leaning forward Myocarditis - inflammation of the myocardium due to a viral, fungal, bacterial infection, or systemic inflammatory disease such as crohn's