SKILL 15-6 Administering a Blood Transfusion A blood transfusion is the infusion of whole blood or a blood component such as plasma, red blood cells, or platelets into a patient’s venous circulation (Table 15-1). Before a patient can receive blood, his or her blood must be typed to ensure that he or she receives compatible blood. Otherwise, a serious and life threatening transfusion reaction may occur involving clumping and hemolysis of the red blood cells and death can occur (Table 15-2). Equipment Blood product Blood administration set (tubing with in-line filter and Y for saline administration) 0.9% normal saline IV pole IV catheter (gauge or larger) Clean gloves Tape Assessment Obtain a baseline assessment of the patient, including vital signs, heart and lung sounds, and urinary output. Review the most recent laboratory values, in particular, the complete blood count (CBC). Ask the patient about any previous transfusions, including the number he or she has had any reactions experienced during a transfusion. Inspect IV insertion site, noting that the gauge of the IV catheter is an 18 or larger, and check the type of solution being given. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Injury Deficient Fluid Volume Excess Fluid Volume Ineffective Peripheral Tissue Perfusion Decreased Cardiac Output SKILL 15-6 Administering a Blood Transfusion(continued) IMPLEMENTATION ACTION RATIONALE 1. Identify the patient. Ask if the patient is allergic to any medication, iodine, tape, or if the patient has had a transfusion or transfusion reaction in the past. Identification of the patient ensures that the right patient receives the correct blood transfusion. Possible allergies may exist related to medications, iodine, or tape. 2. Determine whether patient knows reason for the blood transfusion. Explain to patient what will happen. Check for signed consent for transfusion if required by agency. Advise patient to report any chills, itching, rash, or unusual symptoms. If the physician has ordered any premedication, administer it now. Explanation provides reassurance and facilitates cooperation. Any reactions to the transfusion necessitates stopping the transfusion immediately. 3. Perform hand hygiene and put on clean gloves. Hand hygiene deters the spread of microorganisms. Gloves protect against accidental exposure to the patient’s blood. 4. Hang container of 0.95% normal saline with blood administration set to initiate IV transfusion and follow administration of blood. Dextrose may lead to clumping of red blood cells and hemolysis. The filter administration in the blood set removes particulate material formed during storage of blood. 5. Start IV with 18- or 19-gauge catheter if not already present. Keep IV open by starting flow of normal saline. A large-bore needle or catheter is necessary for the infusion of blood products. The lumen must be large enough not to cause damage to red blood cells. IV should be started before obtaining blood in case the procedure takes longer than 30 minutes. 6. Obtain blood product from the blood bank according to the agency policy. Scan for bar codes on blood products if required. Blood must be stored at a carefully controlled temperature (4◦C). Bar codes on blood products are currently being implemented in some agencies to identify, track, and assign data to transfusions as an additional safety measure. 7. Complete identification and checks as required by agency: Identification number Blood group and type Expiration date Patient’s name Inspect blood for clots Most states/agencies require two registered nurses to verify information: unit numbers match; ABO group and Rh type are the same; expiration date (after 35 days, red blood cell begin to deteriorate). Blood is never administered to a patient without an identification band. If clots are present, blood should be returned to the blood bank. RATINGS SKILL 15-6 Administering a Blood Transfusion(continued) ACTION 8. Take baseline set of vital signs before beginning transfusion. 9. Start infusion of the blood product: a. Prime in-line filter with blood. RATIONALE Any change in vital signs during the transfusion may indicate a reaction. Priming is necessary for blood to flow properly. b. Start administration slowly (no more than 25-50 mL for the first 15 minutes of transfusion. Transfusion reactions typically occur during this period, and a slow rate will minimize the volume of red blood cells infused. c. Assess vital signs at every 15 minutes for the first half hour. Follow institutions recommendations for taking vital signs during the remainder of the transfusion. If there had been no adverse effect during this time, infusion rate is increased. If complications occur, they can be observed and the transfusion can be stopped immediately. d. Observe patient for flushing, dyspnea, itching, hives or rash, or any unusual comments. These signs and symptoms may be early indication of a transfusion reaction. e. Never warm blood in a microwave. Use a blood-warming device, if indicated or ordered, especially with rapid transfusions through a CVP catheter. Rapid administration of cold blood can result to cardiac arrhythmia. 10. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the patient’s overall condition, keeping in mind the outer limits for safe administration. Ongoing monitoring is crucial throughout the entire duration of the blood transfusion for early identification of any adverse reactions. Assess frequently for transfusion reaction. Stop blood transfusion if you suspect a reaction. Quickly replace the blood tubing with new tubing and 0.9% sodium chloride. Notify physician and blood bank. Rate must be carefully controlled, and patient’s reaction must be monitored frequently. If a transfusion reaction is suspected, the blood must be stopped. Do not infuse the normal saline through the blood tubing because you would be allowing more of the blood into the patient’s body, which could complicate a reaction. Besides a serious life-threatening blood transfusion reaction, the potential for fluid-volume overload exists in elderly patients and patients with decreased cardiac function. 11. When transfusion is complete, clamp off blood and begin to infuse 0.9% normal saline. Saline prevents hemolysis of red blood cells and clears remainder of blood in IV line. 12. Record administration of blood and patient’s reaction as ordered by agency. Return blood-transfusion bag to the blood bank according to agency policy. This provides for accurate documentation of patient’s response to the transfusion. RATINGS SKILL 15-6 Administering a Blood Transfusion (continued) The expected outcome is met when the patient receives the blood transfusion without any evidence of transfusion reaction or complication. The patient exhibit signs and symptoms of fluid balance, improved cardiac output, and enhanced peripheral tissue perfusion. EVALUATION DOCUMENTATION Document that the patient received the blood transfusion; include type of blood product. Record the patient’s condition throughout the transfusion, including pertinent data, such as vital signs, lung sounds, and the subjective response of the patient to transfusion. Document any complications or reactions or that the patient received the transfusion without any complications or reactions. Document the appearance of the IV site, and the presence or absence of redness, swelling, and pain. Guidelines Sample Documentation Unexpected Situations and Associated Interventions Special Considerations Patient is becoming febrile but is exhibiting no other signs of a transfusion reaction: Notify physician. The physician may have you pause the blood transfusion and medicate the patient with acetaminophen and an antihistamine before resuming the transfusion. If this is ordered, flush the IV with 3 mL of normal saline. Patient reports shortness of breath, and on auscultation you note crackles bilaterally in the bases: Compare vital signs to normal vital sounds for this patient. Obtain a pulse oximetry reading. Notify physician. The physician may order a dose of a diuretic or may have slow the infusion. Continue to assess the patients for signs and symptoms of fluid overload. Patient is febrile, tachycardic, and complaining of back pain: Patient is having a transfusion reaction. Stop the transfusion immediately. Obtain new IV tubing with 0.9% sodium chloride. Notify physician and blood bank. Send blood unit, tubing, and filter to the lab. Blood is not fusing quickly enough: Adjust the rate with the clamp. If this does not work, try flushing the IV with 3 mL of saline. Electronic infusion devices may be used to maintain the prescribed rate but must be specifically designed for use with blood transfusion. SKILL 15-6 Administering a Blood Transfusion Home care agencies evaluates patients who are candidates for blood transfusion at home. Home transfusion is not appropriate for patients who are actively bleeding, require more than 4 hours for the transfusion, or recently had a reaction to a blood transfusion. Written consent must be obtained from the patient and the physician. The nurse transport the blood product to the patient’s home in a special cooler. The nurse and the patient’s caregiver check the serial number and other identification together. Home Care Consideration TABLE 15-1 BLOOD PRODUCT (continued) Blood Products ABO COMPATIBILITY RATE OF ADMINISTRATION FILTER DOUBLE-CHECKED BY 2 PEOPLE Packed red blood cells Yes 1 unit over 2-3 hours; no longer than 4 hours Yes Yes Platelets Yes (in provided tubing) As fast as patient can tolerate No Yes Cryoprecipitate － Fresh-frozen plasma No IV push over 3 minutes Recommended Yes No 200 mL/hr Yes Yes Albumin In tubing provided 1-10 mL/min (5%) 0.2-0.4 cc/min (25%) No No TABLE 15-2 Transfusion Reactions REACTION SIGNS AND SYMPTOMS Allergic reaction: allergy to transfused blood Hives, itching Anaphylaxis RATE OF ADMINISTRATION Febrile reaction: fever － develops during infusion Fever and chills Headache Malaise Hemolytic transfusion reaction: incompatibility of blood product Immediate onset Facial flushing Fever, chills Headache Low back pain Shock Circulatory overload: too much blood administered Dyspnea Dry cough Pulmonary edema Bacterial reaction: bacteria present in blood Fever Hypertension Dry, flushed skin Abdominal pain Stop transfusion immediately and keep vein open with normal saline. Notify physician stat. Administer antihistamine parenterally as necessary. Stop transfusion immediately and keep vein open with saline. Notify physician stat. Treat symptoms. Stop transfusion immediately and keep vein open with saline. Notify physician stat. Obtain blood samples from site. Obtain first voided urine. Treat shock if present. Send unit, tubing, and filter to lab. Draw blood sample for serologic testing and urine specimen to the lab. Slow or stop infusion. Monitor vital signs. Notify physician. Place in upright position with feet dependent. Stop infusion immediately. Obtain culture of patient’s blood and return blood bag to lab. Monitor vital signs. Notify physician. Administer antibiotics stat.
