Med Surg 2 - Quiz 4

Blood Transfusions & Coagulation Disorders

Define Blood Transfusions

Tansfusions of whole blood or components of whole blood for replacement due to blood loss or blood disease.

Whole Blood Components (4)

• RBCs

• WBCs

• Platelets

• Plasma

Blood Components (8)

• Packed RBCS - RBCs separated from platelets & plasma

• Washed RBCs (WBC-poor RBCs)

• WBCs

• Fresh frozen plasma - Albumin & cryoprecipitate

• Albumin

• Clotting Factors

• Cryoprecipitate

• Platelets

Transfusion Types (3)

• Standard Donation - Transfusion from compatible donor blood.

• Autologous Transfusions

• Intraoperative Blood Salvage

Define Autologous Transfusions (3)

• Client’s blood is collected in anticipation of future transfusions (surgery)

• Blood is for & used only by client

• Client can donate up to 6 weeks prior to procedure & if hgb & hct remain stable donation can occur weekly

Define Intraoperative Blood Salvage (2)

• Sterile blood lost during a procedure is saved/retrieved into a device that filters & drains blood into a bag for transfusion intraoperatively/postoperatively.

• Reinfusion must occur within 6 hr of salvaged blood collection

Transfusion - Indications/Diagnoses (6) HE BACK

• Hemophilia - Cryoprecipitate

• Excessive Blood Loss - Give packed RBCs

• Burns & Hypoproteinemia - Albumin

• Anemia - Hgb < 6 or 6-10, give packed RBCs

• Coagulation Factor Deficiencies - Hemophilia; Give FFP

• Kidney Failure - Packed RBCs

Transfusion - Platelet Transfusion Considerations (3)

• Platelets do not need to match client’s blood type & each bag contains 200-300 mL

• Fragile & must be infused ASAP once in room over 15-30 mins with small filter & short tubing (special set)

• Vitals taken before, 15 mins after, & upon completion of infusion

Transfusion - Plasma Transfusion Considerations (3)

• Plasma is frozen following donation & is then FFP & is transfused as soon as unit is thawed while clotting factors are active

• Client may react to transfusion if ABO compatibility is not matched

• Infuse 200 mL of FFP rapidly over 15-30 mins through reg Y-set or straight filtered tubing

Transfusion - WBC Transfusion (Granulocyte) Considerations (4)

• Immunocompromised client’s rarely receive WBCs due to severe reaction risk

• If on amphotericin B antibiotics wait 4-6 hrs before WBC transfusion as amp B can hemolyze WBCs

• Infuse in 400 mL of plasma over 45-60 mins

• Take vitals q15 minutes, provider may need to be in room

Transfusion - Washed RBC’s Transfusion Considerations (2)

• Infusef 200 mL over 2-4 hrs

• Administer to a client who has a history of transfusion reactions or who has had a hematopoietic stem cell transplant.

Transfusion - Preprocedure (5)

• Incompatibility - Major concern when administering blood/blood products & preventing this requires strict adherence to transfusion protocols.

• Type & cross match is necessary for packed RBCs; Blood products containing RBCs are typed & cross-matched for antigens.

• Plasma products are typed for ABO compatibility but not cross-matched for antigens. Other cells (WBCs, platelets) in plasma products can carry ABO antigens.

• Blood is typed based on the presence of antigens.

• Rh Factor - Clients who are Rh-negative are born without Rh antigen in their RBCs. & do not develop antibodies unless sensitization occurs; Once it occurs, any transfusion with Rh-positive blood will cause a reaction.

Transfusion - Preprocedure Nursing Actions (11)

• Assess vitals & temp prior to transfusion.

• Remain with client during initial 15-30 min of transfusion (most severe reactions occur at this time)

• Review labs to ensure client requires transfusion & to compare to baseline

• Verify prescription for blood product & obtain consent

• Obtain blood samples for compatibility determination, such as type & cross-match.

• Initiate large-bore IV access (18-20 G)

• Obtain blood products from blood bank & inspect for discoloration, excess, bubbles, or cloudiness.

• 2 RNs must identify the correct blood product & client by looking at identification number on blood product & number on client’s ID band to ensure numbers match.

• The nurse completing the blood product verification must administer the blood product.

• Prime blood administration set with NS ONLY; Y-tubing with a filter is used to transfuse blood.

• Begin transfusion & use a blood warmer if indicated & initiate transfusion within 30 min of obtaining product to reduce risk of bacterial growth.

Transfusion - Preprocedure Older Adult Considerations (3)

• No larger than a 19-G needle is used.

• Assess kidney function, fluid status, & circulation prior to blood product administration (increased risk for fluid overload)

• Use blood products that less than 1 week old.

Blood Type Compatability (May Receive From) (8)

• A+ - Compatible with A+, A-, O+, O-

• A - - Compatible with A-, O-

• B+ - Compatible with B+, B-, O+, O-

• B- - Compatible with B-, O-

• O+ - Compatible with O+, O-

• O- - Compatible with O-

• AB+ - Compatible with all types

• AB- - Compatible with AB-, A-, B-, O-

Transfusion - Intraprocedure Nursing Actions (5)

• Remain with client for 1st 15-30 min of infusion, monitor vitals & rate of infusion

• Older Adults - Assess vitals q15 mins throughout transfusion because changes in pulse, BP, & RR can indicate fluid overload, or a transfusion reaction.

• Older adults who have cardiac/renal dysfunction are at an increased risk for heart failure & fluid-volume excess when receiving a blood transfusion.

• Administer blood transfusion over 2-4 hr for older adult clients & withhold other IV fluids during administration to prevent fluid overload​​​​​​​

• Notify HCP immediately if indications of a reaction occur.

Transfusion - Postprocedure Nursing Actions (4)

• Obtain vitals upon completion of transfusion.

• Dispose of the blood-administration set according to policy.

• Complete paperwork, & file in the appropriate places.

• Document client’s response.

Transfusions - Complications (5)

• Acute hemolytic transfusion reaction

• Febrile transfusion reaction

• Allergic transfusion reaction

• Bacterial transfusion reaction

• Circulatory overload

Define Acute Hemolytic Transfusion Reaction (3)

Immediate or during subsequent transfusions

Results from a transfusion of blood products that are incompatible with client’s blood type or Rh factor & can occur following transfusion as few as 10 mL

Mild or life-threatening, resulting in DIC or circulatory collapse

Acute Hemolytic Transfusion Reaction - Findings (10

• Chills

• Fever

• Low-back pain

• Tachycardia

• Hypotension

• Chest tightening or pain

• Tachypnea

• Nausea

• Hemoglobinuria

• Anxiety & impending sense of doom

Acute Hemolytic Transfusion Reaction - Nursing Actions (5)

• Stop transfusion

• Remove blood tubing from IV access & avoid infusing further blood products

• Initiate infusion of NS using NEW tubing

• Monitor vitals & fluid status

• Send blood bag & administration set to lab for testing

Define Febrile Transfusion Reaction (3)

• Commonly occurs within 2 hrs of starting transfusion

• Results from development of anti-WBC antibodies

• Seen in clients who have received multiple transfusions

Febrile Transfusion Reaction - FIndings (5)

• Chills

• Increase of 1 degree celsius (2 F) or greater from pretransfusion temp

• Hypotension

• Tachycardia

• Flushed appearance

Febrile Transfusion Reaction - Nursing Actions (3)

• Use WBC filter for administration to catch WBCs & prevent reaction

• Stop transfusion & administer antipyretics.

• Initiate an infusion of NS using new tubing.

Define Allergic Transfusion Reaction (3)

• Can occur during or up to 24 hrs after transfusion

• Results from a sensitivity reaction to component of blood products

• Can be mild or anaphylactic

Mild Allergic Transfusion Reaction - Findings (3)

• Itching

• Urticaria

• Flushing

Mild Allergic Transfusion Reaction - Nursing Actions (4)

• Stop transfusion

• Initiate infusion of NS with new tubing

• Administer an antihistamine (diphenhydramine)

• If prescribed restart transfusion SLOWLY

Anaphylactic Reaction - FIndings (4)

• Bronchospasm

• Laryngeal edema

• Hypotension

• Shock

Anaphylactic Reaction - Nursing Actions (4)

• Stop transfusion

• Administer epinephrine, corticosteroids, vasopressors, oxygen, or CPR

• Remove blood tubing from IV access

• Initiate NS infusion with new tubing

Define Bacterial Transfusion Reaction (2)

• Occurs during or up to several hours after transfusion

• Results from contaminated blood products

Bacterial Transfusion Reaction - Findings (6)

• Wheezing

• Dyspnea

• Chest tightness

• Cyanosis

• Hypotension

• Shock

Bacterial Transfusion Reaction - Nursing Actions (3)

• Stop tranfusion

• Administer antibiotics & NS infusion with new tubing

• Senf blood culture specimen to lab

Define Circulatory Overload (3)

• Can occur any time during transfusion

• Results from rapid transfusion rates

• Older adults or those with preexisting increased circulatory volume are at an increased risk

Circulatory Overload - Findings (7)

• Crackles

• Dyspnea

• Cough

• Anxiety

• JVD

• Tachycardia

• May progress to pulmonary edema

Circulatory Overload - Nursing Actions

Slow or stop transfusion depending on manifestation severity

Position client upright with feet lower than level of heart

Administer O2, diuretics, & morphine

Transfusion Complications (Other) (2)

Transfusion-Related Acute Lung Injury (TRALI)

Transfusion-Associated Circulatory Overload (TACO)

Define TRALI (2)

• Involves serious & potentially life-threatening swelling in lungs.

• Likely happens when parts of donor’s blood aren’t compatible with your blood.

Define TACO (2)

• Involves having too much plasma in your circulatory system.

• The additional fluid overburdens your system & can lead to high BP & swelling in lungs.

Define Coagulation Disorders

Occur secondary to an alteration in platelets, clotting factors or both

Define Coagulopathy

Any condition affecting an individuals ability to coagulate

Suspected when usual measures to stop bleeding fail

Can occur secondary to an autoimmune disorder, extensive blood loss in which platelets & clotting factors are lost

Types of Coagulation Disorders (5)

• Idiopathic/Immune Thrombocytopenic Purpura (ITP)

• Thrombotic Thrombocytopenic Purpura (TTP)

• Heparin-induced thrombocytopenia (HIT)

• Disseminated intravascular coagulation (DIC)

• Hemophilia

Define ITP (3)

• Coagulopathy that is an autoimmune disorder in which life span of platelets is decreased by antiplatelet antibodies although platelet production is normal.

• Can result in severe hemorrhage following a cesarean birth or lacerations.

• Mortality rate for adults who have ITP is 5%.

Define TTP (5)

• Coagulopathy in which platelets abnormally clump together in capillaries due to autoimmune reaction from platelet aggregation

• Results in an insufficient quantity of platelets in circulation.

• Inappropriate clotting occurs, & clotting fails to occur with trauma.

• Can lead to kidney failure, MI, stroke, & can be fatal within 3 months if untreated.

• Mortality rate for TTP is 10 to 20%.

Define HIT (2)

• Immunity-mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin.

• Mortality rate for HIT is 30%.

Define DIC (2)

• Life-threatening coagulopathy in which clotting & anticlotting mechanisms occur at the same time.

• Risk for both internal & external bleedin & damage to organs resulting from ischemia caused by microclots.

Define Hemophilia (3)

• Inherited bleeding disorder in which hemorrhaging occurs in various parts of the body due to a deficiency in either factor VIII or factor IX

• Often because of minimal trauma.

• Common bleeding disorder, usually diagnosed during early childhood & affects more than 1 million people.

ITP - Risk Factors (4)

• Females (20 to 50 y/o)

• Secondary Conditions - Meds, viruses, HIV, hep c

• Other autoimmune disorder

• Recent virus (children only)

TTP - Risk Factors (1)

Other autoimmune disorders

HIT - Risk Factors (4)

• Females

• Receiving heparin longer than 1 week

• Exposure to heparin (unfractionated more common)

• Postsurgical thromboprophylaxis (prevention of thromboembolic disease)

DIC - Risk Factors (6)

• Septicemia

• Cardiopulmonary arrest

• Trauma (hemorrhage, burns, crush injuries)

• Obstetric complications (toxemia, amniotic fluid embolus)

• Cancer

• Allergic reaction

Coagulation Disorders - Expected Findings (10)

• Unusual spontaneous bleeding from gums & nose (epistaxis)

• Oozing, trickling, or flow of blood from incisions or lacerations

• Petechiae & ecchymoses (extremities, upper chest, neck)

• Hematuria

• Excessive bleeding from venipuncture, injection sites, or slight traumas

• Tachycardia, hypotension, & diaphoresis

• Organ failure secondary to microemboli

• Respiratory distress

• Cyanosis pigmentation of the nails (microvascular thrombosis)

• Redness, pain, warmth & swelling of lower extremities (HIT)

Coagulation Disorders Labs (1)

Blood typing & cross match

Hemoglobin - Reference Range (2)

• Males - 14 to 18

• Females - 12 to 16

Platelet - Reference Range

150,000 to 400,000

Fibrinogen Levels - Reference Range

200 to 400

Prothrombin Time - Reference Range

11 to 12.5 seconds

PTT Time - Reference Range (2)

PTT - 60 to 70 seconds

aPTT - 30 to 40 seconds

Thrombin Time - Reference Range

8 to 11 seconds

Fibrin Split Product Levels/Fibrin Degradation Products - Reference Range

Less than 10

D-dimer - Reference Range

Less than 0.4

DIC - Labs (8)

• Hemoglobin decreased

• Platelets decreased

• Fibrinogen levels decreased

• Increased PT

• PTT increased

• Increased thrombin time

• Fibrin Split Product Levels/Fibrin Degradation Products Increased

• D-dimer increased

ITP - Labs (2)

• Hemoglobin decreased

• Platelets decreased

TTP - Labs (1)

Platelets decreased

DIC - Nursing Care (3)

• Initially assess for & correct underlying cause (sepsis, malignancy, hemorrhage)

• Then focus turns to prevent organ damage secondary to microemboli & replacing blood’s clotting components

• Monitor for manifestations of microemboli (cyanotic nails, pain)

DIC, HIT, ITP, & TTP - Nursing Care (8)

• Regularly assess vitals & hemodynamic status.

• Monitor for manifestations of organ failure or intracranial bleed (oliguria, decreased LOC)

• Monitor labs for clotting factors.

• Administer fluid volume replacement.

• Transfuse blood, platelets, & other clotting products.

• Avoid use of NSAID & Valsalva manuevers (cerebrak hemorrhage)

• Administer supplemental oxygen.

• Provide protection from injury & implement bleeding precautions

ITP - Meds (2)

• Corticosteroids

• Immunosuppressants

TTP - Meds (2)

• Antiplatelet meds (aspirin, alprostadil, plicamycin).

• Immunosuppressive therapy decreases intensity of complications.

HIT - Meds

Anticoagulants with direct thrombin inhibitor (argatroban, lepirudin, bivalirudin)

DIC - Meds

Anticoagulants (heparin) can be used to decrease microclots from forming & using up clotting factors.

TTP - Interventions

Plasma exchange

ITP - Interventions

Splenectomy, performed if the client does not respond to medical management.