Question

a. How do you determine if a patient is a fall risk?

b. What nursing assessments are important for a patient receiving a blood transfusion?

Answer 1

a. Patients who are at a risk of fall can be determined by a fall risk assessment.in this assessement

     identify patients health problems which may be a reason for fall like,

                         * Patient with vision problems like cataract,glucoma and hypermeropia are

                            more succeptable to fall.

                         * Patient with orthostatic hypertension may develop a sudden drop in blood pressure

                            when waking up from the bed.

                         * People with deformities in foot and altered gait are at high risk for fall.

                         * People who are mentally challenged and shows restlessness are at risk of fall.

                         * Patient with neuromuscular disorders are at high risk for fall.

b. Nursing assessment for a patient receving blood transfusion.

                * Nurse should check the physicians order and previous blood transfusion history of the

                  the patient to role out adverse reactions when administration of blood.

                * Make sure that informed consent for blood transfusion taken from the patient.

                * Observe the blood products blood group,identification number,expiry date,compatibility

                   patient name and any abormalities like clots,changes in colour,presence of excess air

                   etc.

                 * Checking of vital signs before and every 15 minutes in the first hour and at the end of

                    blood transfusion is needed for identify changes in blood pressure,pulse and transfusion

                    reactions.

                 * Assess the cannula site of blood transfusion for checking the patency of cannula

and observing allergic reactions.    

               * Assess the begining infusion rate which should be slow (25 to 50 ml per hour) to

                    identiy complications if occur.