Question

1. Identify the complications of blood transfusion administration that the nurse must assess when administering blood products.

2. Develop a nursing care plan for patient with hypertension

Answer 1

(1)Complications of Blood Transfusion that the nurse must assess includes the following,

1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.

Assess for:

• Flushing
• Rash, hives
• Pruritus
• Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion

Assess for:

• Sudden chills and fever
• Flushing
• Headache
• Anxiety

3. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria.

Assess for:

• Rapid onset of chills
• Vomiting
• Marked Hypotension
• High fever

4. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.

Assess for:

• Rise in venous pressure
• Dyspnea
• Crackles or rales
• Distended neck vein
• Cough
• Elevated BP

5. Hemolytic reaction – it is caused by infusion of incompatible blood products.

Assess for:

• Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
• Chills
• Feeling of fullness
• Tachycardia
• Flushing
• Tachypnea
• Hypotension
• Bleeding
• Vascular collapse
• Acute renal failure

Help prevent transfusion reaction by:

• Meticulously verifying patient identification beginning with type and crossmatch sample collection and labeling to double check blood product and patient identification prior to transfusion.
• Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
• Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
• Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
• Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
• Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
• Preventing hypothermia by warming blood unit to 37 C before transfusion.
• Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.

On detecting any signs or symptoms of reaction:

• Stop the transfusion immediately, and notify the physician.
• Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
• Send the blood bag and tubing to the blood bank for repeat typing and culture.
• Draw another blood sample for plasma hemoglobin, culture, and retyping.
• Collect a urine sample as soon as possible for hemoglobin determination.

Intervene as appropriate to address symptoms of the specific reaction:

• Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
• Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
• In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
• Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
• For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions

1. If blood transfusion reaction occurs: STOP THE TRANSFUSION.
2. Start IV line (0.9% NaCl)
3. Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy.
4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician’s order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

(2)A comprehensive nursing care plan for a patient can be formulated with the following details

1.Activity intolerance

May be related to
-Imbalance between oxygen supply and demand
-Generalized weakness
-Sedentary lifestyle

Possibly evidenced by
-Exertional discomfort
-Abnormal blood pressure in response to activity
-Verbal report of fatigue

Desired outcomes
-Demonstrate a decrease in physiological signs of intolerance
-Participate in the desired activity
-Use identified techniques to enhance activity tolerance
-Report an increase in physical activity

Nursing Interventions	Rationale
Evaluate current limitations/degree of deficit in light of usual status.	Provides baseline information on interventions needed to improve the quality of life.
Assess cardiopulmonary response to physical activity, including vital signs before, during, and after activity.	Indicates the patient’s physiological response to the stress of the activity.
Assess emotional/psychological factors affecting the current situation.	Depression about changes in health can affect motivation to participate in activities.
Adjust activities to prevent overexertion (performing activities slowly, sitting down when brushing teeth and combing hair).	Reduces energy expenditures, aiding in balancing out oxygen supply and demand.
Increase exercise/activity levels gradually and plan rest periods between activities (resting for 3 minutes in a 10-minute walk).	Prevents a sudden increase in cardiac workload; reduces fatigue.
Promote comfort measures and provide for the relief of pain, if there’s any.	Enhances patient’s ability to participate in activities.

2.Knowledge, deficient regarding condition, treatment plan and lifestyle changes

May be related to
-Information misinterpretation
-Unfamiliarity with information resources
-Lack of knowledge
-Denial of diagnosis

Possibly evidenced by
-Verbalization of the problem
-Statements reflecting misconceptions
-Request for information

Desired outcomes
-Verbalize understanding of condition/disease process and treatment
-Initiate necessary lifestyle changes and participate in the treatment regimen
-Exhibit increased interest/assume responsibility for own health
-Maintain blood pressure within the normal range

Nursing Interventions	Rationale
Assess the level of knowledge and be alert to signs of avoidance.	The patient must be ready to receive information for intervention to be effective.
Define and specify the desired blood pressure limits.	Enables patient to have a clear understanding of the normal values.
Describe what hypertension is and how it affects the heart, kidneys, brain and blood vessels.	Enables the patient to understand that high blood pressure can happen without any symptoms.
Assist patient in identifying modifiable risk factors and how to take control of them (drinking alcohol, smoking and having a sedentary lifestyle).	Gives the patient a clearer understanding of what caused the condition.
Emphasize the importance of adhering treatment plan.	Failure to comply is one of the most common reasons why treatment plans for hypertension fail.
Teach the patient or his relative on how to take proper blood pressure measurement.	Monitoring blood pressure at home can help determine if the existing treatment plan is working or not.
Make the patient aware of the signs and symptoms that would require an urgent visit to the physician (a persistent headache, a sudden spike in blood pressure, dizziness, chest pain, and fainting).	The earlier complications are detected and reported, the earlier proper interventions can be applied.

3.Imbalanced nutrition: more than body requirements

May be related to
-Excessive intake in relationship to metabolic need
-Sedentary lifestyle

As evidenced by
-Weight 20% over ideal for height and frame
-Triceps skinfold greater than 15 mm in men and 25 mm in
Women
-Weight 10% over ideal for height and frame
-Reports of dysfunctional eating patterns

Desired outcomes
-Demonstrate appropriate changes in lifestyle and behaviors,
including eating patterns, food quantity/quality, and exercise
Program
-Attain desirable body weight

Nursing Interventions	Rationale
Record height, weight, body build, gender, and age.	Serves as baseline data.
Determine the patient’s desire to lose weight. Reassess dietary choices.	The motivation to lose weight is internal; the patient must be ready and willing to lose weight before the process begins.
Discuss the need to have a lower intake of calories, salt, fats, and sugar.	Provides a baseline for creating a dietary program.
Set realistic goals for weekly weight loss.	Excessive intake of salt causes an increase in intravascular fluid volume which can damage the kidneys and aggravate the condition. Too much sugar in the diet can lead to diabetes which can complicate hypertension.
Encourage patient to keep a log of food intake.	Drastic weight loss can put a strain on the heart; helps determine emotional conditions that can affect eating.
Aid in the selection of appropriate food and DASH (Dietary Approaches to Stop Hypertension), like increasing intake of whole grains, low-fat dairy, fruits, and vegetables.	DASH provides the patient with key nutrients that can aid in lowering blood pressure.
Refer to a dietitian as needed.	Provides assistance and additional counseling.