HR slightly increasedc.RR normald.Skin: cool, pale, moiste.Alert and orientedf.Slight decrease in urine outputg.Thirst, decreased capillary refill time2.Compensatory and Progressive Stagesa.Hypotensionb.Rapid thread pulsec.RR: increasedd.Skin: cool, pale, poor turgor, edematous with fluid shifte.Restles, anxious, confused, agitatedf.Less than 30 ml urine per hourg.Thirst, acidosis, hyperkalemia, decreased capillary refill, decreased or absent peripheral pulses3.Irreversible Stagea.Severe hypotension (systolic less than 80)b.Rapid weak pulsec.Shallow, rapid respiration, crackles, wheezesd.Disoriented, lethargic, comatosee.Anuric
f.Loss of reflexes, decreased or absent peripheral pulsesBLOOD AND BLOOD PRODUCTS1.Type AB is the “universal receiver”2.Type O is the “universal donor”3.Blood and blood components increase the amount of hemoglobin available to carry oxygen to the cell, active bleeding, increase intravascular volume, and replace deficient substances such as platelets and clotting factors.BLOOD GROUP TYPES AND COMPATABILITIES ARE ON TABLE 11-4 PAGE 247 (NOT MENTIONED ON BLUEPRINT) don’t know if this is important to know yetMost fatal transfusion reactions are the result of HUMAN ERRORThis will be a review of general guidelines but most institutions have specific policies in place for blood transfusions. PRIOR TO TRANSFUSION1.First and foremost type and crossed match along with order for transfusion must be from doctor/ most HGB results have to be below 7 before blood is necessary. 2.Supplies needed, blood must be typed and crossmatched and blood ready and available in lab, Y-tubing blood administration set with a filter, a large bore intravenous catheter (usually an 18 or 19 gauge), and normal saline solution. (usually a 500cc bag) 3.ONLY NORMAL SALINE IS USED WITH A BLOOD TRANSFUSION, dextrose causes clumping of RBC’S and distilled water causes hemolysis.NURSING RESPONSIBILITES1.Obtain consent/if they refuse notify physician and document refusal 2.Assess / ask pt about any previous blood transfusion reactions3.Explain the procedure, why,when, how and answer any questions4.Prepare the equipment, shut off (roller clamp) one side of the y tubing and attach the other side to the saline solution, FLUSH the tubing and filter with saline.5.If IV access is not available with a 18-19 gauge needle, then access a site and begin the normal saline. 6.Using the hospital policy obtain the blood from the blood bank, meaning you have to walk to lab and sign the blood out, the blood is normally checked by nurse and lab tech numbers must match and be signed for, RODI said one unit of blood can be taken from blood bank at a time. AFTER GETTING SET OF VITAL SIGNS, administer blood immediately if this cant happen you must return blood to blood bank.