Course Task CU 7

2. HYPOVOLEMIA
A teenage patient was rushed to the emergency department due to wrist laceration from a suicide
attempt. The patient is lethargic and have the following findings upon assessment:
● BP –80/50 mm Hg
● HR –110 bpm
● RR –25 bpm
The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the
remaining fluid to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was
ordered to be transfused immediately after proper cross-matching. The patient was hooked to
oxygen 8 liters per minute via face mask.
1. What parameters will the nurse check while the patient is undergoing
rapid fluid resuscitation?
● Regularly monitor the vital signs
● Temperature
● Pulse
● Respiration
● Blood pressure
-Fluid management is an important feature of patient care, particularly in the inpatient medical
setting. Fluid management is both tough and exciting because each patient's fluid needs must be
carefully considered. Unfortunately, there is no way to apply a single, precise recipe to all
patients. However, one fundamental guideline that applies to all patient settings is to restore
whatever fluid is lost as precisely as feasible. These fluid losses can vary in amount and
composition depending on the medical circumstances of the individuals.
The following are some signs that can indicate if a patient is fluid-depleted or volume-
overloaded:
Weight: Body weight is one of the most sensitive indicators of changes in patient volume status.
To measure fluid status, patient weight fluctuations are used to approach a gold standard.
Heart rate: Tachycardia can be a compensatory physiological response to maintain perfusion in
the presence of hypovolemia.
Blood pressure: Falling blood pressure is a concerning result in the presence of tachycardia,
indicating that the cardiovascular system can no longer sufficiently adjust for hypovolemia.
Hypervolemia, on the other hand, can cause high blood pressures.
Respiratory rate: Increased respiratory rate implies a compensatory reaction to metabolic
acidosis caused by lactic acidosis due to inadequate tissue perfusion.

2. For a patient who will undergo blood transfusion, enumerate the steps
that the nurse should prudently undertake while performing the
procedure.
Ensure that the correct preparation of the patient and the care procedure is done.

a. Double-check the order for transfusion and correlate this with the clinical
diagnosis and care plan of the patient.
b. Verify the blood type of the patient on the chart. If needed, obtain a request for
blood typing.
c. Once blood to be transfused or a donor is available, request for crossmatching to
be done. A sample will be obtained from the patient and from the donor/blood
pack and tested.
d. After cross matching is done, a request for the number of units to be transfused
should be made.
e. NOTE: Universal donor is blood type O-, while type AB+ is the universal
recipient.

Obtain consent. The consent must be obtained prior to starting any invasive procedure or
therapy. NOTE: The physician is the one explaining the procedure and asks the patient to
sign the form. The role of the nurse is to witness the signing.

f. Assess for any allergies the client may have.

g. Ask the client for any previous blood transfusion and their reaction to it.
i. If the patient has had a BT before, the physician may need to prescribe
premedication to prevent a febrile non-hemolytic reaction, common with
patients who have had several blood transfusions done.
ii. Usual premedication given is Benadryl (diphenhydramine) and
acetaminophen, 30 minutes to 1 hour before transfusion.
h. Verify the BT order. Check the patient record and the order of the physician.
The following are verified:
i. Patient identification and the information about the patient from the blood
bank;
ii. Results of typing and crossmatching;
 iii. Expiration date of the blood product to be administered.
i. Warm the blood products.
j. Determine the correct gauges of IV needles. Usual IV needles from a blood
transfusion are gauge 18 0r 16. Larger bore needles are needed for BT because it
allows the passage of RBCs.
k. Ensure proper IV tubing and access site. Y-tubing with an in-line filter is
typically used for BT. If the patient needs any other IV fluids, this is administered
on another line.
l. Prime the line. The BT line is primed prior to the administration of BT. 0.9%
NaCl is used to prime the line and is the only compatible IV fluid with blood
transfusions. NOTE: Once the line is primed, the BT can be started.
m. Obtain vital signs. These vital signs are taken prior to the start of the BT and
several times during the BT. Blood pressure, temperature and pulse rate can be
used as indicators of potential adverse reactions to transfusion.
n. Start the transfusion. Ensure that the patient is positioned comfortably since the
BT may last for anytime between 30 minutes to 4 hours.
o. Monitor patient response to the therapy. Apart from vital signs, the patient may
be assessed for the following:
i. Rashes. This is an indication of an allergic reaction either to the blood
type or the additives in the blood products.
ii. Chills. A sign of a pyrogenic reaction, especially when this is seen in the
patient with an increase in temperature.
iii. Shortness of breath. This is a sign of hemolytic reaction and necessitates
the stopping of the transfusion.
iv. Headache, back pain, nausea and vomiting.
p. NOTE: If using an infusion pump, set the pump at 2mL/min for the first 15 to 30
minutes of transfusion and monitor the patient’s response. Vital signs must be
monitored as per the following schedule:
i. At the first 5 minutes after starting the transfusion;
ii. 15 minutes after transfusion started;
 iii. On the 30th minute;
iv. Every hour until the transfusion is done;
v. 1 hour after the transfusion is over.
q. Once transfusion is done, the line should be flushed with normal saline solution.
If there are no more succeeding transfusions, the line is discontinued, and the BT
set is disposed of properly.
3. List down three (3) priority nursing diagnosis for the patient and create a
hypothetical FDAR.

Three Nursing Diagnosis:

· Fluid imbalance- decreased blood volume patient with laceration in wrist after
suicide attempt, blood pressure of 80/50 mmHg, heart rate of 110 bpm, and
respiratory rate of 25 bpm.

· Decreased cardiac output- The patient has a blood pressure of 80/50 mmHg and
has a decreased cardiac output blood loss.

· Risk for hopelessness- A laceration on the wrist of a suicidal attempt.

FDAR:

FOCUS DATA ACTION RESPONSE

Enhance the Subjective: l Administer 1L After performing

patient's of PNSS to a and administering
condition. Suicide attempt fast-drip procedures , patient
Improve the 200c, then condition is
patient's run the alleviated. Patient
mental state remaining undergo
Objective:
fluid for 6 psychological
l BP-80/50 hours as assessments ,
mmHg directed by interventions and
the doctor for treatments to
l HR - 110 fluid improved mental
bpm resuscitation. and cognitive
condition.
l RR - 25 l Administer three
bpm units of
whole blood,
which should
be transfused
 promptly
following
adequate
cross-
matching.

l Check the
patients'
oxygen
levels.
Provide the
patient with a
psychologica
l evaluation
and
intervention.

3.THIRD SPACE EDEMA

A patient with portal hypertension secondary to chronic liver cirrhosis was admitted in the
surgical ward. The patient presented with emaciated body build, distended abdomen with
prominent veins, and jaundice. The doctor ordered paracentesis and the following laboratory
tests prior to the procedure: Prothrombin time (PT), Activated Partial Thromboplastin Time
(APTT), Total Protein, Albumin-Globulin ratio, AST, ALT.
1. List down two (2) nursing diagnoses and create a hypothetical FDAR for
the patient.
Two Nursing Diagnosis:

· Increased cardiac output- ) increased pressure within the portal vein

· Imbalanced nutrition / improper diet- patient presented with emaciated body

build, distended abdomen with prominent veins, and jaundice.

FDAR:

FOCUS DATA ACTION RESPONSE

 Improve the Subjective: Discuss After completing the
patient's arrangements for action, the patient's
condition. Suicide attempt paracentesis. Prior to condition improved,
Alleviate the procedure, assist and he informed the
the patient with the nurse of his
following blood tests: awareness of health
Objective:
Prothrombin time lifestyle and food.
l Emaciated (PT), Activated
body Partial
build. Thromboplastin
Time (APTT), Total
l Distended Protein, Albumin-
abdome Globulin ratio, AST,
n w/ ALT. Keep an eye on
promine the patients' vital
nt veins. signs and overall
health. Provide
l Jaundice. health education on
correct diet and
living a healthy
lifestyle.

2. Why is there a need to check the PT and APTT levels of the patient prior
paracentesis?
PTT and APTT levels are measured to determine or assist doctors in assessing the body's
potential to develop blood clots. Bleeding sets off a chain of events known as the coagulation
cascade. Coagulation is the mechanism through which your body stops bleeding. The
thromboplastin time (TPT) measures the integrity of the intrinsic system as well as factors
common to both systems. This is followed by Prothrombin Time (PT) which measures the
internal structure of the blood clotting fluid. The partial thromboplastin time (PTT) is a screening
test that helps evaluate a person's ability to form blood clots. It measures the number of seconds
it takes for a clot to form in a sample of blood after substances are added.

3. What is the rationale behind the order of checking the Total Protein,
Albumin-Globulin ratio?
Proteins are essential components of all cells and organs. They are necessary for physical
growth, development, and health. They are structural components of most organs, as well as
enzymes and hormones that govern physiological activities. This test determines the level of
protein in your blood.
Total protein and albumin-globulin levels are measured to determine the body's ability to fight
infection and carry nutrients. The total serum protein test determines the concentration of all
proteins in your blood. It can also determine the quantity of albumin you have in comparison to
globulin, or your "A/G ratio."
The blood contains two types of proteins: albumin and globulin:
l Albumin is produced by the liver and accounts for approximately 60% of total protein.
Albumin prevents fluid from escaping from blood arteries, nourishes tissues, and carries
hormones, vitamins, medicines, and calcium throughout the body.
l The remaining 40% of proteins in the blood are globulins. Globulins are a diverse group of
proteins, some of which are produced by the liver and others by the immune system.
They aid in the fight against infection and the transfer of nutrients.
The test also compares the amounts of albumin and globulin and computes the A/G ratio. A shift
in this ratio can help your doctor figure out what's causing the protein levels to fluctuate.

Total protein levels in the blood may grow or decrease to varying degrees depending on the
circumstance.
4. Enumerate the following regarding the nursing role in assisting with
paracentesis:
● Position of choice: To reduce the danger of perforation during paracentesis, the
patient is laid supine and slightly rotated to the side of the procedure. The left-lateral
technique is most usually utilized since the cecum is relatively fixed on the right side

● Site of insertion: Insertion locations may be in the midline or through the oblique
transversus muscle, which is lateral to the thicker rectus abdominus muscles.

● At least three (3) nursing considerations:

1. During the procedure, reassure the patient. Check blood pressure, heart rate, respiration
rate, and temperature, and look for indicators of problems such as ascetic fluid
leakage, infection, bladder and intestine perforation, and bleeding.

2. Take note of the characteristic as well as the amount of fluid aspirated.

3. Compare his or her abdominal girth to the baseline measurement.