Immunologic Disorders

CHAPTER 11 Immunologic Disorders


Section One Transfusion Reactions




Overview/Pathophysiology


Transfusion reactions can occur when mismatched blood or blood products (whole blood, fresh or frozen RBCs, washed RBCs, leukocyte-reduced RBCs, platelets, fresh frozen plasma) are administered. Reactions to blood are most commonly the result of human error; therefore, extreme caution is essential with administration of such products. The most common types of transfusion reactions are immunologic and nonimmunologic.



Immunologic reactions



Acute hemolytic reaction


An acute hemolytic reaction to blood is an immune-mediated reaction most commonly caused by ABO incompatibility. The reaction occurs immediately after the infusion of incompatible blood and may be mild or life-threatening. There are four ABO blood types, two of which have RBC antigens and two of which do not (BOX 11-1). When a person receives donated blood that does not have a matching antigen, the immune system produces antibodies against the donor erythrocytes and destroys these blood cells by hemolysis. For example, if a person with type A blood receives type B blood, anti-B antibodies will be produced against the type B blood. In severe acute hemolytic reactions, hemoglobin (Hgb) is released when donor erythrocytes are destroyed (hemolyzed), thus leading to renal failure, disseminated intravascular coagulation (DIC), cardiovascular collapse, shock, and death.



BOX 11-1 ABO BLOOD GROUPS

























BLOOD TYPE RED CELL ANTIGEN ANTIBODIES AGAINST
A A B
B B A
AB AB None
O None AB


Delayed hemolytic reaction


Delayed hemolytic reactions are often mild and may go unnoticed, or they may cause discomfort for the patient. This reaction occurs when the recipient produces antibodies against donor erythrocytes and thus shortens the life of the RBC.



Febrile reaction


A febrile reaction exists when the recipient develops an unexplained fever and chills while receiving or within several hours of receiving a transfusion. Febrile reactions can occur when antibodies in the recipient’s blood following a previous transfusion or pregnancy react to leukocytes (WBCs) in the donor blood or from cytokine accumulation that occurs when blood is stored. Febrile reactions cause discomfort to the patient but rarely lead to hypotension or other serious problems because erythrocyte hemolysis does not occur.



Allergic reaction


Allergic reactions to blood can be mild or severe (anaphylaxis). Mild reactions are uncomfortable but not life-threatening. Anaphylactic reactions to blood are rare but life-threatening. They most often occur in persons with hereditary immunoglobulin A (IgA) deficiency. Anaphylaxis is a medical emergency. Without intervention, shock and cardiorespiratory collapse are likely. (See “Type I Hypersensitivity Reaction [Anaphylaxis],” pp. 640.)



Graft-versus-host disease (GHD)


Posttransfusion GHD occurs when donor lymphocytes proliferate and reject recipient host cells. The reaction occurs days to weeks following transfusion and damages tissues and organs.



Nonimmunologic reactions



Infectious diseases


Blood, an excellent medium for bacterial growth, may cause disease in recipients especially if blood was contaminated during collection or storage. Platelets, in particular, can harbor bacteria because they must be stored at room temperature. Blood can also transmit diseases from donor to recipient such as human immunodeficiency virus (HIV) infection, hepatitis B and C, malaria, and toxoplasmosis, to name a few. Careful screening of donors and extensive blood testing are the best preventive measures for these transfusion complications.



Circulatory overload


Can occur when blood is infused too rapidly or when fluid is drawn into the intravascular space from osmotic pull.



Other types of transfusion reactions


Possibilities include noncardiac pulmonary edema, hypothermia, iron toxicity, or K+ imbalance.



Assessment



Signs and symptoms/physical findings



Acute hemolytic reaction


Chills, fever, pain (along the IV line, back, chest), hypotension, dark urine, uncontrolled bleeding from DIC.



Delayed hemolytic reaction (may occur days to years after transfusion)


Fever, jaundice, decreased hematocrit (Hct).



Allergic reaction


Rash, hives, anxiety, cyanosis, pallor, hypotension, cough, dyspnea, wheezing, respiratory arrest.



Infection


Fever, chills, hypotension, vomiting, diarrhea, generally occurring within a few hours of transfusion.



Circulatory overload


Tachycardia, hypertension, dyspnea, crackles and/or wheezing, distended neck veins.



History and risk factors


Previous transfusions, pregnancies, and reactions to transfusions. Before infusing blood or blood products, a thorough history should be obtained from the patient about each of these risk factors.



Diagnostic Tests



Blood type and Rhesus (Rh) factor


Identify recipient’s blood type based on the proteins on the surface of blood cells and the presence or absence of Rh factor.



Crossmatching


Tests donor and recipient blood for compatibility.



Antibody screen


Determines the presence of antibodies to prevent recipient’s antibodies from attacking and destroying transfused donor erythrocytes.



CBC


Decreased Hgb and Hct (acute and delayed hemolytic reactions).



Blood cultures


Identify causative pathogen (febrile reactions).



Oximetry


Assesses oxygenation.



Urinalysis


Determines adequacy of urine output, detects the presence of myoglobinuria, and detects presence of hematuria.



Collaborative Management


The focus of collaborative management is on prevention of transfusion reactions, as well as on early identification and treatment of specific reaction.



Prevention


Involves identifying patients at risk, confirming compatibility between donor and recipient blood products, and accurate identification of patient receiving the transfusion.



O2 therapy


Relieves hypoxia and maintains oxygenation; usually given by nasal cannula at 2-4 L/min to maintain O2 saturation greater than 92%.



IV infusion of normal saline


Keeps vein open for emergency drug and fluid administration.



Pharmacotherapy



Acetaminophen


Controls fever.



Corticosteroids (methylprednisolone)


Reduce inflammation.



Diphenhydramine


Antihistamine that prevents mast cell breakdown.



Diuretics


Reduce intravascular fluid volume from circulatory overload and help preserve renal output by increasing renal blood flow.



Epinephrine


Relieves bronchoconstriction.



Morphine


Controls pain.



Calcium chloride or calcium gluconate


Treats symptomatic hypocalcemia.



Nursing Diagnoses and Interventions



Risk for or actual ineffective protection


related to adverse reactions from blood products secondary to blood product incompatibility or contamination



Desired outcomes


Patient remains free of transfusion reaction. If reaction occurs, patient maintains patent airway and demonstrates absence of wheezing or dyspnea, and VS remain within normal limits for patient.



Nursing Interventions



Before Infusion of Blood Product


♦ Ensure that informed consent has been obtained for infusion in accordance with facility policy.

♦ Obtain history of previous transfusion reactions from patient to determine whether patient is at risk for another reaction.

♦ Assess patient’s VS and lung sounds to establish a baseline for later comparison.

♦ Access vein with a large-bore catheter (18 or 19 gauge) and initiate infusion with normal saline to prevent damage to RBCs. Normal saline is the only fluid that should be administered with blood products.

♦ Explain the procedure and reason for the infusion to the patient, to prevent anxiety.

♦ Follow facility protocols for obtaining blood from the blood bank and administer within 20-30 min to minimize the risk for bacterial growth and subsequent infection.

♦ Premedicate with diphenhydramine or acetaminophen at least a half hour before infusion as prescribed to foster comfort and minimize risk for allergic reaction.

♦ Inspect the blood product bag for leaks and verify expiration date. Inspect blood for clots or bubbles. These indicate possible contamination or outdated product and should not be infused.

♦ Use only IV administration set with filter specifically designed for infusion of blood or blood products, to prevent fibrin clots or other matter from infusing into the patient.

♦ With another registered nurse (RN), verify the physician’s order for the infusion, the patient’s identity, and carefully check the blood product label against the patient’s wristband, to prevent transfusion reaction as a result of blood product incompatibility.


During Infusion of Blood Product


♦ Implement standard precautions.

♦ Infuse product slowly over first 15 min, and monitor patient to detect early signs of reaction.

♦ Infuse according to type of product and patient’s tolerance or according to health care provider’s order. Platelets may be infused rapidly, but products such as packed RBCs must be infused more slowly.

♦ Assess VS and lung sounds every 15 min for the first hour following initiation of the infusion and every hour thereafter until the infusion is completed, to detect changes that may indicate a reaction.

♦ Monitor for signs of hemolytic or allergic reaction (see signs and symptoms, p. 637).
• Stop the transfusion.

• Change IV tubing and keep the IV line open with normal saline solution (0.9% sodium chloride [NaCl]).

• Notify health care provider.

• Remain with patient, and monitor VS and lung sounds.

• Prepare to administer emergency drugs such as epinephrine, antihistamines, or corticosteroids.

• Obtain a urine sample to send to the laboratory.

• Return blood tubing, unit of blood or blood product bag, and all identifying documents to the laboratory.

♦ Monitor for signs of circulatory overload (see signs and symptoms, p. 637).
• Slow the infusion.

• Place patient in an upright position and administer O2.

• Notify health care provider.

• Stay with patient and prepare to give prescribed medications (diuretics, analgesics).


After Infusion of Blood Product


♦ Instruct patient to report chills, abdominal pain, nausea, vomiting, diarrhea, difficulty breathing, and other signs that indicate a reaction, to facilitate early treatment.

♦ Monitor for signs of infectious process (fever, chills, nausea, vomiting).
• Notify health care provider.

• Collect blood sample for culture.

• Return blood bag and tubing to laboratory for culture.

• Initiate O2 and prepare to give medications as prescribed (acetaminophen, antibiotics, corticosteroids).

♦ Return blood bag and tubing to laboratory or discard (if no reaction) in accordance with facility policy.

♦ Document the procedure, assessment findings, and reactions according to facility policy.


Acute pain

related to tissue inflammation secondary to infection



Desired outcomes


Within 1 hr of intervention, patient’s subjective perception of discomfort decreases, as documented by pain scale. Objective indicators, such as grimacing, are absent or diminished.



Nursing Interventions



♦ Devise a pain scale with patient, rating pain from 0 (absent) to 10 (worst pain).

♦ Follow protocol for transfusion reaction, to minimize reaction and reduce accompanying pain.

♦ Administer prescribed analgesic as needed and document effectiveness using the pain scale. Encourage patient to request medication before discomfort becomes severe. Pain is more easily controlled when treated before it becomes severe.

♦ Reposition for comfort to reduce pain.

♦ Use nonpharmacologic interventions when possible (e.g., relaxation techniques, guided imagery, distraction). Distraction may reduce patient’s perception of pain.


Deficient knowledge

related to risk factors for transfusion reactions and signs/symptoms of delayed reactions



Desired outcomes


Patient verbalizes knowledge of transfusion reaction risk factors and signs and symptoms that should be reported if they occur.



Nursing Interventions



♦ Assess patient’s facility with language; engage an interpreter or provide language-appropriate written materials if indicated.

♦ Teach the need for reporting signs and symptoms that indicate delayed hemolytic reaction (fever, jaundice, fatigue from decreased Hct), to ensure appropriate intervention.

♦ Teach patient to always report transfusion reaction because a previous reaction is a risk factor for future transfusion reactions.

♦ Encourage patient to take prescribed antihistamines or analgesics to facilitate comfort following transfusion reaction.


imagePatient-Family Teaching and Discharge Planning


Include verbal and written information about the following:


♦ See Deficient knowledge, earlier in this section.

♦ Prescribed medications, including name of medication, dose, schedule, and side effects that must be reported.

♦ Importance of follow-up care if indicated (e.g., infectious disease process following transfusion, delayed hemolytic reaction).

image



Section Two Type I Hypersensitivity Reaction (Anaphylaxis)




Overview/Pathophysiology


Immediate hypersensitivity (type I) reactions occur in persons who have been sensitized to a specific antigen. The first contact with the antigen, such as mold or pollen, serves as the sensitizing dose and prompts the activation of T-helper (TH2) cells. Only genetically predisposed individuals produce these cells. TH2 cells stimulate the production of sensitizing type E immunoglobulins (IgE). Upon subsequent exposure to the same antigen, IgE attaches to mast cells and basophils and causes rapid release of histamine, kinins, and other vasoactive mediators, which are responsible for the manifestations of allergy. Anaphylaxis is the most serious of the type I hypersensitivities. Localized anaphylaxis is confined to one area of the body, such as the lungs, skin, or nasal passages. Systemic anaphylaxis is a severe, widespread hypersensitivity reaction that can result in death without immediate treatment. Latex, drugs (penicillin, aspirin), insect venoms, foods (peanuts) and blood products cause the majority of anaphylactic reactions, which affect between 1% and 3% of the population.



Assessment



Signs and symptoms/physical findings


The characteristics of anaphylaxis vary depending on the location of the reaction and the degree of antigen exposure.



Mild reactions


Hives, urticaria, angioedema, sneezing, nasal congestion, runny nose, or watery eyes.



Moderate reactions


Bronchoconstriction, cough, increased mucous production, wheezing, chest tightness, dyspnea, nausea, vomiting, diarrhea, dizziness, malaise, and anxiety.



Severe reactions (anaphylactic shock)


In addition to moderate symptoms, patients also experience hypotension, tachycardia, throat swelling, cyanosis, pallor, severe apprehension, restlessness, airway compromise, respiratory arrest, coma, and death.



History and risk factors


Previous exposure to known allergens, genetic predisposition (one or both parents with allergies).



Diagnostic Tests



Tryptase level


Elevated level differentiates anaphylaxis from other forms of shock. Test should be performed within 4 hr of the event.



Urinary histamine


If present, aids in differentiation between anaphylaxis and other forms of shock.



Radioallergosorbent test (RAST)


Measures specific IgE antibodies and is useful in identifying specific antigens.



Cap-RAST


IgE antibody assay more sensitive than RAST.



Skin tests


Intradermal test useful for identifying specific allergens. A very small amount of suspected antigen is injected intradermally. A positive reaction indicates allergy.



Eosinophil count


Elevated during allergic reactions.



ABG values


Monitor for acid-base imbalance.



Pulse oximetry


Monitors for adequacy of oxygenation.



Collaborative Management


A severe, systemic, anaphylactic reaction (anaphylactic shock) is a medical emergency.



Establish a patent airway


Tracheotomy may be necessary if airway obstruction is severe.



Pharmacotherapy



Epinephrine


First-line treatment for anaphylaxis. Counteracts histamine and temporarily relieves bronchoconstriction and bronchospasms, to facilitate a patent airway. Intramuscular route of administration may be used when IV access is not available. Intramuscular (IM) dose: 0.3 to 0.5 mL of 1 : 1000 solution; IV dose: 0.5 to 1.0 mg (5 to 10 mL) of 1 : 10,000 solution.



Antihistamines


Prevent action of histamine by competing for histamine receptor sites; do not work immediately.



Corticosteroids


Reduce airway inflammation and help prevent bronchospasms.



Aminophylline


Promotes respiratory tract relaxation and bronchodilation.



O2 therapy


Increases availability of O2 in presence of constricted airway.



IV access


Normal saline or other isotonic fluid may be administered at keep open rate to provide IV access for 24 hr following systemic anaphylaxis. The patient is at increased risk for going back into shock for at least 24 hr as medications are excreted.



Implement shock protocol


Per facility policy.



Nursing Diagnosis and Interventions



Ineffective airway clearance


related to bronchoconstriction and bronchospasms secondary to allergic reaction



Desired outcomes


A patent airway is achieved and maintained immediately after implementation of emergency measures, as evidenced by clear lung sounds, patient report of ability to breathe with ease, and pulse oximetry reading greater than 95%.



Nursing Interventions



♦ Assess for patent airway to detect respiratory compromise. Anaphylaxis can result in death within a few minutes because of airway obstruction.

♦ Administer epinephrine per facility protocol. Opposes histamine and provides temporary bronchodilation to facilitate oxygenation.

♦ Elevate head of bed (HOB) and initiate O2 via a rebreather mask to maximize ventilation and oxygenation.

♦ Encourage slow, deep breathing to maximize oxygenation and decrease anxiety.

♦ Administer bronchodilators and/or corticosteroids as prescribed to maximize ventilation.

♦ Monitor pulse oximetry and ABG values to detect acid-base balance and evaluate oxygenation.


Deficient knowledge


related to cause of reaction, actions to prevent future reactions, and any needed follow-up care



Desired outcomes


Before discharge, patient verbalizes understanding of cause, clinical manifestations, and emergency treatment for anaphylactic reaction and verbalizes need for informing health care providers of allergies and anaphylactic reaction.



Nursing Interventions



♦ Teach patient about the allergen and ways to avoid exposure to the allergen (when possible), to minimize future exposure to the allergen and another anaphylactic reaction.

♦ Teach patient and significant other how to detect future reactions if they occur, to facilitate rapid treatment and reversal of the reaction.

♦ Have patient demonstrate self-administration of epinephrine if prescribed, to ensure correctness of technique and rapid treatment of reaction.

♦ Encourage patient to use MedicAlert system (e.g., necklace or bracelet) and inform heath care providers about allergic reactions. Facilities communication regarding allergy and avoidance of antigen.

♦ Teach patient actions, dosage, schedule, and possible side effects of all prescribed medications, to ensure accuracy of self-administration of medications.


Anxiety


related to fear of death because of inability to breathe



Desired outcomes


Patient reports decreased fear of the situation, rests quietly, has VS within normal parameters for patient, and demonstrates minimal or no breathing difficulty.



Nursing Interventions



♦ Reassure patient that you will stay until patient reports ability to breathe with ease or is moved to critical care area. Reduces patient’s fear and thus lowers anxiety.

♦ Explain all care and treatments, to decrease patient’s anxiety about the unknown.

♦ Carry out functions calmly, to convey a sense of control over the situation.

♦ Encourage slow, deep breathing, to maximize oxygenation and decrease anxiety.


imagePatient-Family Teaching and Discharge Planning


Include verbal and written information about the following:


♦ Medications, including drug names, rationale for use, dosage schedule, route of administration, precautions and potential side effects, and food/drug, herb/drug, and food/drug interactions.

♦ Where to obtain MedicAlert devices:
MedicAlert Foundation: www.medicalert.org

♦ The importance of recognizing signs and symptoms of anaphylaxis and need for initiating immediate treatment, including self-administration of epinephrine if prescribed.

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Sep 1, 2016 | Posted by in NURSING | Comments Off on Immunologic Disorders

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