A blood transfusion is the introduction of whole blood or blood components into the venous circulation.
Human blood is commonly classified into 4 groups: O, A, B and AB.
Antigens, or agglutinogens promote agglutination, or clumping of the blood.
Antibodies, or agglutinins are preformed and react to certain RBCs.
The reason why the blood type O is a universal donor, is because it does not have any antigens.It is compatible with any blood type. The blood type AB is considered the universal recipient because a person who has it can receive blood of any type. It does not have any antibodies.
Blood typing is done to determine the ABO blood group and the Rh factor status. This test is also performed on pregnant women and neonates to assess for possible intrauterine exposure to either to an incompatible blood (particularly Rh incompatibilities)
Crossmatching is also necessary to identify possible interactions of minor antigens with their corresponding antibodies. RBCs from the donor blood are mixed with serum from the recipient; a reagent (Coombs' serum) is added, and the mixture is examined for visual agglutination. If no antibodies to the donated RBCs are present in the recipient’s serum, agglutination does not occur and the risk for blood transfusion reaction is small.
Potential donors are eliminated by:
- History of hepatitis
- HIV infections (Promiscuity, or homosexual men practicing anal sex)
- Heart disease
- IV drug users
- Severe Asthma
- Bleeding disorders
- Blood infections (Dengue, Malaria)
- Low or High blood pressure
Hemolytic transfusion reactions can destroy transfused RBCs and predispose client to subsequent kidney damage or failure. Other forms of tranfusion reactions may also occur, including febrile, allergic, circulatory overload and sepsis. Symptoms include chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia and hypotension.
NURSING INTERVENTIONS FOR TRANSFUSION REACTIONS:
1. Discontinue the transfusion immediately.
2. Maintain vascular access with normal saline solution. *Normal saline must always be used when giving a blood transfusion. If the client has an infusion of dextrose, stop that infusion and flush the line with saline prior to initiating the transfusion. Solutions other than saline can cause damage to the blood components.
3. Notify the physician.
4. Monitor vital signs.
5. Administer any analgesic, antihistamine, etc. as ordered.
6. Monitor fluid intake and output.
7. Send the remaining blood, bag, filter, tubing, a sample of the client’s blood, and a urine sample to the laboratory.
- #18-20 gauge intravenous needle; using a smaller needle may slow the infusion and damage blood cells, although int might be necessary to use in infants and children who have smaller and more fragile veins.
- Obtain blood from the blood bank just before starting the infusion,
- Do not store the blood in the refrigerator of the nursing unit; lack of temperature control may damage the blood.
- Once blood or a blood product is removed from the refrigerator, there is a limited amount of time to administer it. Make sure it is not left at room temperature for more than 30 minutes before starting the infusion. (LESS THAN 4 HOURS, or blood components might be damaged if left in room temperature for too long. It can also encourage bacterial growth in blood, hence, sepsis might occur. RBCs deteriorate and lose their effectiveness after two hours at room temperature. Lysis of red blood cells releases potassium in the bloodstream, causing hyperkalemia.)
- Compare lab blood records with another nurse: Client’s name and identification number, number of the blood bag label and ABO blood group and Rh type on the blood bag label.
- If there are any discrepancies, notify the CHARGE NURSE and the BLOOD BANK.
- OBSERVE THE CLIENT CLOSELY FOR THE FIRST 5 TO 10 MINUTES.
- RUN THE BLOOD SLOWLY FOR THE FIRST FIFTEEN MINUTES AT 20 gtts per minute.
- Fifteen minutes after initiating the transfusion, check the vital signs of the client. Most adults can tolerate receiving one unit of blood in one and a half to two hours.
- Assess and monitor the client every 15 to 30 minutes, or more often, if necessary, until 1 hour post-transfusion.
- Blood administration sets are changed within 24 hours or after 4 to 6 units of blood per agency protocol.
This cannot be delegated to UAP, due to its technical complexity, the need for extensive clinical knowledge and the need to practice sterile technique.
Suctioning is aspirating secretions through a catheter connected to a suction machine or a wall suction outlet.
There are two types of suction catheters: They may either be whistle-tipped or open-tipped.
Whistle-tipped catheters are less irritating to respiratory tissues.
The open-tipped catheter is more effective in removing thick mucous plugs.
The nurse decides when suctioning is needed by assessing the client for signs of respiratory distress.
- Bubbling or ratting breath sounds
- poor skin color (cyanosis)
- decreased O2 saturation (95-100%; An O2 saturation below 70% is life-threatening!)
Suctioning can be irritiating to the mucous membranes and can increase secretions if done too frequently.
Oral and oropharyngeal suctioning removes secretions from the upper respiratory tract; it does not require a sterile technique.
Nasopharyngeal and nasotracheal suctioning provides closer access to the trachea and requires sterile technique.
It can be delegated to nursing assistants and other unlicensed assistive personnel, BUT IT IS NOT USUALLY PRACTICED IN THE PHILIPPINE SETTING. Nasotracheal and nasopharyngeal suctioning, on the other hand, cannot be delegated to any UAP because it requires a sterile technique.
- ORAL SUCTIONING:Conscious, with functional gag reflex: SEMI-FOWLERS, with head turned to one side
- NASAL SUCTIONING: Hyperextend neck
- UNCONSCIOUS CLIENT: Lateral position, facing you
ORAL AND OROPHARYNGEAL
- Moisten the tip of the suction catheter with SALINE or STERILE WATER.
- Do not apply suction (that is, leave your finger off the port) during insertion) It may be necessary during oropharyngeal suctioning to apply suction to secretions that collect in the vestibule of the mouth and beneath the tongue.
- Moisten the tip of the suction catheter with SALINE, STERILE WATER. WATER-SOLUBLE LUBRICANT! (NASOPHARYNGEAL and NASOTRACHEAL)
- Make an appropriate measure of the depth of the insertion of the catheter and test the equipment.
- TIP OF THE CLIENT’S NOSE TO THE CLIENT’S EARLOBE, or about 13 cm (5 in)
- Gently rotate the catheter upon withdrawing to ensure all surfaces are reached.
- Apply suction for 5-10 seconds while slowly withdrawing the catheter.
- A suction attempt should last only 10-15 seconds.
- Encourage client to breathe deeply and cough between suctions.
TRACHEOSTOMY OR ENDOTRACHEAL TUBE
- Hyperoxygenate! (100 % oxygen)
- PERSONAL PROTECTIVE EQUIPMENT! :GOGGLES, MASK GOWN, GLOVES
- If the client does not have copious secretions, hyperventilate the lungs. Never hyperventilate the lungs when copious secretions are present. This will force the secretions deeper into the respiratory tract.
- Ambu bag, 3-5 times.
- Insert the catheter about 13 cm (5 in) in adults. Less for children, or until the client starts coughing or you feel resistance.
- Gently rotate the catheter upon withdrawing to ensure all surfaces are reached.
- Apply suction for 5-10 seconds while slowly withdrawing the catheter.
- A suction attempt should last only 10-15 seconds.
- Before and after each suction attempt, hyperventilate (Ambu bag 3-5 times) and hyperoxygenate (100%) the patient to prevent cardiac dysrhythmias related to hypoxemia.
I am very sorry for the lack (or complete absence) of posts.
My brother got dengue last Saturday, so I had to rush home to Antipolo City to care for him. I am the only health care worker in the family, you see.
Oh well, later!
THIS ALWAYS APPEARS IN ANY VERSION OF THE PNLE. AT LEAST 3-5 QUESTIONS ABOUT IT APPEAR RANDOMLY IN ANY OF THE 5 SETS OF THE EXAM.
Studies have shown that the use of the color orange in tables, diagrams and charts increase brain activity and enhances memory. The color orange radiates warmth and happiness, combining the physical energy and stimulation of red with the cheerfulness of yellow. The color psychology of orange is optimistic and uplifting, rejuvenating our spirit. In fact orange is so optimistic and uplifting that we should all find ways to use it in our everyday life, even if it is just an orange colored pen that we use. The use of an orange highlighter on your notes and books would also do the trick.
This may vary among people, however, and this study is not conclusive. But it works for me, so I will be using the color orange in my tables, diagrams and charts.
Before drawing ABGs from the the radial artery, perform the ALLEN TEST to assess collateral circulation.
1. Make the client’s hand blanch by obliterating both the radial and the ulnar pulses.
2. Release the pressure over the ulnar artery only.
3. If flow through the ulnar artery is good, flushing will be seen immediately. The ALLEN TEST is then POSITIVE, and the radial artery can be used for puncture.
4. If the ALLEN TEST is negative, repeat on the other arm. If this test is also negative, seek another site for arterial puncture. THE ALLEN TEST ENSURES COLLATERAL CIRCULATION TO THE HAND IF THROMBOSIS OF THE RADIAL ARTERY SHOULD FOLLOW THE PUNCTURE.
This topic appeared in the June 2007, June 2008 and July 2010 versions of the PNLE.
What is a pulse oximeter?
It is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger. (best location for a pulse oximeter) The toe, nose, earlobe or forehead can also be used. In neonates, it is used around the hand or the foot. It can detect hypoxemia before clinical signs and symptoms of hypoxemia develop. (THIS STATEMENT WAS ONE OF THE CHOICES THAT APPEARED IN THE June 2007, June 2008 and July 2010 versions of the PNLE.)
This was the question:
You attached a pulse oximiter to a client. You know that the purpose is to:
A. Determine if the client’s hemoglobin level is low and needs blood transfusion
B. Check level of client’s tissue perfusion
C. Measure the efficacy of the client’s antihypertensive medications
D. Detect hypoxemia before clinical signs and symptoms of hypoxemia develop.
This may vary from book to book, but the normal oxygen saturation level is 95-100 % (Fundamentals of Nursing by Kozier and Erb, Volume 1, page 558)
An SaO2 below 70 % is considered life-threatening! (THIS STATEMENT ALSO APPEARED AS ONE OF THE CHOICES IN THE June 2007, June 2008 and July 2010 versions of the PNLE.)
It may be necessary to remove a female client’s dark nail polish, because it can interfere with accuarate measurements.
You should also cover the sensor with a sheet or towel to block large amounts of light from external sources. Bright room light may be sensed by the photodetector of the pulse oximeter and alter the measurements. (THIS STATEMENT ALSO APPEARED AS ONE OF THE CHOICES IN THE June 2007, June 2008 and July 2010 versions of the PNLE.)
1. Look at the pH. Is it acidosis or alkalosis?
2. Check the PaCO2 and HCO3-which one MATCHES the same acid-base status as the pH?
PaCO2 matches the pH. (acidosis) therefore, it is a respiratory problem. Client has respiratory acidosis.
3. Look for evidence of COMPENSATION. Look at the value that does not match the pH. In this case, the HCO3.
- If it is within normal range, there is no compensation.
- If it is below or above normal range, it is compensating.
NORMAL VALUES (This may vary due to the wide array of sources of information. God, why did they have to differ from book to book?)
O2 Saturation-95-100% (Some books say it’s 98-100%)
*An O2 saturation that falls below 70% is CONSIDERED LIFE-THREATENING! (ACTUAL BOARD EXAM QUESTION, JULY 2011 NP1)
Base Excess- 0, + or - 2; a calculated value of bicarbonate levels, also reflective of the metabolic component of acid-base-balance. If the number is preceded by a plus sign, it is a base excess and indicates alkalosis; if preceded by a minus sign, it is a base deficit and indicates acidosis.
REMEMBER THE WORD, R.O.M.E!
Respiratory, opposite (Example: Respiratory acidosis: decreased pH, increased PaCO2)
Metabolic, equal (Example: Metabolic alkalosis: increased pH, increased HCO3)
APPEARED IN THE ACTUAL JULY 2008 NP1 PNLE.
STAGE I, NOVICE
-no experience (e.g. nursing student). Performance is limited, inflexible and governed by context-free rules and regulations rather than experience.
STAGE II, ADVANCED BEGINNER
-demonstrates marginally acceptable performance. Recognizes the meaningful aspects of real situations. Has experienced enough situations to make judgements about them. (e.g. newly registered nurse)
STAGE III, COMPETENT
-has two to three years of experience. Demonstrates organizational and planning abilities. Differentiates important factors from less important aspects of care. Coordinates multiple complex care demands.
STAGE IV, PROFICIENT
-has three to five years experience. perceives situations as wholes rather than in terms of parts, as in Stage III. Uses maxims as guides for what to consider in a situation. Has holistic understanding of the client, which improves decision-making. Focuses on long-term goals.
STAGE V, EXPERT
-performance is fluid, flexible and highly proficient; no longer requires rules, guidelines or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situations. Is inclined to take a certain action because “it felt right.”
- Medical Surgical Nursing-Brunner and Suddarth
- Community Health Nursing, IMCI, Communicable Diseases and COPAR-Public Health Nursing in the Philippines by DOH
- Maternal Health Nursing/OB-Maternal and Child Health Care by Adele Pilliteri
- Pediatric Nursing-Nursing Care of Infants and Children by Wong and Maternal and Child Health Care by Adele Pilliteri
- Emergency Nursing-Schumacher, Brunner and Suddarth
- IMCI-Well, the IMCI Flipchart and Workbook. Our batch owns the green flipchart and purple workbook.
- Nursing Research-Polit and Beck
- Nutrition-All books mentioned, depending on the age and condition of the client
- Oncology Nursing-Brunner and Suddarth
- Perioperative Nursing-Fundamentals of Nursing by Kozier and Erb; Brunner and Suddarth
- Professional Adjustment, Ethics and Nursing Jurisprudence- Venzon, Kozier and Erb
- Psychiatric Nursing-Keltner
- Orthopedic Nursing-Brunner and Suddarth
- FUNDAMENTALS OF NURSING BY KOZIER AND ERB
The reason why I keep mentioning the PNLE in my posts is because, questions from past PNLE’s are repeated in more recent versions of the exams. Take this question for example. (Uhhh by the way, I got a copy of the PNLE online in .pdf format, and you can just buy them outside the PRC office in Morayta.)
11. All of the following are correct methods in assessment of the blood pressure EXCEPT:
A. Take the blood pressure reading on both arms for comparison
B. Listen to and identify the phases of Korotkoff’s sound
C. Pump the cuff to around 50 mmHg above the point where the pulse is obliterated
D. Observe procedures for infection control
The answer is C. If you will read on my recent post, “Assessing Blood Pressure,” a nurse should only pump the cuff up to 30 mmHg above the point where the pulse is no longer felt; that is the point when the blood flow to the artery is stopped.This was taken from our book, Fundamentals in Nursing by Kozier and Erb, Volume 1, page 554.
This question was first asked in the June 2007 version of the exam, and was repeated in the June 2008, November 2008 and June 2010 exams.
My point is this, what are the odds that the same questions would be asked again in the June-July PNLE? Think about it. That is why it is vital for you to self-review. Your life does not depend on review classes. Sure, they are a lot of help, but it never hurts to read. Mind you guys, questions are taken straight from books we used in college, so, read up. :)
NURSE PRACTITIONERS (Adult nurse practitioner, school nurse practitioner, pediatric nurse practitioner, gerontology nurse practitioner)
-advanced education and is a graduate of a nurse practitioner program. They are employed in health care agencies or community-based settings. They usually deal with non-emergency acute or chronic illness and provide primary ambulatory care.
CLINICAL NURSE SPECIALIST (gerontology, oncology)
-advanced degree or expertise and is considered to be an expert in a specialized area of practice. They provide direct client care, educates others, consults, conducts research and manages care.
-completed advanced education in an accredited program in anesthesiology. Carries out pre-op visits and assessments, and administers general anesthetics for surgery under the supervision of an anesthesiologist. Also assesses the post-op status of the client.
-completed a program in midwifery. Gives prenatal and postnatal care and manages deliveries in normal pregnancies. Practices in association with a health care agency and can obtain medical services if complications occur. May also conduct routine Papanicolaou smears, family planning and routine breast examination.
-investigates nursing problems to improve nursing care and to refine and expand nursing knowledge. Employed in academic institutions, teaching hospitals, and research centers. They usually have an advanced education at the doctoral level.
NURSE ADMINISTRATOR (head nurse, chief nurse, nurse supervisor)
-manages client care, including the delivery of nursing services. The functions of nurse administrators include budgeting, staffing and planning programs. The educational preparation for nurse administrators is at least a baccalaureate degree in nursing and frequently a master’s of doctoral degree.
NURSE EDUCATOR (clinical instructors, lecturers, level coordinators, deans)
-employed in nursing programs at educational institutions, and in-hospital staff education. The nurse educator usually has a baccalaureate degree or more advanced preparation and frequently has expertise in a particular area of practice. Responsible for classroom and clinical teachings.
-usually has an advanced degree and manages a health-related business. The nurse may be involved in education, consultation, or research, for example.
This may be the easiest nursing skill yet!
But do you know the standards to assessing blood pressure?
This topic appeared in the actual June 2007, June 2008, November 2008, June 2009, July 2010 and July 2011 Philippine Nurse Licensure Examinations.
- Blood pressure cuffs come in various sizes because the bladder must be the correct length and width for the client’s arm.
- If the bladder is too narrow, the blood pressure reading will be erroneously elevated. (Actual PNLE Question, June 2007 & June 2008)
- If it is too wide, the reading will be erroneously low.
- First, the nurse pumps the cuff up to 30 mmHg above the point where the pulse is no longer felt; that is the point where the blood flow in the artery is stopped. (Actual PNLE Question, June 2007 & June 2008)
- The pressure should be released slowly. (2 to 3 mmHg per second) (Actual PNLE Question, June 2007 & June 2008)
- An auscultatory gap, which occurs particularly in hypertensive clients, is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high followed by the reappearance of sounds at a lower level. Solution? Assess the blood pressure through palpation. Instead of auscultating for the Korotkoff sounds, palpate by using light to moderate pressure to palpate the pulsations of the artery as the pressure in the cuff is released.
- The Korotkoff’s sounds are the identified phases in the series of sounds heard when assessing the blood pressure of a client. Identify the manometer readings at Korotkoff phases I, IV and V. There is no clinical significances to phases II and III.
- Make sure the client has not smoked or ingested caffeine within 30 minutes prior to measurement.Smoking constricts blood vessels, and caffeine increases the pulse rate. Both of these cause a temporary increase in blood pressure.
- Legs crossed at the knee result in elevated systolic and diastolic blood pressures.
- The blood pressure increases when the arm is below heart level, and vice versa.
- Wait 1 to 2 minutes before making further measurements, should you plan to to retake the client’s blood pressure. A waiting period gives the blood trapped in the veins time to be released. Otherwise, false high systolic readings will occur. (Actual PNLE Question, June 2007 & June 2008)