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    NCM1-18 0122

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    This document provides guidelines for nursing management of blood transfusions. It outlines the necessary materials, procedures, observations, and documentation required. Key steps include verifying the doctor's order, blood type and cross-match, monitoring vital signs every 15 minutes for reactions, regulating the transfusion rate, and watching for signs of adverse reactions like fever, chills, rash or breathing difficulties which require stopping the transfusion. Proper refrigeration, expiration dates and aseptic technique are emphasized to prevent transfusion reactions and ensure patient safety.

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    NCM1-18 0122

    Uploaded by

    Cee
    120 views3 pages
    This document provides guidelines for nursing management of blood transfusions. It outlines the necessary materials, procedures, observations, and documentation required. Key steps include verifying the doctor's order, blood type and cross-match, monitoring vital signs every 15 minutes for reactions, regulating the transfusion rate, and watching for signs of adverse reactions like fever, chills, rash or breathing difficulties which require stopping the transfusion. Proper refrigeration, expiration dates and aseptic technique are emphasized to prevent transfusion reactions and ensure patient safety.

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    This document provides guidelines for nursing management of blood transfusions. It outlines the necessary materials, procedures, observations, and documentation required. Key steps include verifying the doctor's order, blood type and cross-match, monitoring vital signs every 15 minutes for reactions, regulating the transfusion rate, and watching for signs of adverse reactions like fever, chills, rash or breathing difficulties which require stopping the transfusion. Proper refrigeration, expiration dates and aseptic technique are emphasized to prevent transfusion reactions and ensure patient safety.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    120 views3 pages

    NCM1-18 0122

    Uploaded by

    Cee
    This document provides guidelines for nursing management of blood transfusions. It outlines the necessary materials, procedures, observations, and documentation required. Key steps include verifying the doctor's order, blood type and cross-match, monitoring vital signs every 15 minutes for reactions, regulating the transfusion rate, and watching for signs of adverse reactions like fever, chills, rash or breathing difficulties which require stopping the transfusion. Proper refrigeration, expiration dates and aseptic technique are emphasized to prevent transfusion reactions and ensure patient safety.

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    Nursing Mgt & Principles in Blood Transfusion 2.

    Ensure that the IV catheter is 18 or 19 gauge


     -Proper refrigeration 3. Use 0.9% NaCl
     -proper typing and cross matching 4. Verify the blood
     type O -universal donor 5. Take baseline vital signs
     type AB - universal recipient 6. Start transfusion slowly (KEEP VEIN OPEN - 10 drops/min)
     85% of people is Rh (+) positive 7. Stay with the client during the initial 15 minutes.
    8. Maintain the transfusion rate
    Concept  FWB = 3 to 4 hours
    1. Aseptic we assemble all materials needed:  PRBC = 2 to 4 hours
     filter set  FFP, platelets, cryoprecipitate - fast drip
     isotonic or PNSS or 0.9 NaCl to prevent hemolysis 9. Monitor adverse reaction
     Hypotonic solution -swell or burst 10. Document the following:
     Hypertonic solution - will shrink or crenate a. Blood component and number
     needle gauge 18 - 19 or large bore needle to prevent b. Infusion started and ended
    hemolysis. c. Client reaction

    2. Instruct another RN to re-check the following: Materials needed:


     patient's name 1. IV tray
     blood typing and Rh 2. Compatible BT set
     cross matching 3. IV catheter/needle gauge 18/19
     expiration date 4. Plaster
    5. Tourniquet
     serial number
    6. Blood product
    7. Plain NSS
    3. Check blood unit for presence of bubbles, cloudiness,
    8. IV stand
    dark in color and sediments - indicates bacterial
    9. Gloves
    contamination.
     Don't dispose, return to blood bank.
    Procedures and rationale
    1. Verify doctors order and make a treatment card *to avoid
    4. Never warm blood products - may destroy vital factors in
    mistakes.
    blood.
    2. Explain procedure to the client *to encourage client
     Warming is done if with warning device -only in
    operation and decrease anxiety of clients.
    emergency! For multiple blood transfusions!!
    3. Request blood/blood component from hospital blood
     What blood still within 30 minutes on room temp.
    bank to include blood typing and cost matching *to prevent
    only!
    untoward blood reaction.
    4. Warm-blooded at room temperature by wrapping the
    5. Blood transfusion should be completed <4 hours because
    blood back with a towel. Blood should be transfused not
    life that is exposed at room temp for more than 2 hours can
    more than 20 min. from the time it arrives from the blood
    start to deteriorate.
    bank *to prevent untoward look reaction.
    5. Have a doctor and a nurse counter check the compatible
    6. Avoid axing for administering drug at BT line - leads to
    blood to be transfused:
    hemolysis.
     name and identification number
     client's blood group and Rh type
    7. Regulate BT 10 - 15 gtts/min KVO or 100 cc/hr to prevent
     donor's blood group and Rh type
    circulatory overload.
     crossmatch compatibility
    8. Monitor VS before, during and after BT especially q15  blood unit and serial component
    mins (local board) for 1st hour.  expiration date of blood product
     NCLEX - q 15 min. for 1st 15 min.
     majority of BT reaction occurs within 1 hour. *To prevent any problem in relation to transfusion.

    Nursing care 6. Get baseline vital signs before transfusion *to compare
    1. Assess history of allergy any change in vital signs before entering BT.
    7. Give premed 30 minutes before transfusion is and he is  dyspnea
    ordered *to prevent minor allergic reactions.  palpitation and tachycardia
    8. Wash hands and don gloves *to prevent contamination of  lumber/sterna/flank pain
    microorganisms.  hypotension
    9. Prepare equipment needed *to facilitate intervention.  flushed skin
    10. Initiate an IV line with appropriate IV catheter with plain  (read) port wine urine.
    NSS, and or catheter properly and regulate rate *to flush out
    to big and keep IV open. Nursing management
    11. Open compatible aseptically & spike blood carefully;  stop BT-remove and change the tubing
    primed to being and remove bubbles *to prevent air  notify Dr.
    embolism.  flush with plain NSS
    12. Disinfect the Y injection and port of IV tubing and
     administer isotonic fluid solution to counteract shock
    inserted the needle from the BT administration sent and
     send blood units of blood bank for re-examination
    secured with adhesive tapes.
     obtain urine and blood sample and send to lab for
    13. Close IV fluid of plain NSS or regulates you KVO while
    re-examination
    transfusion is going on.
     monitor vital signs and allergic reaction
    14. Transfuse the blood (4 hours) by injection port at 10-15
    gtts. initially for 15 min. then regulate at ordered rate
    Allergic reactions-rashes and itchiness, dyspnea,
    *transfusion reaction occurs during the 1st 10 to 15 min. of
    bronchospasm due to sensitivity in foreign proteins in
    transfusion.
    plasma.
    15. Observe for any untoward s/s (flushed skin, chills,
    elevated temperature, itchiness, urticaria and dyspnea). If
    Signs and symptoms
    any occurs, STOP the transfusion, open IV line with NSS and
     fever/chills
    report to the physician *transfusion reaction occurs during
     Urticaria/pruritus
    the 1st 10 to 15 min. of transfusion.
    16. Swirl the bad ones in a hang *to mix the solid and liquid  dyspnea
    element of the blood, RBC which tends to settle at the  laryngospasm/bronchospasm
    bottom of the solution while the plasma rises to the top as  bronchial wheezing
    the blood bag hangs.
    17. If blood is consumed, close roller clamp of BT set then Nursing management
    disconnect from IV line then regulate IVF as ordered.  stop BT
    18. Carry out post BT orders such as re-check Hgb and Hct  notify Dr.
    bleeding time, serial platelet count, etc.  flush with PNSS
    19. Document observation and intervention done.  administer antihistamine - diphenhydramine HCL
    (Benadryl). Give bedtime.
    Blood transfusion reactions  Side effect – adult – drowsiness.
    H- hemolytic reaction  If (+) hypotension - anaphylactic shock administer-
    A- allergic reaction epinephrine
    P- pyrogenic reaction  send the blood unit to blood bank
    C- circulatory overload  obtain you reading and blood samples – send to lab
    A- air embolism  monitor vital signs and input and output
    T- thrombocytopenia  administer antihistamine as ordered for allergic
    C- citrate intoxication - expired blood - hyper K reaction,
    H- hyperkalemia  if (+) to hypotension - indicate anaphylactic
    shock
    Hemolytic reaction-donor blood is incompatible with the  administer epinephrine
    recipient's blood, most feel, may present chills, diaphoresis  administer antipyretic and antibiotic for pyogenic
    and back pains. reaction and TSB.

    Signs and symptoms Pyogenic reaction-fever and chills due to sensitivity to


     Headache leukocyte or placement in addition – most common.
     dizziness
    Signs and symptoms
     fever/chills 2. Which of the following should a nurse to if blood
     tachycardia transfusion reaction occurs?
     headache A. notify physician
     palpitations B. continue IV transfusion
     dyspnea C. stop infusion immediately
     diaphoresis D. assess client

    Nursing management 3. The IV method of medication is the most dangerous


     stop BT routes of administration because:
     notify Dr. A. the vein can only take a small amount of fluid at a time
     flush with PNSS B. the vein may harden and become non-functional
    C. blood clots may become a serious problem
     administer antipyretics, antibiotics
    D. the drug is placed directly into the bloodstream and its
     send blood unit to blood bank
    action is immediate
     obtain urine and blood samples – send to lab
     Monitor VS and IO
    4. As an IVT nurse, what are the sites that you need to avoid
     tepid sponge bath - offer hypothermic blanket
    in inserting IV catheter except:
    A. straight vein and dilated
    Circulatory overload
    B. veins below previous IV or phlebetic sites
    C. infiltration sclerosed or thrombosed veins
    Signs and symptoms
    D. areas of skin inflammation, bruising or breakdown
     dyspnea
     orthopnea
     rales or crackles
     tachycardia and hypertension

    Nursing management
     stop BT in place the client up right with fast
    dependent
     notify physician. Don't flush due to patient has
    circulatory overload.
     Administer diuretics.

    Priority cases
    1st = hemolytic reaction -due to hypotension-attend
    to destruction of Hgb - O2 brain damage
    2nd = circulatory overload
    3rd = allergic reaction
    4th = pyrogenic

    SAMPLE BOARD QUESTIONS:

    1. A patient who is a Jehovah's Witness is scheduled to have


    a bowel resection for colon cancer. When planning care for
    the patient, the nurse should be aware that:
    A. the patient will most likely refuse any blood transfusion
    B. the resected colon and surrounding tissue will be officially
    buried
    C. surgery must be delayed due to the priest would visit
    D. holy Communion should be given on the day of the
    surgery

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