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CAAN Nursing Practice Guidelines
APPENDIX 4
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Reaction/Incident
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Signs and Symptoms
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Treatment
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Adverse Reactions
-Light/Mild
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Pallor,
sweating, nervousness, hyperventilation, yawning, restlessness, weakness,
nausea, light-headedness, fainting, change in pulse rate.
*Should completely resolve in 15 minutes.
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Assist
client to recline, elevate feet. Apply cold compress to forehead, temples
and back of neck. Loosen tight clothing. Divert client's attention. Maintain
normal body temperature. Once recovered, offer cool water and refreshments.
If person does not recover within 15 minutes, report to nursing manager/Designate,
document incident and further assess.
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Adverse Reactions
-Moderate
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As
for light/mild progressing to unresponsive leading to loss of consciousness,
slow pulse rate, shallow respiration-vomiting, hypotension
*Should completely resolve within 15-30 minutes.
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Provide
privacy, turn client to side, check vital signs as indicated by client's
recovery. Offer transportation home, if possible. Provide donor teaching.
Document event on a Reaction/Incident Report. If unresolved, active EMS.
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Adverse Reactions
-Severe
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As
for light/mild or moderate accompanied by unresponsiveness lasting > 30
seconds, convulsions, incontinence, tetany, chest pains.
*Recovery time lasts longer than 30 minutes.
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Activate
EMS as required and/or notify Physician. Maintain open airway, check vital
signs every 15 minutes. Document incident on a Reaction/Incident Report.
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Air Embolism
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Cough,
apprehension (air hunger), rapid laboured breathing, shortness of breath,
pallor, sweating, mental confusion, chest pain, rapid, weak pulse, and hypotension.
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Pause
procedure immediately and keep IV line open with normal saline. Turn donor
to left side, lower head, raise feet. Administer 02. Check vital signs every
15 minutes. Activate EMS. Notify Nursing Manager/Designate And Physician
STAT. Document incident on a Reaction/Incident Report.
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Allergic Reactions
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Apprehension,
weakness, flushing of skin, itching, hives, swelling of eyes, lips or tongue,
runny nose, tightness of chest, sneezing, wheezing, cough, difficulty breathing
or high pitched wheeze, cyanosis, abdominal cramps, nausea, vomiting, rapid,
weak pulse, hypotension, unconsciousness, cardiac arrest.
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Stop
procedure immediately. Activate the EMS and notify Physician as required.
Document vital signs every 5 minutes. Maintain an open airway. Document incident.
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Anxiety (Donor)
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Teariness, uncontrolled laughter, restlessness, agitation.
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Maintain a calm, controlled atmosphere. Divert client through conversation. Provide concise detailed pre-procedural orientation.
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Arterial Puncture
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Bright red blood which pulsates in tubing, rapid filling of collection pack.
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Discontinue
donation immediately. Elevate arm and apply direct, hard pressure over site
for 15 minutes. Once stopped, apply pressure dressing for 4 hours. Document
incident.
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Re-bleeding at Venipuncture Site
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Leakage of blood from Venipuncture site after initial bleeding had stopped.
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Apply
firm pressure to bleed site (on top of sterile gauze or appropriate dressing).
Escort client back to unit, apply 3 finger firm pressure to bleed site (on
top of sterile gauze) for further 5 minutes. Remove soiled gauze/ dressing
and discard into a biohazardous container. Apply a pressure dressing. If
a bruise or hematoma is noted, apply cold pack or ice for up to 15 minutes.
Advise client:
1.Remove bandage in 4-6 hours and resume normal activity.
2. Should swelling persist beyond 24 hours, apply alternating cold compresses and warm compresses to the affected area.
3. Telephone their physician should the injured area become painful.
Clean spills with disinfectant solution. Note: Gloves MUST be worn in treatment
of a Re-bleed. Document on a Reaction/Incident Report if bleeding persists.
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Red Cell Hemolysis
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Pink, lipemic plasma or red plasma, blood in lines or filter may appear dark.
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Pause procedure. Notify Physician and Nursing Manager/ Designate.
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Red Cell Loss
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If unable to return red cells for any reason, document on a Reaction/ Incident Report inform Physician.
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Shock
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Weakness, anxiety, confusion, pale, cold clammy skin, weak, rapid pulse, drowsiness, unconsciousness.
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Assess
for unresponsiveness. If unresponsive, active EMS. Monitor airway, breathing
and circulation, record vital signs frequently. Inform Nursing Manager and
Physician. Document on a Reaction/Incident report.
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Sodium Citrate Reaction
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Numbness/
tingling of lips, nausea, vomiting, sensation of pressure in chest, muscular
twitching, spasm of muscles, particularly hands and feet, convulsions.
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Decrease
draw/flow rate (thus subsequently decreasing anticoagulant delivery rate).
Verify that all disposable equipment has been installed properly to ensure
appropriate anticoagulant infusion rate. Keep client warm with blankets.
An oral antacid containing calcium may be given every 5 minutes (not exceeding
maximum dosage). If mild symptoms subside, continue procedure at rate client
can tolerate. If mild symptoms do not subside within 15 minutes, initiate
calcium gtt. I.V. If symptoms become severe or if tetany, convulsions, or
laryngeal obstruction occur, pause procedure immediately and notify Physician.
Start saline gtt. TKVO, do not rinse back until all symptoms are gone. Document
on a Reaction/Incident Report.
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