Day: January 27, 2024

vaginal irrigation

by

Introduction

Vaginal irrigation, commonly known as a douche, is a procedure used to cleanse the vaginal area. It is important to note that routine douching is generally not recommended, as the vagina is self-cleaning and frequent douching can disrupt its natural balance. However, in certain medical situations, a healthcare provider may prescribe or recommend a vaginal douche for therapeutic purposes.

Purpose:

  • To cleanse and disinfect the vaginal area.
  • To provide relief from specific medical conditions, such as infections or inflammation.

Equipment:

  • Douche kit or bag.
  • Sterile or prescribed solution (e.g., saline solution, antiseptic solution).
  • Towels or disposable pads.
  • Privacy drapes or curtains.

Procedure:

  1. Preparation:
    • Wash hands thoroughly and gather all necessary equipment.
    • Ensure privacy and explain the procedure to the patient, addressing any concerns or questions.
  2. Positioning:
    • Assist the patient into a comfortable position, typically in a supine position with knees bent.
  3. Preparation of Solution:
    • Prepare the prescribed or recommended solution according to healthcare provider instructions.
  4. Setup Douche Kit:
    • Assemble the douche kit or bag, ensuring proper connection to the solution container.
  5. Insertion:
    • Gently insert the nozzle or tubing into the vagina. The insertion should be slow and careful to avoid discomfort or injury.
  6. Administration:
    • Allow the solution to flow into the vaginal area at a slow and controlled rate. The patient should communicate any discomfort or pain.
  7. Drainage:
    • Once the recommended amount of solution has been administered, allow the patient to drain the solution from the vagina into a basin or toilet.
  8. Assist and Support:
    • Assist the patient as needed and provide support during the process. Address any concerns or discomfort promptly.
  9. Observation:
    • Observe for any signs of adverse reactions or complications, such as increased discomfort, bleeding, or allergic reactions.
  10. Post-Procedure:
    • Discard used equipment appropriately.
    • Provide post-douching care instructions as per healthcare provider recommendations.

Note:

  • Healthcare providers should carefully consider the necessity of vaginal irrigation and provide clear instructions to patients.
  • Douching is generally discouraged in routine hygiene practices, as it may disrupt the natural flora of the vagina and lead to complications.

Always follow healthcare provider instructions and adhere to established protocols when performing vaginal irrigation.

 

Read more

Last offices procedure

by

Introduction Providing respectful and compassionate care to the deceased is an important aspect of nursing practice. Here are some considerations for nursing care of the deceased: Communication and Sensitivity: Communicate with empathy and sensitivity to the family or significant others. Use clear and compassionate language to explain the situation. Be responsive to cultural and religious … Read more

Thoracentesis Procedure

by

Introduction

Thoracentesis serves dual purposes, encompassing both diagnostic and therapeutic objectives. In its diagnostic capacity, thoracentesis plays a pivotal role in the analysis of pleural fluid. This analytical process is instrumental in distinguishing between exudate and transudate, shedding light on the underlying causes of pleural abnormalities.

Exudate, identified through thoracentesis, may indicate inflammatory or malignant conditions affecting the pleura. On the other hand, transudate may point towards disruptions in organ systems responsible for maintaining fluid balance within the body. The differentiation between these two types of pleural fluid facilitates a comprehensive understanding of the pathology at hand.

By discerning the nature of the pleural abnormality, thoracentesis aids healthcare professionals in pinpointing the root cause of the condition. This diagnostic precision is invaluable in guiding subsequent medical decisions and tailoring an appropriate treatment strategy for the patient. In essence, the diagnostic application of thoracentesis enhances the accuracy and effectiveness of patient care by providing critical insights into the etiology of pleural disorders.

Thoracentesis is a medical procedure involving the insertion of a needle or a catheter into the pleural space in the chest to remove excess fluid or air. This intervention is typically performed to relieve respiratory symptoms and assist in the diagnosis of underlying conditions affecting the pleura.

Indications:

  1. Pleural Effusion: To drain excessive fluid that has accumulated in the pleural cavity, causing compression of the lungs.
  2. Pneumothorax: To remove excess air that has entered the pleural space, leading to lung collapse.
  3. Diagnostic Purposes: To obtain a sample of pleural fluid for laboratory analysis, aiding in the identification of infections, malignancies, or other pleural diseases.

Thoracentesis Procedure

  1. Patient Positioning:

    • Place the patient in a sitting position with arms and head supported on a bedside table.
    • Alternatively, if sitting is not feasible, the patient can lie on the affected side at the edge of the bed, with the ipsilateral arm over the head and the midaxillary line accessible.
    • Elevate the head of the bed to 30 degrees if possible.

  2. Needle Insertion Site:

    • Identify the posterolateral aspect of the back over the diaphragm under the fluid level.
    • Confirm the site by counting the ribs based on chest x-ray and percussing to determine the fluid level.
    • Mark the top of dullness with washable ink or by indenting the skin.

  3. Site Selection:

    • Choose the thoracentesis site in an interspace below the point of dullness, either in the mid posterior line (posterior insertion) or midaxillary line (lateral insertion).

  4. Sterile Technique:

    • Adhere to sterile technique, including gloves, betadine prep, and draping.

  5. Local Anesthesia:

    • Anesthetize the skin over the insertion site with 1% lidocaine using a 5 cc syringe and a 25 or 27-gauge needle.
    • Anesthetize the superior surface of the rib and the pleura.
    • Insert the needle over the top of the rib (superior margin) to avoid intercostal nerves and blood vessels.

  6. Needle Insertion:

    • Insert the thoracentesis needle or angiocatheter to the depth marked during the initial aspiration.
    • Maintain constant gentle suction on the syringe while advancing the needle over the top of the rib and through the pleura.
    • Ensure avoidance of the neurovascular bundle located below the rib.

  7. Fluid Aspiration:

    • Attach the three-way stopcock and tubing and aspirate the required amount.
    • Evacuate the fluid through the tubing.

  8. Fluid Removal Limits:

    • Do not remove more than 1500 mL of fluid at any one time due to the increased risk of pleural edema or hypotension.
    • Avoid complete drainage of an effusion to minimize the risk of pneumothorax from needle laceration of the visceral pleura.

  9. Completion:

    • When fluid drainage is complete, instruct the patient to take a deep breath and hum before gently removing the needle.
    • Cover the insertion site with a sterile occlusive dressing.

This comprehensive thoracentesis procedure ensures proper patient positioning, site selection, and adherence to aseptic techniques for a safe and effective process.

Thoracentesis Nursing Considerations

Before the Procedure:

  1. Verify the doctor’s order.
  2. Confirm the patient’s identity.
  3. Have the patient sign a consent form after explaining the procedure thoroughly.
  4. Emphasize the procedure’s importance and mention the likelihood of mild pain at the needle insertion site.
  5. Inform the patient that the procedure is brief, depending on the time required for fluid drainage from the pleural cavity.
  6. Advise against coughing during needle insertion to prevent lung puncture.
  7. Explain the timing, location, and individuals present during the procedure.
  8. Reinforce the physician’s explanations about potential diagnostic procedures and sedative use.
  9. Request the removal of clothing, jewelry, or items that may interfere with the procedure.
  10. Shave the area around the puncture site if necessary.
  11. Monitor vital signs before the procedure.

During the Procedure:

  1. Provide verbal support and describe procedure steps when needed.
  2. Monitor vital signs throughout the procedure.
  3. Administer supplemental oxygen if required through a mask or nasal cannula.
  4. Observe for signs of distress such as dyspnea, pallor, or coughing.
  5. Position the patient sitting with raised arms on an overbed table or in a side-lying position if sitting is not feasible.
  6. Cleanse the puncture site with antiseptic solution.
  7. Administer a local anesthetic at the thoracentesis site.
  8. Limit fluid removal to no more than 1000 mL within the first 30 minutes.
  9. Apply a small sterile dressing over the puncture site.

After the Procedure:

  1. Monitor changes in cough, sputum, respiratory depth, breath sounds, and chest pain.
  2. Position the client appropriately; some protocols recommend lying on the unaffected side with an elevated head for at least 30 minutes.
  3. Place the patient in a side-lying position with the unaffected side down for an extended period if necessary.
  4. Document the procedure details, including date, time, primary care provider’s name, amount and characteristics of drained fluid, and nursing assessments/interventions.
  5. Transport specimens to the laboratory.
  6. Monitor the puncture site dressing for bleeding or drainage.
  7. Continue monitoring blood pressure, pulse, and breathing until stable.
  8. Document all relevant information comprehensively.

Potential Nursing Diagnoses:

  1. Impaired Gas Exchange:
    • Related to decreased lung expansion secondary to pleural effusion.
  2. Acute Pain:
    • Related to the invasive nature of the thoracentesis procedure, evidenced by patient reports of discomfort or pain at the puncture site.
  3. Anxiety:
    • Related to the anticipation of the thoracentesis procedure, fear of potential complications, or uncertainty about the outcome.
  4. Deficient Knowledge:
    • Related to lack of information regarding the purpose, procedure, and expected outcomes of thoracentesis.
  5. Risk for Infection:
    • Related to the invasive nature of the procedure and compromised integrity of the skin at the puncture site.
  6. Ineffective Breathing Pattern:
    • Related to the accumulation of pleural fluid restricting lung expansion.
  7. Risk for Hypotension:
    • Related to the potential rapid removal of large volumes of pleural fluid during thoracentesis.
  8. Risk for Pneumothorax:
    • Related to the invasive nature of the procedure and the potential for lung injury during needle insertion.
  9. Disturbed Body Image:
    • Related to alterations in physical appearance due to the thoracentesis procedure or associated conditions.
  10. Ineffective Coping:
    • Related to stressors associated with the thoracentesis procedure, potential discomfort, or uncertainty about the outcome.

These nursing diagnoses provide a basis for identifying and addressing the patient’s needs before, during, and after the thoracentesis procedure. Individual patient assessments will help determine the most appropriate nursing diagnoses and interventions.

 

Read more

Central Venous Pressure

by

Introduction

Description: Central venous pressure (CVP) refers to the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP provides insights into the amount of blood returning to the heart and the heart’s ability to pump blood into the arterial system.

Objectives:

  1. Serve as a guide for fluid replacement in seriously ill patients.
  2. Estimate blood volume deficits.
  3. Determine pressures in the right atrium and central veins.
  4. Evaluate for circulatory failure within the total clinical picture of a patient.

Indications: Patients with cardiovascular disorders.

Nursing Alert: CVP readings should not be relied upon alone; they must be used in conjunction with other assessment data. Any abnormal findings should be promptly reported to the doctor.

Equipment:

  1. Venous pressure tray
  2. Cut-down tray
  3. Infusion solution and infusion set
  4. 3-way or 4-way stopcock (pressure transducer may also be used)
  5. IV pole attached to bed
  6. Arms board
  7. Adhesive tape
  8. ECG monitor
  9. Carpenter’s level (for establishing zero point)

Nursing Interventions:

  1. Assemble equipment according to manufacturer’s directions.
  2. Explain that the procedure is similar to an IV, and the patient may move in bed as desired after the passage of the CVP catheter.
  3. Place the patient in a comfortable position as a baseline for subsequent readings. Serial CVP readings should be consistent in terms of patient position to avoid inaccuracies.
  4. Attach the manometer to the IV pole, ensuring the zero point aligns with the patient’s right atrium, located at the midaxillary line, about 1/3 of the distance from the anterior to the posterior chest wall.
  5. Mark the midaxillary line on the patient as an external reference point for the manometer’s zero level.
  6. Connect the CVP catheter to a 3-way stopcock or transducer for monitoring.
  7. Start the IV flow, filling the manometer 10 cm above the anticipated reading.
  8. Surgically cleanse the CVP site, and insert the catheter through an antecubital, subclavian, or internal/external jugular vein into the superior vena cava, confirming placement via fluoroscopy or chest x-ray.
  9. Observe for respiratory fluctuations as the catheter enters the thorax, and monitor the patient’s ECG during insertion.
  10. Suture and tape the catheter in place, apply a sterile dressing, and label it with the time and date of insertion.
  11. Adjust the infusion rate to prevent a rapid increase in venous pressure.

Measuring Central Venous Pressure:

  1. Place the patient in the identified position and confirm the zero point at the level of the right atrium.
  2. Position the zero point of the manometer at the level of the right atrium, ensuring consistency in measurements.
  3. Turn the stopcock to fill the manometer, observe the fall in fluid height, and record the stabilized level as the central venous pressure (CVP). CVP may range from 5-12 cm H2O.
  4. Assess the patient’s clinical condition, interpreting CVP readings within the context of the entire clinical picture. Frequent changes in measurements will guide the detection of fluid load handling by the heart and the presence of hypovolemia or hypervolemia.
  5. A CVP of zero indicates hypovolemia, and a CVP above 15-20 cm H2O may suggest either hypervolemia or poor cardiac contractility.
  6. Turn the stopcock to allow IV solution flow into the patient’s veins when not recording readings.

Charting:

  1. Location of insertion site
  2. Type and size of needle or cannula used for insertion
  3. Time of insertion
  4. Appearance of needle insertion site.

Read more

Things Nurses Must Never Say To Patients

by

  1. “It’s not that bad.”

    • Downplaying a patient’s pain or discomfort can be dismissive and invalidating. Instead, nurses should acknowledge the patient’s feelings and work together to find ways to manage and alleviate their symptoms.

  2. “You’re just being difficult.”

    • Labeling a patient as difficult can strain the nurse-patient relationship. It’s important to approach each patient with empathy and understand that their behavior may be a result of fear, anxiety, or frustration. Open communication is key to addressing concerns.

  3. “I’m too busy right now.”

    • While nurses often have demanding schedules, expressing busyness without offering assistance or setting a specific time to address the patient’s needs can make them feel neglected. It’s better to communicate a timeframe for when the nurse will be available to help.

  4. “This won’t hurt at all.”

    • Making promises about pain or discomfort that cannot be guaranteed may lead to a loss of trust if the procedure turns out to be painful. Nurses should provide honest information about what to expect and offer support to help manage any discomfort.

  5. “I know exactly how you feel.”

    • Every patient’s experience is unique, and claiming to fully understand their emotions may come across as insincere. Instead, nurses can express empathy, validate the patient’s feelings, and offer support without assuming they know the exact extent of the patient’s emotions.

Read more

Blood Transfusion for low hemoglobin

by

Introduction

Blood transfusion therapy is a medical intervention that involves the intravenous administration of blood or blood components to a patient. This procedure is commonly employed to restore or improve the patient’s blood volume, enhance oxygen-carrying capacity, or replace specific blood components. Here are key aspects related to blood transfusion therapy:

Principles of Blood Transfusion Therapy

  • Clinical Assessment: Conduct a thorough clinical assessment to determine the patient’s need for blood transfusion. Consider factors such as hemoglobin levels, symptoms, and the underlying cause of anemia or blood loss.
  • Informed Consent: Obtain informed consent from the patient or their legal representative before initiating blood transfusion therapy. Provide information about the purpose, potential risks, and benefits of the procedure.
  • Blood Typing and Cross matching: Perform blood typing to determine the patient’s ABO and RhD blood group. Conduct cross matching to ensure compatibility between donor blood and recipient.
  • Compatibility Testing: Ensure compatibility not only for ABO and RhD but also for other blood group antigens to prevent transfusion reactions.
  • Pre-Transfusion Testing: Screen donated blood for infectious diseases, including HIV, hepatitis, and syphilis. Verify that the blood is free from bacterial contamination.
  • Appropriate Blood Component Selection: Choose the specific blood component based on the patient’s clinical condition. Red blood cells are used for anemia, platelets for clotting disorders, and plasma for coagulation factor deficiencies.
  • Administration Protocol: Follow a standardized protocol for the administration of blood transfusions. Use dedicated intravenous lines and infusion sets for blood products to prevent contamination.
  • Continuous Monitoring: Monitor vital signs (blood pressure, heart rate, respiratory rate, and temperature) during the entire transfusion process. Watch for signs of adverse reactions, including fever, chills, rash, or respiratory distress.
  • Rate of Transfusion: Control the rate of blood transfusion to prevent overload and reduce the risk of transfusion reactions. Adjust the rate based on the patient’s tolerance and clinical condition.
  • Documentation: Maintain accurate and complete documentation of the blood transfusion, including patient details, blood components administered, and any adverse reactions. Record vital signs and monitoring observations at specified intervals.
  • Transfusion Reactions Management: Be prepared to manage transfusion reactions promptly if they occur. Treatment may involve stopping the transfusion, providing supportive care, and addressing specific symptoms.
  • Post-Transfusion Assessment: Assess the patient post-transfusion to determine the effectiveness of the intervention. Monitor for improvements in hemoglobin levels and clinical symptoms.
  • Alternatives and Individualized Care: Consider alternatives to blood transfusion when appropriate, such as erythropoietin or iron supplementation. Individualize care based on the patient’s specific needs and clinical condition.
  • Patient Education: Educate patients about the importance of blood transfusion, potential risks, and expected benefits. Address any concerns or questions the patient may have.

Advantages of Blood Transfusion Therapy:

  • Restoration of Blood Volume: Blood transfusion helps restore and maintain adequate blood volume, particularly in cases of hemorrhage, trauma, or surgery.
  • Improved Oxygen-Carrying Capacity: Transfusing red blood cells increases the oxygen-carrying capacity of the blood, addressing conditions such as anemia or low hemoglobin levels.
  • Treatment of Coagulation Disorders: Blood transfusions provide clotting factors and platelets, essential for treating coagulation disorders or conditions associated with bleeding.
  • Support for Bone Marrow Disorders: Patients with bone marrow disorders, such as leukemia or aplastic anemia, may benefit from blood transfusions to support blood cell production.
  • Rapid Reversal of Symptoms: Blood transfusion can rapidly alleviate symptoms associated with anemia, such as fatigue, weakness, and shortness of breath.
  • Emergency Situations: In emergency situations, blood transfusion is a life-saving intervention to address acute blood loss and stabilize the patient’s condition.
  • Treatment of Hypovolemic Shock: Blood transfusion is crucial in treating hypovolemic shock, a condition characterized by a severe decrease in blood volume.
  • Cancer Treatment Support: Patients undergoing cancer treatments, such as chemotherapy, may require blood transfusions to manage treatment-related side effects.
  • Management of Chronic Conditions: Individuals with chronic conditions causing persistent anemia or blood disorders may benefit from regular blood transfusions to improve their quality of life.
  • Prevention of Organ Damage: Maintaining adequate blood volume and oxygen delivery helps prevent organ damage associated with inadequate perfusion.
  • Correction of Clotting Factor Deficiencies: Blood transfusions are essential for patients with clotting factor deficiencies, such as hemophilia, to prevent or manage bleeding episodes.
  • Support for Surgical Procedures: Prior to and during certain surgical procedures, blood transfusions ensure that patients have sufficient blood volume and oxygenation.
  • Treatment of Neonatal Conditions: Neonates with conditions such as hemolytic disease may require blood transfusions to address severe anemia and prevent complications.
  • Increased Hemoglobin Levels: Blood transfusions effectively increase hemoglobin levels in the blood, improving the oxygen-carrying capacity and overall well-being of the patient.
  • Temporary Supportive Measure: In some cases, blood transfusion serves as a temporary measure while underlying conditions are addressed through other medical interventions.
  • Management of Acute Blood Loss: Blood transfusion is a critical component in managing acute blood loss due to accidents, surgeries, or other traumatic events.
  • Prevention of Organ Failure: Ensuring adequate blood supply through transfusions helps prevent organ failure due to inadequate oxygenation and perfusion.
  • Enhanced Wound Healing: Improved oxygen delivery and clotting factors provided by blood transfusions contribute to enhanced wound healing.

The main blood components:

Red Blood Cells (RBCs):

  • Function: Carry oxygen from the lungs to the rest of the body and transport carbon dioxide back to the lungs for exhalation.
  • Composition: Primarily contains hemoglobin, a protein that binds to oxygen.

White Blood Cells (WBCs):

  • Function: Play a crucial role in the immune system by defending the body against infections and foreign invaders.
  • Types: Neutrophils, lymphocytes, monocytes, eosinophils, and basophils.

Platelets:

  • Function: Essential for blood clotting and wound healing. They help prevent excessive bleeding by forming blood clots.
  • Composition: Small cell fragments involved in the coagulation process.

Plasma:

  • Function: Transports nutrients, hormones, and waste products throughout the body. Also plays a role in maintaining blood pressure and electrolyte balance.
  • Composition: A yellowish fluid that consists of water, electrolytes, proteins (albumin, globulins, fibrinogen), hormones, and waste products.

Plasma Proteins:

  • Albumin: Maintains oncotic pressure, contributing to the regulation of fluid balance between blood and tissues.
  • Globulins: Involved in immune responses and transport various substances in the blood.

Fibrinogen: Essential for blood clot formation.

Cryoprecipitate:

  • Function: Contains concentrated clotting factors, particularly fibrinogen, and is used to treat bleeding disorders.
  • Composition: Derived from fresh frozen plasma (FFP).

Factor VIII and Factor IX Concentrates:

  • Function: Essential clotting factors for individuals with hemophilia A (Factor VIII deficiency) or hemophilia B (Factor IX deficiency).

Packed Red Blood Cells (PRBCs):

  • Function: Used to restore or maintain adequate oxygen-carrying capacity in individuals with anemia or significant blood loss.
  • Composition: Red blood cells separated from plasma and other components.

Fresh Frozen Plasma (FFP):

  • Function: Provides clotting factors, albumin, and other plasma proteins to treat conditions such as coagulopathies.
  • Composition: Plasma that has been frozen and contains all clotting factors.

Whole Blood:

  • Function: Used in specific situations where multiple blood components are needed simultaneously.
  • Composition: A combination of red blood cells, white blood cells, platelets, and plasma.

Objectives of Blood Transfusion Therapy:

Enhance Circulating Blood Volume:

  • Objective: Increase the overall volume of circulating blood, particularly in situations such as post-surgery, trauma, or hemorrhage, to improve perfusion and maintain vital organ function.

Boost Red Blood Cell (RBC) Count and Sustain Hemoglobin Levels:

  • Objective: Elevate the number of red blood cells (RBCs) and sustain adequate hemoglobin levels, especially in individuals with severe anemia, to optimize oxygen-carrying capacity and address symptoms associated with low hemoglobin.

Provide Targeted Cellular Component Replacement:

  • Objective: Offer specific cellular components, such as clotting factors, platelets, and albumin, as replacement therapy. This targeted approach aims to address deficiencies or imbalances in these components, ensuring effective hemostasis, clot formation, and maintenance of plasma oncotic pressure.

Nursing Interventions for Blood Transfusion:

Verify Doctor’s Order:

  • Objective: Confirm the physician’s prescription. Inform the client and provide a clear explanation of the purpose and process of the blood transfusion.

Check for Cross-Matching and Typing:

  • Objective: Ensure compatibility by verifying cross-matching and blood typing results to prevent transfusion reactions.

Obtain and Record Baseline Vital Signs:

  • Objective: Establish baseline vital signs to monitor the client’s response during the transfusion.

Practice Strict Asepsis:

  • Objective: Adhere to rigorous aseptic techniques to minimize the risk of infection during the blood transfusion procedure.

Two-Nurse Verification:

  • Objective: Prior to administration, two licensed nurses must independently verify the blood product label, checking for serial number, blood component, blood type, Rh factor, expiration date, and screening test results for blood-borne diseases.

Warm Blood at Room Temperature:

  • Objective: Prevent chills in the client by warming the blood to room temperature before transfusion.

Proper Client Identification:

  • Objective: Ensure accurate patient identification. Two nurses should independently confirm the client’s identity before initiating the transfusion.

Use Needle Gauge 18 to 19:

  • Objective: Facilitate easy blood flow by using a needle gauge between 18 and 19.

Micron Mesh Filter Blood Transfusion Set:

  • Objective: Utilize a blood transfusion set with a special micron mesh filter to prevent the administration of blood clots and particles.

Start Infusion Slowly and Remain at Bedside:

  • Objective: Initiate the infusion at a rate of 10 drops per minute. Stay at the bedside for the first 15 to 30 minutes as adverse reactions typically occur during this time.

Monitor Vital Signs:

  • Objective: Continuously monitor vital signs. Any alterations, such as an increase in temperature or respiratory rate, may indicate an adverse reaction.

Avoid Mixing Medications with Transfusion:

  • Objective: Prevent adverse effects by refraining from mixing medications with the blood transfusion. Do not introduce medications into the blood transfusion, and avoid using blood transfusion lines for IV push of medications.

Administer 0.9% NaCl Before, During, or After Transfusion:

  • Objective: Use normal saline for pre-transfusion, during, or post-transfusion to avoid hemolysis. Never administer IV fluids with dextrose, as it can cause hemolysis.

Follow Transfusion Duration Guidelines:

  • Objective: Administer whole blood or packed red blood cells over 4 hours. For plasma, platelets, and cryoprecipitate, transfuse quickly within 20 minutes, as clotting factors may be easily destroyed.

Observe for Complications and Notify Physician:

  • Objective: Monitor for potential complications and promptly notify the physician if any issues or adverse reactions arise during the blood transfusion.

Complications of Blood Transfusion

Allergic Reaction:

  • Cause: Sensitivity to donor plasma proteins.

Assessment: Flushing, Rash, hives, Pruritus, Laryngeal edema and difficulty breathing.

Febrile Non-Hemolytic Reaction:

Cause: Hypersensitivity to donor white cells, platelets, or plasma proteins.

Assessment: Sudden chills and fever, Flushing, Headache and Anxiety.

Septic Reaction:

Cause: Transfusion of blood or components contaminated with bacteria.

Assessment: Rapid onset of chills, Vomiting, Marked hypotension and High fever

Circulatory Overload:

Cause: Administration of blood volume at a rate exceeding circulatory capacity.

Assessment: Rise in venous pressure, Dyspnea Crackles or rales, Distended neck veins ,Cough and Elevated blood pressure

Hemolytic Reaction:

Cause: Infusion of incompatible blood products.

Assessment: Low back pain (initial sign due to kidney inflammatory response), Chills, Feeling of fullness, Tachycardia, Flushing, Tachypnea, Hypotension, Bleeding, Vascular collapse and Acute renal failure

Assessment Findings of Transfusion Complications:

Hemolytic Transfusion Reaction:

  • Clinical Manifestations: Fever, Chills, Low back pain, Flank pain, Headache, Nausea, Flushing, Tachycardia, Tachypnea, Hypotension and Hemoglobinuria (cola-colored urine)

Delayed Hemolytic Reaction:

  • Clinical Signs and Laboratory Findings: Fever, Mild jaundice, Gradual fall of hemoglobin and Positive Coombs’ test.

Febrile Non-Hemolytic Reaction:

  • Clinical Manifestations: Temperature rise during or shortly after transfusion, Chills, Headache, Flushing and  Anxiety,

Septic Reaction:

  • Clinical Manifestations: Rapid onset of high fever and chills, Vomiting, Diarrhea and Marked hypotension

Allergic Reactions:

  • Clinical Manifestations: Hives, Generalized pruritus and Wheezing or anaphylaxis (rarely)

Circulatory Overload:

  • Clinical Manifestations: Dyspnea, Cough, Rales, Jugular vein distention
  • Infectious Disease Transmission: Manifestations may develop rapidly or insidiously, depending on the disease. Graft-Versus-Host Disease (GVH):
  • Characteristics: Skin changes (e.g., erythema, ulcerations, scaling), Edema, Hair loss and Hemolytic anemia

10 Nursing Diagnoses:

Hyperthermia

Hypothermia

High Risk for Infection

High Risk for Injury

Pain

Ineffective Breathing Pattern

Decreased Cardiac Output

Fluid Volume Deficit

Fluid Volume Excess

Impaired Gas Exchange

Prevention of Transfusion Reaction:

Meticulously verify patient identification, blood product, and labeling. Inspect the blood product for abnormalities before administration. Begin transfusion slowly (1 to 2 mL/min) and observe closely, especially during the first 15 minutes.

Transfuse blood within 4 hours and change blood tubing every 4 hours. Prevent infectious disease transmission through careful donor screening. Ensure irradiation of blood products containing viable WBCs to prevent GVH disease. Prevent hypothermia by warming the blood unit to 37°C before transfusion.

Remove leukocytes and platelet aggregates with a micro aggregate filter in the blood line. Detection and Intervention for Transfusion Reaction: Stop the transfusion immediately and notify the physician. Disconnect the transfusion set, keeping the IV line open with 0.9% saline.

Send 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 for hemoglobin determination. Intervene appropriately based on the specific reaction observed.

Nursing Interventions If Reaction Occurs:

  • Stop the transfusion.
  • Start an IV line with 0.9% NaCl.
  • Place the client in Fowler’s position if experiencing shortness of breath and administer O2 therapy.
  • Remain with the client, observing signs and symptoms, and monitoring vital signs every 5 minutes.
  • Notify the physician immediately.
  • Prepare to administer emergency drugs per physician’s order or protocol.
  • Obtain a urine specimen for hemoglobin determination.
  • Save blood container, tubing, label, and transfusion record for laboratory analysis.

Nursing Evaluation:

  • The patient maintains a normal breathing pattern.
  • The patient demonstrates adequate cardiac output.
  • The patient reports minimal or no discomfort.
  • The patient maintains good fluid balance.
  • The patient remains norm thermic.
  • The patient remains free of infection.
  • The patient maintains good skin integrity, with no lesions or pruritus.
  • The patient maintains or returns to normal electrolyte and blood chemistry values.

Read more

How long does an IV take? Tips & Techniques on IV Insertion

by

Introduction Mastering the skill of intravenous (IV) insertion is essential for nurses, and continuous practice coupled with confidence is key to success. While it may be considered a basic nursing skill, it can be challenging to master without sufficient experience. Successful practitioners often become adept through consistent practice and hands-on experiences in the field. Here … Read more