Nursing Skills & Reasoning

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Nursing Skills & Reasoning

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Blood Transfusion

1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

 

Procedural Safety Principles: Blood Administration

2. What will you do if you have not performed blood administration in the clinical setting?

3. If the nurse was going to administer another unit of packed red blood cells (PRBC), what supplies does the nurse

need to gather?

4. Review and summarize essential steps and knowledge the nurse will apply to administer the remainder of this transfusion safely.

 

5. What will the nurse communicate to educate the patient or family about the need for this procedure and what to expect?

 

 

 

 

Nursing Skills & Reasoning

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

Evaluation

6. You collect the following assessment data. Make a clinical judgment for each finding by placing an “x” in the appropriate column if the finding is expected or unexpected.

Assessment Finding Expected Unexpected T: 98.2 F/36.8 C (oral) P: 108 (regular) R: 25 (regular) BP: 128/83 O2 sat: 88% RA Appears anxious Breathing rapidly Skin is cool and clammy

7. Is the overall status of the patient:

a. Improved b. Declined c. No change

8. Complete the table below for each home medication.

Medication Pharm. Class Mechanism of Action Expected Outcome Metoprolol

 

 

Lisinopril

 

Furosemide

 

 

Ferrous gluconate

 

Potassium chloride

 

9. Which home medication(s) that were not taken would have the greatest impact on his current status?

Medication Rationale

 

 

 

Lucy Myers

 

Nursing Skills & Reasoning

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

10. Calculate the patient’s total intake and output, then interpret the significance of your findings. Intake and Output Clinical Significance

 

11. What clinical data is most important and must be recognized as clinically significant by the nurse?

Most Important Data Clinical Significance

 

12. To interpret the clinical data collected, list at least two possible problems for this patient. Which problem is the

priority? Possible Problems Priority Problem Pathophysiology of Priority Problem

13. After evaluating the patient, identify the current nursing priority and which action(s) the nurse should take. List

interventions by priority and the expected outcome. Nursing Priority Priority Intervention(s) Rationale Expected Outcome

 

 

 

 

Nursing Skills & Reasoning

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

14. Recognizing a potential problem, you use Identify-Situation-Background-Assessment-Recommendation (ISBAR) to update the provider. Summarize what you would communicate for an ISBAR report.

 

I identify Specify who you are/where you work.

• Yourself: name/position/location

• Patient: name/age/gender

 

S situation What is the problem/reason for contact?

Concise summary of primary problem:

B background If urgent, state concern. Provide concise/relevant history

• Primary problem/diagnosis:

• Day of admission/post-op day #:

• Relevant past medical history:

• Relevant treatments/interventions:

 

A assessment Assessment of the situation using the most important clinical data.

State your concern by communicating concerning clinical data:

• Vital signs

• Nursing assessment

• Lab/diagnostic results

Trend of most important clinical data (stable-increasing/decreasing):

 

R recommendation Request specific advice/interventions. Clarify expectations.

• Nurse suggestions to advance the plan of care:

• What do you recommend?

• Repeat and state back new orders/confirm plan of care:

 

 

 

Nursing Skills & Reasoning

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

15. Identify the rationale for each provider order and its expected outcome.

Provider Orders Rationale Expected Outcome Furosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation >92%

 

Dosage Calculation: Furosemide 40 mg IV push

Medication

Time frame to Administer

Show Work Volume to Administer

 

 

 

16. Which findings are expected if the nursing and medical intervention(s) were effective?

Expected Findings Rationale

 

 

 

 

 

 

 

 

Nursing Skills & Reasoning

© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN

17. The nurse has implemented the medical and nursing plan of care. One hour later, you collect the following assessment data below. For each finding, make a clinical judgment by placing an “x” in the appropriate column if the patient’s condition has improved, has not changed, or has declined.

Assessment Finding Improved No Change Declined Urine output: 750 mL HR: 89/minute RR: 18/minute non-labored BP: 124/80 O2 sat: 96% room air Crackles persist in bases but are not as pronounced Resting comfortably appears less anxious

18. Is the overall status of the patient:

a. Improved b. No change c. Declined

Documentation Write a concise nurse’s note to document what was most important in the medical record.

 

Nurse Reflection To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by answering the reflection questions below. Reflection Question Nurse Reflection As you worked through this simulation, how did it make you feel?

 

What did you already know and do well on this simulation?

 

What areas do you need to develop/improve?

 

What did you learn? How will you apply what was learned to improve patient care?

 

 

 

 

Lucy Myers
  1. Most Important Findings: History of heart failure Iron deficiency anemia low hemoglobin
  2. Clinical Significance: low hemoglobin needs blood tranfusion Heart failure can cause breath difficulties
  3. 2: As a student nurse I can not administrater blood alone without supervision, so I will ask charge nurse and also look at the hospital policy.
  4. need to gather: I will need gloves, vital sign machine, blood tubing with fliter, IV pump and normal saline
  5. transfusion safely: Check prescriptions for allergy, expiration, virefied orders with second nurse check vitals before blood tranfusion monitor patient during tranfusion watch for side inffect and decumention.
  6. expect: Educate patient that blood tranfusion will help with their hemonglobin, they should wash and report these symptoms; shortness of breath, and chest pain.
  7. Assessment Finding:
  8. ExpectedT 982 F368 C oral: x
  9. UnexpectedT 982 F368 C oral:
  10. ExpectedP 108 regular:
  11. UnexpectedP 108 regular: x
  12. ExpectedR 25 regular:
  13. UnexpectedR 25 regular: x
  14. ExpectedBP 12883: x
  15. UnexpectedBP 12883:
  16. ExpectedO2 sat 88 RA:
  17. UnexpectedO2 sat 88 RA: x
  18. ExpectedAppears anxious:
  19. UnexpectedAppears anxious: x
  20. ExpectedBreathing rapidly:
  21. UnexpectedBreathing rapidly: x
  22. ExpectedSkin is cool and clammy:
  23. UnexpectedSkin is cool and clammy: x
  24. Medication:
  25. Pharm ClassMetoprolol: Beta blocker
  26. Mechanism of ActionMetoprolol: reduce heart rate
  27. Expected OutcomeMetoprolol: lower heart rate
  28. Pharm ClassLisinopril: ACE inhabitor
  29. Mechanism of ActionLisinopril: lower BP
  30. Expected OutcomeLisinopril: lower BP
  31. Pharm ClassFurosemide: loop diuretic
  32. Mechanism of ActionFurosemide: Increase urine output
  33. Expected OutcomeFurosemide: reduce fluid retention
  34. Pharm ClassFerrous gluconate: iron suppliment
  35. Mechanism of ActionFerrous gluconate: Provide essential iron
  36. Expected OutcomeFerrous gluconate: prevention of iron deficiency enemia
  37. Pharm ClassPotassium chloride: electrolyte suppliment
  38. Mechanism of ActionPotassium chloride: replaces potassium
  39. Expected OutcomePotassium chloride: prevention of hypokalemia
  40. MedicationRow1: furosemide
  41. RationaleRow1: Furosemide, because it causes fliud build up
  42. Intake and OutputRow1: Blood tranfusion
  43. Clinical SignificanceRow1: excess fluid causes respiratory issue, like SOB
  44. Most Important DataRow1: Heart failure and rapid breathing
  45. Clinical SignificanceRow1_2: fluid overload
  46. Possible ProblemsRow1: fluid overload rapid breathing
  47. Priority ProblemRow1: fluid overload
  48. Pathophysiology of Priority ProblemRow1: excess fluid build-up place critical strain on the heart.
  49. Nursing Priority:
  50. Priority InterventionsRow1: Improving breathing
  51. RationaleRow1_2: administrater furosemide, notify provider and applying oxygen,
  52. Expected OutcomeRow1: improving breathing
  53. I identify:
  54. Specify who you arewhere you workYourself namepositionlocation Patient nameagegender: Nurse Lucy Myers, RN nurse on the medicine floor PT. is Andre Ronaine, 64yrs male PT.
  55. S situation:
  56. What is the problemreason for contactConcise summary of primary problem: Rapid breathing during tranfusion
  57. B background:
  58. If urgent state concern Provide conciserelevant historyPrimary problemdiagnosis Day of admissionpostop day Relevant past medical history Relevant treatmentsinterventions: History of heart failure, Iron deficiency anemia and low hemoglobin Admited this morning date of adnission, N/A Heart failure Tranfusion
  59. A assessment:
  60. Assessment of the situation using the most important clinical dataState your concern by communicating concerning clinical data Vital signs Nursing assessment Labdiagnostic results Trend of most important clinical data stableincreasingdecreasing: Pluse is 108, rispiratory 25 and O2 is 88% PT. vital signs Iron deficiency and low hemoglobin
  61. R recommendation:
  62. Request specific adviceinterventions Clarify expectationsNurse suggestions to advance the plan of care What do you recommend Repeat and state back new ordersconfirm plan of care: Give diuretics Give furosemide Continue to monitor Pt vitals
  63. Provider Orders:
  64. RationaleFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92: To eliminate fluid overload Stop more overload To increase oxygen level
  65. Expected OutcomeFurosemide 40 mg IV push Discontinue blood transfusion Apply oxygen to maintain oxygen saturation 92: Enhance rispiration
  66. Administer: 1-2 minutes
  67. Show Work: 40mg/100mg =0.4×10=4ml
  68. Expected FindingsRow1: O2 level>92 rapid breathing
  69. RationaleRow1_3: To improve gas exchange
  70. Assessment Finding_2:
  71. ImprovedUrine output 750 mL: x
  72. No ChangeUrine output 750 mL:
  73. DeclinedUrine output 750 mL:
  74. ImprovedHR 89minute: x
  75. No ChangeHR 89minute:
  76. DeclinedHR 89minute:
  77. ImprovedRR 18minute nonlabored: x
  78. No ChangeRR 18minute nonlabored:
  79. DeclinedRR 18minute nonlabored:
  80. ImprovedBP 12480: x
  81. No ChangeBP 12480:
  82. DeclinedBP 12480:
  83. ImprovedO2 sat 96 room air: x
  84. No ChangeO2 sat 96 room air:
  85. DeclinedO2 sat 96 room air:
  86. ImprovedCrackles persist in bases but are not as pronounced: x
  87. No ChangeCrackles persist in bases but are not as pronounced:
  88. DeclinedCrackles persist in bases but are not as pronounced:
  89. ImprovedResting comfortably appears less anxious: x
  90. No ChangeResting comfortably appears less anxious:
  91. DeclinedResting comfortably appears less anxious:
  92. Write a concise nurses note to document what was most important in the medical record: Furosimide IV push was administrater to pt. during blood transfusion, Pt experienced rapid breathing.
  93. Reflection Question:
  94. Nurse Reflection: It was somehow challenging
  95. Nurse ReflectionWhat did you already know and do well on this simulation: regonizing and understanding some the problem
  96. Nurse ReflectionWhat areas do you need to developimprove: monitoring for adverse effects
  97. Nurse ReflectionWhat did you learn How will you apply what was learned to improve patient care: I have learned that monitoring the patient closely and washing up for symptoms like, chest pain and shortness of breath it’s very essential. for patient care

Nursing Skills & Reasoning

Blood Transfusion Case Study

1. Most Important Findings

Most Important Findings Clinical Significance
History of heart failure Patients with heart failure are at high risk of fluid overload during blood transfusion because the heart cannot effectively pump excess fluid.
Iron deficiency anemia with low hemoglobin Low hemoglobin reduces the blood’s oxygen-carrying capacity. Blood transfusion is necessary to restore adequate oxygen delivery to tissues.

2. What will you do if you have not performed blood administration in the clinical setting?

If I have not previously administered blood in the clinical setting, I would follow hospital policy and seek supervision from an experienced registered nurse or charge nurse. As a student nurse, I would not administer blood independently. I would review institutional protocols, verify provider orders, and ensure that proper safety procedures are followed.

3. Supplies Needed to Administer Another Unit of PRBC

The nurse should gather the following supplies:

  • Personal protective equipment (gloves)

  • Blood administration tubing with filter

  • Intravenous (IV) pump

  • Normal saline solution (0.9% sodium chloride)

  • Vital signs monitoring equipment

  • Blood product from the blood bank

  • Patient identification verification materials

4. Essential Steps to Safely Administer the Transfusion

To safely administer the remainder of the transfusion, the nurse will:

  1. Verify the physician’s order for blood transfusion.

  2. Confirm patient identity using two identifiers.

  3. Verify blood product information with a second nurse (type, compatibility, expiration date).

  4. Obtain baseline vital signs before starting the transfusion.

  5. Begin transfusion slowly and remain with the patient for the first 15 minutes.

  6. Monitor the patient for signs of transfusion reactions (fever, shortness of breath, chills, rash, chest pain).

  7. Reassess vital signs regularly.

  8. Document the procedure and the patient’s response.

5. Patient/Family Education

The nurse should explain that the blood transfusion is necessary to increase hemoglobin levels and improve oxygen delivery in the body. The patient should be informed that the procedure is generally safe but that monitoring is required. The nurse will instruct the patient to immediately report symptoms such as:

  • Shortness of breath

  • Chest pain

  • Fever or chills

  • Itching or rash

  • Back pain

Evaluation

6. Expected vs Unexpected Findings

Assessment Finding Expected Unexpected
Temperature 98.2°F (36.8°C) X
Pulse 108 bpm X
Respiratory rate 25 X
Blood pressure 128/83 X
O₂ saturation 88% RA X
Appears anxious X
Breathing rapidly X
Skin cool and clammy X

These findings suggest respiratory distress and possible fluid overload.

7. Overall Patient Status

Answer:
b. Declined

The patient’s tachycardia, low oxygen saturation, rapid breathing, and anxiety indicate deterioration.

8. Home Medications

Medication Pharmacologic Class Mechanism of Action Expected Outcome
Metoprolol Beta-blocker Reduces heart rate and myocardial workload Decreased heart rate and blood pressure
Lisinopril ACE inhibitor Relaxes blood vessels and decreases blood pressure Improved blood pressure control
Furosemide Loop diuretic Increases urine output to remove excess fluid Reduced fluid overload
Ferrous gluconate Iron supplement Provides iron needed to produce hemoglobin Prevention or treatment of iron deficiency anemia
Potassium chloride Electrolyte supplement Replaces potassium lost through diuretics Prevention of hypokalemia

9. Home Medications Not Taken With Greatest Impact

Medication Rationale
Furosemide Missing this medication can lead to fluid retention, worsening heart failure symptoms, and respiratory distress.

10. Intake and Output

Intake and Output Clinical Significance
Blood transfusion increases fluid volume In patients with heart failure, excess fluid can cause pulmonary congestion and shortness of breath.

11. Most Important Clinical Data

Most Important Data Clinical Significance
History of heart failure and rapid breathing Suggests fluid overload and potential pulmonary edema during transfusion

12. Possible Problems

Possible Problems Priority Problem Pathophysiology
Fluid overload Fluid overload Excess circulating volume increases pressure in pulmonary vessels, leading to pulmonary edema and impaired oxygen exchange.
Impaired gas exchange

13. Nursing Priority and Interventions

Nursing Priority Priority Interventions Rationale Expected Outcome
Improve breathing and oxygenation Stop transfusion, administer oxygen, notify provider, administer furosemide Reduces fluid overload and improves oxygen delivery Improved breathing and oxygen saturation

14. ISBAR Communication

I – Identify

My name is Lucy Myers, RN, working on the medical floor. I am calling about Andre Ronaine, a 64-year-old male patient.

S – Situation

The patient developed rapid breathing and low oxygen saturation during a blood transfusion.

B – Background

The patient has a history of heart failure and iron deficiency anemia. He was admitted today and started on a blood transfusion for low hemoglobin.

A – Assessment

The patient’s pulse is 108 bpm, respiratory rate is 25, and oxygen saturation is 88% on room air. The patient appears anxious and is breathing rapidly.

R – Recommendation

I recommend stopping the transfusion and administering a diuretic such as furosemide. Oxygen therapy should also be started to maintain oxygen saturation above 92%.

15. Provider Orders

Provider Orders Rationale Expected Outcome
Furosemide 40 mg IV push Removes excess fluid and reduces pulmonary congestion Improved breathing and increased urine output
Discontinue blood transfusion Prevents further fluid overload Stabilization of patient condition
Apply oxygen to maintain O₂ saturation >92% Improves oxygenation Increased oxygen saturation

Dosage Calculation

If the medication concentration is 100 mg/10 mL:

40 mg ÷ 100 mg × 10 mL = 4 mL

Volume to administer: 4 mL IV push over 1–2 minutes

16. Expected Findings if Treatment is Effective

Expected Findings Rationale
Oxygen saturation greater than 92% Improved oxygen exchange
Reduced respiratory rate Decreased respiratory distress
Increased urine output Removal of excess fluid

17. One Hour Later Assessment

Assessment Finding Improved No Change Declined
Urine output 750 mL X
HR 89/min X
RR 18/min non-labored X
BP 124/80 X
O₂ sat 96% room air X
Crackles less pronounced X
Appears less anxious X

18. Overall Patient Status

Answer:
a. Improved

Nurse’s Note (Documentation)

Patient developed shortness of breath and rapid breathing during blood transfusion. Vital signs showed HR 108 bpm, RR 25/min, and oxygen saturation 88% on room air. Blood transfusion discontinued per provider order. Oxygen therapy initiated and furosemide 40 mg IV push administered. Patient monitored closely. One hour later, patient demonstrated improved respiratory status with O₂ saturation 96% on room air and urine output of 750 mL. Patient resting comfortably with reduced anxiety.

Nurse Reflection

How did the simulation make you feel?

The simulation was challenging but helped me understand the importance of recognizing early signs of complications during blood transfusion.

What did you already know and do well?

I was able to recognize abnormal vital signs and understand the potential complications associated with heart failure and fluid overload.

What areas do you need to improve?

I need to improve my skills in monitoring patients for transfusion reactions and responding quickly to abnormal findings.

What did you learn?

I learned that close monitoring during blood transfusion is essential, especially in patients with heart failure. Recognizing symptoms such as shortness of breath and low oxygen saturation early can prevent serious complications and improve patient outcomes.

 

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