Acute hemolytic transfusion reaction is a serious clinical condition associated with adverse complication in an individual following blood transfusion. It is the condition resulting in the accelerated destruction of either the recipient or the transfused RBC. The adverse signs and symptoms visible within 24 hours of the therapy include fever, chills, dizziness, bloody urine, back pain and others. This form of hemolytic reaction occurs when an individual’s immune system destroys the red blood cells given as transfusion. The incompatibility between a person’s blood and blood received as transfusion lead to production of antibodies against the donor blood cells causing hemolytic reaction (Massey, Davenport, & Kaufman, 2013). Hence, signs of severe shortness of breath, red urine and loss of consciousness give the first indication of fatal reaction in patient following transfusion.
Hemolytic reaction may be caused by major incompatibility or minor incompatibility. Major incompatibility is seen when antibodies react with antigen of donor’s RBC and the minor incompatibility is seen when antibodies in donor plasma react with recipient RBCs. In very rare cases, inter-donor compatibility is also seen (Strobel, 2008). The pathophysiological mechanism behind transfusion related acute lung injury includes antibody hypothesis and neurophil priming. According to this, human leukocyte antigen in the transfused component reacts with neutrophils in the recipient and attach to the pulmonary capillaries. This results in release of mediators causing pulmonary capillary leakage. Secondly, circulatory overload occurs in an individual when volume of transfused blood components causes hypervolemia in patient. Bacterial contamination by means of non-sterile environment might also be the cause of hemolytic reactions following transfusion. Cytokines plays a central role behind the pathophysiology of hemolytic transfusion reactions. On the other hand, non hemolytic transfusion reaction is seen when RBC is destroyed before transfusion resulting in hemoglobinuria (Sandler, 2017).
The nursing care plan focused on planning care for Mr. Ha, a 45 year old patient who had been admitted to hospital for a gastroscopy. This was because of his symptoms of black stool and burning epigastric pain. He was scheduled for blood transfusion and received two units of blood transfusion. His vital signs were normal after administration of first transfusion. However, after the second transfusion, he experienced acute transfusion reaction. His transfusion was immediately stopped when he was found to have symptoms of shaking and stiffness. To prepare care plan for such patient experiencing acute transfusion reaction, the APIE approach to nursing care is followed. This involved administration and planning of care through the process of APIA (Assessment, planning, intervention and evaluation). This promotes systematic and organized methods of planning and providing individualized care to patient (Hill, 2015). The following is the care plan for Mr. Ha, a patient with acute transfusion reaction:
Assessment: The first step in nursing assessment is to monitor vital signs of Mr. Ha to check if has any signs of hemolytic reaction persist. This will be done by ABC (Airway, breathing and circulation) assessment to identify symptoms of shortness of breath and circulation problems in patient. To identify airway obstruction in patients, airway of Mr. Ha will be assessed for patency. Secondly, auscultation of lungs would helps to identify normal or abnormal breathing sounds in patient. Wheezing sound may indicate partial airway obstruction whereas coarse crackles may indicate presence of secretions along airways. Breathing assessment like observing for signs of sweating, central cyanosis and accessory muscles use during respiration may give information regarding respiratory distress in patient (Lewis et al., 2015). In addition, pulse rate assessment and assessment of hand and limb temperature of patient will indicate signs of hypovolemia or circulatory state of patient.
Another important priority will be to assess cardiac status of patient. This is because allergic reactions in patient might lead to cardiovascular instability. This can be identified by clinical manifestations of hypotension, tachycardia and loss of consciousness in patient. The next priority will be to assess urinary status of patient. This is because the condition of acute transfusion reaction in patient might lead to red urine. Hemoglobinuria or hematuria in the lower urinary tract will indicate hemolytic reactions. After the blood transfusion reaction, the patient vital signs will be monitored and compared with those at the start of transfusion (DeYoung Sullivan et al., 2015).
Planning:
The comparison of vital signs of patient revealed significant different in values before ad after transfusion. After transfusion his temperature was a little higher, however his pulse rate and blood pressure has increased. Hence, to priorities care of Mr. Ha in such condition, the plan of care for Mr. Ha are as follows:
Intervention:
As there is chance of fluid deficits in patient, oral fluid replacement will be given to patient. In case of signs of severe hypovolemia, hydration status will be maintained by the administration of parenteral fluids in patient (Mannem & Donahoe, 2017). Another possibility for Mr. Ha is he may develop cardiac arrest due to transfusion reaction. In such situation, nurse will have to assess oxygen saturation level, signs of fatigues, reduced activity tolerance and chest pain. The nursing intervention for addressing decreased cardiac output might include recording urine output on an hourly basis. If sigs of chest pain and cardiac output is abnormal, then position changes, oxygen supply and pharmacological intervention will be given to patient. Diuretics, angiotensin-converting enzyme inhibitor and digitalis therapy may provide relied to patient (Delaney et al., 2016).
Another duty of care for nurse will be to closely monitor blood compatibility level of Mr. Ha before initiating transfusion again. To address new symptoms of chills and hypertension in patient, transfusion should be immediately stopped and antipyretic drug should be given. In addition, allergic symptoms of patient such skin itching and rashes can be addressed by giving antihistamines and other drugs. Oxygen and respiratory support will be extremely vital for patient (Delaney et al., 2016).
Evaluation: The above care plan of management of patient’s vital signs and allergic reaction in patient has the potential to reduce major complications in patient post hemolytic reactions. The pharmacological management will help to restore normal health status of patient.
Reference
Delaney, M., Wendel, S., Bercovitz, R. S., Cid, J., Cohn, C., Dunbar, N. M., … & Van De Watering, L. (2016). Transfusion reactions: prevention, diagnosis, and treatment. The Lancet, 388(10061), 2825-2836.
Delaney, M., Wendel, S., Bercovitz, R. S., Cid, J., Cohn, C., Dunbar, N. M., … & Van De Watering, L. (2016). Transfusion reactions: prevention, diagnosis, and treatment. The Lancet, 388(10061), 2825-2836.
DeYoung Sullivan, K., Vu, T., Richardson, G., Castillo, E., & Martinez, F. (2015). Evaluating the frequency of vital sign monitoring during blood transfusion: an evidence-based practice initiative. Clinical journal of oncology nursing, 19(5).
Hill, R. (2015). Assessment, Planning, Implementation and Evaluation (APIE). Essentials of Nursing Practice, 197.
Lewis, S. L., Maltas, J., Dirksen, S. R., & Bucher, L. (2015). Study guide for medical-surgical nursing: Assessment and management of clinical problems. Elsevier Health Sciences.
Mannem, H. C., & Donahoe, M. P. (2017). Transfusion and Acute Respiratory Distress Syndrome: Clinical Epidemiology, Diagnosis, Management, and Outcomes. In Hematologic Abnormalities and Acute Lung Syndromes (pp. 213-228). Springer International Publishing.
Massey, E. J., Davenport, R. D., & Kaufman, R. M. (2013). Haemolytic Transfusion Reactions. Practical Transfusion Medicine, Fourth Edition, 77-88. DOI: 10.1002/9781118520093.ch7
Sandler, G. (2017). Transfusion Reactions. [online] Available at: https://emedicine.medscape.com/article/206885-overview#a5 [Accessed 13 Jun. 2017].
Strobel, E. (2008). Hemolytic transfusion reactions. Transfusion Medicine and Hemotherapy, 35(5), 346-353. doi:10.1159/000154811
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