Study GuideExam #3 - IV

1. . Review the ABO System and the Rh System: know the universal Donor and Universal Recipient Table 11-1 and 11-2 Page 687.

Rh system: - 2nd most important antigen is the D antigen Presence of D antigen = Rh+ Absence of D antigen = Rh- - 5 Principle antigens: D, C, E, c and e Universal Donor = O-negative Universal Receiver = AB-positive

What are the factors that we look at when we are typing and crossing patient? - Donor blood - Recipient blood Look for the: 1) Rh and ABO factors (Type) 2) HLA Antigen = important in patients with transplants or multiple infusions and paternity typing

2. The Components of Blood and their uses: Table 11-5 page 729-731 Whole Blood = RBCs, Plasma, WBCs and platelets - 500 mL -------> 200 mL - RBCs & 300 mL - Plasma Red Blood Cells (Packed Cells) - 300 mL (Anemia = low hgb) Look at Hematocrit (RBC%) Level = tells allergy significant level - Want free of particular matter - FILTERED (Poll Blood filter) = microfiber filter out LEUKOCYTES (PREVENTS FEBRILE, NON-HEMOLYTIC TRANSFUSION RXNS)

Granulocytes = Neutropenic (low white blood count) - Not reactive to new-last or neupogen Plasma = replenish fluid and protein lost from injury/bleed

Blood Groupings Recipient Antigens on RBCs

Antibodies Present in Plasma

A A Anti-B

B B Anti-A

AB A & B None

O None Anti-A & Anti-B

( < 14 M;

5. Types of transfusion reactions: Table 11-8 Pages 736-740 Etiology S/S Key Interventions Prevention

Acute hemolytic transfusion reaction

FEBRILE NONHEMOLYTIC

REACTION

Allergic Reactions (Mild)

Severe Allergic Reactions; Anaphylaxis

Delayed Transfusion Reactions

TRANSFUSION ASSOCIATED GRAFT-

VERSUS-HOST DISEASE

(TA-GVHD)

Hemolysis occurs when antibodies in plasma attach to antigens on the donors RBCs - C/b infusion of ABO-incompatible RBCs

- Fever w/ or w/out chills

- Tachycardia - Abdominal,chest,

flank, back pain - Hypotension - SOB- Red/dark urine- Shock

- STOP TRANSFUSION!!!!- Get help immediately - Change administration set and infuse NS - Treat shock - Maintain BP/renal perfusion - Administer diuretics to maintain blood flow

Exercise extreme care during the entire identification process - Start infusion slowly and monitor for first 15 minutes

- Occurs as a result of antibodies directed against leukocytes or platelets

- Febrile reactions occur immediately or 1-2hrs after infusion in complete

- Fever rise of 1 C (2 F) in association w/ transfusion

- Chills - Headache - Vomiting

- STOP TRANSFUSION!!!!- Change administration set and infuse NS -Notify the LIP - Monitor VS- Anticipate order for

antipyretic agents - If ordered, restart transfusion

- Use leukocyte-reduced blood transfusion

- C/b recipient sensitivity to allergens in the blood component

- Itching - Hives (local) - Urticaria - Facial Flushing- Runny eyes - Anxiety - Angioedema

- STOP TRANSFUSION!!!!- Keep the vein open w/ NS - Notify the LIP- Monitor VS - Anticipate antihistamine

order - If ordered, restart

transfusion slowly - Mild reactions can precede

severe allergic rxn,

- If known mild allergic reaction occurs w/ blood transfusion, may premedicate with diphenhydramine 30 minutes before the transfusion

- Antibodies to donor blood plasma

- Hypotension - Urticaria - Bronchospasm - Anxiety - Shock

- STOP TRANSFUSION!!!!- Keep the vein open w/ NS - Administer CPR if

necessary - Anticipate order for

steroids - Maintain BP

- Use autologous blood - Use blood from donors

who are IgA deficient or administer only well-washed RBCs in which all plasma has been extracted

- Result of RBC antigen incomptability other than the ABO group

- Occur due to destruction of transfused RBCs by alloantibodies not discovered during the crossmatch procedures

- Fever (continual, low grade)

- Malaise - Jaundice (mild) - Decreased

hematocrit and hemoglobin

- Increased bilirubin

- NO acute tx required - Monitor hematocrit level - Renal function - Coagulation profile - Notify LIP and transfusion

services

- Exercise extreme care during the entire identification process

- Rare and fatal - Viable t-lymphocytes in

transfusion component engraft in recipient and react against recipient tissue antigens

- Highest risk in the immunocompromised pt

- Fever- Maculopapular

rash - ^ levels on hepatic

function tests - Watery diarrhea - Pancytopenia

- No effective therapy - Tx of symptoms

- Adminster irradiated blood products in immunocompromised pts.

Check when giving a Unit of blood 1) ABO and Type of blood (Rh) 2) Unit number = number on recipients armband; on anything the pt. is receiving

3) Expiration date

6. What are the goals of parenteral nutrition - Slides 4 & 5 Goals: - Provide all essential nutrients in adequate amounts to sustain nutritional balance during periods when oral or enteral routes of feedings are not possible or are insufficient to meet the patients caloric needs - Preserve or restore the bodys protein metabolism and prevent the development of protein or caloric malnutrition - Diminish the rate of weigh loss and to maintain or increase body weight - Promote wound health (^ protein) - Replace nutritional deficits

7. What are the components of Total Parental Nutrition TPN = HYPERTONIC Solution 1) Carbohydrates: Provide energy = 10-20% Dextrose 2) Protein: body-building nutrient, functions to promote tissue growth and repair and replacement of body cells = 8 essential Amino Acids 3) Lipids (Fats): primary source of heat and energy = Essential for the structural integrity of ALL cell membranes - Fewer problems with glucose homeostasis - carbon dioxide production is lower - Hepatic tolerance may improve = fatty acids ---> repair the body Others Additives: Eletrolytes: infused as a component already contained in the amino acid solution or as an additive Vitamins: necessary for growth and maintenance, multiple metabolic processes - both fat and water soluble are needed - Vitamin K can be given IM Heparin, Regular Insulin Histamine 2 (H2) Inhibitors

8. How is TPN administered: ie Line, filter. Pages 796-797; 814 TPN delivered via a CVAD (any type = nontunneled, PICC, subQ tunneled, or VAP) is the I.V. administration of HYPERTONIC glucose (20%-70%) and amino acids (3.5%-15%), along with all additional components required for complete support. (Caller hyperalmentation or 2-in-1) Lipids, Carbs & Proteins (TNAs) = 3-in-1 Filters: - Use of a 0.22-micron filter = remove microoganisms - Use of a 1.2-micron filter = formulas with lipids *(Lipid solution = Watch for calcium precipitating out)* - = get rid of w/ 70% ethonal (dissolves fat)

Sensible Loss = aware fluid floss = wound drainage, GI tract losses, & urination INsensible loss = occurs daily through the skin (sweat & oil) and respiration Tx: *Manage I/Os *

9. What patients are candidates for Nutritional support. p. 814 Candidates for nutritional support include those with: - Altered catabolic states - Chronic weight loss - Conditions requiring bowel rest - Short bowel syndrome - Excessive nitrogen loss - Hepatic or renal failure - Hypermetabolic states - Malabsorption states - Malnutrition = look at what the pt. is lacking - unable to intake nutrients > 3-5 days = parenteral feed = MC in ICU patients (comatose pts = mixed nutr.) - Multiple trauma - Serum albumin levels below 3.5 g/dL

Nutritional Assessment includes: - Hx (medical, social, dietary) - Anthropometeric measurements (height, weight, skinfold tests, midarm circumference) Skinfold test = uses a capiller - Laboratory testsing (serum albumin, serum transferrin, prealbumin and retinal-binding protein, total lymphocyte counts, serum electrolytes) - Energy requirements - Physical examination

10. Review complications of Total Parenteral Nutrition: Table 12-8 Pages 801-803

- VAD-related complications - Metabolic complications - Nutritional complications

11. In chapters 3,and 6 read the information on peds and geriatrics Pediatric Infusion Therapy - Physiological changes must be kept in mind: = total body weight (85%-90% water) - heat production - immature renal and integumentary systems (reg F&E needs)

- Physical assessment: - measuring the head circumference ( 1yo) - checking height/length - VS - Skin turgor - Presence of tears - moistness and color of membranes - urinary output - characteristics of fontanelles - level of childs activity - Peripheral routes include : - four scalp veins, - dorusm of the hand and forearm, - lower extremities prior to walking age - Selection of PIV equipment must keep in mind the pts safety, activity, age and size - Needle selection depends on the age of the child = 22- to 26-gauge - Use small volumes of solution (250-500 mL); use a VSS and, when indicated infusion pumps - Always have extra help when starting an IV in a child - Perform venipuncture in a seperate room, use a pacifier for neonates and infants, warm your hands before applying gloves, and use stickers or drawing as rewards - Delivery of medications to children can be by intermittent infusion, retrograde infusion, or syringe pump

Geriatric Infusion Therapy - Physiological changes include: - decreased renal function - decreased drug clearance - increased rx for infection as a result of immunosuppression - cardiovascular changes = alt. electric thinning of the vein walls

- skin losses (THINing) - subcutaneous support ----> look for sensory deficit - thinning of skin - Assessment includes: - skin turgor - temp - rate and filling of vein in hand or foot - daiy weight - I/O - postural blood pressure - swallowing ability - functional assessment of pts ability to obtain fluids if not NPO - Venipuncture techniques should take into consideration the skin and vein changes of elderly persons. = USE SMALL-GAUGE CATHETERS, BLOOD PRESSURE CUFF, OR PLACE A LOOSE TURNIQUET OVER CLOTHING - Use WARM COMPRESSES to visualize veins - Consider microdrip adminstration sets

12. Read the chapter on TPN and Blood transfusions. Draw blood = Turn TPN off 3-5 mins prior to draw blood

- flush vigorously prior w/ 5mL NS - done flush 20mL NS

* TPN can be around-the-clock ---> flush vigorously w/20mL NS b/w bags* = hang for 24 hours (Tx: hang new bag after 24hrs.)

13. Chemo therapy from the hand out focus on the last 4 slides. SHORT TERM COMPLICATIONS OF Antineoplastics (CHEMO) - Venous Fragility - Alopecia - Diarrhea - Constipation - Altered Nutritional Status - Anorexia and Alteration in Taste - Fatigue ACUTE REACTION - Hypersensitivity and Anaphylaxis - Extravasation - Stomatitis and Mucositis - Myelosuppression - Neutropenia

- Thrombocytopenia - Anemia TOXICITIES - Neurotoxicity - Cardiac Toxicity - Pulmonary Toxicity - Renal Toxicity ROUTES OF ADMINISTRATION FOR CHEMOTHERAPY - IV - Intrathecal - Regional - Intra-arterial - Intraperitoneal - Cerebrospinal Fluid Reservoirs - Infusion Pumps

14. Power point on Pain and Information on Pain in the book. Check the index Patient-controlled analgesia (PCA) = a philosophy of treatment rathter than a single method of drug administration - Anticipating pain that is severe but intermittent - Constant pain that gets worse with activity - Old and young who can use it - Ability to manipulate the dose button - Pt. MUST be motivated to control pain - Not already sedated from other medications