성인간호학 / V-sim / Lloyd Bennett / 5번 6번 / 디브리핑 보고서

소개

성인간호학 / V-sim / Lloyd Bennett / 5번 6번 / 디브리핑 보고서 입니다.

목차

I. Documentation Assignments
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.

II. Guideline Reflection Questions
1. How did the scenario make you feel?
2. Prior to blood administration, what assessments of the blood product and the patient are required to promote safe delivery and lessen potential complications?
3. What signs and symptoms first indicated the patient was having a transfusion reaction?
4. Review the immediate priorities when a transfusion reaction occurs and the rationale for each.
5. 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?
7. What follow-up disclosure is required with Lloyd Bennett and his family?
8. 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.

76세 남성으로 2일전 야외에서 넘어져 femoral head fracture 이 발생하여 응급실에 입원하여 왼쪽 고관절 인공관절 수술을 받았다. 드레싱은 깨끗한고 건조하며 온전한 상태이나 대상자는 물리치료로 피로를 호소했으며, CBC에서 Hb이 69g/L로 cross match를 위해 혈액을 채취하였으며 혈액형은 O형, Packed red blood cells 이 처방되었다.

2. Document Lloyd Bennett’s allergies in his chart.

대상자는 V/S을 측정하고 두명의 간호사와 혈액, 등록번호, 혈액의 유형 및 교차 일치를 확인하고 Packed red blood cells 150mL/hr 주입을 시작하였으나 수혈반응을 나타내기 시작했다.

참고자료

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