브이심(v-Sim) Lloyd Bennett 5/6단계 답변 (수혈반응)

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"브이심(v-Sim) Lloyd Bennett 5/6단계 답변 (수혈반응)"에 대한 내용입니다.

목차

1. Document your focused postoperative assessment for Lloyd Bennett.
2. Document Lloyd Bennett’s allergies in his chart.
3. Document Lloyd Bennett’s vital signs during the transfusion reaction.
4. Document the priority nursing actions completed during the transfusion reaction.
5. Identify and document key nursing priorities for Lloyd Bennett.
6. Referring to your feedback log, document the nursing care you provided.
7. How did the scenario make you feel?
8. Prior to blood administration, what assessments of the blood product and the patient are required to promote safe delivery and lessen potential complications?
9. What signs and symptoms first indicated the patient was having a transfusion reaction?
10. Review the immediate priorities when a transfusion reaction occurs and the rationale for each.
11. What key elements would you include in the handover report for this patient? Consider the ISBAR (introduction, situation, background, assessment, recommendation) format.6. What follow-up blood work may be required?
12. What follow-up disclosure is required with Lloyd Bennett and his family?
13. What would you do differently if you were to repeat this scenario? How would your patient care change?

본문내용

1. Document your focused postoperative assessment for Lloyd Bennett.
-수술 후 고통이 있거나 불편하지 않은지
-환자 수술부위, 드레싱 상태
-바이탈 상태

2. Document Lloyd Bennett’s allergies in his chart.
-알고 있는 알러지 없음

3. Document Lloyd Bennett’s vital signs during the transfusion reaction.
-1:10 Heart rate: 91. Pulse: Present. Blood pressure: 105/68 mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C)
-4:10 Heart rate: 92. Pulse: Present. Blood pressure: 104/67 mmHg. Respiration: 17. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C)
-10:10 Heart rate: 98. Pulse: Present. Blood pressure: 112/72 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C)
-18:10 Heart rate: 94. Pulse: Present. Blood pressure: 106/69 mmHg. Respiration: 17. Conscious state: Appropriate. SpO2: 94%. Temp: 99 F (37 C)

4. Document the priority nursing actions completed during the transfusion reaction.
-수혈반응 발생 시 수혈을 중단하고 연결되어 있던 혈액 튜브를 제거한다.

참고 자료

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