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BLOOD TRANSFUSION REACTION

Reaction: Cause

Clinical Signs

Nursing Intervention* 1. Discontinue the transfusion immediately. NOTE: When the transfusion is discontinued, the blood tubing must be removed as well. Use new tubing for the normal saline infusion. 2. Keep the vein open with normal saline, or according to agency protocol. 3. Send the remaining blood, a sample of the clients blood, and a urine sample to the laboratory.

Chills, fever, headache, 1) Hemolytic reaction: blood and donors blood backache, dyspnea, cyanosis, hypotension incompatibility between clients chest pain, tachycardia,

4. Notify the physician immediately. 5. Monitor vital signs.6. Monitor fluid intake and output. 1. Discontinue the transfusion immediately.

2) Febrile reaction: sensitivity of the clients blood to white blood cells, platelets, or plasma proteins. headache; anxiety, muscle pain

2. Give antipyretics as ordered. 3. Notify the physician. Fever; chills; warm, flushed skin; 4. Keep the vein open with a normal saline infusion. 1. Stop or slow the transfusion, depending on agency protocol.

3) Allergic reaction (mid): sensitivity to infused plasma proteins. Flushing, itching, urticaria, bronchial wheezing

2. Notify the physician. 3. Administer medication (antihistamines) as ordered. 1. Stop the transfusion 2. Keep the vein open with normal saline. 3. Notify the physician immediately. 4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed.

4) Allergic reaction (severe): antibody-antigen reaction

Dyspnea, chest pain, circulatory 5. Administer medications and/or collapse, cardiac arrest oxygen as ordered. 1. Place the client upright, with feet dependent 2. Administer diuretics and

5) Circulatory overload: blood administered faster than the circulation can accommodate

Cough, dyspnea, crackles (rales), oxygen as ordered. distended neck veins, tachycardia, hypertension 3. Notify the physician. 4. Stop or slow the transfusion

2 1. Stop the transfusion. 2. Send the remaining blood to laboratory 3. Notify the physician. 4. Obtain a blood specimen from the client for culture. 5. Administer IV fluids, antibiotics. 6) Sepsis: contaminated blood administered High fever, chills, vomiting, diarrhea, hypotension 6. Keep the vein open with a normal saline infusion.

Cardiac Catheterization

Cardiac catheterization involves passing a catheter into the right or left side of the heart. Catheterization can determine blood pressure and blood flow in the chambers of the heart, permits blood sample collection, and record films of the hearts ventricles (contrast ventriculography) or arteries (coronary arteriography or angiography). Catheterization of the hearts left side assesses the patency of the coronary arteries, mitral and aortic valve function, and left ventricular function. Catheterization of the hearts right side assesses tricuspid and pulmonic valve function and pulmonary artery pressures. Purpose of Cardiac Catheterization

To evaluate valvular insufficiency or stenosis, septal defects, congenital anomalies, myocardial function, myocardial blood supply, and cardiac wall motion. To aid in diagnosing left ventricular enlargement, aortic root enlargement, ventricular aneurysms, and intracardiac shunts.

Cardiac Catheterization Procedure

3 Patient Preparation 1. Explain the procedure to the patient. 2. Tell him to restrict fluids for at least 6 hours before the test. 3. Inform him that the test takes 1 to 2 hours. 4. Tell him that he may receive a mild sedative but will remain conscious during the procedure. 5. Have the patient to void just before the procedure. 6. Check the patient history for hypersensitivity to shellfish, iodine, or contrast media used in other diagnostic tests. Discontinue any anticoagulant therapy as ordered. Implementation 1. The patient is placed supine on padded table and his heart rate and rhythm, respiratory status, and blood pressure are monitored throughout the procedure. 2. An I.V. line is started, if not already in place, and a local anesthetic is injected at the insertion site. 3. A small incision is made into the artery or vein, depending on whether the test is for the left or right. 4. The catheter is passed through the sheath into the vessel and guided using fluoroscopy. 5. In the right-sided catheterization, the catheter is inserted into the antecubital or femoral vein and advanced through the vena cava into the right side of the heart and into the pulmonary artery. 6. If left-sided heart catheterization, the catheter is inserted into the brachial or femoral artery and advanced retrograde through the aorta into the coronary artery ostium and left ventricle. 7. When the catheter is in place, contrast medium is injected to make visible the cardiac vessels and structures. 8. Nitroglycerin is given to eliminate catheter-induced spasm or watch its effect on the coronary arteries. 9. After the catheter is removed, direct pressure is applied to the incision site until bleeding stops, and a sterile dressing is applied. Nursing Interventions 1. Monitor the patients heart rate and rhythm, respiratory and pulse rates, and blood pressure frequently. 2. Monitor the patients vital signs every 15 minutes for 2 hours after the procedure, every 30 minutes for the next 2 hours, and then every hour for 2 hours. 3. If no hematoma or other problems arise, begin monitoring every 4 hours. If vital signs are unstable, check every 5 minutes and notify the practitioner. 4. Observe the insertion site for a hematoma or blood loss. Additional compression may be necessary to control bleeding. 5. Check the patients color, skin temperature, and peripheral pulse below the puncture site. 6. Enforce bed rest for 8 hours. If the femoral route was used for catheter insertion, keep the patients leg extended for 6 to 8 hours. 7. If medications were withheld before the test, check with the practiotner about resuming their administration. 8. Administer prescribed analgesics. 9. Make sure a posttest ECG is scheduled to check for possible myocardial damage. Interpretation Normal Results

No abnormalities of heart valves, chamber size, pressures, configuration, wall motion, or thickness, and blood flow. Coronary arteries have a smooth and regular outline. Coronary artery narrowing greater than 70% suggests significant coronary artery disease.

Abnormal Results

Narrowing of the left main coronary artery and occlusion or narrowing high in the left anterior descending artery suggests the need for revascularization surgery. Impaired wall motion suggests myocardial incompetence. A pressure gradient indicates valvular heart disease. Retrograde flow of the contrast medium across a valve during systole indicates valvular incompetence.

Precautions

Coagulopathy, impaired renal function, and debilitation usually contraindicate catheterization of both sides of the heart. Unless a temporary pacemaker is inserted to counteract induced ventricular asystole, left bundle-branch block contraindicates catheterization of the right side of the heart.

If the patient has valvular heart disease, prophylactic antimicrobial therapy may be indicated to guard against subacute bacterial endocarditis.

Complications

Ineffective endocarditis in a patient with vulvular heart disease. Myocardial infarction, arrhythmias, cardiac tamponade, pulmonary edema, hematoma, blood loss, adverse reaction to contrast media, and vasovagal response.

PULMONARY CAPILLARY WEDGE PRESSURE

What does it measure? Pulmonary capillary wedge pressure (PCWP) provides an indirect estimate of left atrial pressure (LAP). Although left ventricular pressure can be directly measured by placing a catheter within the left ventricle, it is not feasible to advance this catheter back into the left atrium. LAP can be measured by placing a special catheter into the right atrium then punching through the interatrial septum; however, for obvious reasons, this is not usually performed because of damage to the septum and potential harm to the patient.

How is it measured? PCWP is measured by inserting balloon-tipped, multi-lumen catheter (Swan-Ganz catheter) into a peripheral vein, then advancing the catheter into the right atrium, right ventricle, pulmonary artery, and then into a branch of the pulmonary artery. Just behind the tip of the catheter is a small balloon that can be inflated with air (~1 cc). The catheter has one opening (port) at the tip (distal to the balloon) and a second port several centimeters proximal to the balloon. These ports are connected to pressure transducers. When properly positioned in a branch of the pulmonary artery, the distal port measures pulmonary artery pressure (~ 25/10 mmHg; systolic/diastolic pressure) and the proximal port measures right atrial pressure (~ 0-3 mmHg). The balloon is then inflated, which occludes the branch of the pulmonary artery. When this occurs, the pressure in the distal port rapidly falls, and after several seconds, reaches a stable lower value that is very similar to left atrial pressure (normally about 8-10 mmHg). The balloon is then deflated. The same catheter can be used to measure cardiac output by the thermodilution technique.

5 The pressure recorded during balloon inflation is similar to left atrial pressure because the occluded vessel and its distal branches that eventually form the pulmonary veins act as a long catheter that measures the blood pressures within the pulmonary veins and left atrium. Why is it measured? It is helpful to measure PCWP to diagnose the severity of left ventricular failure and to quantify the degree of mitral valve stenosis. Both of these conditions elevate LAP and therefore PCWP. These pressures are normally 8-10 mmHg. Aortic valve stenosis and regurgitation, and mitral regurgitation also elevate LAP. When these pressures are above 20 mmHg,pulmonary edema is likely to be present, which is a life-threatening condition. Note that LAP is the outflow or venous pressure for the pulmonary circulation and increases in LAP are transmitted almost fully back to the pulmonary capillaries thereby increasing their hydrostatic pressure and filtration of fluid. By measuring PCWP, the physician can titrate the dose of diuretic drugs and other drugs that are used to reduce pulmonary venous and capillary pressure, and thereby reduce pulmonary edema. Therefore, measurement of PCWP can help guide therapeutic efficacy. PCWP is also important to measure when evaluating pulmonary hypertension. Pulmonary hypertension is often caused by increased pulmonary vascular resistance. To calculate this, pulmonary blood flow (usually measured by the thermodilution technique), pulmonary artery pressure and pulmonary venous pressure (PCWP) measurements are required. Pulmonary hypertension can also result from increases in pulmonary venous pressure and pulmonary blood volume secondary to left ventricular failure or mitral or aortic valve disease. PCWP is also useful in evaluating blood volume status when fluids are administered during hypotensive shock. One practice is to administer fluids at a rate that maintains PCWP between 12-14 mmHg.

Tracheostomy Care

Explain procedure to patient. 1. If tracheostomy tube has been suctioned, remove soiled dressing from around tube and discard with gloves on removal. 2. Perform hand hygiene and open necessary supplies. Cleaning A Nondisposable Inner Cannula 1. Prepare supplies before cleaning inner cannula. 1. a. Open tracheostomy care kit and separate basins, touching only the edges. If kit is not available, open two sterile basins. b. Fill one basin fraction -inch (1.25 cm) deep with hydrogen peroxide. c. Fill other basin fraction -inch (1.25 cm) deep with saline. d. Open sterile brush or pipe cleaners if they are not already in cleaning kit. Open additional sterile gauze pad. 1. Don disposable gloves. 2. Remove oxygen source if one is present. Rotate lock on inner cannula in a counterclockwise motion to release it.

6 3. Gently remove inner cannula and carefully drop it in basin with hydrogen peroxide. Remove gloves and discard. 4. Clean inner cannula. 1. a. Don sterile gloves. b. Remove inner cannula from soaking solution. Moisten brush or pipe cleaners in saline and insert into tube, using back-and-forth motion. c. Agitate cannula in saline solution. Remove and tap against inner surface of basin. d. Place on sterile gauze pad. 1. Suction outer cannula using sterile technique. 2. Replace inner cannula into outer cannula. Turn lock clockwise and make sure that inner cannula is secure. Reapply oxygen source if needed. Replacing Disposable Inner Cannula 1. Release lock. Gently remove inner cannula and place in disposable bag. Discard gloves and don sterile ones to insert new cannula. Replace with appropriately sized new cannula. Engage lock on inner cannula. Applying Clean Dressing and Tape 1. Dip cotton-tipped applicator in saline and clean stoma under faceplate. Use each applicator only once, moving from stoma site outward. 2. Apply hydrogen peroxide to area around stoma, faceplate, and outer cannula if secretions prove difficult to remove. Rinse area with saline. 3. Pat skin gently with dry 4 x 4 gauze. 4. Slide commercially prepared tracheostomy dressing or prefolded non-cotton-filled 4 x 4 dressing under faceplate. 5. Change tracheostomy tape. 1. a. Leave soiled tape in place until new one is applied. b. Cut piece of tape that is twice the neck circumference plus 4 inches (10 cm). Trim ends on the diagonal. c. Insert one end of tape through faceplate opening alongside old tape. Pull through until both ends are even. d. Slide both tapes under patients neck and insert one end through remaining opening on other side of faceplate. Pull snugly and tie ends in double square knot. Check that patient can flex neck comfortably. e. Carefully remove old tape. Reapply oxygen source if necessary. 1. Remove gloves and discard. Perform hand hygiene. Assess patients respirations. Document assessments and completion of procedure.