HR slightly increased c RR normal d Skin cool pale moist e Alert and oriented f

Hr slightly increased c rr normal d skin cool pale

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HR slightly increased c. RR normal d. Skin: cool, pale, moist e. Alert and oriented f. Slight decrease in urine output g. Thirst, decreased capillary refill time 2. Compensatory and Progressive Stages a. Hypotension b. Rapid thread pulse c. RR: increased d. Skin: cool, pale, poor turgor, edematous with fluid shift e. Restles, anxious, confused, agitated f. Less than 30 ml urine per hour g. Thirst, acidosis, hyperkalemia, decreased capillary refill, decreased or absent peripheral pulses 3. Irreversible Stage a. Severe hypotension (systolic less than 80) b. Rapid weak pulse c. Shallow, rapid respiration, crackles, wheezes d. Disoriented, lethargic, comatose e. Anuric
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f. Loss of reflexes, decreased or absent peripheral pulses BLOOD AND BLOOD PRODUCTS 1. 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 yet Most fatal transfusion reactions are the result of HUMAN ERROR This will be a review of general guidelines but most institutions have specific policies in place for blood transfusions. PRIOR TO TRANSFUSION 1. 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 RESPONSIBILITES 1. Obtain consent/if they refuse notify physician and document refusal 2. Assess / ask pt about any previous blood transfusion reactions 3. Explain the procedure, why,when, how and answer any questions 4. 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.
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