Darknights

This is for every patient, including those with heart failure. The rationale is that there is no reason not to administer the packed cells over one hour. However, when the pt has been admitted with heart failure and were overloaded we are reluctant to give a unit so quickly.

Hi, We frequently have extremely elderly patients with heart failure and multiple co-morbidities who require blood transfusions. The physician wants the 350ml Packed Cells administered over an hour and doesn't provide an order for frusemide. Is this volume enough to overload an already compromised patient? IF so, what is your standard over in the U.S for duration of transfusion of Packed Cells for such patients. And, I'd be extremely grateful if someone could tell me why vaccines, heparin, Enoxaparin etc are given via DEEP subcutaneous injection. I can't find the rationale for it to be deep, less pain receptors in the deep tissue????

She said it was to decrease errors. As most safety experts talk about having less steps in a process, to lessen the risk of errors....I can't see how administering from a trolley out in the corridor will decrease errors. And it would be less productive, heaps more walking.

My worst scripting experience was dealing with a telecommunications company lately. The call centre personnel were totally unable to deviate from their script and actually stumbled if I tried to divert them straight to my issue. It took me 5 1/2 hours of going through the same series of questions and answers with every person I was put through to, until I finally got someone who had no script and within five minutes she had identified my issue and promised to correct it herself personally. I will not forget her because she was such a welcome contrast to all those robot voices I'd been unable to get any sense from previously. Some of their scripted responses to what I'd say were so ridiculous and completely out of context that I felt like I was trapped in some sort of call centre hell.

We have med lockers on the wall next to each patient's bed. Nurses are responsible for restocking them or initially stocking them from meds stocked in cupboards in the treatment room. Our DON has suddenly dictated that we must now purchase a medication trolley for each end of the ward and administer meds from that. It's drawers will contain a box for each patient's meds. She said this will reduce the number of med errors. As it would take one nurse three hours to administer meds to an end we would have two nurses sharing each trolley so it is supposed to be put in the middle of the corridor with the nurses doing laps between it and the patients. To me this will increase the possibility for errors. I can also see the potential for med charts to not be put back on the right beds etc. How can a dedicated locker next to each patient result in more errors? I just can't see it, but it is the only system I know.

You care. From what you said I don't think you sound like a bad nurse. Try to remember that New Grads aren't considered able to work confidently and independently until they have at least 12 months experience. You have a lot of knowledge to connect with the benefit of the experience you are getting so it all can slowly come together for you. Unfortunately ward work is hectic most of the time now. You do what you can, when you can. Make the minutes count. Here, we RN's shower patients too. That's where most of my deep and meaningful conversations with patients happen. Just remember to look after yourself. Do what you can in your time off to replenish your care bank. Then you always have something to give and those minutes you can enjoy with your patients will be enough to keep you going. You are like an apprentice RN. It is hard for everyone.

"Keep your chin up matey and at least you know ur not alone :)" ..................................... I can tell you're an Aussie. :)

What programs are in place for New Grads in the U.S? Are they just given a couple of days supernumerary like here, or are there extended programs? When staff are run off their feet it is ridiculous to expect them to hold a New Grads hand. Last week when we had two New Grads on day shift it was like being two staff short. So we ran around doing the extra work, while the New Grads did very little, then complained about our lack of support. I'm also wondering what the nurse educators are doing and why they aren't helping the New Grads......

Thanks for all your responses. I think I can let this incident go now.

When a patient died a couple of months ago I had an audience of new nurses who all wanted to see a dead body and learn what to do before taking the body to the morgue. When I showed them how to get the body into the body bag one of them said, 'This is so sad. A life has passed and this is it. We put them in a plastic bag and they no longer exist.' I can see what he means. But he forgot the person does still exist in the hearts and minds of their loved ones. The death of a person is a very significant event. Perhaps there should be trumpets and angels carrying the body off towards the light. Morning tea that day was very funny as everyone tried to outdo each other with their ideas about what should happen to mark the end of a life.

We don't. I have some friends who work as nurses in the U.S so I know what our equivalents are. The minimum qualification for RN's here as been the equivalent to your BSN, and has been like that for many years. LPN's here are called EN's, Enrolled Nurses. CNA's are AIN's, Assistants in Nursing. These mainly staff nursing homes. Our nursing homes aren't like yours. Anyone needing IV's etc is sent back to the acute care facility. Our best New Grads tend to be those who have worked as AIN's to fund their degree. They have mastered time management BEFORE they start with us. Our EN's did a medication course a few years ago that enabled them to become Endorsed Enrolled Nurses. This allows them to give out all the same meds as we RN's, including IV's and narcotics. However, they can't NIM medications. In my hospital we RN's have to do without respiratory techs or therapists, IV teams etc. We do the lot, and this includes ADL's and bedmaking. If there is already a crisis happening in the hospital we have to deal with our own too. We also frequently do bed moves and transport patients through the hospital ourselves, take bodies to the morgue etc. We're also amateur social workers and counsellors. You name it, we do it.

Paracetamol, Coloxyl and Senna, pantoprazole, frusemide, clarithromycin, ceftriaxone, metformin, coated aspirin, perindopril, atenolol.

And I always thought the pillow cases faced away from the door so all the departing spirits didn't get trapped in the pillowcases on their way out the windows. :-) I read some of the original nursing texts last year and I am sure that old Flo didn't mention the way a pillow opening should face. Nor do I believe did texts until at least the 1920's. I didn't read after that so I don't know where the tradition came in . The early texts advised on how to stuff pillows with straw or horsehair and not to leave them lumpy. They also sometimes mentioned that beds and wards should look clean and uniform to improve the patient's sense of wellbeing. Those original texts also advised on colours of walls, how to tend the fire for temperatures in accordance with patient's conditions etc. As an RN working in a hospital without assistants, and being an ex-Naval officer, I'd actually forgotten there was any way to make a bed without hospital corners. It wouldn't take me any longer to do this than any other method for pulling up a bed. Now you have to explain to me what you all do with those Chux. I've never heard of using Chux on beds before. We just have a bottom sheet. Incontinent patients wear pads. We move patients in the bed using a Slippery Sam (slide sheet).

Thanks everyone. I expected feedback on what I'd done wrong. I hadn't anticipated your positive comments. I really thought there was some answer on what I should do in such a situation and I just couldn't see what it was.

I am working in a very remote hospital in outback Australia. It is a 5 1/2 hour drive to the next town. We have to fly critically ill patients interstate for care as we are too far from city hospitals in our state. My ward is general Medical/Rehab. Our patient population is acute stroke and MI patients, chronic care patients, oncology, psychiatry, palliative care, dementia pts with behavioural issues who the one local nursing home refuses to take, detox, rehab. The union doesn't get involved because we are so remote that nurses don't want to work here. However, I always say that if they looked after the nurses here they would actually stay. 4:1 ratios have just been approved for this state but we've heard our hospital will be 5:1. That seems a stupid move as it isn't going to encourage anyone to go remote. We've also been told that our ratios will depend on staffing and they can't enforce mandated ratios out here if there are no nurses. We are a 70 bed hospital. Last year we were short 30 RN's -FTE. It became a news story when it was discovered that the hospital had never even advertised for more nurses.

I started here as a New Grad so L know what it is like. I graduated from university with a degree and 12 weeks practicum experience. I did 3 supernumerary shifts when I started my employment. My fourth shift was my first afternoon shift and I had a CNA help me to care for 13 patients. I had only those previous three shifts as experience in caring for surgical patients. At the start of my second week L had night shift, with an LPN to help me care for the ward of 26 patients. When I'd said I didn't want to do the in charge night shifts L was asked why. IT was eight years ago but I still remember my words.....'What if something goes wrong and I don't know what to do. The patient might die.' The ADON replied, 'patients die. If a patient is going to die it won't matter whether you are a New Grad, or a veteran, they will still die.'It didn't reassure me. What happens to our New Grads is wrong. It shoudn't happen. But what I am asking is how the hell can we get all the work done every shift AND support them. Remember that the work they can't do is more work for us and we were struggling before they arrived and the staff were all fully functioning nurses. We now average two New Grads on a day shift with four other nurses. It is like working two short every shift and the four having to do the work of six. I don't know what the answer is.

Our DON has admitted that morale in our hospital has decreased over the last two years and is now rock bottom. We have been critically shortstaffed and an attempt to address this was to hire a lot of New Grads. Due to the resignations recently it turns out we are still really shortstaffed and struggling to cope, but now it is worse because there are so many New Grads and we just don't have the time or ability to support them. They get three shifts as supernumerary, then they are expected to function as any other nurse on the team. I've found that in the last two weeks the LPN and I working with the New Grad have seen a huge increase in the load we've had. Instead of three of us showering six patients each, two of us are doing up to 16 every shift. One shift it was 17. The New Grads are always keen to give out medications, but when they average half an hour per patient so that meds for six takes three hours, then a shower takes them the rest of the shift........what are you supposed to do? I am told we have to support them. When I hear the New Grads are complaining to the DON about the lack of support they are getting I feel extremely frustrated. I know I can't be there to hold their hands every minute, because I am buried trying to do the work they can't do as well as my own work. I suggested to my manager that perhaps we should forget about the New Grads giving out meds and focus on their time management with ADL's. Once they have mastered that we can start them giving out meds. She said we can't do that as they would really complain. One New Grad has already upset the LPN's by telling them it isn't her job to do showers, her job is to tell them what to do. That might happen elsewhere but it doesn't happen here, there aren't enough LPN's to do the ADL's. She was the one who took half the day to give meds, then the rest of the shift to do one shower, after attempting to get the LPN to do it when I wasn't around. The next morning the same New Grad didn't turn up for her shift. An hour into the shift my manager rang her at home. She said she'd slept in and now that she was awake felt like a day off so wouldn't be coming in. When asked if she'd told the Supervisor she wouldn't be coming she said she hadn't, but she might do that later. We are really getting flak about our New Grads not being supported, and how they were hired to help us and we aren't treating them right etc. The nurses who already had extremely low morale just feel like this is yet another thing to knock them down. I can't see a solution for how to get the ward to work with all these New Grads, and how to give them an experience where they feel supported. Obviously taking on the majority of their workload isn't an acceptable solution for them either. FWIW, nursing students come out here and say they have a grand time. We determine within a few hours whether it is safe to let them loose or not, then have them on the ward as a functional member of our team. Unfortunately they are often counted as team members by admin, so we are forced to work our students hard. I always apologise to them, but they seem to like feeling needed. I guess it is easy for us to do this when we don't have the fear of litigation like you do in the U.S. No patient has ever been harmed and our students usually leave after four weeks, able to take on the care of six patients. We just don't seem to be able to do this once they become New Grads.

I am an RN working in an extremely remote hospital in outback Australia. We are generalist nurses caring for a patient population ranging from psych to acute stroke, chronic care to palliative care. Unlike other places our nursing has the RN's out on the ward doing as many showers etc as the LPN's. I can't remember a time in nine years when we haven't been shortstaffed, or have been given adequate resources to do our jobs properly. But we do our best, and we really do care about our patients. They are mostly elderly and have endured horrific conditions in a harsh desert, while the men did dangerous work in the mines.....they are tough and resilient, and grateful for everything we manage to do for them. Three weeks ago a patient was diagnosed with terminal cancer. This was a shock to her and her huge loving family. Two days later she was unconscious. Not an unusual story out here. On the day I am writing about I was working with the family for the first time. They weren't coping so I was trying to provide as much support and education as possible. The patient had a death rattle that was becoming louder and more distressing to the family, despite multiple doses of anticholinergics and morphine. It was a bad situation just becoming worse. I asked an LPN to help me give the pt a wash, check her incontinence pad, and try some postural drainage. As tipping a dying patient so their head is much lower than their feet is not a very dignified act I asked the family if they'd mind stepping out of the room for a short while. They were reluctant as they wanted to be there every minute until the patient died. I said we'd be quick and just wanted to make sure the patient was comfortable and dry. So they left. We tipped the bed and noticed an instant decrease in volume of the death rattle. When I rolled the patient towards myself I commented to the LPN that sometimes repositioning and drainage is the best intervention. I rolled the pt back and was horrified to see dark blood pouring out of her nose and mouth. I grabbed the suction and started suctioning the blood, but it soon became clear that the patient was about to die and the blood flow wasn't going to stop. At least this event explained the worsening death rattle not responding to meds. By then there was blood everywhere. I was doing my best to suction and to try to help the LPN change the linen, hindered by her having to run out of the room for linen and other supplies. I could see my patient's life ebbing and wanted to get her cleaned up so I could get the family back before she actually died. Our frantic efforts to change her clothes, keep suctioning and change the linen meant the yankeur had sprayed blood up the wall and across the floor, so we were trying to clean that up to. I felt totally hopeless. I didn't know what to do. I wanted the family to be able to come back in to be with the patient, but how could I confront them with an image of her drowning in her own blood? And with every second I was thinking about it she was one more breath closer to being dead. It ended with us getting her on her side, draining as much as we could, cleaning her face, throwing covers over the linen, then hoping she'd die before the blood built up and poured out of her face and mouth again. I got the family back in, telling them she was about to die. She took one more breath, then was dead. Three weeks later I still haven't come up with an answer for this situation. What if it was obvious nothing was going to stop the blood flow and the patient was so close to death there was no opportunity to prepare the family for what they were about to see? Do you delay things until the patient is dead? Do you just let them in to witness the event, then counsel them afterwards? I've seen some awful deaths. It was the first death the LPN had witnessed. She was so traumatised by it I took her out for a five minute coffee. My manager made a comment about our going but I said we were going for a few minutes to have a coffee. I was traumatised too, because I had been so stuck. The LPN cried while she drank the coffee and I got to explain to her that such a death isn't common. Then we went back to work. My manager came up to me later and I told her what had happened. She said perhaps in future when such things happen it is a good idea to take a few minutes to debrief as it seemed to be helpful. As it has never happened in the nine years I've been here that is one good outcome from a not good death. Other staff have said that we might have to get red sheets for when patients have a bleed. I'm not convinced that families won't notice pools of blood on red sheets. This is going to happen again. We've recently had three patients with fungating tumours involving their necks and the doctors expected them to die from catastrophic haemorrhages. They didn't. My patient did. Have others been in similar situations? What did you do? After all that the family thanked me for the care I'd given their mother that day. I still don't know what I should think about it.

Although this is an Aussie publication I don't think our measurements of blood volumes etc are too different to you. I found this interesting because it has quite a few actual examples of transfusion incidents. Amazing how delayed some reactions can be. http://www.health.qld.gov.au/qhcss/qbmp/documents/faq.pdf

Oh, and Frusemide......all elderly heart failure patients have their transfusion over three hours rather than our standard one hour. They have an order for IV Frusemide between units if a clinical review by the administering nurse finds them becoming overloaded.

And if you've read all that.......can anyone remember how much blood loss is required to have malaena (not spelling errors. We spell haem, malaena etc differently down under)? I have an idea it is about one unit but I'm not confident that it is right.

Why do you want to take blood to check Haemoglobin post transfusion? Your Red Cross states: Unless the recipient is bleeding or hemolyzing, and provided the transfused red cells are compatible, the post-transfusion hemoglobin can be accurately predicted from the patient’s estimated blood volume, baseline red cell volume (=blood volume X venous hematocrit X 0.91) and transfusion volume. Hemoglobin alone should not be the stimulus for a decision to transfuse. From the American Red Cross Transfusion Guidelines: Red blood cells are indicated for patients with a symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to an inadequate circulating red cell mass. They are also indicated for exchange transfusion (e.g., for hemolytic disease of the newborn) and red cell exchange (e.g., for acute chest syndrome in sickle cell disease). Patients must be evaluated individually to determine the proper transfusion therapy, taking care to avoid inappropriate over- or under- transfusion. Transfusion decisions should be based on clinical assessment and not on laboratory values alone. Red blood cells should not be used to treat anemia that can be corrected with a non-transfusion therapy (e.g. iron therapy). They also should not be used as a source of blood volume, or oncotic pressure or to improve wound healing, or sense of well being. The function of a RBC transfusion is to augment oxygen delivery to tissues. Hemoglobin levels during active bleeding are imprecise measures of tissue oxygenation. Adequate or inadequate fluid resuscitation can significantly alter the measured hemoglobin concentration. In addition, a number of factors must be considered besides the blood hemoglobin level such as oxygenation in the lungs, blood flow, hemoglobin- oxygen affinity and tissue demands for oxygen. Consequently, the adequacy of oxygen delivery must be assessed in individual patients, particularly in patients with limited cardiac reserve or significant atherosclerotic vascular disease. If available, mixed venous O 2 levels, O2 extraction ratios, or changes in oxygen consumption may be helpful in assessing tissue oxygenation. patients (see above). The effects of anemia must be separated from those of hypovolemia, although both can impede tissue oxygen delivery. Blood loss of greater than 30% of blood volume causes significant clinical symptoms but resuscitation with crystalloid alone is usually successful in young healthy patients with blood loss of up to 40% of blood volume (e.g., 2- liter blood loss in an average adult male). Beyond that level of acute blood loss after adequate volume resuscitation, acute normovolemic anemia will exist. However, oxygen delivery in healthy adults is maintained even with hemoglobin levels as low as 6-7 g/dL. Thus up to 40% of the blood volume in a bleeding, otherwise healthy young adult can be replaced with crystalloid without the need for red cell transfusion. In support of a conservative red cell transfusion policy in critical care is a multicenter, randomized, controlled trial comparing a transfusion trigger of 7 g/dL with a trigger of 9 g/dL in normovolemic critically ill patients. Overall 30-day mortality was similar in the two groups and in the subset of more seriously ill patients. However, in less acutely ill or younger patients, the restrictive strategy resulted in lower 30-day mortality. In support of considering cardiovascular status in the decision to transfuse red cells is a retrospective study of transfusion in elderly patients with acute myocardial infarction which showed lower short-term mortality when patients were transfused with a hemoglobin as high as 10 g/dL. This recent article suggests there is a lot of inappropriate transfusing of RBC's occurring. Also interesting how much can be taken for phlebotomy during an ICU stay. No wonder they need transfusions! http://www.east.org/tpg/SCCMrbc.pdf ClinLab Navigator - Transfusion Each unit increases an adult's (70kg) hemoglobin 1g/dL and hematocrit 3%. Follow up measurement of the recipient's hemoglobin and/or hematocrit can be performed between 15 minutes and 24 hours post-transfusion. The optimal time interval for assessment is 15 minutes. Hemoglobin levels obtained at 24 hours post-transfusion are 10% higher than values obtained after 15 minutes. One unit can replace a blood loss of 500mLs. American Red Cross Practice Guidelines for Blood Transfusion Each unit contains approximately 42.5-80 g of hemoglobin or 128-240 mL of pure red cells, depending on the hemoglobin level of the donor, the starting whole blood collection volume, and the collection methodology or further processing. When leukoreduced, RBC units must retain at least 85% of the red cells in the original component. Each unit of Red Blood Cells contains approximately 147- 278 mg of iron, most in the form of hemoglobin.

Medical Laboratory Observer 2007 Q How long after the completion of a blood-product transfusion can blood for a complete blood count be drawn? A The objective in obtaining accurate post-transfusion blood counts is to obtain a sample that is a homogeneous mixture of patient and donor cells. If the patient is receiving blood because of an acute hemorrhage, (i.e., from a trauma or during surgery), homogeneity of the circulating blood will not occur until all hemorrhaging has been stopped. How long this takes depends on a multitude of variables including the condition of the patient's heart, kidneys, and circulatory system; the patient's pre-transfusion blood volume; and the age and volume of the transfused cells. Nevertheless, physicians who are transfusing patients often want to know the effect of an infusion immediately. Except in trauma cases in which the patient's condition is changing rapidly and must be monitored frequently, cell counts drawn during a transfusion provide little useful information. Once all donor cells have been transfused, however, it is conceivable that accurate cell counts can be obtained immediately after transfusion. In light of the many variables that contribute to donor-cell distribution, waiting an hour after the transfusion may provide more accurate results if time allows. (1) Such determinations should be made by the physician on a case-by-case basis. Drawing post-transfusion blood for chemistry tests, however, temporarily raises the level of several chemistry analytes for prolonged periods. Because up to 25% of the cells in a donor unit can be hemolyzed during storage, specimens drawn after transfusion can have elevated levels of plasma hemoglobin, potassium, LD, and serum iron. (2,3) Depending on the patient's kidney function and other variables, these levels can remain elevated up to 24 hours. --Dennis J. Ernst MT(ASCP) Director Center for Phlebotomy Education Coalition for Phlebotomy Personnel Standards References 1. Becan-McBride K, Eisenbrey A, Haraden L. Venipuncture after transfusion. Adv Med Lab Prof. 1999;17(2):4. 2. Narayanan S. The Preanalytic Phase An Important Component of Laboratory Testing. Am J Clin Pathol. 2000;113:429-452. 3. Myhre B. Iron values after transfusion. Tips on specimen transfusion. Montvale, NJ: Medical Economics;1997.

From College of American Pathologists 2008 Q. How long should you wait after a unit of blood has been transfused before drawing a complete blood count, or doing other lab work, to ensure accurate test results? A. Optimum timing of post-transfusion phlebotomy is critical for ensuring meaningful laboratory testing results, and medical judgment is required in making this determination. Several factors must be considered, including the type and amount of blood product given, purpose of the test (that is, the question it is intended to answer), and clinical setting. In general, it is best to perform phlebotomy when the patient’s circulatory system is in homeostasis. A patient who is bleeding or undergoing blood product transfusion, or both, is not in a steady state. Whenever possible, samples for laboratory testing should be postponed until bleeding has stopped and transfusion is complete. One obvious exception to this rule, however, would be the setting of massive transfusion, during which monitoring certain laboratory values, such as cell counts and coagulation parameters, is essential to guide ongoing therapy. Variables such as patient blood volume, cardiac output, renal function, and volume of blood products transfused affect how quickly homeostasis is achieved following transfusion. For the evaluation of post-transfusion increments in hemoglobin, hematocrit, and platelet counts, a practical approach is to draw blood samples within 10 to 60 minutes after completing transfusion, as this time interval is aimed at measuring peak recovery.1 Results determined from blood samples drawn later than 60 minutes post-transfusion are increasingly affected by confounding conditions, such as splenic sequestration, sepsis, and consumption.1,2 If the intent is to determine the extent of such confounding processes on red cell and platelet counts, one should combine a 10-minute post-transfusion sample with sequential samples drawn at one hour and 24 hours post-transfusion. Alterations in chemistry test results following transfusion are not usually a concern in the low-volume transfusion setting. However, assay results may be affected for varying periods following transfusion of large amounts of blood products, as seen in massive transfusion, red cell, or plasma exchange—particularly if the recipient has impaired hepatic or renal function. Banked storage of red cells results in elevated plasma levels of hemoglobin, potassium, LDH, and iron in the blood unit that may, particularly in the metabolically impaired patient, be reflected in the post-transfusion laboratory values. In addition, citrate anticoagulant present in blood products may result in transient hypocalcemia in the recipient.3 Therefore, following large-volume transfusions or exchanges, waiting 12 to 24 hours before drawing samples for chemistry assays will provide results that are more reflective of the patient’s underlying metabolic state. References Choo Y. The HLA system in transfusion medicine. In: McCullough J, ed. Transfusion Medicine. New York, NY: McGraw–Hill Book Co;1998:401. Legler TJ, Fischer I, Dittman J, et al. Frequency and causes of refractoriness in multiply transfused patients. Ann Hematol. 1997;74:185–189. Brecher ME, ed. Technical Manual. 15th ed. Bethesda, Md.:AABB;2005;649–650.

I was surprised when reading about your laws over there and your scope of practice. You do have to be careful about anything you do off duty that can be said to be nursing related. And if you give advice about a diagnosis or medication you also run the risk of being reported for giving medical advice. Failing to tell someone to seek medical advice for a condition also puts you at risk.