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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