[Lebo_Angel]

Mr John Brown is a 29 year old male, 170cm tall and weighs 70kgs. Drinks and smokes socially and is not currently taking any medications. Past history of Von Willebrand's Disorder and is allergic to shellfish. He presented to emergency via ambulance after fracturing his right tibia skiing yesterday, and is booked for an open reduction and internal fixation later this afternoon. Plaster of paris back slab currently insitu and lower leg has moderate swelling. IV inserted into right arm and neurovascular observations taken 4/24.
Medical team has ordered 4/24 PRN morphine 7.5 IV for pain relief, current pain score 2/10. Six (6) units of platelets has also be ordered and to be given prior to theatre. Commenced on 12/24 Ceftriaxone 1g IV with the first does given. Baseline observations are as follows; HR 84bpm, BP 135/80mmHg, RR 16, T 36.2°C, SpO2 99%. All platelet infusion checking completed according to correct policy and procedure, bag intact. Giving set primed with normal saline and commenced.
Ten minutes into the infusion Mr. Brown complained of back pain and feeling itchy. A new set of observations revealed the following; HR 86bpm, BP 130/80mmHg, RR 20, T 37.1°C, SpO2 98%.
On further investigation John informs you that he is experiencing significant pain in his back which was not there prior to the infusion. The pain has lasted for 5 minutes does not radiate anywhere and he describes it as a dull ache in his lower back. Nothing appears to relive the pain. His leg pain is at 3/10 from movement and he expresses no change in the characteristics of the pain in his leg. John is complaining of feeling itchy.
John informs you that he remembers having this antibiotic before on another hospital admission and he did not have a reaction to it at that time.
You cease the transfusion and recheck the blood product with a colleague to ensure it is correct.
On inspection John's airway is patent and he appears flushed. John has small red urticaria on his chest, back and neck. He is scratching at his chest and neck. John is holding his lower back, is restless and unable to lie still.
Assessment of respiratory fields indicates air entry is equal with no adventitious sounds. Neurological assessment indicates a GCS of 15. The medical officer is informed of the assessment findings and after reviewing John he diagnoses an allergic reaction to the blood product transfusion. He orders 12.5 mg Phenergan IV and 1 gram Panadol IV for lower back pain. He orders that the transfusion to be recommenced slowly If the symptoms of the reaction subside in 30 minutes.
You commence normal saline 0.9% IV as ordered and administer the medications. You obtain blood and urine samples as per protocol and send specimens to blood bank for testing. You complete the relevant documentation. In 30 minutes John symptoms have resolved and the infusion is slowly recommenced.

[Fr_Chuck]

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[Lebo_Angel]

I have found the below information however I am worried that I may have missed something more important.
Mr Brown is at risk of acute pain related to his acute heamolotic reaction and right tibial fracture indicated by his lower back caused by the acute haemolytic reaction from the blood transfusion and the acute pain from the fracture of this right tibia which has most likely caused direct irritation to the nerve endings by chemical mediators released at the site thus sending signals to the cortex and thalamus of the brain producing pain perception.
Mr Brown is at risk of respiratory distress and infection that may lead to the worst case scenario of arrest related to secretion build up in the lungs related to his past history of social smoking, acute pain, decreased mobility, drug therapies, impaired gas exchange and a build up of carbon dioxide in his blood which could lead to acid-imbalances (hypercapnia) due to possible complications and reactions from the blood transfusion.
Mr Brown is at risk of infection related to the break in the continuity of the first line of defence which is the skin due to his IV line allowing easy access for pathogens to invade the bodies systems thus increasing his risk of infection and increasing the risk of internal bleeding related to his right tibial fracture and possible internal tissue trauma.
Mr Brown is at risk of fluid and electrolyte imbalance, hypo-volemeia, dehydration and constipation related to his pre-op fasting, nil oral intake, medications, possible internal bleeding.
Mr Brown is at risk of possible kidney complications and acute lung injury related to her acute pain, drug therapy, horizontal positioning and lack of skeletal muscle activity.
Mr Brown is at risk of the absence of or decreased intestinal peristalsis and constipation related to the disruption to his pattern of food and fluid intake and skeletal muscle activity.
Mr Brown is at risk of hygiene self care deficit related to impaired mobility and may be unable to attend to his hygiene needs due to decreased mobility related to his right tibial fracture and acute pain related to his haemolytic reaction.
Mr Brown is at risk of impaired tissue integrity related to the his impaired mobility due to his right tibial fracture and possible tissue damage caused by his right tibial fracture.
Mr Brown is at risk of possible knowledge, understanding and education deficits related to the complex and specific nature of his current presenting medical condition and past medical conditions.
Ms. Olcay is at risk of impaired individual resilience and increased stress and anxiety related to his current medical condition, complications arisen from his treatment, prolonged stay in hospital and being away from his home, work and social environments.
Mr Brown is at risk of situational low self-esteem and disturbed body image related to his current medical condition, change of familiar environment, extended hospital stay and his inability to maintain his work, family, social and other cultural or religious commitments in the very near future.

[Lebo_Angel]

Also...
My first diagnosis is that due to Mr. Brown's current complaints of back pain, past history of Von Willebrand's Disorder, right tibial fracture and the recent changes in his vital signs; increase in T, HR and RR and a small drop in his BP and O2 saturation he may be suffering from an acute haemolytic immune reaction. Data to support this is best described by The New York Health Times (2011), explaining that the reaction is caused by one's own immune system recognising the blood product as not its own, therefore identifying and destroying the foreign platelets. Mr. Brown's Von Willebrand's Disorder may require him to have or have had regular blood transfusions, therefore making his immune system antibodies more concentrated and ready to attack and destroy future infusions (Goldman, 2008; Mannucci, 2011; Bruce M. S. 2006). Lastly Reikeras, 2010 states that an imbalance between the early systemic inflammatory response syndrome and the later compensatory anti-inflammatory response syndrome caused by the right tibial fracture may be responsible for organ dysfunction and increase susceptibility to infections.

INTERVENTIONS:
• Baseline obs
• IV insitu-at least 19 G needle as 23 G impedes flow & could cause hemolysis
• Equip nearby-eg. O2, adrenaline, resuscitation
• 1 of the checkers must hang the bag
• 30 minute & 4 hour rule
• Reactions can occur within few minutes or hours
• First 15 minutes stay in room with patient
• Generally T,P,R,BP 15minutes 1 hr, then ½ hrly
• Educate patient to self report

My second diagnosis is that due to Mr. Brown's current fever he may be suffering from a febrile non-haemolytic reaction. Data to support this is his recent temperature rise and changed in other vital signs. According to Blumberg, N. Kaufman, J. & Phipps, P. P. (2001) an inflammatory reaction is one of the most common reactions to platelet transfusions, occurring in more than 30% of transfusions and increasing a patients fever. There is also good evidence that shows the association between high concentrations of platelet-derived cytokines and leukocyte in stored platelets with FNHTR (Blumberg N. P. 2011; Brittingham, 2011).
My third diagnosis is that due to Mr. Brown's current complaints of feeling itchy as well as the increase in his HR, RR and T and a small drop in his BP and O2 sats, he is likely to be suffering from an acute allergic reaction. Data to support this is that an allergic reaction is very common with platelet infusions and is mediated by the response of the patient's antibodies to the donor platelets, therefore setting off a change in vitals accompanied with a rash that usually resolves with antihistamines (Bakdash, 2007; Blood Transfusion, 2010; Transfusion adverse reactions, 2011).
My forth diagnosis is that due to Mr. Brown's current change in his baseline observations and his complaints of feeling itchy and having a sore back he may be suffering from the adverse effects of acute transfusion associated sepsis, better known as bacterial contamination of the platelet infusion. Data to support this includes reports of increasing bacterial sepsis associated with the incorrect and prolonged storage of platelets at room temperature (Barbeyrac, 2001; Arduino, 2008; Shrivastava, 2009; Champion, 2009; Eder A. F. 2010). As sighted in Mathai (2009) & Beckers, E. A. M. Blajchman, M. A. ****meiss, E. Lin, L. Moore, R. & Muylle, L. (2005) it was noted that an estimated 5% of blood that had been stored for 10 days at 4-6°C were grossly contaminated.
My fifth diagnosis is that due to Mr. Brown's current right tibia fracture, moderate lower leg swelling and past history of Von Willebrand's Disorder he is likely to be suffering from acute compartment syndrome. Data to support this includes research indicating that compartment syndrome may take place in any osteofascial compartment after injury and occurs in 1–9% of tibial shaft fractures and is the most common type (Porter, 2006; Hessmann, 2007). And according to Badhe, S. Baiju, D. Calthorpe, D. Elliot, R. & Rowles, J. (2008) although pain is considered to be one of the earliest and most reliable symptoms of compartment syndrome there have been reported cases of patients presenting with silent compartment syndrome without any significant pain following a tibial plateau fracture.
My sixth and final diagnosis is due to Mr. Brown's current change in his baseline vital signs and his complaints of itching and back pain he may be suffering from an acute adverse drug interaction. Data to support this include studies that found a strong negative correlation between blood products, in particular platelet and ceftriaxone (Ackley, B. J. & Ladwig, G. B. 2008; Bruce L. C. 2009).
In order to validate or negate the above hypothesis I would ask the following questions. Firstly I would ask Mr. Brown how he is feeling, and if there are any other symptoms that he is experiencing. In relation to his temperature I would ask him if he was feeling hot, needed cool drink or would like a cool breeze from an open window. I would as Mr. Brown if he has previously had any blood transfusions and if so any adverse reactions. I would then go on to obtaining consent to having his bloods and urine collected. I would also ask him if he was uncomfortable, and reposition him (Browns, D. & Edwards, H. 2010; Crisp, J. & Taylor, C. 2009).
It is clear to see from the above diagnoses and supporting evidence that there are many different possible reactions that may occur whilst providing patient care and administering treatment therefore it is of the upmost importance that the care providers familiarise themselves with their patient, their medical conditions and treatments in order for the care and treatment to be successful. The above information will also help with gaining an understanding of what complications may arise and what questions and courses of action need to be taken.