Lab Activity #4 Blood Transfusions Consent Cardiovascular Tests Overview In this learning activity you will learn the

skills and knowledge needed to interpret and explain cardiovascular diagnostic tests, care of vascular devices, the initiation and safe infusion of blood products, reasons for initiation of parenteral nutrition, reasons for Trendelenberg position, in addition to performing a nutritional assessment for obese clients. Ends-In-View y y y Demonstrate assessment, teaching and monitoring in relation to tests commonly conducted for diagnosing and treatment of cardiovascular disorders Implement the nursing process in relation to the use of blood products Explore the meaning of consent for blood transfusions

In Preparation for Lab 1. Read about and be prepared to discuss the following tests commonly used for the diagnosis and monitoring cardiovascular disorders (focus on assessment and monitoring of the client and areas for client teaching): a) Blood Studies Lipid profile y Cholesterol blood lipid that is a risk factor for atherosclerotic heart disease if elevated Normal: <5.2 mmol/L (varies with age and sex) y Triglycerides mixtures of fatty acids which can be a risk for cardiovascular disease if high Normal: 0.45-1.69 mmol/L male: 0.45-1.81 female: 0.40-1.52 y Lipoproteins HDL, LDL, VLDL (day-to-day fluctuations) LDL: <3.37 mmol/L HDL: >0.75 (men) >0.91 (female) b) Troponin I - contractile protein that is released following an MI Troponin I: <0.03 mcg/L c) Serum electrolytes (potassium, Chloride, sodium) y Potassium low levels are associated with high blood pressure and heart failure Normal: 3.5-5.0 mmol/L y Chloride low levels are associated with CHF Normal: 98-106 mmol/L y Sodium high levels of sodium can lead to high blood pressure Normal: 135-145 mmol/L

d) ECG - electrodes that are placed on the chest and extremities to record cardiac electrical activity from different views (rhythm, conduction abnormalities, position of heart, size, presence of injury, and history of myocardial infarction) e) Chest x-ray - client is placed in two upright positions to examine lung fields and size of the heart (pregnancy, last X-ray, lead shielding, and jewelry removal) f) Holter monitor - ECG rhythm is recorded for 24-48 hr in correlation with symptoms recorded in diary with electrodes placed on chest (prepare skin for electrodes placement, skin irritation, no bathing) g) Exercise tolerance test - protocol use to evaluate the effect of exercise on myocardial function such as 3 minutes stages at set speeds and elevation of treadmill belt with the monitoring of vital signs and ECG rhythms h) Echocardiogram - transducer that emits and receives ultrasound waves is placed on four locations on the chest above the heart (transforms to audio and graphical data) i) Electrocardiography - noninvasive ultrasound procedure that uses sound waves to assist in diagnosing cardiovascular disorders j) Telemetry - observation of the clients heart rate and rhythm used to rapidly diagnose dysrhythmias, ischemia, or infarction 2. Read from Lewis, S.L., Heitkemper, M.M., Dirksen, S., OBrien, P.G., & Bucher, L. (2010). Medical surgical nursing in Canada: Assessment and management of clinical problems. (2nd ed.). St. Louis: Mosby Elsevier Canada. Chapter 33 Chapter 32 Dx studies of the Cardiovascular System p. 811-820. Blood Component Therapy p. 789-794

3. Perry, A. & Potter, P. (2006) Clinical nursing skills and techniques. (6th ed.). Toronto, ON: Mosby. Chapter 28 Blood Therapy p. 965-982

4. Explain autologous transfusion. Autologous transfusion or autotransfusion is when the donor is the patient. This type of transfusion is advantageous since it has an increased patient safety with the elimination of incompatibility reactions. Autologous donations can occur preoperatively, perioperatively, and postoperatively. 5. Complete the following chart.

RBC

Indications Anemia, acute blood loss, autotransfusion, stockpiling for donors

FFP

Bleeding caused by deficiency in clotting factors

Platelets

Albumin

Rich in clotting factors, but contains no platelets. Ability to transmit HIV/HBV. Bleeding caused Multiple units of paltelets yRisk of by can be obtained by one infectious thrombocytopenia donor and can be kept for disease (HIV) 1-5 days. yIncompatibility ABO and Rh group Hypovolemic Hyperosmolar solutions Not able to shock, are heated and do not transmit hypoalbuminemia transmit viruses. HIV/HBV

Special Precautions Using RBCs for treatment allows the use of remaining components and less dangerous for fluid overload. Leukocyte depletion may be used to reduce hemolytic febrile reactions. Use of plasma to treat hypovolemic shock is being replaced.

Hazards Increase of hemoglobin level by 10 g/L or Hct by 30% Ability to transmit HIV/HBV.

Rate of Infusion y250-350mL within 4 hr

y200-250mL within 4 hr yinfuse within 24hr of thawing Single donor = 200-500ml (<4 hr) Multiple = 4070ml/unit (<6 hr of pooling) 5% = 250-500ml 1-10ml/min 25% = 50-100ml 0.2-0.4 ml/min

a) What is the protocol for your clinical agency for the transfusion of red blood cells? * See Sudbury Hospital For policy and procedure for administration of blood or blood products* b) Can you add medication to blood? Medications cannot be added to blood or blood products as it poses a risk for contaminating the blood product with pathogens and the possibility of incompatibility. A separate IV access must be maintained.

c) What IV solutions can be used to prime the blood tubing? The IV solution that can be used to prime blood are normal saline since it is compatible with blood products, unless contraindicated in patients with sodium restriction where it is necessary to connect the blood component to prime the common tubing. Solutions that contain dextrose cause coagulation of door blood. d) List the complications of a blood transfusion. y Acute or delayed hemolytic transfusion reaction (ABO, Rh incompatibility) y Febrile, nonhemolytic (sensitivity of leukocytes) y Allergic Reaction (allergy to plasma protein) y Graft-Versus-Host Disease (donor lymphocytes are destroyed by recipients immune system) y Circulatory Overload (transfusion of excessive volume or rapid rate) y Iron Overload y Infectious Disease (contaminants of infused products) e) How does Ferrous gluconate, ferrous sulphate, Eprex, & Lasix relate to clood administration? In most institutions, these medications are being withheld during blood administration to prevent fluid overload and overdose. 6. Complete the following Case Study BEFORE LAB Rose Marier is a 65 year old, who has had a total knee replacement. Her hemoglobin has dropped from 140 pre-op to 79 post-op. The physician has ordered 2 units of packed red blood cells to be given. Lasix 40 mg. IV is ordered in between the units. Her temperature was 36.5oC pre transfusion and has risen to 37.9 oC one hour into the transfusion. 1. What are the dangers of low hemoglobin? The dangers of low hemoglobin are anemia, hemorrhage, and states of hemodilution, such as those that occur when the fluid volume is excessive (fluid overload). 2. How fast would you infuse each unit overall? Initial flow during the first 15 minutes of a transfusion is 2 mL/min, or 20 gtt/min. In older adults, regulate flow rate at 1 mL/kg/hr to decrease risk of circulatory overload. 3. Would you stop the transfusion when her temperature rises? Yes, you would stop the transfusion when her temperature rises as a fever is a sign of a transfusion reaction. Once the transfusion is stopped, start normal saline with new primed tubing directly to the VAD to keep vein open (KVO) rate and notify the health care provider immediately. 4. Why is Lasix used in between the units? Lasix, a diuretic, is used in between the units to reduce intravascular volume and decrease vascular tone to prevent circulatory overload. 5. When you are preparing the Lasix, what IV solution would you mix it with? Lasix can be mixed with sodium chloride 0.9%, Ringers lactate, or dextrose 5%.

6. What lab work do you need to look at before you infuse the Lasix? The lab work that you would need to look at before you infuse Lasix is the plasma levels as this liquid part of the blood contain sodium, and potassium which can be greatly affected by the use of diuretics. 7. What lab work should be monitored after the transfusion? The lab work that should be monitored in the RBCs to verify that the patient hemoglobin levels have risen. In Lab 1. Discuss indications for blood transfusions, and how to obtain consent for blood transfusions. Describe possible blood products and reasons for transfusion. Describe blood transfusion reactions. Demonstrate the initiation and monitoring of blood transfusions. 2. There will be a review of the Infusion of Blood Products study guide and a demonstration of the equipment used for the administration of blood products. In Practice Lab 1. Review the tubings used for blood administration. Regulate the flow of the saline and simulated blood as if it were being administered to a client. 2. Simulate an adverse reaction to blood administration on a Sim Man. What do you do? Why did this happen? How could this have been prevented?