Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage quizlet?

GIVEN ON COAGULATION ISSUES
PRIOR: INFORMED CONSENT
pt must be typed and crossed.
Identify patient
Two licensed nurses / MD
Identify blood type/donor number/expiration date
Explain the procedure to the patient and purpose
Get baseline VS (if temp is >100 notify MD)
Plasma given for fluid and blood loss

s/s: chills, itching, fever, rash, headache, and back pain
*repeated transfusions can cause hemosiderosis (r/t the excess iron deposits stored in tissue)
Remain with pt for first 15-20 min during blood admin.
Monitor VS immediately prior and 15 min during blood infusion.
Hang RBC within 30 min from collection from blood bank.
Infuse no longer than 4 hrs r/t to the risk of bacterial growth in blood.
MUST BE HANG WITH 0.9% NS ALONG WITH BLOOD
Use 18G or 20G needle to prevent hemolysis of RBC
Use Y tubing or tubing that has a filter
Given in slow infusion
Warm blood prior to admin due the risk of cardiac arrhythmias (within 15-30min from blood bank)
PLT/FFP must be give STAT from blood bank.
Have clean tubing at the bedside in the event of an reaction
If another unit of blood is needed CHANGE ENTIRE IV LINE!
MUST RUN AT 2-5ml/min RATE!!
Observe for an increase in hbg and hct (H&H)

Contamination through blood products:
HIV/AIDS
Hep B/C
CMV
CJD
GVHD (graft vs host disease)
Syphilis

MNEUMONIC s/s: REACTION
Rash (hives)
Elevated Temp (1-2 degrees above baseline VS)
Aching
Chills
Tachycardia
Increased RR
Oliguria *hematuria
Nausea

ACUTE HEMOLYTIC REACTION
s/s: fever, chill, N/V, lower back pain, hypotension, dyspnea, DIC, bronchospasm
Stop the infusion, remove tubing, run NS, and contact HCP/blood bank
Send urine and blood samples to blood bank/lab
Follow MD orders
Document actions
Monitor VS/LOC (temp)

ALLERGIC REACTION
s/s: hives (utica), itching (all over), flushing
-MILD reaction; stop transfusion; call HCP for antihistamine (Benadryl), & then continue transfusion.
-SEVERE reaction: (s/s: bronchospasm, laryngeal edema, shock). Treated with epinephrine, corticosteroids. D/C transfusion and call MD
Monitor VS/LOC (temp)
DOCUMENT

BACTERIAL CONTAMINATION (septicemia)
contamination of blood products (usually r/t blood out from blood bank >4hrs)
s/s: fever, chills, hypotension, tachycardia, vomiting, diarrhea
Discontinue blood immediately; keep IV on
Connect saline
Notify MD
Collect blood cultures as ordered
Monitor VS/LOC (temp)
DOCUMENT

OTHER COMPLICATIONS OF TRANSFUSION:
Circulatory Overload: (s/s: Blood flow infused too rapidly, cough, tachycardia, dyspnea and edema.)
-NSG INTV: Elevate HOB to high fowlers, stop infusion, notify HCP
Air Emboli
Febrile reaction
Shock

TRANSFUSIONS ARE AVOIDED BY JEHOVAH'S WITNESSES

- Soft tissue injuries
- Lacerations, puncture wounds, abrasions, contusions, edema, ecchymoses, impaled objects
- Palpate for areas of tenderness, step-offs, and crepitus
- Bone deformities
- Asymmetry of facial expression
- Any exposed tissue or bone that may suggest disruption of CNS
- Palpate for depressions, angulations, tenseness

- Spontaneous breathing
- Resp rate, depth, and effort; use of accessory or abd muscles and any paradoxical chest movement
- Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, scars that may indicate previous chest surgery
- Expansion and excursion of chest
- Pain with breathing
- Lung sounds
- Heart sounds for presence of murmurs, friction rubs, or muffled heart tones
- SQ edema
- Bony crepitus or deformities (step offs or areas of tenderness) to the clavicles, sternum, and ribs

- Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, and scars indicating previous abdominal surgery
- Evisceration
- Distention
- Bowel sounds
- Palpate for rigidity, guarding, masses, tenderness

- Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, and scars
- Bone deformities or exposed bone
- Blood at urethral meatus, vagina, rectum
- Priapism
- Pain and/or urge, but inability to void
- Palpate for instability if pelvis by applying gentle pressure over iliac wings downward and medially or on symphysis pubis

- Lacerations, puncture wounds, abrasions, contusions, avulsions, ecchymoses, edema, impaled objects, deformity, and any open wounds
- Bleeding
- Angulation, deformity, and open wounds with evidence of protruding bone fragments, edema
- Correct placement of previously applied splints
- Skin color
- Presence of dialysis catheters, PICCs, or other signs of complex medical hx
- Skin temp and moisture
- Pulses
~ Always compare sides
- Crepitus
- Deformity and areas of tenderness
- Sensation
- Spontaneous movement of all extremities
- Motor strength and ROM in all extremities
- Test equality of strength in bilateral extremities

Will lead to death without rapid intervention

- Obtunded, stuporous, or comatose
- Marked hypotension and heart failure
- Bradycardia with possible dysrhythmias
- Decreased and shallow respirations
- Pale, cool, clammy skin
- Kidney, liver, other organ failure
- Severe acidosis, elevated lactic acid levels, and worsening base excess
- Coagulopathies with petechia, purpura, or bleeding

Which of the following mnemonics can help the nurse prioritize care for a trauma patient with massive uncontrolled hemorrhage?

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