Hematological Problems - In Depth Notes

Anatomy and Physiology Review

• Review videos in the Pre-Class Lecture Checklist, which cover important aspects of the hematologic system:

  • Anatomy of the Hematologic System: Focus on the structures involved, including the bone marrow, spleen, and lymphatic tissues, which play critical roles in blood production and immune responses.

  • Blood Components: Characterize the functions of plasma, red blood cells (RBCs), leukocytes (white blood cells), and platelets in maintaining homeostasis and responding to injury.

  • Blood Clotting Mechanisms: Understand the physiological processes that initiate and regulate blood clot formation, including the roles of various clotting factors.

  • Hemostasis: Review mechanisms of control for bleeding, coagulation processes, and thrombosis to grasp how the body maintains vascular integrity during injury.

Hematologic Changes Associated with Aging

• Notable changes in hematologic function include:

  • A decrease in overall blood volume and a reduction in plasma protein levels can impact hemostatic balance in older adults.

  • Reduced efficiency of bone marrow leads to fewer blood cells being produced, increasing the risk for anemia and other blood-related disorders.

  • A documented decrease in both RBC and WBC counts can elevate the risk for infections due to compromised immune function.

  • There is often a reduction in hemoglobin levels noticed after middle age, which requires monitoring in patient care, especially in the geriatric population.

Patient History Assessment Components

• Essential demographics include age, gender, and other relevant personal factors.

  • Women have a lower RBC count than do men. This difference is greater during menstrual yrs because menstrual blood loss may occur faster than blood cell production. This difference is also related to blood dilution caused by fluid retention from female hormones. Always assess for RBC adequacy in women hospitalized for any reason.

• Thorough health history assessments should inquire about:

  • Liver function: The liver is important in producing clotting factors. Ask about symptoms that may indicate liver problems, such as jaundice, anemia, and gallstones.

  • Occupation and hobbies: Identifying possible exposures to harmful substances or lifestyle factors affecting hematologic health.

  • Drug use and nutritional status: including dietary habits that may influence blood health and any substances that may interact with medications.

    • Vitamin K, can be found in leafy green veggie, may increase the rate of blood.

    • ask about alcohol consumption because chronic alcoholism causes nutritional deficiencies and impairs the liver, both of which reduce blood clotting

  • Social support and family medical history: Understanding the environment surrounding the patient and hereditary factors relevant to hematological conditions.

• Identify current health problems related to hematologic status, which may provide insight into underlying conditions or complications.

  • Most common symptom of anemia is fatigue as a result of decreased oxygen delivery to cells

Common Drug Classes Affecting the Hematologic System

• Bone Marrow Suppressants such as Ganciclovir and Zidovudine inhibit bone marrow function, often leading to decreased blood cell production.

• Hemolysis Agents like amoxicillin, penicillin G, benzathine, penicillin V, vitamin K, and Glyburide can trigger destruction of red blood cells, resulting in anemia.

• Platelet Action Disruptors, including Aspirin, ibuprofen, meloxicam (mobic), naproxen (aleve), and Valproic Acid affect platelet aggregation which can increase the risk for bleeding complications.

Clinical Assessment Findings

• Key signs include:

  • Petechiae: Tiny red or purple spots indicating small bleedings – <3 mm in size.

    • visible only on the palms of the hands, the soles of the feet, the oral mucous membranes, and the conjunctiva.

  • Ecchymosis: Larger bruises, typically measuring >10 mm, indicate larger areas of bleeding under the skin.

  • Purpura: Intermediate in size between petechiae and ecchymosis, representing a more significant bleeding issue.

  • A red, beefy tongue can indicate a Vitamin B12 deficiency, emphasizing the need for dietary assessment.

  • Signs of oxygen deprivation should include condition indicators such as cyanosis and shortness of breath, linking these signs to potential hematologic or cardiovascular issues.

• Physical assessment findings

  • skin: for pallor or jaundice, assess nail beds for pallor or cyanosis. Assess body hair patterns, areas with poor circulation, especially the lower legs and toes, may have sparse or absent hair, although this may be a normal finding in older adults.

  • head and neck: the tongue is smooth in pernicious anemia and iron deficiency anemia or smooth and beefy red in (b12 deficiency.

    respiratory: Assess RR and depth while at rest and during physical activity.

  • cardiovascular: pulses become weaker and thready. Observe for distended neck veins, edema, or indications of phlebitis, assess BP

  • kidney and urinary: test urine for protein, inspect urine for blood (hematuria)

  • musculoskeletal:

  • abdominal: a palpable spleen is usually due to enlargement (don’t palpate can rupture easily,y which can lead to hemorrhage and death)

  • CNS:

  • psychosocial

Hematologic Assessment, Normal Ranges, and Key Indicators

• Red Blood Cell Count normals include:

  • Females:

  • Males:

  • A decrease suggests anemia or hemorrhage, while an increase may indicate chronic hypoxia or conditions such as polycythemia vera.

• Hemoglobin (Hgb) levels are typically:

  • Females: 12-16 g/dl

  • Males: 14-18 g/dl

  • Decreased Hgb levels often indicate potential anemia etiology.

• Hematocrit (Hct) normals are as follows:

  • Females: 37%-47%

  • Males: 42%-52%

  • It can be calculated by multiplying Hgb levels by 3,

• WBC: 5000-10000

• reticulocyte count: 0.5 % - 2.0% of RBCs

  • increased levels: possible chronic blood loss or recovery from anemia

  • decreased levels: possible inadequate RBC production

• Iron (Fe)

  • females: 60 - 160 mcg/dl

  • males: 80-180 mcg/dl

    • increased levels: iron excess, liver disorders, hemochromatosis, megaloblastic anemia

    • Decreased levels: possible iron deficiency anemia, hemorrhage.

• platelet count: 150,000–400,000/mm

• hemoglobin electrophoresis: lab tests to help detect sickle cell disease

  • Hgb A1: 95% - 98%

  • HbA2: 2%-3%

  • HbF: 0.8 % - 2%

  • Hgb S: 0%

  • Hgb C: 0%

  • Hgb E: 0%

lab test to determine antibodies against RBCs and circulatory antiglobulin

• INR: 0.8-1.1 times the control value

  • increased value: longer clotting times ( desirable for Warfarin therapy)

  • decreased values: hypercoagulation and increased risk for VTE

• PT: 11-12.5 sec

  • decreased time may indicate vitamin K excess

Bone Marrow Aspiration and Biopsy

• evaluate the pt’s hematologic status, results provide information about bone marrow function, including the production of all blood cells and platelets.

• pre-op

  • provide accurate information and emotional support

  • explain procedure

• follow-up care

  • teach to inspect the site every 2 hrs for 24 hrs, avoid activity that could result in trauma

  • analgesics (aspirin-free) and ice packs.

Sickle Cell Disease: Overview

• An inherited genetic disorder affecting hemoglobin structure.

  • autosomal recessive pattern of inheritance

• It causes red blood cells to sickle, which leads to blocked blood vessels and results in hypoxia in tissues.

  • the clumps block blood flow; tissues become hypoxic

• Characterized by severe pain during vaso-occlusive crises due to disruption in blood flow and subsequent tissue ischemia.

• The prevalence is notably high in African Americans, with statistics showing 1 in 500 individuals affected. Expected life expectancy averages around 42 years for men and 48 years for women, contingent upon management and advancements in healthcare.

• History

  • assess for previous crises, severity, and usual management

    • ask about changes to sleep and rest patterns, ability to climb stairs, any activity that induces SOB

  • physiological/psychosocial

    • vaso-occlusive crisis

    • Pain is the most common symptom of SCD crisis

    • pain due to poor tissue perfusion and joint destruction with low oxygen levels

    • fatigue

    • potential for infection, sepsis, multiple organ dysfunction syndrome (MODS), and death

• Physical assessment/ signs and symptoms

  • cardiovascular

    • high-output HF, murmurs, S3 heart sounds, JVD, reduced perfusion (note pulses)

  • respiratory

    • pulmonary hypertension, recurrent pneumonia,

    • acute chest syndrome is a common reason for hospitalization and is the most common cause of death.

      • life-threatening condition usually associated with respiratory infection and can also be caused by fat embolism and debris from sickled cells

        • S/S are similar to pneumonia with cough, SOB, abnormal breath sounds, and infiltrate on chest x-ray.

  • Priapism

    • prolonged penile erection (can cause pt inability to urinate

  • Eyes

    • visual deficits

  • Abdominal

    • sleen, liver, gallbladder

  • skin changes

    • pallor or cyanosis due to poor gas exchange

    • Jaundice results from RBC destruction and the release of bilirubin

    • ulcers due to poor perfusion

      • usually located on the lower legs (outer sides and inner aspect of the ankle or shin. These can become necrotic or infected.

  • Abdominal changes

    • The liver and spleen may feel firm and enlarged with a nodular or “lumpy” texture in later stages of the disease.

  • Kidney and Urinary Changes

    • Chronic kidney disease (CKD) makes the kidney less effective at filtration and reabsorption

      • The urine contains protein, and the pt may not concentrate urine, which eventually leads to the kidneys failing

  • Musculoskeletal

    • Arms and legs are often sites of blood vessel occlusion

    • joints may be damaged from hypoxic episodes and have necrotic degeneration

    • inspect the arms and legs and record any areas of swelling, temp, or color difference. ask pt to move all joints

    • Dactylitis (swelling of the hands and feet)

  • CNS

    • long-term effect can lead to infarcts with repeated episodes of hypoxia, causing the pt to have seizures or symptoms of a stroke

    • assess for the presence of “pronator drift”, bilateral hand grasp strength, gait, and coordination

Sickle cell disease: Diagnostics

• lab assessment

  • percentage of HbS on electrophoresis (80% to 100%)

  • Hematocrit is usually low during crisis (between 20% and 30%)

  • high reticulocyte count, indicating anemia of long duration

  • WBC high because of the chronic inflammation caused by tissue hypoxia and ischmia

• Imaging assessment

  • X-rays, CT, PET, MRI

    • x-ray: the skull may show changes ( crew cut appearance)

  • ECG indicating cardiac infarcts and tissue damage

  • Echocardiograms may show cardiomyopathy and decreased cardiac output (low ejection fraction)

Sickle Cell Disease: Management Strategies

• managing pain

  • acute pain episode has a sudden onset, usually involving the chest, back, abdomen, and extremities

    • goal: pain controlled to a level acceptable to the pt

  • drug therapy

    • morphine and hydromorphone are given IV on a routine schedule or PCA, and tapered once relief is obtained

    • Moderate pain may be managed with oral doses of opioids or NSAIDs.

    • Hydroxyurea may reduce the number of sickling and pain episodes by stimulating fetal hemoglobin (HbF) production, which is the main type present during fetal life. (This drug increases the risk for leukemia)

      • the drug is a teratgen (agent that can increase cause of birth defects). teach sexully active women of childbearing age to adhere to strict contraceptive measures while taking it and for 1 month after it is discontinued.

  • Hydration, by oral or IV route helps reduce the duration of pain episodes

    • pt are usually dehydrated and there blood is hypertonic, hypotonic fluids are usually infused at 250 mL/hr for 4 hrs. once pt’s blood osmolarity is reduced to a normal range of 270 to 300 mOsm, rate is reduced to 125 ml/hr

  • Integrative therapies

    • keeping the room warm, using distraction and relaxation techniques, positioning with support for painful areas, aromatherapy, therapeutic touch, warm soaks or compresses all help reduce pain perception.

  • prevent sepsis, MODs, and death

    • prevention and early detection

      • Frequent, handwashing is especially important. any person with an upper respiratory tract infection who enters the pt’s room must wear a mask. Strict aseptic technique is used for all invasive procedures

    • hydration (stop clumping of RBCs)

      • the pt in acute crisis needs an oral or IV fluid intake of at least 200 mL/hr

    • oxygen given during crises because lack of O2 is the main cause of sickling

      • Nebulized therapy to prevent dehydration

      • If saturation is low, evaluation of ABGs and chest x-ray may be needed

    • transfusion with RBCs can be helpful to increase HbA levels and dilute HbS levels

• Care of the Pt in sickle cell crisis

  • administer O2

  • adminster prescribed pain meds

  • hydrate pt with normal saline IV and with beverages of choice (without caffeine)

  • remove any constrictive clothing

  • encourage pt to keep extremities extended to promote venous return

  • don’t raise the knee position of the bed

  • elevate the HOB no more than 30 degrees

  • keep room temp at or above 72 F(22.2 C)

  • avoid taking BP with a standard or automatic external arm cuff

  • check circulation in extremities every hour

    • pulse ox of fingers and toes

    • peripheral pulses

    • cap refils

• Prevention of Sickle Cell Crisis

  • drink at least 3 to 4L of liquids every day

  • avoid alcoholic beverages

  • avoid smoking cigarettes or using tobacco or nicotine in any form

  • contact PHP at 1st sign of illness of infection

  • be sure to get a “flu shot” every year

  • ask your PHCP about receiving the pneumonia vaccine

  • avoid hot or cold temps extremes

  • be sure to wear socks and gloves when going outside on cold days

  • avoid airplanes with unpressurized passenger cabins

  • avoid travel to areas at high altitudes (denver, flagstaff, santa fe, lake louise)

  • be sure all your health care providers know that you have sickle cell disease, especially the anesthesia provider and radiologist.

  • consider genetic counseling before becoming sexually active

  • avoid strenous physical exercise

  • when not in crisis, perform mild, low-impact exercise 3 times a wk.

Sickle Cell Disease: Evaluation/Outcomes

• report pain to be maintained at an acceptable level

• maintain perfusion and gas exchange to extremities and vital organs

• remain free of infection, sepsis, and multiple organ dysfunction syndrome (MODs)

• pregnancy in women with SCD may be life-threatening. barrier methods of contraception ( cervial cap, diaphragm, or condoms with or without spermicides) are often recommended for women with SCD.

  • the use of progestin-only hormonal contraception is recommended to reduce the risk for VTEs.

Anemia: Overview

• anemia is a reduction in the number of RBCs, the amount of H&H

  • for men Hgb less than 13.5g/dl)

  • for women with levels less than 12.0g/dl)

    • blood loss

    • insufficient RBC production

    • excess destruction of RBCs

    • deficiency of necessary components (iron, folic acid, vitamin B12, erythropoietin)

• clinical indicator (not specific disease); occurs with many health problems

  • Sickle cell anemia

    • autosomal-recessive inheritance of 2 defective gene alleles for hemoglobin synthesis

  • glucose-6-phosphate dehydration (G6PD) deficiency

    • x-linked recessive deficiency of the enzyme G6PD

  • autoimmune hemolytic anemia

    • abnormal immune function in which a person’s immune reactive cells fail to recognize his or her own RBCs as self-cells

  • Vitamin B12 deficiency anemia

    • dietary deficiency

    • Failure to absorb vitamin B12 from the intestinal tract as a result of

      • partial gastroectomy

      • pernicious anemia

      • malabsorption syndromes

  • Folic Acid Deficiney anemia

    • dietary deficiency

    • malabsorbtion syndrome

    • drugs:

      • oral contraceptives

      • anticonvulsants

      • methotrexate

  • aplastic anemia

    • exposure to myelotoxic agents

      • radiation

      • benzene

      • chloramphenicol

      • alkylatine agents

      • antimetabolites

      • sulfonamides

      • insecticides

    • viral infection

      • Epstein-Barr virus

      • hep B

      • cytomegalovirus

Anemia: Physical Assessment/ Signs and Symptoms

• Skin S/S

  • general pallor (more noticeable on the ears, nailbeds, palm creases, and around the mouth)

  • cool to the touch

  • pt doesn’t tolerate cooler temps

  • when chronic, nails become brittle and concave

• Cardiovascular S/S

  • continuous rapid heartbeat that increases after meals and with activity

  • With severe anemia, abnormal heart sounds (murmurs and gallops) may be heard

  • orthostatic hypotension

• Respiratory S/S

  • breathless in exertion

  • decreased oxygen sat levels

• Neurologic S/S

  • fatigue

  • increased need for sleep

  • reduced energy levels

• Vitamin B12 deficiency anemia specific S/S

  • pallor and jaundice

  • glossitis: a smooth, beefy-red tongue

  • older pt often have poor diets or chewing difficulties which puts them at risk for anemias. B12 deficiency anemia often occurs in pt 50 to 80 yrs of age

  • fatigue and weight loss

  • paresthesias (abnormal nerve sensations) in the feet and hands and poor balance,e because Vitamin B12 helps maintain nerve function

Anemia: Interventions

• iron deficiency anemia

  • Increase oral intake of iron

    • ex: red meat, egg yolks, organ meats, kidney beans, leafy green vegetables, raisins

  • iron supplements (ferrous Sulfate)

• vitamin B12 definciney anemia (pernicioud anemia)

  • increase intake of foods rich B12

    • Ex: animal proteins, fish, eggs, nuts, dairy products, dried beans, citrus fruits, and leafy green veggie

  • injections, oral preparations, nasal spray, sublingual cobalamin

• folic acid deficiency anemia

  • Prevent deficiency with a diet rich in folic acid and vitamin B12

• aplastic anemia

  • dependent upon the cause

  • blood transfusions

  • immunosuppressive therapy

• G6PD Anemia

  • test those at high risk

  • hydration

  • osmotic diurectics

  • transfusions

• Autoimmune hemolytic anemia

  • Immunotheraphy

  • splenectomy

  • immunosuppressive therapy with chemotherapy

Polycythemia Vera

• PV is one of the chronic myeloproliferative neoplasms (MPNs) in which there is loss of cellular regulation with excessive expansion of specific groups of abnormal myeloid cells with decreased function

• cancer of the RBCs

  • massive production of RBCs

  • excessive leukocyte production

  • excessive platelet production

Polycythemia Vera: Assessment Findings

• facial skin and mucous membranes are dark purple or cyanotic, flushed (plethoric) appearance with distended veins

• intense itching

• vascular status causes thrombosis (clot formation) within the smaller vessels, occluding them, which interferes with perfusion and leads to tissue hypoxia, anoxia, later infarction and necrosis

• poor gas exchange with severe hypoxia

• bleeding problems are common because of platelet impairment with poor clotting

PV: interventions

• fatal if untreated

• Apheresis: is the withdrawal of whole blood and removal of some of the pt’s blood components, in this case RBCs. The plasma is then reinfused back into the pt

• increase hydration

• promote venous return help prevent clot formation

• drug therapy

  • anticoagulants

  • aspirin

  • hydroxyurea

• Self-management of PV

  • drink at least 3L of liquids each day

  • avoid tight or constrictive clothing, especially garters and girdles

  • wear gloves when outdoors in temp lower than 50 F (10 C)

  • keep all health care-related appointments

  • contact your PHCP at the 1st sign of infection

  • take anticoagulants as prescribed

  • wear support hose or stockings while you are awake and up

  • elevate your feet whenever you are seated

  • exercise slowly and only on the advice of provider

  • stop activity at 1st sign of chest pain

  • use electric shaver

  • use soft-bristle toothbrush to brush your teeth

  • don’t floss between your teeth

  • smoking cessation

Leukemia and Preleukemia

• pathophysiology Overview

  • blood cancer that results from a loss of normal cellular regulation, leading to uncontrolled production of immature WBCs (“blast” cells) in the bone marrow

    • This overproduction prevents the growth of RBCs, platelets and normal WBC

  • Acute: acute myelogenous leukemia (AML) and acute Lymphocytic leukemia (ALL)

    • immature, nonfunctioning WBCs, abrupt and common in kids

  • Chronic: chronic myelogenous leukemia (CML) and chronic Lymphocytic leukemia (CLL)

    • mature cells with reduced function, slow onset of years, are common in older adults

  • Common Medical Terms to Know

    • Thrombocytopenia: reduced circulating platelet numbers

    • Leukopenia: reduced circulating WBC numbers

Leukemia

• Etiology and Genetic Risk

  • genetic and environmental factors

  • damage to genes that control cell growth

  • risk factors

    • ionizing radiation

    • viral infection

    • exposure to chemicals and drugs

• History

  • ask about risk and genetic factors

  • occupation, hobbies, medical history, exposure

  • history of infections, bleeding or bruising, weakness, fatigue

    • colds, influenza, pneumonia, bronchitis, or unexplained fevers, during the past 6 months

  • note S/S of excessive bleeding

  • Note S/S specific to weakness and fatigue from anemia

Leukemia Assessment Findings

• Integumentary

  • ecchymoses

  • petechiae

  • open infected lesions

  • pallor of the conjunctivae, the nail beds, the palmar creases, and around the mouth

• GI

  • anorexia

  • bleeding gums

  • weight loss

  • enlarged liver and spleen

• Renal

  • hematuria

• Musculoskeletal

  • bone pain

  • joint swelling and pain

• Cardiopulmonary

  • tachycardia at basal activity levels

  • orthostatic hypotension

  • palpitations

  • Dyspnea on exertion

• Neurologic

  • fatigue

  • headache

  • fever

• psychosocial assessment

  • anxiety, fear, lifestyle changes, off work for treatment

• Laboratory assessment

  • low H&H

    • normal Hgb: women 12-16/Men 13-18

    • normal Hct: women 36-48/men 39-54

  • Low platelets

    • normal: 150,000-400,000

  • abnormal WBC count (usually elevated)

    • normal: 5000-10000

  • bone marrow aspiration and biopsy is the definitive test

  • blood clotting times and factors are usually abnormal, and whole-blood clotting time is prolonged, as is aPTT

  • chromosome analysis

  • Imaging assessment

    • chest x-ray

    • skeletal x-ray

Leukemia: interventions

• prevention infection

  • goal is to halt infection and control new infection early

    • drug therapy

    • handwashing

    • strict aseptic technique-cather care

    • hematopoietic stem cell transplantation (HSCT)

  • minimizing injury

  • conserving energy

  • central venous catheters and infusions

    • required for home infusion therapy

      • keep the catheter open, flush it quickly with saline once a day, and after completing the infusion

      • change the Luer-Lok cap on each catheter lumen weekly

      • clean the existing site with alcohol and povidone-iodine or with chlorhexidine

Malignant Lymphomas

• Lymphomas are cancers of the lymphoid cells and tissue, with abnormal overgrowth of lymphocytes

• Two major adult forms of lymphoma:

  • Hodgkin’s lymphoma

    • specific cell type: Reed-Sternberg cell

  • Non-Hodgkin’s lymphoma

    • all lymphoid cancers that don’t have the Reed-Sternberg cell

• Physical assessment S/S

  • large, painless lymph nodes

  • fevers, drenching night sweats, unplanned weight loss

  • some have no symptoms at time of diagnosis

• Interventions

  • external radiation of lymph node regions

  • for more extensive disease, radiation and combination chemotherapy is used

  • CAR-T therapy

  • 

Multiple Myeloma

• WBC cancer of mature B-lymphocytes

• S/S: fatigue, easy bruising, bone pain

• treatment involves watchful waiting: proteasome inhibitors, immunodulating drugs, HSCT

Thrombocytopenic Purpura

• destructive reduction of circulating platelets after normal platelet production; impaired clotting occurs

  • there are many types (ITP, TTP)

  • heparin-induced thrombocytopenia (HIT)- most common

    • Unexplained drop in platelet count after heparin treatment

• ecchymosis, purpura, anemia may be present

• treatment involves platelet transfusions, anticoagulants, splenectomy

Blood Transfusion Protocols

• Adhere to critical procedures to ensure patient safety:

• Before Infusion

  • assess lab values to ensure agency guidelines for blood transfusions are followed

  • verify the PHCP’s prescription for the type of product, dose, and duration of transfusion because the therapy legally requires a prescription

  • assess pt’s VS, urine output, skin color, and history of transfusion reactions to establish a baseline for identifying possible reactions during and after the procedure

  • establish or use venous access with a 19-gauge needle or catheter to prevent catheter occlusion or damage to RBC

  • transfuse blood products (after all safety checks) soon after receiving them from the blood bank to suppress bacterial growth and prevent product deterioration

  • with another RN, verify the pt by name and number, check blood compatibility, and note expiration time because human error is the most common cause of incompatibility reaction.

• During infusion

  • administer the blood product using the appropriate filtered tubing to remove aggregates and possible contaminants

  • unless directed otherwise, infuse blood products only with IV normal saline solutions because some other IV solutions can cause hemolysis

  • stay with the pt for the 1st 15 to 30 minutes of the infusion because this is the time when hemolytic transfusion reactions occur

  • infuse the blood product at the prescribed rate for the transfusion type to avoid the possible complication of fluid overload

  • monitor vital signs at least as often as the agent policy and the pt’s condition indicates to identify early indications of adverse transfusion reactions

• After infusion

  • when the transfusion is completed, discontinue the infusion and dispose of the bag and tubing according to agency and blood-bank policies to prevent the spread of bloodborne pathogens

  • document all aspects of the transfusion (type of product, product number, volume infused, duration of infusion, VS, and any adverse reactions) identify pt response to the transfusion as part of the permanent record

  • never add to or infuse other drugs with blood products because they may clot the blood during transfusion

Transfusion therapy

• pretransfusion responsibilities

  • review ageny policy

  • test donor’s/recipient’s blood for compatibility

  • examine blood bag label, attached tag, and requisitions slip for ABO and Rh comtabilibility with the client

  • inspect blood for discoloration, gas bubbles, cloudiness

  • 

transfusion responsibilities

• Administer the blood product using the appropriate filtered

  tubing to remove aggregates and possible contaminates

• Infuse blood products only with IV normal saline solutions

  because some other IV solutions can cause hemolysis

• Stay with the patient for the first 15 to 30 minutes of the

  infusion because this is the time severe reactions occur

• Infuse the blood product at the prescribed rate for the

  transfusion type to avoid the possible complication of fluid

  overload

• Monitor vital signs at least as often as agency policy and the

  patient’s condition indicates to identify early indications of

  adverse transfusion reactions

transfusions

• PRBC transfusions

  • replaces cells lost from trauma or surgery

• Platelet Transfusions

  • given for low platelet counts, active bleeding, scheduled for invasive procedure

• Plasma transfusion

  • replaces blood vol and clothing factors

• Granulocyte (WBC) transfusions

  • given (rarely) to neutropenic clients

• Massive transfusion protocol

  • given when H&H levels are low

Acute Transfusion Reactions

• Febrile

• hemolytic

• allergic

• bacterial

• circulatory overload

• transfusion-associated graft-versus-host disease (TA-GVHD)

  • occurs more often in immunosuppressed pt

• Interventions for reactions

  • begin with stopping the transfusion and removing the blood tubing (for hemolytic and suspected bacterial reactions, return the components of bag, labels, and all tubing to the blood bank or lab

  • initiate RRT

  • if the pt has no other IV access, keep the access and flush with normal saline. Don’t flush the contents of the blood transfusion tubing, which would allow more of the reaction-causing blood to enter the pt

  • if shock is present, fluid resuscitation and hemodynamic monitoring are needed

  • blood pressure support with vasopressors may be needed

  • drug therapy like antipyretics for fever, antibiotics, and meperidine for rigors

autologous blood transfusions

• collection and infusion of pt’s own blood

• eliminates compatibility problems

• reduces risk for transmitting bloodborne disease