Surgical Case 5: Lloyd Bennett Documentation Assignments 1. Document your focused postoperative assessment for Lloyd Bennett. - I began my focused postoperative assessment by obtaining the patient’s vital signs. After obtaining the HR, RR, SPO2, temperature, and attaching an NIBP cuff, I proceeded with my assessment by observing the patient’s skin. I then assessed his dressings, auscultated the lungs, and auscultated the heart. I also assessed the patient’s IV site and verified the patient’s blood type and cross-match after checking for allergies. 2. Document Lloyd Bennett’s allergies in his chart. - According to Mr. Bennett’s medical record, he has no known allergies. 3. Document Lloyd Bennett’s vital signs during the transfusion reaction. - BP: 110/72 - HR: 97 BPM - RR: 19 breaths per min - SPO2: 94% - Temperature: 99°F 4. Document the priority nursing actions completed during the transfusion reaction. - The most critical component of providing care during a transfusion reaction is to immediately discontinue the blood transfusion. After stopping the transfusion, the provider should be called immediately once the patient has been stabilized. After calling the provider, re-checking the patient’s vital signs is an important component of monitoring the patient’s status. Lastly, new orders should be initiated if appropriate and the blood bank should be notified as quickly as possible. 5. Identify and document key nursing diagnoses for Lloyd Bennett. - Acute pain r/t incompatible blood transfusion - Risk for injury 6. Referring to your feedback log, document the nursing care you provided. - Nursing Interventions: o Washed hands, verified identity, determined allergies, verified signed consent o Assessed respirations, temperature, HR, SPO2, and attached NIBP cuff o Assessed the patient’s skin o Auscultated the lungs and heart o Assessed the post-surgical dressings, assessed the IV site to ensure patency o Verified blood/cross-matching, flushed the IV site o Began administering 100mL/hr of packed RBC o Patient began to have a transfusion reaction (as confirmed by immediate onset low back pain and elevated vital signs), promptly discontinued infusion o Called the provider for new orders o Provided patient education regarding transfusion reaction o Reassessed vital signs and auscultated breath sounds o Obtained a urine culture and venous blood sample per new provider orders o Began infusion of NS at 100mL/hour per new provider orders o Contacted blood bank o Performed patient hand-off Guided Reflection Questions 1. How did the scenario make you feel? - This scenario made me feel a bit frustrated due to accidentally double clicking the “administer” button when attempting to discontinue the infusion of RBCs. This resulted in the system mistakenly thinking that I meant to restart the infusion, which was not my intention. This resulted in a xxx error on my first attempt, but I was able to successfully retry the simulation with a 100% score after making sure to only click the “administer” button once to discontinue the infusion. 2. Prior to blood administration, what assessments of the blood product and the patient are required to promote safe delivery and lessen potential complications? - The patient’s IV site should be assessed for patency and flushed with NS - The patient’s identity, blood type, cross-matching, DOB, and blood type in hand must be verified by 2 RNs - The patient’s allergies must be confirmed - Obtain vital signs - Provide patient education regarding potential reactions - Begin infusion, watching patient closely for adverse reactions 3. What signs and symptoms first indicated the patient was having a transfusion reaction? - The first sign of a transfusion reaction in this particular case was the immediate onset of Mr. Bennett’s lower back pain. This is one of the first signs of a transfusion reaction, which requires immediate intervention by the RN to stop the transfusion/halt the reaction before it worsens. 4. Review the immediate priorities when a transfusion reaction occurs and the rationale for each. - The transfusion must be immediately stopped upon possible sign of a transfusion reaction in order to halt the reaction and prevent possible life-threatening complications - Notify the provider immediately for further instruction and to alert them of the reaction - Provide patient education regarding the reaction to maintain transparency and explain their new symptoms - Reassess vital signs to closely monitor the patient’s status - Initiate new orders if indicated (i.e. infusing NS) - Contact the blood bank as soon as possible to alert them of the reaction and send back the blood/possibly a venous sample from the patient 5. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. - Situation: o Patient began having acute-onset low back pain upon receiving packed RBCs at 100mL/hour, transfusion was immediately discontinued. - Background: o Patient is a 76 year old male that is s/p left hip arthroplasty. Packed RBC’s were ordered due to HgB of 7 g/dL, which resulted in a transfusion reaction. He had no known allergies prior to this incident. - Assessment: o Transfusion was immediately discontinued, after which the patient’s vital signs were: BP of 110/72, HR of 97, temperature of 99°F, RR of 19, and SPO2 of 94%. Patient’s condition stabilized after discontinuing the infusion. The provider was contacted, after which NS was ordered and initiated at 100mL/hour. A urine culture and venous sample were drawn and sent to the lab, which are now noted in the patient’s chart. - Recommendation: o I recommend that we continue to closely monitor the patient’s vital signs and overall condition to determine possible worsening. The blood bank has been contacted for evaluation of the reaction, after which they will send an alternate bag of RBCs after determining the cause of the reaction. Continue with care plan unless otherwise specified by the provider. 6. What follow-up blood work may be required? - Venous Sample: CBC, including BUN and serum creatinine. Hgb should be monitored closely. - A urine sample was also acquired to monitor kidney function and possible complications from the transfusion reaction. 7. What follow-up disclosure is required with Lloyd Bennett and his family? - The patient and his family must be educated regarding the transfusion reaction and possible complications. After determining the cause of the reaction, the patient and chart should be updated in order to prevent possible reactions in the future. 8. What would you do differently if you were to repeat this scenario? How would your patient care change? - On my first attempt, I accidentally restarted the transfusion again after discontinuing the RBCs due to an accidental double click. I also did not prioritize taking the patient’s temperature after the reaction, and accidentally forgot to flush the IV line prior to starting the infusion of RBCs. I corrected these mistakes during my second attempt and was able to get a perfect score. Besides those errors, I feel that I did well with prioritization during the simulation and was able to complete all provider orders.