skill 15-6 blood transfusion

Home transfusion is not appropriate for patients who are ________ or _____________.

(1) actively bleeding (2) recently had a reaction to a blood transfusion

What are the equipment you should bring in for a blood transfusion?

1) Blood product 2) Blood administration set (tubing with in-line filter, or add-on filter, and Y for saline administration) 3) 0.9% normal saline for IV infusion 4) IV pole 5) Venous access; if peripheral site, initiated with a 20- to 24-gauge catheter (adults) 6) Alcohol or other disinfectant wipes 7) Clean gloves 8) Additional PPE, as indicated 9) Tape (hypoallergenic) 10) Second registered nurse, other licensed practitioner (hospital/outpatient setting), or responsible adult (home setting) to verify blood product and patient information (INS, 2016b)

What are some nursing diagnosis?

1) Risk for injury 2) Excess fluid volume 3) Decreased cardiac output

Albumin Filter? Rate of Administration? ABO compatibility? Doubled checked by two licensed practitioners?

1) Yes 2) 1-10 ml/min (5%) 0.2-0.4 ml/min (25%) 3) No 4) No

Fresh Frozen Plasma Filter? Rate of Administration? ABO compatibility? Doubled checked by two licensed practitioners?

1) Yes 2) 15-30 or as quickly as tolerated 3) Yes 4) Yes

Platelets Filter? Rate of Administration? ABO compatibility? Doubled checked by two licensed practitioners?

1) Yes 2) Over 30-60 minutes or as quickly as the patient can tolerated 3) No 4) Yes

Packed Red blood cells: Filter? Rate of administration? ABO compatibility? Double-checked by 2 licensed practitioners?

1) Yes. 2) 1 unit over 2-3 hours; no longer than 4 3) Yes. 4) Yes.

Cryoprecipitate Filter? Rate of Administration? ABO compatibility? Doubled checked by two licensed practitioners?

1) Yes. 2) 30-60 mins or as quickly as tolerated 3) Recommended 4) Yes

Allergic reaction What is it? Signs and symptoms? (3) Nursing

1) allergy to transfused blood 2) hives, itching, anaphylaxis 3) Stop tranfusion immediately & keep vein open with normal saline, notify primary care provider stat, administer antihistamine parenterally

Bacterial reaction What is it? Signs and symptoms? Nursing?

1) bacteria present in blood 2) fever, hypertension, dry, flushed skin, abdominal pain 3) stop infusion immediately, obtain culture of pt blood, vitals, notify PCP, administer antibiotics

Hemolytic transfusion Reaction What is it? Signs and symptoms? (6) Nursing? (6)

1) incompatibility of blood product 2) immediate onset, facial flushing, fever & chills, headache, low back pain, shock 3) Stop infusion immediately and keep vein open with normal saline. -Notify primary care provider stat. -Obtain blood samples from site & first voided urine -Treat shock if present. -Send unit, tubing, and filter to laboratory. -Draw blood sample for serologic testing and send urine specimen to the laboratory.

What should we asses prior to administering blood?

1) most recent CBC 2) any previous blood transfusions- #, reaction 3) IV insertion site 4) vital signs, lung assessment

What should we document regarding blood transfusions? (8)

1) pt received it 2) type of blood 3) pts condition thru out- vitals, lungs, subjective response 4) any complications 5) assessment of iv site 6) any other fluids 7) transfusion volume & other iv fluid intake

Circulatory overload What is it? Signs and symptoms? Nursing?

1) too much blood administered 2) dyspnea, dry cough, pulmonary edema 3) slow or stop infusion, monitor vitals, notify PCP, place in upright position w feet dependent

Pressure should not exceed

300 mm Hg

The nurse should stay with the patient for the first how many minutes?

5-15 min

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client's room to begin the transfusion?

Arrange for another nurse to monitor the nurse's other assigned clients.

Patient reports shortness of breath; on auscultation you note crackles bilaterally in the bases:

Compare vital signs and lung sounds with previous vital signs and lung sounds for this patient. Obtain a pulse oximetry reading. Notify the primary care provider. The primary care provider may order a dose of a diuretic or may decrease the rate of the transfusion. Continue to assess the patient for signs and symptoms of fluid overload.

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?

Discontinue the infusion and record the volume left in the blood bag.

True or false. We can warm blood in the microwave.

False. Use a blood-warming device, if indicated or ordered, especially with rapid transfusions through a CVAD. Blood warmers should also be used for large-volume transfusions, exchange transfusions, patients with clinically significant conditions, and the neonate/pediatric population

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply.

Name on the client's identification band, Number on the client's identification band

Patient experiences slight increase in temperature, but is exhibiting no other signs of a transfusion reaction:

Notify the primary care provider. The primary care provider may order an antipyretic and an antihistamine for the patient.

Patient is febrile (temperature increase of 2°F), tachycardic, and complaining of headache and/or back pain:

Patient is having a transfusion reaction. Stop the transfusion immediately. Obtain the new IV tubing with 0.9% sodium chloride. Notify the primary care provider and blood bank. Administer medications as prescribed. Send blood unit, tubing, and filter to the laboratory. Obtain additional diagnostic tests, such as blood and urine tests, based on facility policy.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Stop the transfusion and infuse normal saline using a new administration set.

Which finding best indicates to the nurse that the client has a therapeutic outcome from a blood transfusion?

The client has a steady gait while ambulating to void.

Serious life threatening transfusion reactions may occur if blood types don't match involving what?

clumping and hemolysis of the red blood cells and possibly death

When a rapid transfusion is required, a ______sized catheter gauge is recommended

larger. (14 to 18g)

autologous transfusion

occurs when a patient donates one's own blood for a transfusion

External compression devices, if used for rapid transfusions, should be equipped with a ___________________.

pressure gauge

At what rate should we start the administration?

slowly, 2 ml per min for the first 15 mins

blood transfusion

the infusion of whole blood or a blood component, such as plasma, red blood cells, cryoprecipitate, or platelets, into the patient's venous circulation

What are the expected outcomes? (2)

the patient receives the blood transfusion without any evidence of a transfusion reaction or complications. the patient exhibits signs and symptoms of fluid balance, improved cardiac output, and enhanced peripheral tissue perfusion.

Before a patient recieves a blood product, his/her blood must be?

typed to ensure that he/she receives compatible blood

Why is a blood transfusion given?

when a patient's red blood cells, platelets, or coagulation factors decrease to levels that compromise a patient's health.

When should we assess the patients vital signs/

within 5 to 15 mins after initiating the transfusion, after the transfusion and as needed depending on pt condition