Danielle Louise L.

Villaseñor

BSN 2-B

Nursing Responsibilities for Oxygen Administration

Before

 Check the patient’s identification using two identifiers

 Check the patient’s diagnosis and need for oxygen therapy
 Check MAR against doctor’s order
 Perform 10 rights
 Check order for specific precautions regarding the movement and proper positioning of the
client upon administration
 Assess Patient for any signs of anemia
 Check patient’s mental state and ability to follow instructions
 Check patient’s vital signs
 Explain to the client the flammability risks of oxygen (clear bedside of any smoking materials)
 User warning signs on the client’s door
 Make sure that the equipment to be used is patent and working properly.

During

 Administer oxygen on prescribed rate and percentage.

 Turn on oxygen before turning putting on the mask
 Maintain a constant oxygen concentration for the client to breath
 Monitor equipment at regular intervals
 Monitor vital signs of the patient
 Watch for respiratory distress and depression
 Discontinue oxygen only after a physician has evaluated the client
 Gradually decrease oxygen in stages
 Monitor the client’s arterial blood gases or oxygen saturation level.

After

 Monitor patient’s vital signs

 Administer pain medication as prescribed
 Provide health education on the side effects of the oxygen therapy
 Advise client to report any severe adverse effect

Nursing Responsibilities for Blood components

Before

 Check the patient’s identification using two identifiers

 Verify doctor’s order.
 Inform the client and explain the purpose of the procedure.
  Obtain patient’s consent
 Obtain patient’s vital signs
 Practice strict asepsis within the area
 At least 2 licensed nurses check the label of the blood transfusion. Check the following:
a. Serial number
b. Blood component
c. Blood type
d. Rh factor
e. Expiration date
f. Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free
from blood-carried diseases and therefore, safe from transfusion.
 Warm blood at room temperature before transfusion to prevent chills.
 Identify client properly. Two Nurses check the client’s identification.

During

 Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in
respiratory rate)
 Use needle gauge 18 to 19 to allow easy flow of blood.
 Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
 Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes.
 If blood transfusion reaction occurs: STOP THE TRANSFUSION.
 Observe for adverse reaction as it usually occurs during the first 15 to 20 minutes.
 Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate
medication into the blood transfusion. Do not use blood transfusion lines for IV push of
medication.
 Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose.
Dextrose based IV fluids cause hemolysis.
 Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate,
transfuse quickly (20 minutes) clotting factor can easily be destroyed.

After

 Obtain patient’s vital signs.

 Administer 0.9% NaCl before, during or after BT. Never administer IV fluids with dextrose.
Dextrose based IV fluids cause hemolysis.
 Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate,
transfuse quickly (20 minutes) clotting factor can easily be destroyed.
 Observe for potential complications. Notify physician.

Nursing Responsibilities for collecting laboratory Specimens

Before

• Check the patient’s identification using two identifiers

 • Verify doctor’s order.
• Inform the client and explain the purpose of the procedure.
• Obtain patient’s consent
• Obtain patient’s vital signs
• Provide client comfort, privacy, and safety
• Administer prescribed medication if required
• Fill out labels in container appropriately

During

• Collect specimen using correct procedure

• Assist client into appropriate position
• Assist client in obtaining specimen

After

• Secure specimen collected

• Ensure appropriate amount is collected
• Transport specimen promptly to laboratory
• Document procedure
• Report abnormal results to primary care provider