Nursing International Normalised Ratio

Question: Discuss about the Nursing for International Normalised Ratio. Answer: Introduction: An 86 year old man was admitted for surgery of fractured neck of the femur. Due to an elevated level of international normalised ratio (INR) up to 1.6, the patient needed a unit of fresh frozen plasma (FFP). The medical officer (MO) took group O FFP instead of group A and gave it to the nurse. The nurse on duty and the patient service attendant (PSA) did not check the paperwork for FFP unit and administered the wrong FFP of group O. As a result, the transfusion was incompatible. Plasma of group O contains both A and B antibodies and is therefore potentially incompatible for group A and group B (Puetz, 2013). The nursing and medical staff were under the impression that group O was the universal group both for FFP and red blood cells. But due to the presence of both A and B antibodies plasma from group O is incompatible for group A and group B patients. In this case study, incorrect FFP was administered to the patient, but the error was detected soon and immediate treatments were conducted. As a consequence of this incompatible transfusion, the patient experienced a mild rise in bilirubin. His surgery procedure was postponed as a safety measure to observe him for additional outcomes of the incorrect transfusion therapy. There are several cases of group O plasma and platelet transfusion to patients with other blood groups. Some of these cases showed delayed haemolytic transfusion reaction, complicated recovery, even morbidity (Zimring Spitalnik, 2015). Transfusion of plasma, platelets and blood can save a life. An error in transfusion process, at the same time, may take life. As described by Pandey and Vyas (2015), incompatible transfused blood cells react with the anti-A or anti-B antibodies of patients which can lead to complement activation and disseminated intravascular coagulation (DIC). There is about one in three of ABO incompatibility and ten percent mortality rate with severe reactions observed among group O individuals received group A red blood cells (Bersus et al., 2013). Being a nurse, I believe that we have the last opportunity to prevent transfusion errors. Most transfusion errors result from human mistakes and therefore, can be preventable. Transfusion errors, resulting in the patients getting the inappropriate blood components, remains the leading risk associated with transfusion. I chose this case because I think a nurse can increase compliance in high-risk cases of the transfusion and decrease the potential for mistakes by evolving accessible blood transfusion policies, auditable action standards and preparation, and learning initiatives. Understanding and awareness about pathophysiology of transfusion reactions, symptoms and treatment methods are vital for safe administration and observation of transfusions (Stout Joseph, 2016). This case study is significant because I want to enhance my professional skills and prevent every chance of transfusion errors. I also want to raise awareness among nurses and medical staff about incorrect transfusion to reduce similar incidents (Hijji et al., 2013) and this case study can help me to accomplish my purposes for improved patient care. The incident was a result of mistakes done by multiple health care staff. The first mistake was committed by the MO who went to the laboratory to collect a unit of FFP. The laboratory scientist showed him the location of FFP and told the MO to take it after signing the blood register. But the FFP collected by the MO was not labelled and was allocated for another patient which was group O FFP. Here is also a mistake of laboratory scientist who did not label the allocated FFP. The MO took the FFP without product details and patients details in the blood register. The MO gave the FFP to the charged nurse of the patient. The nurse was unaware of the transfusion process but noted the lack of paperwork and sent the PSA with the FFP unit again to the laboratory to collect the required paperwork. When the PSA returned, told the nurse there was no paperwork for this unit of FFP and checking was not required. But the laboratory staff stated that they never talked to that PSA regarding the FFP. The nurses believed the PSA and thought that group O is the universal group for FFP and administered the wrong FFP of group O to the 86-year-old man who needed group A. The patient suffered a mild rise in bilirubin due to incompatible transfusion and his surgery was delayed. The whole incident was a result of lack of concern, attentiveness and communication among the medical staff members. My first priority is to never do or let incorrect transfusion of blood or blood components happen. If yet similar clinical condition occurs I will do every possible intervention to recover and restore the patient's health. Monitoring the signs and symptoms of transfusion reaction like fever, low back pain, headache, and haemoglobinuria are vital. Clinical signs of delayed haemolytic reactions are mild jaundice, fever, fall in haemoglobin etc. and febrile non-haemolytic reactions include the rise in body temperature, headaches, chills, anxiety and flushing (Crookston et al., 2015). On detection of any of the signs, I will stop the transfusion immediately and will notify the doctors. Initializing IV line for saline (0.9% NaCl) is important. Then I will collect urine sample as soon as possible to determine the presence of haemoglobin due to red blood cell haemolysis (Crookston et al., 2015 and Yahalom Zelig, 2015). Being the nurse in-charge, I should stay with the patient for observing other signs and symptoms and determination of vital signs in every five minutes interval. The patient should be placed in Fowler's position if shortness of breath is observed and immediate administering oxygen therapy is essential. After notifying the physician I must administer emergency drugs like vasopressor, antihistamines, steroids and fluids as per protocol doctors instruction. Then I need to evaluate conditions like the patient is reporting any discomfort, patient is maintaining normal breathing pattern, the patients are maintaining good fluid balance, the patient is demonstrating satisfactory cardiac output etc. (Crookston et al., 2015). References Bersus, O., Boman, K., Nessen, S. C., Westerberg, L. A. (2013). Risks of hemolysis due to anti-A and anti-B caused by the transfusion of blood or blood components containing ABO-incompatible plasma.Transfusion, 53(S1), 114S-123S. Crookston, K. P., Koenig, S. C., Reyes, M. D. (2015). Transfusion reaction identification and management at the bedside.Journal of Infusion Nursing, 38(2), 104-113. Hijji, B., Parahoo, K., Hussein, M. M., Barr, O. (2013). Knowledge of blood transfusion among nurses.Journal of clinical nursing,22(17-18), 2536-2550. Pandey, S., Vyas, G. N. (2012). Adverse effects of plasma transfusion. Transfusion,52(s1), 65S-79S. Puetz, J. (2013). Fresh frozen plasma: the most commonly prescribed hemostatic agent.Journal of Thrombosis and Haemostasis,11(10), 1794-1799. Stout, L., Joseph, S. (2016). Blood transfusion: patient identification and empowerment.British Journal of Nursing,25(3), 138-143. Yahalom, V., Zelig, O. (2015). Handling a transfusion haemolytic reaction. ISBT Science Series,10(S1), 12-19. Zimring, J. C., Spitalnik, S. L. (2015). Pathobiology of transfusion reactions.Annual Review of Pathology: Mechanisms of Disease,10, 83-110.