Med Surg week 5: Heme/Blood transfusions VOPP (ch 34)

perfusion- peripheral and arterial

total arterial blood flow through the tissues (peripheral)

and blood that is pumped by the heart (central)

clotting

complex multistep process where blood forms protein based structure

bone marrow

production of blood cells

blood forming organ

involved w immune responses

accessory organs: spleen

balance red blood cell production w red blood cell destruction

immunity (w/out spleen pt is immunocompromised)

accessory organs: liver

makes prothrombin and other clotting factors

helps form vit K in intestinal tract

stores blood cells

plasma proteins

albumin= osmotic pressure, prevents plasma leakage

globulins= antibodies, prevent inf

fibrinogen= blood clotting

RBC lifespam, produces and production is triggered by

120 days

produces hbG (need iron too)

production (erythropoiesis) is triggered the need for tissue oxygenation (low o2), which signals the kidneys to release EPO which increases B marrow production of RBC

RBC medications- epoetin alfa: examples, route, use, action

procrit

Epogen

given SQ or IV, use= anemia from chemo

acts as epoetin, stimulants bone marrow to make more RBC

WBC- role

inflammatory response and immunity

WBC normal levels

5,000-10,000 K

WBC meds: filgrastim (Neupogen)- type

biological response modifiers

shorter action

biological response modifiers action

act on bone marrow to stimulate production of RBC/WBC

WBC meds: PEG filgrastim (neulasta)

longer lasting

use for chemo, ANC is low and want to prevent infection

action= stim bone marrow to produce neutrophils

platelets- lifespan, held in…, main action, growth factor

life span 1-2 weeks

circulate active/inactive, held in spleen

stick to BV wall and form platelet plug

growth factor is thrombopoetin

blood clotting/hemostasis- definition, overview 3 phases

balacnes producttion of blotting and dissolving facotrs

three phases:

plt aggregation (plt plug)

blood clotting cascade

ormation of complete fibrin clot

platelet aggregation

platelet plug IS NOT a clot, lasts only few hrs

need to be activated by collagen/other (exogenous/themselves)

activation= membranes sticky, plt clump together, distrusts BF in BV

anticlotting factors- fibrinolysis

process that dissolves fibrin clot edges w special enzymes

activates plasminogen to plasmin (with enzyme)

plasmin digests fribrin/fibrongen/prothrombin to control clot size

anticlotting factors

fibrin clots keeps forming until all blood coagulates (obvi don’t want that) soooo

anti clotting factors are also started to limit aggregation ONLY at site of injury so perfusion persists
promote fibrinolysis

clotting factors

inactive enzymes activated via a sequential sequences

clotting factor sequence

platelet plug——> clotting factors

prothrombin—→ thrombin, which actives fibrinogen

fibrinogen——> fibrin

fibrin ——> clot

*only fibrin molecules can form a clot

diagnostic assessment of heme sys

CBC= WBC, h/h, plt

reticulocyte count (retic)= immature RBC (have nucleus)

*high retic seen w truama/hemorrgahes or in elderly the bone marrow has too little cells, need to get stuff out

good if bleeding, bad otherwise bc makes blood thick

older adults heme labs

overall blood volume decreases

decrease plasma proteins

hbg decreases, falls after middle age

RBC decreases

platelets stay same

WBC/lymphcytes are less reactive, don’t increase as much with w infections (lose immune function)

prothrombin PT

measures how long it takes for blood to clot

need control sample from diff adult

clotting factors II, V, VII, X

normal PT

10-14 sec

11–12.5 seconds

International normalized ratio (INR)

clients PT divided by NL PT value to find the stnadard/mean of PT

INR normal range, warfarin therapy

normal= 0.7-1.8 OR 0.8-1.2

warfarin= 2-3 (therapeutic level <2)

INR nursing implications w warfarin

diet impacts INR, warfarin need blood drawn frequently

heparin to warfarin bridge

on heparin drop, started on warfarin and dx heparin when INR level is >2 (therapeutic level)

partial thromboplastin time- PTT

assess intrinsic clotting cascade w factors II, V, VIII, IX, XI, XII

normal= 32-45 sec

abnormal PTT values

pt below therapeutic range= subtheraputic

pt above therapeutic range= supratheraputic

heparin protocols

standing orders of…

pt wt (kg) loading dose/bolus or IV drip (anticoagulant)

sub Q as prophylactic Q8/12 hrs *don’t need to draw PTT levels

adjust levels based on PTT values

PTT is only used in heparin w

IV heparin, not sq

bone marrow aspiration

just marrow suctioned out, assess bone marrow function

bone marrow biopsy

remove solid tissue and cells

bone marrow aspiration/biopsy pt preparation

informed consent (provider)

answer questions and emotional support

position pt sidelying

give sedative/pain meds before

bone marrow aspiration/biopsy procedure

clean skin over site

place pressure at insertion site when needle is removed

bone marrow aspiration/biopsy follow up care

teach to inspect site every 2 hours for 24 hours

avoid activity that could result in trauma

analgesic (ASPIRIN FREE), and ice packs

what can we diagnose with using bone marrow aspiration/bipsy

leukemia, malengiceis to determine cause of anemia

ABO antigens

A= antibody B

B= antibody A

AB= universal recipient, no antibodies

O= universal donor, has antibody A and B

Rh factor

negative= born w out antigen, sensitization via pregnancy will cause future reactions

positive= no antibodies

Rh factor blood donation considerations

Rh negative= cannot receive rh positive (along w negative)

Rh positive= CAN receive rh negative (along w positive)

packed red blood cells are for

replacing lost RBC with trauma/surgery/gi bleed/sickle cell

PRBC bag, documentation

250 mL bag

check compatibility with ABO and RH

platelet transfusions- for, levels, consideration

severe thrombocytopenia or an active bleed when levels are <10k

you do not need ABO compatibility

platelet transfusions administration- bag, tubing, time, intervention

bag from pooled donors therefore no ABO compatibility needed

use platelet filters (smaller filter and shorter tubing)

infuse rapidly over 15-30 mins

take VS 15 mins after and at completion

what kind of tubing should you avoid with platelet transfusions

standard long blood transfusion tubing, platelets can stick

plasma transfusions are for

replacing blood volume and clotting factors

plasma transfusions bag, tubing, time, needs?

200 mL of FFP (frozen right after donation)

use Y set or straight filter tubing

give immediately after unthawing as rapid as pt tolerates (30-60 min)

NEED ABO compatibility

cryoprecipitate transfusion

from plasma but only has some clotting facotors

don’t need ABO

granulocyte (WBC) transfusion is for

severe neutropenia

granulocyte (WBC) transfusion bag, administration, consideration

400 mL of plasma

give slowly (45-60 mins)

take VS every 15 mins because WBC have antigens that can cause severe reactions

monitor closely

determination for blood transfusions- labs

hgb 7 or less

and signs and symptoms

clinical manifestations warranted for blood transfusions (CV, resp, CNS, VS, etc)

cardiovascular= poor circulation, palpitations?

respiratory = dyspnea and wheezing, SOB

CNS= unconscious

vs= tachycardia, hypotension

active bleeding

pretransfusion RN responsibilities to prevent adverse reactions

pr education

verify prescription

test donors and recipients blood for compatibility (type/cross match)

examine blood bag for identification (two people)

check expiration date

inspect blood for discoloration, gas bubbles, cloudiness

verifying prescription on a blood product

type, volume (units), time, consent via provider

elderly blood products consideration

increased risk of circulatory overload

how long do we have to administer blood once it is out of the fridge

4 hours, administer within 30 mins

what can we give a pt pre transfusion if we know they are prone to reactions

dyphenhydramine (Benadryl) and acetaminophen

What are must knows with blood administration?

no medications in same IV line as blood (hemolysis)

can flush with normal saline

max Amt of time to administer is 4 hrs

must administer within 30 mins

what are reactions we should report to the provider with blood administration

moderate chills, mild temp

anaphylactic= sob, hives

TURN OFF BLOOD

pretransfusion steps BEFORE handing blood

verify prescription and order

test donor/recipient compatibility (type/cross match)

baseline VS and review labs

educate pt- report chills/sob/hives/itching

prepare normal saline, blood tubing

pretransfusion steps once in pt room with blood

get two blood from bank

2 RN check at bedside: pt identification, correct blood, compatibility, blood bag identification, expiration date

inspect blood for discoloration, gas, bubbles

start transfusion slowly (next flashcard)

transfusion steps

start transfusion slowly

stay w pt for first 15-30 mins

recheck VS at 15/30 mins after starting, then monitor VS per hospital policy

then you can increase rate to 1 unit in 2 to 4 hours (total max hrs run is 4 hrs)

post transfusion steps

get vital signs

assess s/s of reaction

dispose bag/tubing

document transfusion and pt response

hemolytic reaction time

immediate or 1 unit of blood later

hemolytic reaction occurs with _____

signs of this reaction are ___

rH factor imcompabitibility (antibody/antigen complex)

s/s= fever, chills, anxious/impending doom, hemoglobinuria, h/a, lower back pain, high bp hr

hemolytic reaction treatment

stop transfusion

flush

administer rescue medications

allergic transfusion reactions occurs in pts w ____. How do we prevent this?

other types of allergies

we prevent this by premeditating with Benadryl and using leukocyte reduced or washed RBC

allergic transfusion reactions time? s/s

up to 24 hrs post transfusion or during

itchy, bronchopspamas, anaphylacis

treatment Benadryl

febrile transfusion reactions time? do we we prevent this? s/s

after multiple transfusions typically w anti WBC antibodies

prevent with premedication of Tylenol

s/s= chills, fevers, h/a, tachycardia, low bp and hi RR

circulatory overload transfusion reaction? how can we precent?

infuse over four hours

careful w cardiac/older adult pt

give lasix in between, before or after

mild transfusion reactions

slight temp, itching, chills, sob= call provider, give Tylenol/diphenhydramine

severe reaction treatment

flush w new bad of 0.9% NS and new IV tubing

call RRT and provider

administer rdiphenhydramine, vaspressors, fluid resuscitation, and O2

document, blood samples, save blood and return to lab

emergency cases of blood administration

family contact if pt is unresponsive