Tutor profile: Midhy K.
Explain nursing management of Parenteral Nutrition.
Parenteral nutrition refers to administration of nutriotions by route other than GI sytem. parenteral nutrition is administered when there is hindrance in intake , absorption and digestion in the GI system. Parenteral nutrition supplies all the essential nutrients to the body through an alternate route. CONTENTS Parenteral nutrition consists of dextrose, electrolytes, lipids, amino acids and trace elements. ADMINISTRATION Parenteral nutrition is available in forms that can be administered via peripheral veins temporarily, and central PNs are used in central venous catheters. Follow aseptic practices for administering PN , as it is an excellent culture media for microbes. Use microfilters while administering lipids and solution containing fat emulsions. change the tubings every 24hr. Always use an infusion pump to maintain the rate of infusion. Examine the solution for leaks , color changes before administration. Check the label and ingredients with the physicians order. Do not mix any additives to the tubing used for administering PN. Monitor the vital signs of the patient every 4hr. Daily weights give an idea about the hydration status of the patient. The patient should be monitored for blood glucose and electrolyte level, along with basic metabolic panel. Dressings must be changed as per the institutional protocol. Assess the patient for thrombophlebitis at regular intervals. NURSING RESPONSIBILITIES Infection control by using sterile techniques, change of dressings as per protocol etc Monitor for early signs of infection. Monitor for signs of hypoglycemia/hypoglycemia to ensure early intervention. Monitor signs of volume overload. Monitor serum electrolyte levels daily.
A male patient in ICU requires a dopamine drip at 5mcg/kg/hr. The patient weighs 75kg. A 200mg/5ml vial of dopamine and 50ml 5%dextrose solution is available for drug preparation. Explain the procedure of drug preparation and deduce the infusion rate to be set up in the pump.
To determine the rate of infusion of any drug, first calculate the amount of drug in 1ml of the prepared drug. In this case, we prepare 200mg/5ml vial of dopamine in a total of 50ml dextrose solution. (discard 5ml dextrose and mix 5ml dopamine + 45ml of 5% dextrose) Now we have 200mg dopamine in 50ml Dextrose. So 1ml contains 4mg dopamine. 1mg = 1000micrograms , that is 1ml has 4000mcg dopamine. This is the way we calculate the drug concentration. It can vary with the amount of drug added and dilution. It is the amount of drug in 1ml of the preparation. Most of the infusion pumps work at ml per hour so we convert 1hr to 60min , to match our desired dose of 5mcg/kg/hr. The weight of the given patient is 75kg and the dose of the drug is 5mcg. We have 4000mcg in 1ml so 1mcg will be 1/4000 So the desired amount of drug will be (5 x 1/4000)mcg per 75kg per 60min that is 0.00125 x 75 x 60 = 5.625ml. Start the dopamine infusion at 5.625ml . This can be used for any drug. If we change the drug as dobutamine 250mg/5ml in 45 ml of 5% dextrose, the drug concentration will be 5000mcg/ml. And the infusion will be started at 4.5ml which is 5mcg/kg/hr of dobutamine for the same patient.
An elderly male patient was brought in to the emergency department with gastrointestinal bleeding from unknown origin. He was administered multiple transfusions. Enumerate blood products and Describe the procedure of blood/blood component administration. Explain breifly about the various transfusion reactions you will be monitoring the patient for and what actions would you take followed by atransfusion reaction.
Blood transfusion traditionally meant administration of whole blood. It has gained a broader meaning with the technological advancement in separating the different components of blood and using it for specific needs. Following are the blood products and their indications of use: PACKED RBCs - The remaining components of blood are separated by centrifugation and used for specific purposes. Leukocyte depleted to reduce hemolytic reactions INDICATIONS - severe or symptomatic anemia, acute blood loss. FROZEN RBCs Prepared from RBCs and frozen, Can be stored for upto 10yrs at - 188.6 F or -87 C Must be used within 24hrs of thawing. INDICATIONS - Autotransfusion, stockpiling or rare donors . FRESH FROZEN PLASMA Plasma is rich in clotting factors but contains no platelets. Must be used within 1hr after thawing. INDICATIONS - Bleeing caused by deficiency in clotting factors eg. DIC, liver diseaes, massive transfusion, vitamin K deficiency. PLATELETS Prepared from fresh whole blood within 4hrs after collection. can be stored at room temperature for 1-5 days. INDICATIONS - Platelet count less than 10000/micro L, heparin induced thrombocytopenea. ALBUMIN Prepared from plasma. INDICATIONS - Hypovolemic shock, hypoalbuminemia. CRYOPRECIPITATES Prepared from FFP. Can be stored for one year.must be used once thawed. INDICATIONS - Replacement of clotting factors. ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS IV ACCESS : A large gauge free flowing IV line is preferred for transfusion. Smaller gauge size may cause hemolysis. Blood products are administered using " Y-type" tubing with micro aggregate filter, with one Y for isotonic saline solution (0.9 % NaCl). All other solutions ( dextrose, Lactated ringers )cause hemolysis. No other additives or medications should be given via the same tubing as the blood. IDENTIFICATION The blood /blood product received from the blood bank must be positively identifiend with the recepient. Check the grouping and crossmatiching of the product. Get an informed consent for transfusion. ADMINISTRATION Take the patients vital parameters before starting a transfusion to get abaseline measure. The blood must be administered as soon as it is brought to the patient. It should not be refrigerated in the nursing unit. Should be returned to the blood blank if not used within 30min. Start transfusion at the rate of 2ml/m, for the first 15 min and remain with thw patient for monitoring any adverse reaction. Repeat vital sings after 15 min. Rate of transfusion is adjusted according to the clinical condition of the patient. 1 unit of PRBCs can be transfused over 2hrs unless the patient is in fluid overload. The transfusion should not exceed 4hrs. FFP, Plasma and cryoprecipitate can be administered over 15 to 30min. BLOOD TRANSFUSION REACTIONS ACUTE HEMOLYTIC REACTION Chills, fever, low back pain, flushing, tachycardia, dyspnea, hypotension, hemoglobinuria, acute renal failure, shock, cardiac arrest, death. FEBRILE REACTIONS Sudden chills, rise in temperature ,headache, flushing, anxiety, vomiting, muscle pain. ALLERGIC REACTION Flushing, itching, urticaria ANAPHYLACTIC REACTION Anxiety, urticaria, dyspnea, wheezing, bronchospasm, hypotension, shock. CIRCULATORY OVERLOAD Cough, dyspnea, pulmonary congestion, headache, hypertension, tachycardia. SEPSIS Rapid onset of chills, high fever, vomiting, diarrhoea, hypotension, shock. TRALI ( Transfusion related acute lung injury ) Fever, hypotension, tachypnea, decreased oxygen saturation, frothy sputum. MASSIVE BLOOD TRANSFUSION REACTION Complication of transfusing large volumes of blood products. Hypothermia, Hypocalcemia, Hyperkalemia, and Citrate toxicity may occur when massive transfusions are done.