AnaphylacticReactiontoBloodAdministration

PNCILearner

JillianFerguson

Age:46Weight:70kgLocation:MedicalSurgicalUnit

Background
PatientHistory
PastMedicalHistory:Patienthasahistoryoflargeuterinebroids.
Overthepasttwoyears,shehadincreasingpainthatwasnotrelieved
withmedication,anexcessivelylargemenstrualowandlongstanding
anemiarefractorytostandardtreatment.Despiteearlier
recommendationsfromherhealthcareprovidertoseeksurgical
intervention,sheelectedtowaitduetomultiplepersonalissues
includingherrecentdivorceandhavingtwoteenagechildrenathome.
Duringthistimeofpostponingthesurgery,sherequiredtwooutpatient
bloodtransfusionsduetothesevereanemia.Hersignicant
preoperativelabvaluesincludedahemoglobinof8.4andahematocrit
of32%
Allergies:NoknownallergiesMedications:Overthecounterdaily
vitaminsandironsupplementsCodeStatus:FullcodeSocial/Family
History:Recentlydivorcedwithtwoteenagechildrenathome

HandoReport

Situation:
Thepatientisarecentlydivorced,46yearoldfemaleinherrstday
postoperativefollowingatotalabdominalhysterectomywithbilateral
salpingooophorectomyduetomultiplelargeuterinebroids.Shehasan
increasedrespiratoryrateandlowbloodpressure.
Background:
Uponadmissiononthemorningofhersurgery,thepatient
demonstratedaHRof78,BPof110/70,RRof16andatemperatureof
37C.HerbloodtypeisAnegative.Intraoperatively,herestimated
bloodlosswas450mL.Herpostoperativeperiodhasbeenuneventful
sofar.Thepatientsleptwelllastnightbuthasbeenawakecomplaining
ofdiscomfortforafewhours.
ProgramforNursingCurriculumIntegration(PNCI)1
2012CAEHealthcare,Sarasota,FLv.5

AnaphylacticReactiontoBloodAdministration
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HandoReportContinued
Assessment:
VitalSigns:HR88,BP102/60,RR18,SpO292,Temp37.4CGeneral
Appearance:RestlessCardiovascular:SinusrhythmRespiratory:
Clearinalllobes.Nasalcannulainplacewithoxygenat2LPMGI:
Hypoactivebowelsounds.Abdomensoft.Complainingofincreasing

painaroundincision.Abdominaldressingintactwithsmallamountof
previouslynotedserosanguinousdrainageGU:Urinarycatheterin
place.Urineoutput50mL/hour.Perinealpadinplacewithscant
sanguinousdrainage
Extremities:Noedema.FullrangeofmotiontoextremitiesSkin:
Warm,dryandpaleNeurological:Alertandorientedtoperson,place
andtime.Pupilsequal,round,reactivetolightandaccommodation.No
neurologicaldecitsIVs:IVintherightforearm,patentandnon
reddened.Dextrose5%inLactatedRingerswith20mEqKCl/Liter
infusingat125mL/hourLabs:Drawnthismorning,resultspending
Pain:Hasmorphinepatientcontrolledanalgesia(PCA)thatsheis
using
Recommendations:
Performroutineassessmentandobtainlabresults
ProgramforNursingCurriculumIntegration(PNCI)2
2012CAEHealthcare,Sarasota,FLv.5

AnaphylacticReactiontoBloodAdministration
PNCILearner

Orders
InitialHealthcareProvidersOrders:
AdmittoMedicalSurgicalUnitDiagnosis:Statusposttotalabdominal
hysterectomywithbilateralsalpingooophorectomyFullcodeNPOuntil
passingflatus,thenbeginclearliquiddietandadvanceastoleratedOut
ofbedtochaireveningofsurgeryandthenambulate3timesperday

Vitalsignsevery4hoursNotifyhealthcareproviderforacutechanges
ContinuouspulseoximeterOxygentomaintainSpO2greaterthan92%

IVofD5LRwithKCl20mEqperliterat125mL/hourMorphinePCA:
1mg/mLconcentration;1mgevery15minwith4hourlockoutof16
mgOndansetron4mgIVpushevery8hoursprnnauseaKetorolac30
mgIVpushevery6hoursfor3daysFerroussulfate325mgPOtwicea
daywithmeals,beginwhenoralintakeresumesDocusatesodium100
mgPOdailyMilkofMagnesia30mLPOdailyprnconstipation
IncentivespirometereveryhourwhileawakeSequentialcompression
devices(SCD)onwhileinbedUrinarycathetertobedsidedrainage,
discontinuemorningofpostoperativedayoneIntakeandoutputevery
shiftAMlabs:Hemoglobinandhematocrit,BUNandelectrolytes,
creatinine,glucose
ProgramforNursingCurriculumIntegration(PNCI)3
2012CAEHealthcare,Sarasota,FLv.5

AnaphylacticReactiontoBloodAdministration
PNCILearner

Preparation
LearningObjectives

Differentiatesbetween,discussestheimplicationsforanddescribesthe
differencesinthenursingmanagementforthevarioustypesofblood
andbloodproducts(UNDERSTANDING)

Formulatesanursingplanofcareforapatientreceivingbloodorblood
products(CREATING)

Prioritizestheimplementationandapproachtothenursing
managementofapatientreceivingbloodorbloodproduct
ProgramforNursingCurriculumIntegration(PNCI)4
2012CAEHealthcare,Sarasota,FLv.5

AnaphylacticReactiontoBloodAdministration
PNCILearner

PreparationQuestions

Discussthenursingmanagementofthepostoperativepatientwhohas
undergoneatotalabdominalhysterectomywithbilateralsalpingo
oophorectomy.
monitorvitalsignsandLOC
assesspainandadministeranalgesicsasprescribed
monitorsurgicalsiteandforanyvaginaldrainage
cathetercare
ambulateptassoonaspossible
provideSCDsandanticoagulanttherapytopreventthrombus
formation
encouragedeepbreathingandrepositioning

Identifyprioritynursingcaretopreventpotentialcomplications
followingthistypeofsurgery.
DVTorVTE
infection
atelectasis

Discusstreatmentmodalitiesforpotentialcomplicationsasidentified

above.
topreventDVTorVTE:
o providecompressiondeviceswhenptisnotambulating
o ambulateassoonaspossible
o reposition
preventionofinfection:
o administerprescribedprophylacticantibiotics
o standardprecautions,cleanorsteriletechnique
o providewoundcareasordered
o cathetercare
preventionofatelectasis:
o encouragedeepbreathingandcoughing
o useofincentivespirometer

Discussthestandardofnursingcarewhentransfusinganyblood
product.
Nursingcarewhentransfusingblood:
obtaininformedconsent
mustverifythecorrectptandthecorrectbloodproductand
expirationdate
o mustbeverifiedwith2nurses
takevitalsbeforebeginningtransfusion
administerantihistamine30minutesbeforetransfusion
begintransfusionimmediatelyafterretrievingfrombloodbank,
andmustbeinfusedwithin4hours
musttakevitalssignsfirst15minutesofstartingtransfusionand
staywithpt
continuetomonitorvitalsigns,output,andassessforanysignsof
areaction
ifareactionoccursstopbloodimmediatelyandtreatsignsand
symptoms
contactbloodbankandprovider
documentbloodunitnumberandtimeinfused

Summarizetheassessmentdataneededtodetectanadverseblood

transfusionreaction.
assessmentofvitalsignsfrequentlyiscriticalfordetermining
adversereaction
mostreactionsincludethefollowing:
o fever,chills
o hypotension/hypertension
o tachycardia
o tachypnea,dyspnea
o tightnessinchest,bronchospasm
o pain
o hematuriaorincreased/decreasedurineoutput
o flushing
o urticarial

Describebloodtransfusionreactionsincludingclinicalmanifestations,
treatment,andpotentialshortandlongtermcomplications.
acutehemolyticduetoincompatibleblood
o usuallydevelopsin15mins,
o s/s:chills,fever,lowbackpain,flushing,tachycardia,
dyspnea,tachypnea,hypotension,jaundice,bleeding
o treatbystoppingtransfusion,drawingbloodsamplesfor
testing,providediuretics,andfluidstostabilizeBP
o potentialcomplications:renalfailure,shock,cardiacarrest
febrilenonhemolyticsensitivitytodonorsbloodcells
o sensitivitytoWBCsismostcommon
o mostcommontypeofreaction
o s/s:suddenchills,fever,headache,flushing,anxiety,
vomiting,andmusclepain
o treatbygivingantipyretics
avoidgivingaspirin
mildallergicreactionsensitivitytoforeignplasmaprotein
o typicallyinpeoplewithahistoryofallergies
o s/s:flushing,itching,pruritus,urticarial
o treatbygivingantihistamines,epinephrine,and
corticosteroid

o complicationsmayincludepulmonarysymptoms
anaphylaxissensitivitytodonorantibodies
o severeallergicreaction
o s/s:anxiety,urticarial,dyspnea,wheezing,bronchospasms,
hypotension,shock,possiblecardiacarrest
o treatbygivingepinephrineinjection,antihistamine,and
corticosteroids
startCPRifnecessary
o complicationsincludeshockandcardiacarrest
circulatoryoverloadrapidfluidadministration
o ptwithcardiacandrenaldiseaseatincreasedrisk
o s/s:cough,dyspnea,pulmonarycongestionwithadventitious
lungsounds,hypertension,tachycardia,headache
o treatbyplacingptupright,administerdiureticsand
morphine,oxygen,andobtainchestxray

Describethepathophysiologyofanaphylaxis.
Whenanaphylaxisoccurs,itisbecausethebodycreatesantibodiestoa
pathogenorforeigninvaderofthebody.Theantibodieswillattackthe
invaderandthiscreatesthereactionsseeninanaphylaxis,suchas
inflammation,hives,andshortnessofbreath.

Whatistheprotocolforthetreatmentofanaphylaxis?
1)thepriorityactionwhenanaphylaxisisdeterminedistostopthe
transfusionanddisconnectbloodfrompt
2)maintaintoIVsitepatentandflushwithsaline
3)notifythebloodbankandhealthcareproviderimmediately
4)rechecktheidentificationofptandblood
5)monitorvitalsignsandurineoutput
6)treatsymptomsperorders
7)sendbloodwithtubingtothebloodbank
8)obtainrequiredbloodandurinebasedonhospitalprotocoltobe
tested
9)documentreaction

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JonesandBartlett.ProgramforNursingCurriculumIntegration(PNCI)5
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AnaphylacticReactiontoBloodAdministration
PNCILearner

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Authors
KathyCarver,JohnsonCountyCommunityCollegeOverlandPark,
KS,andThomasJ.Doyle,CAEHealthcareSarasota,FL.Reviewed
byCathyKing,StateCollegeofFloridaSarasota,FL,andChristie
Schrotberger,DianeMathe,LyndeRabine,GwenLeighandDonna
Walls,CAEHealthcareSarasota,FL,2012
ProgramforNursingCurriculumIntegration(PNCI)6
2012CAEHealthcare,Sarasota,FLv.5