CHAPTER 49. Special Procedures
Theresa L. Clifford
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. List common ambulatory nonsurgical diagnostic or interventional procedures.
2. Describe assessment parameters pertinent to the patient undergoing special procedures.
3. Identify nursing interventions appropriate to the care of the patient undergoing select nonsurgical diagnostic or interventional procedures.
4. Describe six types of reactions that can occur as a result of a blood transfusion.
5. Identify three potential complications for the patient undergoing electroconvulsive therapy (ECT).
I. OVERVIEW
A. Definition
1. Variety of procedures performed throughout facility may be termed “special procedures.”
a. Endoscopic procedures
b. Diagnostic procedures
c. Interventional procedures
d. Electroconvulsive therapy
e. Infusion therapies
2. May be performed in:
a. Endoscopy
b. Radiology
c. Vascular or catheterization lab
d. Operating room/minor surgery suite
e. Nursing unit
f. Post anesthesia care unit (PACU)
g. Ambulatory care unit
B. Responsibilities of perianesthesia staff
1. May or may not include:
a. Preprocedure preparation of patient
b. Intraprocedure assessment and monitoring
c. Postprocedure recovery and discharge
2. Varies according to facility protocols
3. Varies according to patient workflow processes
II. ANATOMY AND PHYSIOLOGY
A. Gastrointestinal (GI) procedures (see Chapter 35)
1. Anatomy of GI tract
a. Mouth (oral or buccal cavity)
(1) Teeth, tongue, hard and soft palates, cheeks, lips, pharynx
(2) Salivary glands
(a) Parotid
(b) Sublingual
(c) Submandibular
b. Esophagus
(1) Hollow muscular tube
(2) Approximately 23 to 25 cm (10 inches) long
(3) Approximately 2 to 3 cm (1 inch) in diameter
(4) Extends from pharynx to stomach
(a) Passes through diaphragm into the abdomen opening called diaphragmatic hiatus
(5) Positioned posterior to trachea and anterior to vertebral column
(6) Wall made up of three layers
(a) Mucosa
(b) Submucosa
(c) Muscularis
(7) Sphincters
(a) Upper pharyngoesophageal
(b) Lower esophagogastric (cardiac)
(8) Disorders
(a) Gastroesophageal reflux disease
(b) Esophageal varices
(c) Tumors
(d) Diverticula
(e) Motility disorders
(f) Foreign bodies
(g) Strictures, rings, and webs
(h) Infectious disease
c. Stomach
(1) J-shaped distensible organ
(2) Located in left upper quadrant of abdomen (just below diaphragm, between esophagus and duodenum)
(3) Approximately 25 to 30 cm (l0-12 inches) long
(4) Approximately 10 to 15 cm (4-6 inches) wide at widest point
(5) Function
(a) Digests food and prepares nutrients for absorption
(b) Serves as reservoir for swallowed food, drink, and digested secretions
(c) Mixes and delivers chyme to the small intestine for further digestion and absorption
(d) Originates signals for hunger and satiety
(6) Consists of:
(a) Fundus
(b) Body
(c) Pylorus (antrum)
(d) Cardiac region
(7) Sphincters
(a) Esophagogastric (cardiac)
(i) Prevents backward reflux of stomach contents
(b) Pyloric
(i) Works with duodenum to create pressure gradient, which allows emptying of stomach
(8) Disorders
(a) Acid-peptic disorders
(b) Helicobacter pylori
(c) Polyps
(d) Gastritis
(e) Gastric cancer
(f) Gastric varices
(g) Hiatal hernia
(h) Gastric outlet obstruction
(i) Stress ulcers
(j) Motor dysfunction—swallowing disorders
(k) Bezoars (concretions of foreign material found in stomach)
d. Small intestine
(1) Tube-shaped structure
(2) Approximately 18 feet long, 1 inch in diameter
(3) Three sections
(a) Duodenum
(i) C shaped
(ii) First section
(iii) Begins at pyloric sphincter
(iv) Ends at ligament of Treitz
(b) Jejunum
(i) Middle section (proximal two fifths)
(c) Ileum
(i) Last section
(ii) Distal three fifths of small bowel
(4) Properties
(a) Circular folds increase absorptive surfaces of small intestine.
(5) Disorders
(a) Duodenal ulcer
(b) Bacterial and viral infections
(c) Parasitic disease
(d) Crohn’s disease
(e) Meckel’s diverticulum
(f) Malabsorption syndromes
(g) Celiac spruce (poor food absorption and gluten intolerance)
(h) Tropical sprue (chronic disorder acquired in endemic tropical areas)
(i) Whipple disease
(i) Rare disorder characterized by chronic diarrhea and progressive wasting
(j) Short bowel syndrome
(k) Lactase deficiency
(l) Small bowel tumors
(m) Motility disorders
e. Large intestine
(1) Tube-shaped structure
(a) Approximately 4 to 6 cm (2 inches) in diameter
(b) Approximately 90 to 150 cm (4-5 feet) long
(c) Extends from ileocecal value to the anus
(2) Consists of:
(a) Cecum
(i) Positioned at junction of ileum and colon
(ii) Contains ileocecal valve and appendix
(b) Ascending colon
(i) Portion from cecum to hepatic flexure
(c) Transverse colon
(i) Segment from hepatic flexure to splenic flexure
(ii) Transverses abdominal cavity
(d) Descending colon
(i) Segment from splenic flexure to iliac crest
(ii) Located on left side of abdomen
(e) Sigmoid colon
(i) S-shaped segment
(ii) Ends at rectum
(f) Rectum
(i) Last portion of large intestine
(ii) Approximately 5 inches long
(iii) Segment after sigmoid colon
(iv) Connects to anal canal
(3) Disorders
(a) Polyps
(b) Angiodysplasia (vascular dilations in the submucosa)
(c) Colitis
(d) Necrotizing enterocolitis
(e) Ulcerative colitis
(f) Pseudomembranous colitis
(g) Crohn’s colitis
(h) Irritable bowel syndrome
(i) Diverticular disease
(j) Diverticulosis
(k) Colorectal cancer
(l) Hemorrhoids
(m) Anorectal disorders
(n) Encopresis (chronic constipation that results in involuntary leaking of feces)
(o) Anal fissure
(p) Rectal prolapse
(q) Anorectal abscess
(r) Anorectal fistula
(s) Anorectal fissure
2. Nerve supply—occurs two ways
a. Neural transmission to smooth muscle
(1) Stimulates movement of food through GI tract
(2) Occurs as a result of distention of myenteric plexus or submucosal plexus
b. Autonomic nervous system
(1) Sympathetic
(a) Thoracic and lumbar splenic nerves
(b) Inhibit secretions and movement
(c) Cause contraction of sphincters
(2) Parasympathetic
(a) Vagus nerve: causes increase in motor activity
(b) Causes increase in secretions
(c) Causes sphincters to relax
(d) Results in peristalsis
3. Function of GI system
a. Ingestion
b. Transport
c. Digestion
d. Absorption
e. Elimination
B. Pulmonary procedures
1. Pulmonary anatomy (see Chapter 31)
a. Nose and sinuses
(1) Upper airway cleans, humidifies, and warms air.
(2) Sinuses lighten the skull, assist in speech, and produce mucus.
b. Pharynx
(1) Divided into three regions
(a) Nasopharynx
(i) Area where tonsils and adenoids (masses of lymphoid tissue in the back wall of nasopharynx) trap and destroy infectious agents
(b) Oropharynx
(i) Carries both air and food
(ii) During swallowing, the soft palate rises to prevent food from entering the nasopharynx.
(iii) The lining of the oropharynx protects it from damage by friction and from chemicals in food and fluids.
(c) Laryngopharynx
[i] Passageway for both food and air; connects oropharynx to larynx
c. Larynx
(1) Contains vocal cords to produce speech
(2) Protected by cartilages to keep it open
d. Lungs
(1) Soft and spongy, composed of elastic connective tissue
(2) Apex of each lung just below the clavicle
(3) Base of each lung rests on the diaphragm.
(4) Right lung has three lobes.
(5) Left lung is smaller, with only two lobes.
e. Bronchi and alveoli
(1) Trachea divides into right and left mainstem bronchi .
(2) Mainstem bronchi enter lungs at the hilus .
(3) Bronchi branch into smaller bronchi.
(4) Smaller bronchi branch into smaller bronchioles.
(5) Bronchioles end in the tiny alveoli.
(a) Where gas exchange occurs
(b) Extremely thin walls, made of a single layer of cells over a very thin connective tissue (basement) membrane
(c) Oxygen and carbon dioxide easily diffuse across the walls of the alveoli and capillaries.
(d) Alveoli contain cells that secrete surfactant, a detergent-like substance that helps keep them open.
C. Vascular procedures
1. Vascular anatomy (see Chapter 44)
a. Peripheral vascular system
(1) Network of blood vessels that carries blood to peripheral tissues and then returns it to the heart; network includes arteries, veins, and capillaries.
b. Arteries
(1) Arteries carry blood away from the heart.
(2) Oxygenated blood leaves the left ventricle via the aorta.
(3) Major arteries branch off the aorta and into successively smaller arteries. These eventually divide into arterioles.
(4) Arterioles feed into beds of hairlike capillaries within the organs and tissues.
(a) In capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated blood begins its journey back to the heart through venules.
(5) Venules join onto veins, which in turn join larger veins.
c. Veins
(1) Carry blood toward the heart
(2) Peripheral veins empty into the superior and inferior vena cava, and then into the right atrium.
d. Three layers of blood vessel walls
(1) Tunica intima
(a) Endothelium; has a slick surface to assist blood flow
(2) Tunica media
(a) Contains smooth muscle
(b) Layer is thicker and more elastic in arteries than it is in veins.
(c) Allows arteries to expand and contract, maintaining blood flow to the capillaries between heartbeats
(3) Tunica adventitia
(a) Outermost layer
(b) Connective tissue that protects and anchors the vessel
III. GENERAL CARE
A. Preprocedure education
1. General
a. Nothing-by-mouth (NPO) instructions as appropriate
b. Hygiene
c. Environment
d. Facility protocols
e. Aftercare arrangements
f. Amnesic effects of sedation and analgesia
g. Medication—discontinue or dose as usual
B. Perianesthesia priorities
1. Preprocedure
a. Objectives
(1) Assess and prepare patient for procedure.
(2) Obtain baseline data.
(3) Allow for development and implementation of nursing care.
(4) Initiate educational process.
(a) Continues throughout continuum of care
b. Nursing process
(1) Assessment parameters
(a) Physical assessment as noted previously
(b) Assess for educational needs.
(c) Assess for psychosocial needs related to developmental age including:
(i) Availability of family member or responsible adult companion
(ii) Community resources needed
c. Plan of care
(1) Include patient, family, responsible adult companion in developing plan of care appropriate to patient’s age.
(2) Nursing diagnosis might include:
(a) Anxiety and fear related to:
(i) Knowledge deficit
(ii) Unfamiliar environment
(iii) Separation from family
(iv) Lack of control
(b) Pain related to procedural intervention
(c) Potential for injury
(d) Potential for infection
d. Interventions
(1) Nursing interventions might include:
(a) Ensure that all laboratory studies completed as ordered and indicated.
(b) Provide information on preprocedure preparation.
(i) NPO status
(ii) Medications
(iii) Hygiene
(iv) Discharge arrangements
[a] Ride
[b] Aftercare
(c) Obtain baseline vital signs.
(d) Ensure legal authorization is appropriate (informed consent).
(e) Provide orientation to surroundings.
2. Evaluation
a. Evaluation of interventions and patient response might include:
(1) Laboratory results reviewed, and follow-up completed as indicated
(2) Patient, family, responsible adult companion questioned to determine understanding of preoperative instructions
(3) Determine that patient has arranged for aftercare as appropriate.
C. Nursing interventions
1. General
a. Monitor vital signs per protocol.
b. Administer medications for pain and nausea as ordered.
c. Observe for bleeding and other complications.
d. Ensure a safe environment.
D. Postprocedure
1. Objectives
a. Ensure that patient safely recovers from immediate effects of procedure and anesthesia.
b. Provide care in PACU, depending on facility policy.
c. Transport directly to PACU phase II, depending on facility policy.
2. Nursing process
a. Assessment parameters
(1) General
(a) Routine PACU protocol
(b) Airway status—patient is at high risk for airway compromise.
(c) Vital signs monitored frequently during and after procedure
(d) Effects of medications administered
(e) Intravenous (IV) sedation and analgesia protocol
3. Plan of care
a. Include patient, family, responsible adult companion in developing a plan of care appropriate to patient’s age.
b. Nursing diagnoses might include those listed previously.
c. Provide for patient safety.
d. Be alert for potential complications.
4. Nursing interventions
a. Monitor vital signs per protocol.
b. Administer medications as ordered.
c. Observe for potential complications.
d. Ensure a safe environment.
5. Evaluation
a. Respond to interventions continually throughout patient’s stay.
b. Alter plan of care.
E. Preparation for discharge
1. Objective
a. Ready the patient to return home.
b. Prepare patient and caregiver to successfully manage postprocedure care.
c. Educate patient and caregiver.
2. Nursing process
a. Assessment parameters
(1) Airway and respiratory status
(2) Vital signs
(3) Level of consciousness
(4) Postoperative nausea and vomiting
(5) Bleeding
(6) Reactions to local anesthetics
(7) Discomfort
3. Plan of care
a. Include patient, family, responsible adult companion.
b. Plan should be appropriate for patient’s age.
c. Nursing diagnoses might include:
(1) Anxiety and fear related to:
(a) Knowledge deficit
(b) Unfamiliar environment
(c) Separation from family
(d) Lack of control
(2) Alteration in comfort level
(3) Ineffective breathing patterns related to sedation
(4) Potential for infection
4. Educational interventions
a. Discussion, demonstration, written materials
b. Copies of all materials given to patient should be maintained in medical record.
F. Evaluation
1. Evaluation of clinical interventions is ongoing until patient is stable and ready for discharge.
2. Evaluation of learning
a. Patient and caregiver verbalize understanding.
b. Patient and caregiver able to demonstrate skill
(1) Patient and responsible adult companion should sign that they have been instructed and had the opportunity to have questions answered.
IV. GI PROCEDURES
A. Abdominal paracentesis
1. Removal and drainage of ascitic fluid in the peritoneal cavity
2. Diagnostic tool to examine ascitic fluid
3. Palliative measure to relieve abdominal pressure that may be interfering with respiratory function
4. Fluid withdrawn with a large-bore needle or a trocar and cannula inserted in the abdominal wall
5. Before paracentesis, important to have patient void to reduce risk of accidental injury to the bladder
B. Endoscopy—overview
1. Direct visual examination of lumen of GI tract
2. Usually performed with lighted flexible fiberoptic scope or videoscope
3. Provides undistorted image of body cavity
4. Illumination provided by external light source
5. Scope designed to allow for passage of instruments
a. Allows for:
(1) Pictures to be taken
(2) Biopsies to be obtained
(3) Polyps to be removed
(4) Foreign objects to be removed
(5) Bleeding areas to be cauterized
C. Anoscopy
1. Anoscope: a clear plastic or metal speculum designed to examine the anus and lower rectum
D. Anal manometry
1. Used to assess:
a. Anal and rectal muscles
b. Sphincter problems
(1) Can be associated with several disorders, especially fecal incontinence
c. Chronic constipation
E. Colonoscopy
1. Direct visualization of lower GI tract from rectum to ileocecal valve using a long, flexible endoscope (length, 120-180 cm)
2. Used to evaluate for:
a. Malignancy
b. Polyps
c. Inflammatory bowel disease
d. Diverticulitis
e. Strictures
f. Bleeding
F. Endoscopic retrograde cholangiopancreatography (ERCP)
1. Invasive exam using both endoscopic and radiological techniques to visualize pancreatic ducts, hepatic ducts, and common bile ducts
2. Uses a flexible fiberoptic duodenoscope
3. Contrast material injected
4. May include removal of stones, sphincterotomies, or dilation
G. Esophageal dilation
1. Enlargement of lumen of esophagus
2. Accomplished by forcing a series of increasingly larger dilators through a narrowed area (axial force)
3. May use a balloon dilator to accomplish opening of a narrowed area (radial force)
H. Esophagogastroduodenoscopy (EGD)
1. Direct visualization of esophagus, stomach, and proximal duodenum
2. Flexible fiberoptic endoscope (<10 mm in diameter) passed through mouth allows for direct vision with still and video photography.
3. Used to assess, diagnose and/or treat:
a. Esophageal or gastric lesions
b. Hiatal hernia
c. Esophageal varices
d. Esophagitis
e. Ulcer disease
f. Polyps
g. Strictures (achalasia)
h. Bleeding
i. Motility disorders
j. Preoperative evaluations
I. Liver biopsy
1. Use of sterile technique to excise or needle punch a small sample of liver
a. Tissue examined microscopically for cell morphology and tissue anomalies
b. May also be done using ultrasound or computed tomographic guidance
2. Performed to diagnose or confirm the cause of chronic liver disease and liver tumors
3. After liver transplants performed to determine
a. Cause of elevated liver function test values
b. Whether rejection is occurring
J. Paracentesis
1. Sterile procedure using a needle inserted through the abdominal wall to obtain a sample of any fluid that is present
2. Purpose: to obtain fluid for diagnostic purposes or to drain a larger volume of fluid to relieve pressure
K. Percutaneous endoscopic gastrostomy (PEG)
1. Placement of feeding tube via endoscopy for enteral nutrition
2. Procedure
a. Lighted endoscope inserted into stomach
b. Light shines against abdominal wall.
(1) Allows visualization of tube placement site
c. Large-gauge needle and suture passed through abdominal wall and stomach wall
(1) Snare or biopsy forceps used to bring inner end of suture up through patient’s mouth (via endoscope)
d. PEG tube tied to suture
(1) Pulled through mouth into stomach
(2) Pulled out abdominal wall
e. Tube anchored using internal and external rubber bumpers or internal retention balloon and outer disk
3. Advantages
a. Less risk than surgical gastrostomy
b. Procedure done under sedation rather than general anesthesia
c. Faster recovery
d. Feedings can begin within 24 hours.
e. Can be performed in endoscopy suite or at bedside
f. Less costly
L. Percutaneous endoscopic jejunostomy (PEJ)
1. Tube passed into jejunum through opening in abdominal wall
2. Approach can be surgical or percutaneous.
3. Procedure
a. Small tube passed through percutaneous endoscopic gastrostomy tube
b. Guided via endoscope into duodenum
c. Tube propelled by peristalsis into jejunum
d. Placement confirmed by x-ray
(1) Contrast medium injected
4. Considerations
a. Small diameter of tube predisposes it to clogging.
b. Tube can migrate back to stomach as a result of vomiting.
c. Feedings are continuous because jejunum is not a normal reservoir for nutrients.
M. Polypectomy
1. Removal of a protruding growth or mass of tissue that protrudes from a mucous membrane; usually performed via endoscope
a. Pedunculated—attached to mucous membrane by a slender stalk or pedicle
b. Sessile—broad-based polyp
N. Proctosigmoidoscopy (also called rectosigmoidoscopy)
1. Endoscopic exam of distal sigmoid colon, rectum, and anal canal using a small, hollow, stainless steel tube approximately 1.5 cm in diameter
2. Performed to evaluate:
a. Rectal bleeding
b. Polyps
c. Tumors
d. Persistent diarrhea
e. Fissures
f. Fistulas
g. Abscesses
h. Inflammatory bowel disease
3. Performed as an initial colorectal cancer screen
4. Advantages
a. Better tolerated than rigid proctosigmoidoscopy
b. Allows for examining more of colon than possible with proctoscope
O. GI procedures education
1. Bowel preparation as appropriate
2. Course of procedure
3. Expectations
4. Recovery period
P. GI procedures assessment parameters
1. Preprocedure
a. Preprocedure emphasis on screening for:
(1) Bleeding disorders in patient or family
(2) Medications affecting clotting
(3) Bowel activity
(4) Swallowing ability
b. Ensure understanding of preprocedure preparation.
(1) Nothing per orum (NPO) status
(2) Diet
(3) Enema
2. Postprocedure
a. General
(1) Airway and respiratory status
(2) Vital signs
(3) Level of consciousness
3. Procedure specific
a. Upper GI tract
(1) Swallowing ability
(2) Pain
(3) Bleeding
(4) Reaction to local anesthetic
(5) Temperature
b. Lower GI tract
(1) Pain
(2) Flatus
(3) Bleeding
Q. Nursing interventions
1. Withhold fluid until gag reflex intact.
2. Observe for complications.
3. Activity restriction per physician orders
R. Potential complications
1. GI
a. Bleeding
b. Perforated viscus
(1) Signs include:
(a) Increased temperature
(b) Abdominal distention
(c) Pain
(d) Shortness of breath
(e) Subcutaneous emphysema
c. Respiratory depression
d. Vasovagal reaction
2. Liver biopsy
a. Hemorrhage
b. Fluid leakage
c. Subcutaneous emphysema
d. Perforation of viscus
S. Key patient educational outcomes
1. Patients undergoing a GI procedure will be able to identify the signs and symptoms of a perforation
a. Abdominal/chest pain
b. Dyspnea
c. Fever
d. Light-headedness
e. Distended abdomen
V. Electroconvulsive Therapy (ECT)
A. Application of brief electrical stimulus to induce a cerebral seizure
1. Used to treat major psychiatric disorders (e.g., severe depression)
2. Procedure may be performed in PACU setting.
B. Education
1. Preprocedure emphasis includes screening for:
a. Baseline mental status
b. Confusion
c. Disorientation
d. Cardiovascular disease
e. Cerebral pathology and/or suspected increased intracranial pressure
2. Instruct patient to wash hair night before procedure to remove hair products that may interfere with conduction.
C. Assessment parameters
1. Preprocedure assessment per routine protocol
a. Assess for hypotension and bradycardia.
(1) Orientation to time, place, and person
b. Preprocedure parameters
(1) Have patient void immediately before procedure.
(a) Prevents incontinence
(b) Prevents bladder distention
(2) Apply monitoring devices as indicated.
(a) Electrocardiogram
(b) Pulse oximetry
(c) EEG according to facility policy
(d) Nerve stimulator
2. Postprocedure assessment parameters
a. Airway status
(1) Patient is at high risk for airway compromise.
b. Vital signs monitored frequently (per protocol) during and after ECT procedure
c. Effects of medications
d. IV sedation and analgesia protocol
3. Plan of care
a. Include patient, family, responsible adult companion in developing a plan of care appropriate to patient’s age.
b. Nursing diagnoses might include those listed previously.
c. Provide for safety.
d. Be alert for potential complications.
4. Nursing interventions
a. Monitor vital signs per protocol.
b. Administer medications as ordered.
c. Observe for complications.
(1) Dysrhythmias
(2) Aspiration
(3) Hypotension
(4) Prolonged seizure
d. Ensure a safe environment.
(1) Bite block to prevent damage to teeth and oral cavity during seizure
5. Evaluation
a. Response to interventions evaluated continually throughout patient’s stay
b. Alterations to plan of care made as indicated
D. Potential complications
1. Bradycardia
2. Tachycardia
3. Hypotension
4. Hypertension
5. Airway management problems
VI. PULMONARY PROCEDURES
A. Bronchoscopy
1. Direct visualization of walls of trachea, mainstem bronchus, and major subdivisions of the bronchial tubes through a bronchoscope
a. Rigid bronchoscopy—performed under general anesthesia
b. Fiberoptic (flexible) bronchoscopy
2. Indications
a. Diagnosis
(1) Lesions, bleeding sites
(2) Obtain biopsies, bronchial brushing, bronchial washing.
b. Treatment
(1) Destroy or remove lesions.
(2) Clear airway of retained secretions.
(3) Foreign body
c. Evaluation of disease progression
d. Evaluation of effectiveness of therapy
e. May be combined with laser (yttrium-aluminum-garnet [YAG]) therapy for ablation of tracheal and bronchial obstructions
B. Thoracentesis
1. Withdrawal of fluid or air from the pleural space
a. Amount of removal limited to 1 to 2 L at one time to avoid mediastinal shift and impaired venous return
2. Indications
a. Diagnostic
(1) Obtain specimen—fluid evaluated for chemical, bacteriologic, and cellular composition.
b. Therapeutic
(1) Relieve respiratory distress.
(2) Instill medication into pleural space.
C. PT education and teaching
1. Bronchoscopy
a. Maintain NPO at least 4 to 6 hours prior.
b. Instruct not to drive self.
c. Review nonverbal communication signals when unable to talk.
d. Report any unusual shortness of breath or prolonged hemoptysis.
e. Maintain NPO at least 2 hours after procedure.
2. Thoracentesis
a. Review necessary positioning for procedure.
b. Instruct not to move suddenly during procedure.
c. Instruct to report any unexplained dyspnea, chest pain, fever, or cough.
D. Assessment parameters
1. Bronchoscopy
a. Preprocedure
(1) NPO for 4 to 6 hours before procedure
(a) Decrease risk of aspiration.
(b) Remove dentures.
b. Postprocedure
(1) Assess for return of swallow and gag reflex.
(2) Blood-streaked sputum expected for several hours postprocedure
(3) Frank bleeding indicative of hemorrhage
E. Potential complications
1. Bronchoscopy
a. Bronchospasm
b. Laryngospasm
c. Hypoxia
d. Bleeding
e. Pneumothorax
f. Perforation
g. Aspiration
h. Cardiac dysrhythmias
i. Reaction to local anesthetic
2. Thoracentesis
a. Hemothorax
b. Pneumothorax
c. Air embolism
d. Subcutaneous emphysema
e. Bleeding
F. Key patient educational outcomes
1. Report any of the following:
a. Shortness of breath
b. Prolonged hemoptysis
c. Unexplained dyspnea
d. Chest pain
e. Fever
f. Cough
VII. Infusion therapy
A. Therapy types
1. Blood transfusion
a. Types
(1) Whole blood
(2) Packed red blood cells
(3) Frozen red blood cells
(4) Platelets
(5) Granulocytes
(6) Plasma
(7) Albumin
(8) Coagulation factor concentrates
(9) Prothrombin complex
(10) Cryoprecipitate
(11) Immune serum globulins
b. Collected from:
(1) Donor (homologous)
(2) Recipient (autologous)
(3) Donor designated by recipient (designated direct blood)
2. Medical infusion therapy
a. Treat illness.
b. Provide for patients who need:
(1) Medication for chronic illnesses such as Crohn’s disease, asthma, multiple sclerosis, diabetes
(2) Pain management
(3) IV hydration
(4) Low-dose chemotherapy
(5) Long-term antibiotic therapy
(6) Immunomodulators
(7) Therapeutic phlebotomy
B. Education
1. Patient’s level of understanding regarding procedure
2. History of transfusion reactions
3. Prepare for any preinfusion requirements.
C. Assessment parameters
1. Blood transfusion
a. Preprocedure
(1) Ensure informed consent and/or specific transfusion consent form is complete.
(2) Obtain baseline vital signs, including temperature.
(3) Assess patient history of transfusion reactions.
(4) Educate patient to signs and symptoms of potential reactions.
b. Administration
(1) Ensure blood has been typed and crossmatched and that ABO group and Rh factor match patient’s type.
(2) Check blood for abnormal color or cloudiness (indicates hemolysis).
(3) Check for presence of gas bubbles (indicates bacterial growth).
(4) Check expiration date on blood bag.
(5) Confirm information with another professional.
(6) Document confirmation.
(7) Administration of unrefrigerated blood should begin within 1 hour.
(8) Total administration time should generally not exceed 4 hours.
c. Nursing interventions during procedure
(1) Assess vital signs per protocol.
(2) Be alert for signs of transfusion reaction.
(3) Types of reactions
(a) Acute hemolytic
(i) Caused by infusion of ABO-incompatible blood
(ii) May cause most severe symptoms
(b) Febrile, nonhemolytic
(i) Most common
(ii) Treat symptomatically.
(c) Mild allergic
(i) Rash, itching, low-grade fever
(ii) May administer antihistamines
(d) Anaphylactic
(i) Mild to severe symptoms
(e) Circulatory overload
(i) Rare
(ii) Caused by rapid infusion in patient unable to accommodate volume
(iii) Patient may have history of cardiac disease.
(f) Septic reaction
(i) Caused by contaminated blood
(ii) Symptoms are immediate.
(iii) Fever, chills, hypotension, shock
(iv) Treat with IV antibiotics.
(g) Delayed
(i) Can occur several days to 2 weeks after transfusion
(4) Blood transfusion potential complications
(a) Transfusion reaction signs and symptoms
(i) Integumentary
[a] Itching
[b] Rashes
[c] Swelling
[d] Cyanosis
[e] Excessive perspiration
(ii) Respiratory
[a] Tachypnea
[b] Dyspnea
[c] Apnea
[d] Wheezing
[e] Cyanosis
[f] Rales
(iii) Urinary
[a] Pain on or during urination
[b] Oliguria
[c] Changes in urine color
[1] Dark, concentrated
[2] Shades of red, brown, amber
(iv) Circulatory
[a] Chest pain
[b] Increased heart rate
[c] Palpitations
[d] Hypotension
[e] Hypertension
[f] Bleeding
(v) General
[a] Muscle aches, pain
[b] Back pain
[c] Chest pain
[d] Headache
[e] Fever
[f] Chills
(vi) Nervous system
[a] Tingling
[b] Numbness
[c] Apprehension, impending doom
2. Medical infusion assessments
a. Vital signs per protocol
b. Confirm known patient allergies.
c. Assess for infusion reactions.
d. Monitor infusion sites.
D. Key patient educational outcomes
1. Patient undergoing a blood transfusion will be able to accurately relate information regarding the transfusion and the signs and symptoms of a latent reaction.
2. Patients undergoing infusion therapy must report signs of site irritation or infection, reactions to medications, etc.
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