Capstone Project Slides

Situation 4
Hospitalized 12-year-old boy with sickle cell

disease develops blood transfusion reaction
Scenario: A 12-year-old male patient is a direct admit
to the hospital from his pediatrician in a sickle cell pain
crisis accompanied by his mother. Documentation from
the pediatrician shows that the patient is up to date on
all immunizations and this is his fourth sickle cell crisis
in the last 3 years and the patient is admitted to the
med/surg floor. IV access has already been obtained as
well as baseline lab work, including a type and cross and
the patient weighs 88 lbs (40 kg).
Sickle Cell Anemia
▣ Hemoglobinopathy primarily affecting African Americans and
individuals of Mediteranian descent
▣ Autosomal Recessive Disorder
▣ Hemoglobin in the RBC becomes sickle or crescent shaped
▣ Symptoms occur under conditions of decreased levels of O2
▣ Causes vaso-occlusion, pain and organ infarction; and

increases the risk of developing certain infections
Sickle Cell Anemia
▣ Multi-system involvement:
◼ Spleen: engorged; prone to infection
◼ Liver: necrosis & cirrhosis
◼ Kidney: glomeruli become congested
◼ Bones: development of osteoporosis
◼ CNS: major complication of stroke (CVA)
◼ Cardiac: MI may occur
Sickle Cell Treatment
▣ Prevention of RBC Sickling
◼ Avoid fever, infection, acidosis, dehydration, constricting
clothing, exposure to cold - health prevention
◼ Adhere to childhood immunizations schedule
◼ Prophylactic oral Penicillin until age 5
◼ If at risk for CVA: routine blood transfusion q3-4 wks with
chelation therapy
▣ Pain management (ibuprofen, acetaminophen, or
morphine via PCA for very severe cases)
▣ IV fluids (150ml/kg/day)
▣ Short term oxygen
▣ Splenectomy - to decrease the chance of a perforated
spleen
▣ Cholecystectomy - considered if the patient has
gallstones
Sickle Cell Crisis Nursing Interventions
▣ Around the clock pain management
▣ Apply heat to painful area, AVOID COLD
▣ Engage in passive ROM to avoid venous stasis
▣ Assess for S&S of anemia (tachycardia) and obtain

frequent vitals
What to do
▣ Patient is 12 year old boy with known
diagnosis of COVID-19
▣ History of Sickle Cell Crisis
▣ Symptoms- Fever, chills, pain, body aches
▣ Assess Vitals
▣ Draw CBC with Differential (SCD or COVID)
▣ Hgb= decreased=severe anemia (possible CVA,
splenic sequestration)=>Blood Transfusion
Transfusion Protocol
▣ Confirmation:
◼ Informed consent signed and verified
◼ Blood type on file and/or type and cross
◼ Two IV placements (separate sites for blood and
medication administration)
▣ Call blood bank: obtain 1 unit of blood at a time,

transfusion must be started within 30 minutes of arrival on
unit
▣ NEED 2 RNs TO VERIFY BLOOD TYPE MATCH
▣ Filter needed on tubing, prime with 0.9%NS
▣ Observe patient for first 15 mins, begin transfusion no

faster than 2 mL/min. Typically, transfuse 1 unit over 2
hours, but no longer than 4 hours.
Hemolytic Reaction
▣ Life-threatening complication characterized by
destruction of the RBCs by the patient’s immune
system
▣ Main cause is ABO incompatibility
▣ Symptoms- flushing, back pain, hematuria, chills,

fever, flank pain, dizziness, itching, hypotension,
and shortness of breath
▣ Complications- severe hypotension, renal failure,

and DIC
Hemolytic Reaction
▣ Action-
◼ STOP transfusion
◼ Infuse 0.9% normal saline
◼ Notify physician and blood bank
◼ Send IV tubing and blood back to blood bank
◼ Draw blood from patient, obtain urine sample,
assess vital signs
◼ Treat symptoms accordingly
After Patient Stabilized
▣ Incident report filed by both RNs who verified
the label on the blood bag with the patient
chart
▣ New type and cross evaluated
▣ Blood type of transfused blood verified
▣ ABO incompatibility caused hemolytic
transfusion reaction
▣ State Board of Nursing notified of error
Vitals
Before Transfusion After Transfusion
BP: 104/64 BP: 85/50

HR: 65 HR: 94
SpO2: 99% SpO2: 88%
RR: 18 RR: 26
Temperature: 98.6 Temperature: 101.2
1. According to the American Association of
Blood Banks, What is the Recommended
hemoglobin level for a blood transfusion?
1. 5-7 g/dL
2. 7-8 g/dL
3. 4-7 g/dL
4. 9-10 g/dL
Answer and Rationale
Answer
▣ 1. 7-8 g/dL
Rationale
▣ The recent recommendation for blood
transfusions by the AABB is 7-8 g/dL
▣
▣ Normal hemoglobin levels for a male is 13.5-17.5

g/dL and a female is 12-15.5 g/dL
2. A patient needs two units of packed red blood
cells. The patient is typed and crossmatched. The
patient has B+ blood. As a nurse you know can
receive which type of blood? Select all that apply.
1. B-
2. A+
3. O-
4. B+
5. O+
6. A-
7. AB +
8. AB -
Answer
▣ 1. B-, 3. O-, 4. B+, 5. O+
Rationale
▣ The patient must receive blood from a donor that
has either B (patient’s blood type) or O (universal
donor type) blood.
▣ Since the donors Rh factor is + they can receive
either - or + blood.
▣ A patient with B+ blood can receive B -/+ or O -/+
3. Before a blood transfusion, you educate the patient
to report immediately which of the following signs
and symptoms during the transfusion that could
indicate a transfusion reaction? Select all that apply.
1. Sweating 7. Back pain

2. Chills 8. Pruritus
3. Hives 9. Paresthesia
4. Poikilothermia 10. SOB
5. Tinnitus 11. Nausea
6. Headache
Answer
▣ 1. Sweating, 2. Chills, 3. Hives, 6. Headache, 7.
Back pain, 8. Pruritus, 10. SOB, 11. Nausea
Rationale
▣ As the nurse, it is important to educate the
patient to report signs and symptoms associated
with blood transfusion reactions, which would
include: sweating, chills, hives, headache, back
pain, pruritus (itching), shortness of breath, and
nausea.
4. You are providing seminar teaching to a
group of nurses about sickle cell anemia. Which
of the following is NOT a treatment for this
condition?
1. Blood Transfusion
2. Stem cell transplant
3. Intravenous fluids
4. Iron supplements
5. Antibiotics
6. Morphine
Answer
▣ 4. Iron supplements
Rationale
▣ Iron supplements would not be prescribed
because sickle cell anemia is not caused by low
iron levels. This treatment would be appropriate
for iron deficiency anemia. Patients with SCD
that take iron supplements are at risk of building
up too much iron in the body, which can cause
organ damage.
5. You are educating the parents of a 12-year-old,
who was recently treated for sickle cell crisis, on
ways to prevent further sickle cell crises in the
future. Which statement by the parents
demonstrates they understood your instructions?
1. “We will limit fluid intake to 1-2L/day.”

2. “Cold showers are best to help with pain
associated with sickling”
3. “We will avoid traveling to high altitude
locations”
4. “It is important that we refuse all future
vaccinations unless absolutely necessary.”
Answer
▣ 3. “We will avoid travelling to high altitude
locations”
Rationale
▣ Sickle cell crisis can be caused by blood loss,
illness ( important for vaccinations to be up to
date), high altitudes, stress, dehydration,
elevated body temperature, and exposure to
extremely cold temperatures.
Debriefing
▣ Mistakes made while filming the video include:
◼ Not using an IV pump to administer the blood
to the patient
◼ Not showing the nurses give the patient their
pain medication
◼ Proper hand hygiene & gloves should have
been included
References
Pediatrics Class Notes by Dr. Ballone Fall 2020
Hemolytic transfusion reaction: MedlinePlus

Medical Encyclopedia. (n.d.). Retrieved from
https://medlineplus.gov/ency/article/001303.htm

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Situation 4

Hospitalized 12-year-old boy with sickle cell

▣ Autosomal Recessive Disorder

▣ Hemoglobin in the RBC becomes sickle or crescent shaped

▣ Symptoms occur under conditions of decreased levels of O2

▣ Causes vaso-occlusion, pain and organ infarction; and

▣ Apply heat to painful area, AVOID COLD

▣ Engage in passive ROM to avoid venous stasis

▣ Assess for S&S of anemia (tachycardia) and obtain

▣ Call blood bank: obtain 1 unit of blood at a time,

▣ NEED 2 RNs TO VERIFY BLOOD TYPE MATCH

▣ Filter needed on tubing, prime with 0.9%NS

▣ Observe patient for first 15 mins, begin transfusion no

▣ Main cause is ABO incompatibility

▣ Symptoms- flushing, back pain, hematuria, chills,

▣ Complications- severe hypotension, renal failure,

BP: 104/64 BP: 85/50

▣ Normal hemoglobin levels for a male is 13.5-17.5

1. Sweating 7. Back pain

1. “We will limit fluid intake to 1-2L/day.”

Hemolytic transfusion reaction: MedlinePlus

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