NURS 3466 Nursing Care of The Adult 1 Transfusion Case Study 2021 | Primary Concept: Perfusion

NURS 3466 Nursing Care of The Adult 1 Transfusion Case Study Primary Concept: Perfusion Interrelated Concepts (In order of emphasis) 1. Gas Exchange 2. Clinical judgment Present Problem: You are the nurse caring for Anthony Robinson, a 67-year-old African American male patient with a history of heart failure and iron deficiency anemia who was admitted to the medical floor from the emergency department earlier this morning for low hemoglobin. Mr. Robinson’s initial hemoglobin was 6.2 and the primary care provider ordered 2 units of packed red blood cells (PRBC). He received the first unit in the emergency department (ED) over 90 minutes and tolerated well with no change in status. Current Labs Complete Blood Count (CBC) WBC HGB HCT PLT 7.5 6.2 34 154 Basic Metabolic Panel (BMP) & Mg Na K Cl CO2 BUN Cr Glu Mg 143 3.5 110 26 16 1.1 132 1.8 The second unit was started after he arrived on the floor and is nearly 2/3 finished. You are rounding on your other patients when Mr. Robinson presses his call light and states “I feel like I can’t catch my breath.” When you enter the room, you see Mr. Robinson in bed breathing rapidly and he appears anxious. What data from the assessment is RELEVANT and must be recognized as clinically significance by the nurse? List relevant data and include clinical significance. Relevant data from the assessment Clinical Significance of each piece of relevant data - Chloride is 110 - Glucose is 132 - HGB: 6.2 and HCT: 34 - Rapid breathing and appears - Elevated chloride can indicate metabolic acidosis, respiratory alkalosis or hypercortisolism (Ignatavicius, 2021 p.242). anxious - Elevated glucose (greater than 106 mg/dL) indicate hyperglycemia (Ignatavicius, 2021 p. 1267). - Decreased hemoglobin and hematocrit can indicate anemia or even hemorrhage (Ignatavicius, 2021 p. 787). - Respiratory alkalosis has some features like hyperventilation and feeling anxious (Ignatavicius, 2021 p.272). Recognizing a potential problem, you stop the blood, allowing saline to infuse TKO, and promptly collect a full set of VS before contacting the primary care provider: - - -