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Care of Patients with Hematologic Disorders (WBCs and more)

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Marsha Woodall

on 21 February 2013

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Transcript of Care of Patients with Hematologic Disorders (WBCs and more)

Care of Patients with Hematologic Disorders (WBCs and more) Assessment Skin
Head and neck
Respiratory
Cardiovascular
Renal and urinary
Musculoskeletal
Abdominal
Central nervous system
Psychosocial Physical Assessment What patient teaching would the nurse provide for these types of tests? Diagnostic Assessment presented for NIP 210 by Marsha Woodall, MBA, MSN, RN Febrile transfusion reactions
Hemolytic transfusion reactions
Allergic transfusion reactions
Bacterial transfusion reactions
Circulatory overload
Transfusion-associated graft-versus-host disease Transfusion Reactions Red blood cell
Platelet
Plasma—fresh frozen plasma
Cryoprecipitate
Granulocyte (white cell) Types of Transfusions Transfusions Provide patient education.
Assess vital signs.
Begin transfusion slowly, and stay with patient first 15 to 30 minutes.
Ask patient to report unusual sensations such as chills, shortness of breath, hives, or itching.
Administer blood product per protocol.
Assess for hyperkalemia. Transfusion Responsibilities Pretransfusion responsibilities to prevent adverse transfusion reactions:
Verify prescription.
Test donor’s and recipient’s blood for compatibility.
Examine blood bag for identification.
Check expiration date.
Inspect blood for discoloration, gas bubbles, or cloudiness. Transfusion Therapy Hemophilia A (classic hemophilia) is deficiency of factor VIII and accounts for 80% of cases.

Hemophilia B (Christmas disease) is deficiency of factor IX and accounts for 20% of cases. Hemophilia Rare disorder; platelets clump together abnormally in the capillaries, and too few platelets remain in circulation
Inappropriate clotting yet blood fails to clot properly when trauma occurs
Treatment—plasmapheresis, fresh frozen plasma, aspirin, alprostadil, plicamycin, and immunosuppressive therapy Thrombotic Thrombocytopenic Purpura (TTP) Drug therapy—corticosteroids, azathioprine, IV immunoglobulin, IV anti-Rho, or low doses of chemotherapy
Platelet transfusions
Maintaining a safe environment
Surgical management ITP: Interventions Also called idiopathic thrombocytopenic purpura (ITP).
Total number of circulating platelets is greatly reduced even though production in the bone marrow is normal.
Patients make an antibody directed against the surface of their own platelets. Autoimmune Thrombocytopenic Purpura PLATELET DISORDERS Chemotherapy
Autologous stem cell transplant
Analgesics
Alternative approaches for pain management
Bisphosphonates Interventions for MM 20% have no symptoms at time of Dx
Elevation of serum total protein or detection of monoclonal protein in blood or urine
Fatigue, anemia, bone pain, pathologic fx’s, recurrent bacterial infections, renal dysfunction
Diagnosis: x-ray findings of bone loss that resemble Swiss cheese, along with labs Assessment of MM White blood cell cancer that involves a more mature lymphocyte called a plasma cell
MM cells produce exxcess cytokines that increase cancer cell growth rates and destroy bone
12,000 deaths per year in US
Median age at time of dx is 65 years of age Multiple Myeloma (MM) All lymphoid cancers that do not have the Reed-Sternberg cell
More than 12 types of non-Hodgkin’s lymphoma Non-Hodgkin’s Lymphoma One of the most treatable types of cancer
External radiation
Chemotherapy
Combination radiation and chemotherapy Hodgkin’s Lymphoma: Interventions Cancer that starts in a single lymph node or a single chain of nodes
Marker—Reed-Sternberg cell
Large, painless lymph node, usually in the neck, becomes painful when alcohol ingested; fever, drenching night sweats, and unexplained weight loss
Staging (p. 913 chart 42-3) Hodgkin’s Lymphoma Nursing diagnosis: Fatigue and activity intolerance

Goal: Participation in self-care and recognition of symptoms of fatigue to alter activity when needed Plan of Nursing Care Nursing diagnosis: Risk for Injury (bleeding problems)

Goal: Maintenance of H/H (WNL)
Absence of frank bleeding, petechiae, or echymosis

See chart 42-12 Plan of Nursing Care A staging system for the skin involvement in acute GVHD has been outlined as follows
Stage 1 - Involvement of less than 25% of the body surface
Stage 2 - Involvement of 25-50% of the body surface
Stage 3 - Involvement of 50-100% of the body surface (erythroderma)
Stage 4 - Vesicles and bullae GVHD Success is greatly influenced by nursing care throughout the transplant process
Patients are at high risk for dying from sepsis and bleeding
Ongoing assessment necessary for late complications (post 100 days)
Varicella zoster, pulmonary abnormalities, chronic GVHD, psychosocial needs
Caring for donors
Mood alterations, decrease self-esteem, guilt if transplant fails Nursing Management in BMT Bone Marrow Transplantation Infection is a major cause of death in the patient with leukemia, and sepsis is a common complication.
Autocontamination
Cross-contamination
Drug therapy
Hematopoietic stem cell transplantation Leukemia Interventions: Risk for Infections Decreased hemoglobin and hematocrit levels
Low platelet count
Abnormal white blood cell count; may be low, normal, or elevated but is usually quite high
Bone marrow aspiration and biopsy
Blood-clotting times
Chromosome analysis
Imaging assessment Leukemia: Laboratory Assessment Anxious
Fearful
Boredom
Loneliness
Isolation
Financial stress
Ineffecive coping Psychosocial assessment WBC differential (look at bands vs segs) for risk of infection – ask about fevers, colds, pneumonia etc.

Thrombocytopenia – ask about bruising/bleeding

Anemia – ask about weakness & fatigue, HA, decreased alertness, loss of appetite Assessment Chronic Mylogenous Leukemia (CML)
Accounts for 20%
Occurs mostly in those 50 years & older
3 phases: chronic, accelerated, blast Main Types Acute Mylogenous Leukemia (AML)
Most common form of adult-onset

Acute Lymphocytic Leukemia (ALL)
10% of adult-onset but most common in children Main Types Lymphocytic or lymphoblastic – leukemic cells coming from the lymphoid pathways

Myelocytic or myelogenous – abnormal cells from the myeloid pathways Leukemia – classified by cell type Ionizing radiation
Chemicals and drugs
Bone marrow hypoplasia
Genetic factors
Immunologic factors
Accounts for 2% of new and 4% of all deaths in US
44,000 new cases of leukemia each year Leukemia – Etiology/Incidence Unlike red blood cells, white blood cells (WBCs) have nuclei and other organelles, but they lack hemoglobin
White blood cells, a.k.a. leukocytes, are responsible for:
defending the body against
infection
foreign cells
toxins
assisting in the cleanup and repair of damage tissues Basic Info Excessive growth of immature leukocytes in bone morrow stops normal bone marrow production of RBCs, platelets U mature leukocytes

Immature cells (bands) cannot provide infection protection Leukemia in stem cells Type of cancer with uncontrolled production of immature white blood cells in the bone marrow (blasts)

Acute - sudden onset & short duration

Chronic – slow onset & symptoms persist for years Leukemia Leukocytes Disorders: Leukemias Leukemia refers to cancerous conditions involving white blood cells
Leukemias are named according to the abnormal white blood cells involved
Myelocytic leukemia – involves myeloblasts
Lymphocytic leukemia – involves lymphocytes
Acute leukemia involves blast-type cells and primarily affects children
Chronic leukemia is more prevalent in older people Hormonally regulated by cytokines – 2 types
Interleukins & colony stimulating factors (CSFs)
Interleukins are numbered (e.g., IL-1, IL-2), whereas CSFs are named for the WBCs they stimulate (e.g., granulocyte-CSF stimulates granulocytes)
Macrophages & T lymphocytes are most important source (agranulocytes)
Released in response to specific chemical signals
Granulocyte:erythrocyte production = 3:1
Granulocytes live 0.5-9days Leukopoiesis 2nd in WBC population
20-30% of WBC’s
Some in blood/most in “lymph”
T Lymphocytes – vs virus/tumor cells
B Lymphocytes – produce antibodies to be released to blood
Give rise to plasma cells
NK (natural killer) Cells – immune surveillance Lymphocytes 0.5% total WBCs
Are functionally similar to mast cells
Cells produce histamine (vasodilator)
Bind to IgE w/allergic reactions
Initiate inflammation
Cells also contain heparin (anticoagulant) Basophils Lobulated nucleus
Polymorphonuclear cells (PMNs)
Most numerous WBC (50-70% of WBC population)
Granules have lysosomal enzymes & bactericides
Chemically attracted to sites of inflammation & are active phagocytes
Release prostaglandins/leukotrienes
Bacteria slayers…increased w/bacterial infections Neutrophils Agranulocytes
No noticeable staining granules
Have spherical (lymphocytes) or kidney-shaped (monocytes) nuclei

Lymphocytes
Monocytes Granulocytes
Staining granules present
Roughly spherical
Lobed nuclei
Are all phagocytic cells

Neutrophils
Eosinophils
Basophils Leukocytes, cont. Leukocytes from greatest [ ] to least
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils Never Let Monkeys Eat Bananas 6,000-9,000/mm3 blood
<1% of total blood volume
Provide protection from infection and cancer development Leukocytes WBC (leukocytes) – provide protection from infection and cancer development

Protection depends on maintaing normal numbers and rations of different mature, circulating WBCs WHITE BLOOD CELL DISORDERS Marsha Woodall MBA, MSN, RN Assessment and Care of Patients White Blood Cell Disorders Chapter 41 and 42 Collection and infusion of patient’s own blood
Eliminates compatibility problems; reduces risk for transmission of bloodborne disease
Types:
Preoperative
Acute normovolemic hemodilution
Intraoperative autologous transfusion
Postoperative blood salvage Autologous Blood Transfusion Monitor for excessive bleeding from minor cuts, bruises, or abrasions.
Joint and muscle hemorrhages can lead to disabling long-term problems.
Tendency to bruise easily.
Prolonged and potentially fatal hemorrhage after surgery. Hemophilia: Collaborative Care Chemotherapy
Monoclonal antibodies
Localized radiation therapy
Radiolabeled antibodies
Hematopoietic stem cell transplantation
Vaccine therapy
Proteasome inhibitors Non-Hodgkin’s Lymphoma: Collaborative Care Stem cell transplantation by apheresis
Allogeneic (from unrelated donor)
for disease of the bone marrow
Risks: GVHD, sepsis, bleeding
Autologous (from self)
done if no match and/or healthy bone marrow
Risks: infection, toxicities
Syngeneic (from identical twin)
fewer complications / no marrow rejection Bone Marrow Transplantation Nursing diagnosis: Risk for infection related to decreased immune response

Goal: Prevention of infection

See chart 42-11 Plan of Nursing Care Cardiovascular changes
Respiratory changes
Skin changes
Intestinal changes
Central nervous system changes
Miscellaneous changes Leukemia: Clinical Manifestations Leukemia Immature white blood cells are found in the bloodstream in all leukemias
Bone marrow becomes totally occupied with cancerous leukocytes
The white blood cells produced, though numerous, are not functional
Death is caused by internal hemorrhage and overwhelming infections
Treatments include irradiation, antileukemic drugs, and bone marrow transplants 2-8% of WBCs
Largest in size of all WBCs
Differentiate into macrophages
Increase w/ chronic infections, viruses, and some bacterial parasites
Activate lymphocytes to mount immune response
Secrete substances that attract immune system cells and fibroblasts to injured area Monocytes 2-4% of all WBCs
Function against parasitic worms too large to be phagocytized by other immune cells
Lessen the severity of allergies with enzymes that counteract inflammatory effects of neutrophils and mast cells Eosinophils Sources from beyond2000.com Sources from Arginine.umdnj.edu White Cell Platelet Red Cell Blasts Blood with leukemia Platelet Red Cell White Cell Normal human blood Pictures Of Blood Collection and infusion of patient’s own blood
Eliminates compatibility problems; reduces risk for transmission of bloodborne disease
Types:
Preoperative
Acute normovolemic hemodilution
Intraoperative autologous transfusion
Postoperative blood salvage Autologous Blood Transfusion Red blood cell
Platelet
Plasma—fresh frozen plasma
Cryoprecipitate
Granulocyte (white cell) Types of Transfusions Transfusions Provide patient education.
Assess vital signs.
Begin transfusion slowly, and stay with patient first 15 to 30 minutes.
Ask patient to report unusual sensations such as chills, shortness of breath, hives, or itching.
Administer blood product per protocol.
Assess for hyperkalemia. Transfusion Responsibilities Pretransfusion responsibilities to prevent adverse transfusion reactions:
Verify prescription.
Test donor’s and recipient’s blood for compatibility.
Examine blood bag for identification.
Check expiration date.
Inspect blood for discoloration, gas bubbles, or cloudiness. Transfusion Therapy Monitor for excessive bleeding from minor cuts, bruises, or abrasions.
Joint and muscle hemorrhages can lead to disabling long-term problems.
Tendency to bruise easily.
Prolonged and potentially fatal hemorrhage after surgery. Hemophilia: Collaborative Care Hemophilia A (classic hemophilia) is deficiency of factor VIII and accounts for 80% of cases.

Hemophilia B (Christmas disease) is deficiency of factor IX and accounts for 20% of cases. Hemophilia Rare disorder; platelets clump together abnormally in the capillaries, and too few platelets remain in circulation
Inappropriate clotting yet blood fails to clot properly when trauma occurs
Treatment—plasmapheresis, fresh frozen plasma, aspirin, alprostadil, plicamycin, and immunosuppressive therapy Thrombotic Thrombocytopenic Purpura (TTP) Drug therapy—corticosteroids, azathioprine, IV immunoglobulin, IV anti-Rho, or low doses of chemotherapy
Platelet transfusions
Maintaining a safe environment
Surgical management ITP: Interventions Also called idiopathic thrombocytopenic purpura (ITP).
Total number of circulating platelets is greatly reduced even though production in the bone marrow is normal.
Patients make an antibody directed against the surface of their own platelets. Autoimmune Thrombocytopenic Purpura PLATELET DISORDERS Chemotherapy
Autologous stem cell transplant
Analgesics
Alternative approaches for pain management
Bisphosphonates Interventions for MM 20% have no symptoms at time of Dx
Elevation of serum total protein or detection of monoclonal protein in blood or urine
Fatigue, anemia, bone pain, pathologic fx’s, recurrent bacterial infections, renal dysfunction
Diagnosis: x-ray findings of bone loss that resemble Swiss cheese, along with labs Assessment of MM White blood cell cancer that involves a more mature lymphocyte called a plasma cell
MM cells produce exxcess cytokines that increase cancer cell growth rates and destroy bone
12,000 deaths per year in US
Median age at time of dx is 65 years of age Multiple Myeloma (MM) Chemotherapy
Monoclonal antibodies
Localized radiation therapy
Radiolabeled antibodies
Hematopoietic stem cell transplantation
Vaccine therapy
Proteasome inhibitors Non-Hodgkin’s Lymphoma: Collaborative Care All lymphoid cancers that do not have the Reed-Sternberg cell
More than 12 types of non-Hodgkin’s lymphoma Non-Hodgkin’s Lymphoma One of the most treatable types of cancer
External radiation
Chemotherapy
Combination radiation and chemotherapy Hodgkin’s Lymphoma: Interventions Nursing diagnosis: Fatigue and activity intolerance

Goal: Participation in self-care and recognition of symptoms of fatigue to alter activity when needed Plan of Nursing Care A staging system for the skin involvement in acute GVHD has been outlined as follows
Stage 1 - Involvement of less than 25% of the body surface
Stage 2 - Involvement of 25-50% of the body surface
Stage 3 - Involvement of 50-100% of the body surface (erythroderma)
Stage 4 - Vesicles and bullae GVHD Success is greatly influenced by nursing care throughout the transplant process
Patients are at high risk for dying from sepsis and bleeding
Ongoing assessment necessary for late complications (post 100 days)
Varicella zoster, pulmonary abnormalities, chronic GVHD, psychosocial needs
Caring for donors
Mood alterations, decrease self-esteem, guilt if transplant fails Nursing Management in BMT Stem cell transplantation by apheresis
Allogeneic (from unrelated donor)
for disease of the bone marrow
Risks: GVHD, sepsis, bleeding
Autologous (from self)
done if no match and/or healthy bone marrow
Risks: infection, toxicities
Syngeneic (from identical twin)
fewer complications / no marrow rejection Bone Marrow Transplantation Infection is a major cause of death in the patient with leukemia, and sepsis is a common complication.
Autocontamination
Cross-contamination
Drug therapy
Hematopoietic stem cell transplantation Leukemia Interventions: Risk for Infections Decreased hemoglobin and hematocrit levels
Low platelet count
Abnormal white blood cell count; may be low, normal, or elevated but is usually quite high
Bone marrow aspiration and biopsy
Blood-clotting times
Chromosome analysis
Imaging assessment Leukemia: Laboratory Assessment Anxious
Fearful
Boredom
Loneliness
Isolation
Financial stress
Ineffecive coping Psychosocial assessment WBC differential (look at bands vs segs) for risk of infection – ask about fevers, colds, pneumonia etc.

Thrombocytopenia – ask about bruising/bleeding

Anemia – ask about weakness & fatigue, HA, decreased alertness, loss of appetite Assessment Chronic Mylogenous Leukemia (CML)
Accounts for 20%
Occurs mostly in those 50 years & older
3 phases: chronic, accelerated, blast Main Types Acute Mylogenous Leukemia (AML)
Most common form of adult-onset

Acute Lymphocytic Leukemia (ALL)
10% of adult-onset but most common in children Main Types Lymphocytic or lymphoblastic – leukemic cells coming from the lymphoid pathways

Myelocytic or myelogenous – abnormal cells from the myeloid pathways Leukemia – classified by cell type Ionizing radiation
Chemicals and drugs
Bone marrow hypoplasia
Genetic factors
Immunologic factors
Accounts for 2% of new and 4% of all deaths in US
44,000 new cases of leukemia each year Leukemia – Etiology/Incidence Unlike red blood cells, white blood cells (WBCs) have nuclei and other organelles, but they lack hemoglobin
White blood cells, a.k.a. leukocytes, are responsible for:
defending the body against
infection
foreign cells
toxins
assisting in the cleanup and repair of damage tissues Basic Info Excessive growth of immature leukocytes in bone morrow stops normal bone marrow production of RBCs, platelets U mature leukocytes

Immature cells (bands) cannot provide infection protection Leukemia in stem cells Type of cancer with uncontrolled production of immature white blood cells in the bone marrow (blasts)

Acute - sudden onset & short duration

Chronic – slow onset & symptoms persist for years Leukemia Leukocytes Disorders: Leukemias Leukemia refers to cancerous conditions involving white blood cells
Leukemias are named according to the abnormal white blood cells involved
Myelocytic leukemia – involves myeloblasts
Lymphocytic leukemia – involves lymphocytes
Acute leukemia involves blast-type cells and primarily affects children
Chronic leukemia is more prevalent in older people Hormonally regulated by cytokines – 2 types
Interleukins & colony stimulating factors (CSFs)
Interleukins are numbered (e.g., IL-1, IL-2), whereas CSFs are named for the WBCs they stimulate (e.g., granulocyte-CSF stimulates granulocytes)
Macrophages & T lymphocytes are most important source (agranulocytes)
Released in response to specific chemical signals
Granulocyte:erythrocyte production = 3:1
Granulocytes live 0.5-9days Leukopoiesis 2nd in WBC population
20-30% of WBC’s
Some in blood/most in “lymph”
T Lymphocytes – vs virus/tumor cells
B Lymphocytes – produce antibodies to be released to blood
Give rise to plasma cells
NK (natural killer) Cells – immune surveillance Lymphocytes 2-4% of all WBCs
Function against parasitic worms too large to be phagocytized by other immune cells
Lessen the severity of allergies with enzymes that counteract inflammatory effects of neutrophils and mast cells Eosinophils Agranulocytes
No noticeable staining granules
Have spherical (lymphocytes) or kidney-shaped (monocytes) nuclei

Lymphocytes
Monocytes Granulocytes
Staining granules present
Roughly spherical
Lobed nuclei
Are all phagocytic cells

Neutrophils
Eosinophils
Basophils Leukocytes, cont. Leukocytes from greatest [ ] to least
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils Never Let Monkeys Eat Bananas 6,000-9,000/mm3 blood
<1% of total blood volume
Provide protection from infection and cancer development Leukocytes WBC (leukocytes) – provide protection from infection and cancer development

Protection depends on maintaing normal numbers and rations of different mature, circulating WBCs WHITE BLOOD CELL DISORDERS Marsha Woodall MBA, MSN, RN Assessment and Care of Patients White Blood Cell Disorders Chapter 41 and 42 Febrile transfusion reactions
Hemolytic transfusion reactions
Allergic transfusion reactions
Bacterial transfusion reactions
Circulatory overload
Transfusion-associated graft-versus-host disease Transfusion Reactions Cancer that starts in a single lymph node or a single chain of nodes
Marker—Reed-Sternberg cell
Large, painless lymph node, usually in the neck, becomes painful when alcohol ingested; fever, drenching night sweats, and unexplained weight loss
Staging (p. 893 chart 42-3) Hodgkin’s Lymphoma Nursing diagnosis: Risk for Injury (bleeding problems)

Goal: Maintenance of H/H (WNL)
Absence of frank bleeding, petechiae, or echymosis

See chart 42-8 Plan of Nursing Care Bone Marrow Transplantation Nursing diagnosis: Risk for infection related to decreased immune response

Goal: Prevention of infection

See chart 42-7 Plan of Nursing Care Cardiovascular changes
Respiratory changes
Skin changes
Intestinal changes
Central nervous system changes
Miscellaneous changes Leukemia: Clinical Manifestations Leukemia Immature white blood cells are found in the bloodstream in all leukemias
Bone marrow becomes totally occupied with cancerous leukocytes
The white blood cells produced, though numerous, are not functional
Death is caused by internal hemorrhage and overwhelming infections
Treatments include irradiation, antileukemic drugs, and bone marrow transplants 2-8% of WBCs
Largest in size of all WBCs
Differentiate into macrophages
Increase w/ chronic infections, viruses, and some bacterial parasites
Activate lymphocytes to mount immune response
Secrete substances that attract immune system cells and fibroblasts to injured area Monocytes Lobulated nucleus
Polymorphonuclear cells (PMNs)
Most numerous WBC (50-70% of WBC population)
Granules have lysosomal enzymes & bactericides
Chemically attracted to sites of inflammation & are active phagocytes
Release prostaglandins/leukotrienes
Bacteria slayers…increased w/bacterial infections Neutrophils 0.5% total WBCs
Are functionally similar to mast cells
Cells produce histamine (vasodilator)
Bind to IgE w/allergic reactions
Initiate inflammation
Cells also contain heparin (anticoagulant) Basophils Sources from beyond2000.com Sources from Arginine.umdnj.edu White Cell Platelet Red Cell Blasts Blood with leukemia Platelet Red Cell White Cell Normal human blood Pictures Of Blood Questions to ask:
Physiological questions
Family history
Genetic history
Work history
Environmental hazards
Nutritional status Which laboratory and diagnostic tests would the nurse anticipate? The patient is a 56-year-old woman who has been recently diagnosed with AML. Her past medical history includes breast cancer at 42 years of age, for which she was treated with lumpectomy, chemotherapy, and radiation. She also has hypertension. She is admitted to your unit to begin induction chemotherapy.
1. What risk factors would predispose this patient to development of AML?
2. What are some of the physical findings you would expect to see when examining her?
3. What abnormalities would you expect when reviewing her laboratory tests and bone marrow biopsy?
4. What routine vital signs and assessments could be delegated to an LPN/LVN and to a PCA? DECISION-MAKING CHALLENGE: The patient is a 56-year-old woman who has been recently diagnosed with AML. Her past medical history includes breast cancer at 42 years of age, for which she was treated with lumpectomy, chemotherapy, and radiation. She also has hypertension. She is admitted to your unit to begin induction chemotherapy.
1. What risk factors would predispose this patient to development of AML?
2. What are some of the physical findings you would expect to see when examining her?
3. What abnormalities would you expect when reviewing her laboratory tests and bone marrow biopsy?
4. What routine vital signs and assessments could be delegated to an LPN/LVN and to a PCA? DECISION-MAKING CHALLENGE: Delegation/Supervision Malignant Lymphomas PLATELET DISORDERS The client is receiving a unit of packed red blood cells. Vital signs are stable 15 minutes into the infusion, and the states he feeling fine, just a little cold. The nurse tells him that the blood and fluid being infused are cooler than body temperature and that is probably what is making him feel cold. When the nurse returns returns 45 minutes later, the client is shaking with chills. His pulse is rapid and thready and his blood pressure is 88/40, a change from the 122/76 obtained at the last check. What is the nurse’s priority first action?

A.  Increase the infusion rate
B.  Stop the blood transfusion
C.  Call the rapid response team
D.  Continue the infusion but at a slower rate NCLEX EXAMINATION CHALLENGE A 7-year old girl who is brought in to her physician by her mother with complaints of general fatigue, anorexia, and unexplained bruises and “rash” for the past 2 weeks

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