PBL Part 2
SARAH SMITH
Action point:
While you are admitting Sarah, she tells you that her GP has
strongly advised her to stop smoking. She seems very upset about
this telling you that smoking is her only stress release. How would
you respond to Sarah?
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I would also reassure her that her GP isn’t “out to get her”
it is the responsibility of the health professional to ask and
inform our patients about the risks involved with smoking.
Sit down with Sarah and discuss why the doctor advised
quitting smoking and why it is particularly important for her.
Discuss with Sarah other potential stress relieving factors.
Discuss with Sarah why she is so stressed.
Action point:
You know that a risk associated with bowel surgery is post-operative
bleeding. Describe the underlying pathophysiology of hypovolemic
shock and the associated signs & symptoms. Then discuss the
immediate nursing management.
Definitions:
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Shock is a clinical state, with a number of different
aetiologies, characterised by a state of decreased oxygen
delivery to the tissues.
The aetiology of shock can be classified in three categories
with one category having three separate subcategories. The
three main categories are hypovolemic, cardiogenic and
distributive
shock.
Distributive
shock
can
be
further
delineated with septic, neurogenic and anaphylactic shock.
Commonest cause of shock with either traumatic or nontraumatic shock is hypovolemic.
Hypovolemic shock is an emergency condition in which a severe
lack of sufficient fluid in the intravascular space making the
heart unable to pump enough blood to the body. This type of
shock can cause many organs to stop working.
Pathophysiology:
The aetiology of this is that the hypovolemic shock can occur one of
two ways:

The first way is an external loss of body fluid such as blood
or plasma. An example of this is a laceration to an artery
that is not stopped or does not stop on its own.
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Another form of hypovolemic shock is when fluid in the body is
moved to an area where it is not used such as what is called
third spacing. An example of extracellular fluid loss is
severe sodium deficiency.
The pathophysiology of hypovolemic shock is that when fluid
volume goes down a decrease in the circulating volume of blood
is seen. When the circulating volume of blood occurs, the
preload to the heart is decreased. A decrease in preload
causes a decrease in stroke volume which will cause a decrease
in the cardiac output. With reduced cardiac output you will
see decreased cellular oxygen perfusion. When cells don’t
receive enough oxygen they die.
Signs and symptoms:
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Tachnoea
Tachycardia (weak & thread), Low BP, decreased peripheral
perfusion “shut down”, capillary refill >2 seconds, peripheral
cyanosis (pre-terminal sign), myocardial ischemia
decreased end organ perfusion – urine output
LOC/decrease in conscious state, confusion
Signs of dehydration – loss in weight, fluid loss, skin
turgor, eyes, fontanel (infants), look – energetic/lethargic.
Actions of the nurse:
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ABC’s – alert medical staff
Fluid replacements (e.g. IV fluids to stabilise blood pressure
or blood products to replace loss of blood) (if blood products
administered adhere to protocols – staying with patients,
taking observations etc.), treatment of underlying cause
(maybe
administrating
medications/antibiotics
etc.),
monitoring
patients
response
to
therapies
&
taking
observations,
deliver
oxygen
if
needed
or
prescribes,
comfortable position – preferably with legs higher than body,
unless injury does not allow.
Action point:
Access the policy / guideline for blood administration used by staff
in your clinical area. Write a brief summary outlining the key
aspects of the policy / guideline.
Key aspects:
COUNTIES MANUKAU DISTRICT HEALTH BOARD; Procedure: Transfusion of
RED BLOOD CELLS, PLATELETS, FRESH FROZEN PLASMA AND CRYOPRECIPITATE.
***CHECK, CHECK, CHECK!!!
Equipment: prescribed blood component, approved blood component
administer set with filter, thermometer, sphygmomanometer and
stethoscope or arterial blood pressure monitoring, watch or clock
with a second hand.
1. Ensure IV access for patient and maintain patency with normal
saline or other saline that is compatible with blood.
2. Check that informed consent has been given - clinician’s
protocols.
3. Ensure component has been prescribed on patients FBC,
including date, time and rate of infusion – this must be
signed by prescribing doctor.
4. Order the component from the blood bank, using the IV blood
component collection and safety checklist and send via lamson
tubing to laboratory. Blood bank will arrange for the orderly
to collect using task manager.
5. Check with the orderly that unit delivered is the correct unit
for your ward and patient. Continue with checklist if unit is
correct.
6. Check the components expiry date, donor details are on the
back and match those on the label and the colour and
appearance of the component.
7. Check
patient’s
id,
verbally
if
possible.
Then
check
wristband.
8. Check the ABO and rhesus compatibility of patient and donor
component.
9. BOTH the person administering the component and the person
checking must sign the label attached to the bag which must be
dated and timed.
10.
Transfusion must commence 30 minutes of issue from blood
bank. RBC’s, fresh frozen plasma and cryoprecipitate (once
thawed) must be completed within 4 hours and platelets should
be completed in 60mins.
11.
Baseline obs need to be recorded with patient label and
dated before bloods are given.
12.
Giving set and alaris pump.
13.
Remain with patient for the first 20-30 mins – THIS IS
WHERE THE MOST SEVERE REACTIONS ARE LIKELY TO BEGIN.
14.
Repeat
obs
at
15
minutes
and
30
minutes
after
commencement of each component.
15.
After first 30minutes record obs hourly and temperature
and bp hourly.
16.
Record urine output on patients FBC
17.
Attach check label to blood products label sheet and
document the completion time in the box provided and record
the amount given on the FBC, document transfusion in patient
notes.
18.
Return empty blood bag to blood bank – protocol
19.
Discard giving set
20.
Closely observe patient for a further 30minutes after
transfusion
Action point:
Haemolytic and anaphylaxis are two significant blood reactions.
Discuss the pathophysiological differences between these two
reactions.
Acute transfusion reactions present as adverse signs or symptoms
during or within 24 hours of a blood transfusion.
TRANSFUSION REACTIONS
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HAEMOLYTIC REACTION
Fever (increase in temp of
>1.5.c)
Chills, rigors, chest pain,
low back pain (kidneys)
Dyspnoea
Tachycardia, hypotension
Haemoglobinaemia
Nausea and vomiting
Anuria (no urine)
Shock
Collapse
Acute
hemolytic
transfusion
reactions may be either immunemediated
or
nonimmune-mediated.
Immune-mediated
hemolytic
transfusion
reactions
caused
by
immunoglobulin M (IgM) anti-A, antiB, or anti-A,B typically result in
severe,
potentially
fatal
complement-mediated
intravascular
hemolysis. Immune-mediated hemolytic
reactions caused by IgG, Rh, Kell,
Duffy, or other non-ABO antibodies
typically result in extravascular
sequestration, shortened survival of
transfused red cells, and relatively
mild clinical reactions.
 Acute
hemolytic
transfusion
reactions
due
to
immune
hemolysis
may
occur
in
patients
who
have
no
antibodies
detectable
by
routine laboratory procedures
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ANAPHYLAXIS REACTION
Hypotension
Anxiety
Rapid weak pulse
Urticarial (raised red rash)
Wheezing
Cyanosis
Shock
Collapse
Cardiac arrest
Allergic reactions typically present
with rash, urticaria, or pruritus
and
are
indistinguishable
on
examination from most food or drug
allergies. Allergic reactions are
IgE mediated. These reactions are
usually
attributed
to
hypersensitivity
to
soluble
allergens found in the transfused
blood component.
Anaphylactic
reactions have
been
associated
with
anti-IgA
in
recipients who are IgA deficien
*** Anaphylaxis can be the cause of a haemolytic reaction because of
the major fluid shift.
Actions of the nurse:
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Stop infusion – remove the cause
Check ABC’s – deal with problems when checking
Notify doctor and person in charge, hit emergency bell if
needed.
Bibliography
Sandler, G. (2009, November 20). Transfusion Reactions. Retrieved August 22, 2011, from Medscape
Reference: http://emedicine.medscape.com/article/206885-overview
Trip Williams. (2006, August 20). SHOCK! Retrieved August 22, 2011, from
http://www.alpharubicon.com/med/shockaricrn.htm