NURSES’ POCKET NOTESNORMAL VALUESLUNG SOUNDSCrackles orralesCrackling or rattling soundswheezingHigh-pitched whistlingexpirationsstridorHarsh, high-pitchedinspirationsrhonchiCoarse, gravelly soundsPULSE OXIMETRYRangeValueTreatmentNormal95-100%None or placebicMildhypoxia91-94%Give oxygenModeratehypoxia86-90%Give 100% oxygenSeverehypoxia<85%Give 100% oxygenwith positivepressureAlbumin3.2 g/dlAlkaline Phosphatase(Adults: 25-60)33-131 IU/LAdults: >61yo51-153 IU/LAmmonia20-70 mcg/dlBilirubin, direct0-0.3 mg/dlBilirubin, tota0.1-1.2 mg/dlBLOOD GASESArterialVenouspH7.35-7.457.32-7.42pCO
2
35-4538-52pO
2
70-10028-48HCO
3
19-2519-25O
2
Sat %90-9540-70BUN7-20 mg/dlCOMPLETE BLOOD COUND (CBC) ADULTSMaleFemaleHemoglobin (g/dl)13.5-16.512.0-15.0Hematocrit (%)41-5036-44RBC’s (x10
6
/ml)45-5540-49RDW (RBCdistribution width)<14.5MCV80-100MCH26-34MCHC %31-37Platelet count100000-450000CREATININE KINASE (CK) ISOENZYMESCK-BB0%CK-MB (cardiac)0-3.9%CK-MM96-100%Creatinine Phosphakinase(CPK)8-150 IU/LCreatinine (mg/dl)0.5-1.4ELECTROLYTESCalcium8.5-10.2mg/dlCalcium, ionized2.24-2.46mEq/LChloride95-107 mEq/LMagnesium1.6-2.4mEq/LPhosphate2.5-4.5 mg/dlPotassium3.5-5.2 mEq/LSodium135-145mEq/LFerritin (ng/ml)13-300Folate (ng/ml)3.6-20Glucose, fasting60-110(mg/dl)Glucose (2 hours postprandial)(mg/dl)Up to 140Hemoglobin A
10
6-8Iron (mcg/dl)65-150Lactic acid (mEq/L)0.7-2.1LDH (lactic dehydrogenase)56-194 IU/LLIPOPROTEINS AND TRIGLYCERIDESCholesterol, total<200 mg/dlHDL cholesterol30-70 mg/dlLDL cholesterol65-180 mg/dl Triglycerides45-155 mg/dl (<160)Osmolality289-308 mOsm/kgSGOT (AST)<35 IU/L (20-40)SGPT (ALT)<35 IU/L THYROID FUNCTION TESTSFree T32.3-4.2 pg/mlSerum T370-200 ng/dlFree T40.5-2.1 ng/dlSerum T44.0-12.0mcg/dl TSH0.25-4.30 microunits/ml Total iron binding capacity(TIBC)250-420 mcg/dl Transferrin>200 mg/dlUric acid (male)2.0-8.0 mg/dlUric acid (female)2.0-7.5 mg/dlWBC + DIFFERENTIALWBC (cells/ml)4500-10000Segmentedneutrophils54-62%Band forms3-5% (above 8% indicatesleft shif)Basophils0-1 (0-0.75%)Eosinophils0-3 (1-3%)Lymphocytes24-44 (25-33 %)monocytes3-6 (3-7%)NURSING CONSIDERATIONS FOR BT
•
Confirm that the transfusion is prescribed
•
Check if Px blood has been typed and cross-matched
•
Verify the consent from has been signed
•
Explain the procedure to the Px and instruct pxfor s/sx of transfusion reaction (itching, hives,chills, sweeling, fever, shortness of breath)
•
Take px’s vital signs to establish baseline forcomparing of vital signs during transfusion
•
Standard precaution during BT as per hospitalpolicy
•
Use gauge 20 or larger needles for BT
•
Maximum hours for BT is 4 hours
•
Double check obtained PRBC from blood bank
•
Double check labes with other RN or MD to makesure of ABO and Rh compatibility
•
Check blood for unusual color, bubbles orcloudiness, it may indicate bacterial growth orhemolysis
•
Make sure PRBC is initiated within 30 minutesafter removal from blood bank refrigerator
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