Colostomy Care

Colostomy is the opening of some portion of the colon onto the abdominal face Reasons for Performing a Colostomy

When feces cannot progress naturally from the colon to the anus When it is more desirable or manageable to divert the feces, as for paraplegics In any condition where the rectum or anus is nonfunctional because of disease, a birth defect or a traumatic condition. It is performed to divert the fecal flow away from an area of inflammation or around an operative area

General Procedure for Changing an Ostomy Pouch Assessment 1. Identify the type of ostomy the patient has and its location (Bowel Urinary Diversion) 2. Assess the skin integrity around the stoma and as general appearance 3. Note the amount and character of any fecal material or urine in the pouch 4. Determine whether the patient is being taught self-care at the moment Planning 1. Wash your hands 2. Gather the equipment needed in changing a pouch or dressing

Cleansing supplies including tissues, warm water, mild soap, wash cloth and a towel Clean pouch of the type currently being used Seal or use tape to prevent leakage Clean belt Dressing materials Receptacle for the soiled pouch or dressing (bedpan, paper bag/newspaper for wrapping) Protective spray Clean gloves

1. Determine whether the patient is to participate actively 2. Choose the appropriate location in performing the procedure (bathroom/ bedside) Implementation 1. 2. 3. 4. 5. 6. Identify the patient Explain the procedure to the patient Put on clean gloves for infection Assist the patient to the bathroom or provide privacy Remove the soiled dressing Using warm water and a mild soap, cleanse the skin around the stoma thoroughly. Inspect the skin for redness or irritation. 7. Cover the stoma with a tissue to prevent feces or urine from contacting. Change tissues as necessary during the procedure 8. Dry the skin around the stoma carefully, patting gently 9. Apply a skin protective spray if needed 10. Allow the skin to dry thoroughly so the pouch will adhere firmly (a hair dryer on a low setting at least 18 inches from the skin may be used) 11. Remove the tissue from the stoma and apply the clean pouch or dressing 12. Remove gloves and wash hands Evaluation 1. Evaluate using the following criteria

Pouch or dressing secure Area clean Odor free Patient comfortable If the patient is being taught the procedure, add the following criteria: o Patient is able to change pouch using correct technique o Patient verbalizes understanding of key points in care

Documentation

1. Record the following information:

The amount, color, and consistency of the fecal material or urine in the pouch The application of the clean pouch and dressing change The knowledge and ability of the patient t participate in the procedure or ability to change independently.

Blood Transfusion Therapy

Blood transfusion therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII). Blood components include: 1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygencarrying capacity of blood with minimal expansion of blood. 2. Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions. 3. Platelets, either HLA (human leukocyte antigen) matched or unmatched. 4. Granulocytes ( basophils, eosinophils, and neutrophils ) 5. Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors). 6. Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation. 7. Albumin, a plasma protein. 8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin. 9. Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 10. Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma. 11. Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI. Advantages of blood component therapy 1. Avoids the risk of sensitizing the patients to other blood components. 2. Provides optimal therapeutic benefit while reducing risk of volume overload. 3. Increases availability of needed blood products to larger population.

Principles of blood transfusion therapy 1. Whole blood transfusion o Generally indicated only for patients who need both increased oxygencarrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed. 2. Packed RBCs o Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%. 3. Platelets o Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipients platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension. 4. Granulocytes o May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production. 5. Plasma o Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringers lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing. 6. Albumin o Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure. 7. Cryoprecipitate o Indicated for treatment of hemophilia A, Von Willebrands disease, disseminated intravascular coagulation (DIC), and uremic bleeding. 8. Factor IX concentrate o Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors. 9. Factor VIII concentrate o Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission. 10. Prothrombin complex-Indicated in congenital or acquired deficiencies of these factors.

Complications of Blood Transfusion 1. Hemolytic transfusion reaction- is a life-threatening complication occurring from transfusion of donor blood that is incompatible with the recipients blood. 2. In hemolytic transfusion reaction, antibodies in the recipients plasma combine with antigens on donor erythrocytes, causing agglutination and hemolysis in circulation or in the reticuloendothelial system. Similarly, antibodies in donor plasma combine with antigenon the recipients eyhrocytes; however, complications from infusion of incompatible plasma are less severe than those associated with infusion of incompatible erythrocytes. The most rapid hemolysis occurs in ABO incompatibility; Rh incompatibility is often less severe. 3. Delayed hemolytic transfusion reaction occurs 1 to 2 weeks after transfusion; erythrocytes hemolyzed by antibody are not detectible during crossmatched but are formed rapidly after transfusion. It generally is not dangerous, but subsequent transfusions may be associated with acute hermolytic reaction. 4. In hemolytic reaction, severity of complications correlates with the amount of incompatible blood transfused; chances of fatal reactions are decreased if less than 100 ml of incompatible blood is infused. 5. Febrile, non hemolytic Transfusion reaction, the most common type of reaction, is commonly caused by sensitivity to leukocyte or platelet antigens. 6. Septic reaction is an often serious complication resulting from transfusion if a blood product contaminated with bacteria. 7. Allergic reactions may result from sensitivity to plasma protein or donor antibody, which reacts with recipient antigen. 8. Circulatory overload results from administration at a rate or volume greater than can be accommodated by the circulatory system, precipitating congestive heart failure or pulmonary edema. 9. Several infectious diseases can be transmitted through blood transfusion, including: o Hepatitis B o Non-A, non-B hepatitis o Malaria o Syphilis o Acquired immunodeficiency syndrome (AIDS) 10. Graft-versus-host (GVH) disease results from engraftment of immunocompetent lymphocytes in bone marrow of immunosuppressed recipients, which triggers the immune response of the graft against the host. 11. Reactions associated with massive transfusions (>10 units of packed RBCs on 1 or 6 hours) include: o Hypocalcemia, resulting from binding of recipients circulating calcium to anticoagulant (citrate) in packed RBCs. o Citrate intoxication due to accumulation of citrate. o Hyperkalemia, in which stored red cells progressively increase extracellular potassium concentrations. o Exacerbation of liver disease die to increased ammonia levels in stored blood.

o o o

Hypothermia, in which transfusion of cold blood (below 37 C) at rates >100 mL/min may produce dysrhythmias and cardiac arrest. Aggregates of leukocytes and platelets in the lungs, resulting from accumulation of these aggregates during blood storage. Hemorrhage resulting from excessive dilution of the recipients platelets and clotting factors.

Assessment findings 1. Clinical manifestations of transfusions complications vary depending on the precipitating factor. 2. Signs and symptoms of hemolytic transfusion reaction include: o Fever o Chills o low back pain o flank pain o headache o nausea o flushing o tachycardia o tachypnea o hypotension o hemoglobinuria (cola-colored urine) 3. Clinical signs and laboratory findings in delayed hemolytic reaction include: o fever o mild jaundice o gradual fall of hemoglobin o positive Coombs test 4. Febrile non-hemolytic reaction is marked by: o Temperature rise during or shortly after transfusion o Chills o headache o flushing o anxiety 5. Signs and symptoms of septic reaction include; o Rapid onset of high fever and chills o vomiting o diarrhea o marked hypotension 6. Allergic reactions may produce: o hives o generalized pruritus o wheezing or anaphylaxis (rarely) 7. Signs and symptoms of circulatory overload include: o Dyspnea o cough

rales jugular vein distention 8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease. 9. Characteristics of GVH disease include: o skin changes (e.g. erythema, ulcerations, scaling) o edema o hair loss o hemolytic anemia 10. Reactions associated with massive transfusion produce varying manifestations
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Possible Nursing Diagnosis 1. Ineffective breathing pattern 2. Decreased Cardiac Output 3. Fluid Volume Deficit 4. Fluid Volume Excess 5. Impaired Gas Exchange 6. Hyperthermia 7. Hypothermia 8. High Risk for Infection 9. High Risk for Injury 10. Pain 11. Impaired Skin Integrity 12. Altered Tissue Perfusion Planning and Implementation 1. Help prevent transfusion reaction by: o Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion. o Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration. o Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion). o Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures. o Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents. o Preventing GVH disease by ensuring irradiation of blood products containing viable WBCs (i.e., whole blood, platelets, packed RBCs and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide. o Preventing hypothermia by warming blood unit to 37 C before transfusion.

Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion. 2. On detecting any signs or symptoms of reaction: o Stop the transfusion immediately, and notify the physician. o Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion. o Send the blood bag and tubing to the blood bank for repeat typing and culture. o Draw another blood sample for plasma hemoglobin, culture, and retyping. o Collect a urine sample as soon as possible for hemoglobin determination. 3. Intervene as appropriate to address symptoms of the specific reaction: o Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria. o Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. o In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed. o Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.) o For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.
o

Evaluation 1. 2. 3. 4. 5. 6. 7. 8. The patient maintains normal breathing pattern. The patient demonstrates adequate cardiac output. The patient reports minimal or no discomfort. The patient maintains good fluid balance. The patient remains normothermic. The patient remains free of infection. The patient maintains good skin integrity, with no lesions or pruritus. The patient maintains or returns to normal electrolyte and blood chemistry values.

Blood Transfusion Complications

Blood transfusions always come with various side effects and complications. The health team, especially the doctors and nurses should be responsible in educating the patients receiving blood transfusion regarding the reason of the transfusion, its benefits and risks involve and the expected outcomes during transfusions. It is also important that we obtain a

signed consent from the patients agreeing to undergo a transfusion. Nursing management is focused on recognizing, preventing and intervening complications. Acute Hemolytic Reaction - This is the most dangerous and most fatal transfusion reaction there is. Thus happens when the blood donor is incompatible to the blood recipient. Antibodies present in the blood recipient plasma combine with the antigens of the donor plasma causing the destruction of red blood cells in the circulation. This type of reaction can occur very quickly just after transfusing 10 mL of blood. Symptoms include fever, chills, low back pain, nausea, chest tightness, dyspnea and anxiety. When RBCs are destroyed, the hemoglobin is released in the urine. This leads to hypotension, bronchospasm and vascular collapse that may be eventually cause acute renal failure. The transfusion should be stopped eventually and reassessment of the patient should be initiated (blood volume and renal perfusion). Laboratories (blood and urine specimen) should be evaluated. Delayed Hemolytic Reaction - After transfusion, reactions may be delayed; antibodies react a little later and have increased in time. This occurs within 14 days after transfusion. Signs and symptoms include fever, increased bilirubin levels, decreased or absent haptoglobin, anemia, and jaundice, Febrile Non Hemolytic Reaction - This is the most common type of transfusion reaction. This reaction is caused by anti bodies to donor WBCs that are still present in the blood unit or blood component. Patients with febrile non haemolytic reaction manifests fever (starts two hours after the transfusion), chills and muscle stiffness. In order to prevent such, before transfusion, he blood can undergo a leukocyte reduction filter to eliminate WBCs in the blood component. Antipyretics are given as ordered, tepid sponge bath is rendered and continuous monitoring is done. Allergic Reaction - This reaction is due to a sensitivity reaction to a plasma protein from the blood being transfused. Symptoms include flushing, itching and urticaria, severe allergic reaction includes bronchospasms, laryngeal edema and shock. Management includes administration of antihistamines, epinephrine and corticosteroids as ordered. Circulatory Overload - If too much blood is transfused then this may cause circulatory overload or hpervolemia. Signs and symptoms would be orthopnea, dyspnea, tachycardia and anxiety, crackles, neck vein distention and hypertension. Slowing the rate of transfusion and administering diuretics as ordered is the intervention for such. Oxygen inhalation can also be initiated. Bacterial Contamination - Contaminated blood products are very dangerous since it may transmit a disease or infection to the recipient. Signs and symptoms of bacterial contamination are fever, chills and hypotension. Antibiotics are administered as ordered to treat the infection as early as possible. Friday, June 23, 2006 NURSING PROCEDURE : BLOOD TRANSFUSION

1.Definition Is the introduction of whole blood or component of the blood, e.g. plasma or erythrocytes into venous circulation. 2.Blood Group Human blood is classified in to four main groups (A, B, AB and O) on the basic of polysaccharide antigen on the erythrocyte surface. These antigens type A and Type B, commonly cause antibody reaction and are called agglutinogens. In other words group A blood contain type A agglutinogen, group B blood contain type B agglutinogen, group AB contain both A & B agglutinogens, and group O blood containe neither agglutinogen. In addition to agglutinogens on the erythrocytes agglutinin (antibody) are present in the blood plasma. No individual can have agglutinin and agglutinogen of the same type, that person's system would attack its own cells. Then group A blood does not contain agglutinin A but does contain agglutinin B. Group B blood does not contain agglutinin B but does contain agglutinin A. Group AB blood contain neither agglutinin and group O contain both anti A and anti B agglutinin. Blood transfusion must be match to the patient blood type in term of compatible agglutinogen mismatch blood will cause hemolytic reaction. Rhesus (Rh) and other factors Rh antigen also on the surface of erythrocytes are present in about 85% of the population are can be a mayor cause of hemolytic reaction. Persons who possess the Rh factor are referred to as Rh positive those who do not are referred to as Rh negative. Unlike the A and B agglitinogen, the Rh factor cannot cause a hemolytic reaction on the first exposure to mismatched blood, because the Rh antibody is not normally present in the plasma of Rh negative person. 3.Transfusion reaction Transfusion reaction can be categorized as hemolytic, febrile, circulatory over load and allergic. The nurse must asses a client closely for reactions. Sign of an acute reaction include sudden chills or fever, low back pain, drop in blood pressure, nausea, flushing agitation or respiratory disorders. Sign of less severe allergic reaction include hives and itching but no fever. Nursing management for transfusion reaction: Stop the transfusion. Maintain the intravenous line with normal saline solution through new intravenous tubing, administered at a slow rate. Asses the patient carefully, compare the vital sign with those from the base line assessment.

Notify the physician of the assessment findings and implement any order obtained. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture, the identifying tag and number are verified. Before commencing a blood transfusion determine: 1.Base line data regarding blood pressure, temperature, pulse and respiration. 2.Any previous reaction to a blood transfusion. 3.The request for blood transfusion form has been completed and send specimen for typing and cross matching, 3 ml in plain tube/red without wax or gel and 2 ml in CBC tube. 4.Purpose 1.Restore blood volume after hemorrhage 2.Maintain hemoglobin levels in severe anemia 3.Replace specific blood component. 5. Assessment focus Clinical signs of reaction (e.g. sudden chills, nausea, itching rash, dyspnea) status of infusion, site, any unusual symptoms. Equipment 1.Unit of whole blood 2.Blood administration set either a straight line or a Y set ( Y set is preferred) 3.Normal saline solution 4.IV dressing 5.Vena puncture set containing a 18 needle or catheter, or if blood is to be administered quickly no 16 needle or a larger. 6.Alcohol swab 7.Tape 8.Disposable gloves (Sterile) 6.Initiating, Maintaining and Terminating a Blood Transfusion * Nursing Intervention a.Pre Procedure 1.Obtain patients base line data before the transfusion. Asses base line data: Temp, Pulse, Respiration and Blood Pressure. Determine any known allergies or previous adverse reaction to blood. Note specific signs related to the client's pathology and reason for transfusion (e.g. an anemic client, note the hemoglobin level less than 10g/L). 2.Obtain the correct blood component for the patient. Check the physician's order with the requisition. See that doctor check and write to start. Check the requisition form and the blood bag label with a specially check the

patient name, identification number, blood type and Rh group the blood donor number, and the expiration date of blood. Ensure that doctors counter check and sign With another nurse (RN) compare the laboratory blood type round with : The client's name and identification number. Ask the patient to state the full name as a double check. The number on the blood bag label The patients blood group and label, amount of blood, calculate and adjust. Check blood for any abnormalities, gas bubles dark color or cloudiness, clots and excess air Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. Agencies may designate different times at which the blood must be returned to the blood bank if it has not been started. As blood component warm, the risk of bacterial growth also increases. Rational : If the patients Clinical status permits, delay transfusion if baseline temperature is greater than 38.50 C b.Procedure 1.Wash and dry hands 2.If any pre medication order, give before transfusion 3.Prepare the patient Identify the patient and explain the procedure and its purpose to the patient such as blood product to be transfused, approximate length of time, and desired outcome of transfusion. 4.Assemble the equipment and bring to the patient 5.Wear gloves. 6.Positioning the patient comfortably 7.Prime the tubing with saline solution. Establish the saline infusion See that the set used in appropriate, as sometimes attached filteris not suitable for some product 8.If the patient has an intravenous solution infusing check whether the needle and solution are appropriate to administer blood. The needle should be no. 18 gauge or larger and the solution must be saline. If solution is not compatible remove it and dispose of it according to hospital policy. Dextrose which causes lysis of RBCs, Ringer's Solution, medication and other additives and hyper alimentation solution are incompatible. 9.If patient does not have an intravenous solution infusing, in the case you will need to perform veni puncture on a suitable vein. Select a large vein that allows patient some degree of mobility and place bed protector under the site. Start the prescribed intravenous infusion 10.Establish the blood transfusion. Invert the blood bag gently several times to mix the cell within the plasme

11.Start infusion slowly at 2 ml/mnt. Remain at bed side for 5-30 minutes. If there are not sign of circulatory overloading, the infusion rate may be increased 12.Observe the patient closely for chilling, nausea, vomiting, skin rashes tachycardia as they early sign and symptom reaction and check vital sign at least hourly until 1 hour post transfusion. Report sign and symptoms of reaction immediately to physician to minimize consequences. Acute reaction may occur at anytime during the transfusion.If any reaction: close clamp & run normal saline, report to doctor, save urine and observe. Rational : The majority of acute fatal transfusion reaction are caused by clerical errors. Patient and product verification is the single most important fucntion of the nurse. It is strongly recommended that two qualified individuals perform this task. Do not proceed with the transfusion if there is any discrepancy. Contact the blood bank immediately cPost procedure Obtain vital sign and compare with base line assessment. Document procedure in patient's medical record including: Product , blood type Rh, volume transfused, rate, site infused. Product identification number Name of individual verifying, patient ID, name of person starting and ending transfusion. Patient assessment findings and tolerance to procedure. Monitor patient for response to and effectiveness of the procedure. Terminate the transfusion Discard administration set according to policy procedure. (i.e. If any reaction, save the set for further investigations) Rational : Rationale it must be possible to trace each transfusion product to the original blood donor.