You received a patient from the previous shift in Room 22 Step Down Unit, Dean Malone 45 y/o male, who had abdominal surgery for colon resection and...

Question HI, Can you help me break down this scenario according to the bolded points following the scenario: You received a patient from the previous shift in Room 22 Step Down Unit, Dean Malone 45 y/o male, who had abdominal surgery for colon resection and creation of colostomy 10 hours ago. He had a history of colon cancer and hypertension. After your initial assessment, you found your patient complaining of pain 7/10 in the abdomen. He has an order of morphine 5 mg IV Piggyback in 50 ml. of normal saline to run in 30 minutes. After you administer the medication, you came back and re-check on him and you found out that he is still in pain, relatively the same level. You check his vital signs and obtained the following: BP=90/45, HR=110, Temperature=98.2, RR=22, Saturations of 95 % on room air. You also noticed that his colostomy bag is half-filled with blood. You called the provider and relayed your findings using the SBAR. The patient was seen and ordered the following: Give 500 ml of Normal saline stat, obtain CBC stat and type and screen. A bolus of IVF was given and results of CBC came back with hemoglobin=7.0 and hematocrit =29.2. The provider has ordered 1 unit of PRBC to run for 3 hours. The patient is Type A Rhesus (-) negative. You requested blood to the Blood bank and the patient has an available blood cross-matched. One unit of PRBC arrived in your unit and now ready to transfuse. Current vital signs are as follows: BP=84/45, HR=113, Temperature is 98.3, RR=22, Saturations=95% room air which you obtained 15 minutes ago. Repeat CBC 30 minutes post-transfusion was also ordered. Discuss and Role Play the events in the scenario efficiently with your partner student nurse who is working with you in carrying out the blood transfusion. This will measure how you optimize collaboration as members of the health care team. Phases of Presentation: 1. Scenario review/Background 2. Safety measures (Patient identification, there is consent for blood transfusion, Provider Order verification in the EHR, Administer health education on blood transfusion indication, IV site check, and equipment preparation: Y-tubing blood transfusion set, Normal Saline 250 ml as flush and pump) 3. Pre-transfusion (Patient Identification, Obtain a full set of vital signs 15 minutes prior to blood transfusion and document in using the Blood Transfusion Record. Administer health education on blood transfusion indication and reporting of complication to the caregiver and documentation). 4. During transfusion: On the exact time of transfusion. Verification of the following must ensue with 2 nurses:Using both the Blood product release form and Unit of Blood Product (PRBC) 2 nurses check and document:· Patient identifiers (name, date of birth, and MRN) · Donor unit number· Blood Unit Number· Blood typing and Rhesus group and volume,· Expiration of blood product· Health education in prompt reporting complication to the caregiver and· Infuse blood product. Order: During the first 15 minutes, infuse the blood at 120 ml/hr. Then, re-program the remaining blood to run for 3 hours. · Documentation 5. Intra-transfusion: 15 minutes post blood transfusion initiation then every hour. (Patient Identification, full set of vital signs, health education on blood transfusion indication, prompt reporting of complication to the caregiver, and documentation) 6. Post-transfusion: 30 minutes post-blood transfusion. (Patient Identification, full set of vital signs, health education on blood transfusion indication, prompt reporting of complication to the caregiver and documentation) Health Science Science Nursing NURSING 123 Share QuestionEmailCopy link Comments (0)