TRAINING DESIGN Title: Blood Transfusion Description of Learners: Fifty Clinical Nurses from Mariano Marcos Memorial Hospital & Medical Center General Objective: After 1 hour and 30 minutes of imparting knowledge through lecture discussion and demonstration, the fifty clinical nurses from Mariano Marcos Memorial Hospital & Medical Center will be able to: Learning Objectives Content Explain at least 3 Introduction to Blood Transfusion blood products for IV fluids can be effective in restoring intravascular (blood) transfusion. volume; however, they do not affect the oxygen-carrying capacity of the blood. When red or white blood cells, platelets, or blood proteins are lost because of hemorrhage or disease, it may be necessary to replace these components to restore the bloods ability to transport oxygen and carbon dioxide, clot, fight infection, and keep extracellular fluid within the intravascular compartment. A blood transfusion is the introduction of whole blood or blood components into venous circulation. Purposes ● To restore blood volume after severe hemorrhage ● To restore the oxygen-carrying capacity of the blood ● To provide plasma factors, such as antihemophilic factor TeachingLearning Activities LectureDiscussion Time Frame Instructional Resources Methods of Evaluation 40 minutes Laptop LCD projector Power point Presentation Question and Answer ● (AHF) or factor VIII, or platelet concentrates, which prevent or treat bleeding. To treat severe anemia. Blood Products for Transfusion 1. Whole blood. Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, tresh platelets, and other clotting factors. 2. Packed red blood cells (PRBCs). Used to increase the oxygencarrying capacity of blood in anemias, surgery, and disorders with slow bleeding. One unit of PRBCs has the same amount of oxygen-carrying BCs as a unit of whole blood. One unit raises hematocrit by approximately 2% to 3%. 3. Autologous RBCs. Used for blood replacement following planned elective surgery. Client donates blood for autologous transfusion 4-5 weeks prior to surgery. 4. Platelets. Replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets are most effective. Each unit should increase the average adult client's platelet count by about 5,000 platelets/ microliter. 5. Fresh frozen plasma. Provides clotting actors. Does not need to be typed and crossmatched (contains no RBCs). 6. Albumin and plasma protein fraction. Blood volume expander; provides plasma proteins 7. Clotting factors and cryoprecipitate. Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contains fibrinogen. Steps in Performing Blood Transfusion 1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, back pain, or other unusual symptoms. 2. Provide for client privacy and prepare the client. ● Assist the client to a comfortable position, either sitting or lying. Expose the IV site but provide for client privacy. 3. Perform hand hygiene and observe other appropriate infection prevention procedures. 4. Prepare the infusion equipment. ● Ensure that the blood filter inside the drip chamber is suitable for the blood components to be transfused. Attach the blood tubing to the blood filter, if necessary. ● Apply gloves. ● Close all the clamps on the Y-set: the main flow rate clamp and both Y-line clamps. ● Insert the piercing pin (spike) into the saline solution. ● 5. ● ● ● ● 6. ● ● ● ● 7. ● Hang the container on the IV pole about 1 m (39 in.) above the venipuncture site. Prime the tubing. Open the upper clamp on the normal saline tubing, and squeeze the drip chamber until it covers the filter and one third of the drip chamber above the filter. Tap the filter chamber to expel any residual air in the filter. Open the main flow rate clamp, and prime the tubing with saline. Close both clamps. Start the saline solution. If an IV solution incompatible with blood is infusing, stop the infusion and discard the solution and tubing according to agency policy. Attach the blood tubing primed with normal saline to the IV catheter. Open the saline and main flow rate clamps and adjust the flow rate. Use only the main flow rate clamp to adjust the rate. Allow a small amount of solution to infuse to make sure there are no problems with the flow or with the venipuncture site. Obtain the correct blood component for the client. Check the primary care provider's order with the requisition. Check the requisition form and the blood bag label with a laboratory technician or according to agency policy. Specifically, check the client's name, identification number, blood type (A, B, AB, or O) and Rh group, the blood donor number, and the expiration date of the blood. Observe the blood for abnormal color, RBC clumping, gas bubbles, and extraneous material. Return outdated or abnormal blood to the blood bank. ● With another nurse (most agencies require an RN), verify the following before initiating the transfusion: a. Order: Check the blood or component against the primary care provider's written order. b. Transfusion consent form: Ensure the form is completed per facility policy. c. Client identification: The name and identification number on the client's identification band must be identical to the name and number attached to the, unit of blood. d. Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit must agree. e. Blood type: The ABO group and Rh type on the primary label of the donor unit must agree with those recorded on the transfusion form. f. Expiration: The expiration date and time of the donor unit should be verified as acceptable. ● g. Compatibility: The interpretation of compatibility testing must be recorded on the transfusion form and on the tag attached to the unit. h. Appearance: There should be no discoloration, foaming, bubbles, cloudiness, clots, or clumps, or loss of integrity of the container. ● If any of the information does not match exactly, notify the charge nurse and the blood bank. Do not administer blood until discrepancies are corrected or clarified. ● Sign the appropriate form with the other nurse according to agency policy. ● Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. Agencies may designate different times at which the blood must be returned to the blood bank if it has not been started. ● If the start of the transfusion is unexpectedly delayed, return the blood to the blood bank after 30 minutes. Do not store blood in the unit refrigerator. 8. Prepare the blood bag. ● Invert the blood bag gently several times to mix the cells with the plasma. ● Expose the port on the blood bag by pulling back the tabs. ● Insert the remaining Y-set spike into the blood bag. ● Suspend the blood bag. 9. Establish the blood transfusion. ● Close the upper clamp below the IV saline solution container. ● Open the upper clamp below the blood bag. The blood will run into the saline-filled drip chamber. If necessary, squeeze the drip chamber to reestablish the liquid level with the drip chamber one third full. (Tap the filter to expel any residual air within the filter.) ● Readjust the flow rate with the main clamp. ● Remove and discard gloves. ● Perform hand hygiene. 10. Observe the client closely for the first 15 minutes. ● Phillips and Gorski (2014) report that the AABB recommends that "transfusions of RBCs be started at 1-2 mL/min for the first 15 minutes of the transfusion" (p. 732). ● Note adverse reactions, such as chills, nausea, vomiting, skin rash, dyspnea, back pain, or tachycardia. ● Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion such as chills, nausea, itching, rash, dyspnea, or back pain. ● If any of these, reactions occur, report these to the nurse in charge, and take appropriate nursing action. 11. Document relevant data. ● Record starting the blood, including vital signs, type of blood, blood unit number, sequence number (.g. #1 of three ordered units), site of the venipuncture, size of the catheter, and drip rate. 12. Monitor the client. ● Fifteen minutes after initiating the transfusion (or according to agency policy), check the vital signs. If there are no signs of a reaction, establish the required flow rate. Most adults can tolerate receiving one unit of blood in 1.5 to 2 hours. Do not transfuse a unit of blood for longer than 4 hours. ● Assess the client, including vital signs, per agency policy. If the client has a reaction and the blood is discontinued, send the blood bag and tubing to the laboratory for investigation of the blood. 13. Terminate the transfusion. ● Apply clean gloves. ● If no infusion is to follow, clamp the blood tubing. Check agency protocol to determine if the blood component bag needs to be returned or if the blood bag and tubing can be disposed of in a biohazard container. The IV line can be discontinued or capped with an adapter or a new infusion line and solution container may be added. If another tansfusion is to follow, clamp the blood tubing and open the saline infusion arm. Check agency protocol. A new blood administration set is to be used with each component (Philips & Gorski, 2014, p. 733). ● If the primary IV is to be continued, flush the maintenance line with saline solution. Disconnect the blood tubing system and reestablish the IV infusion using new tubing. Adjust the drip to the desired rate. Often a normal saline or other solution is kept running in case of delayed reaction to the blood. ● Measure vital signs. 14. Follow agency protocol for appropriate disposition of the used supplies. ● Discard the administration set according to agency practice. ● Dispose of blood bags and administration sets. a. On the requisition attached to the blood unit, fill in the time the transfusion was completed and the amount transfused. b. Attach one copy of the requisition to the client's record and another to the empty blood bag if required by agency policy. c. Agency policy generally involves returning the bag to the blood bank for reference in case of subsequent or delayed adverse reaction. ● Remove and discard gloves. ● Perform hand hygiene. 15. Document relevant data. Record completion of the transfusion, the amount of blood absorbed, the blood unit number, and the vital signs. If the primary IV infusion was continued, record connecting it. Also record the transfusion on the IV flow sheet and intake and output record. Verbalize Blood Transfusion Reactions understanding on ● Transfusion-associated Circulatory Overload. It is at least 3 blood characterized by respiratory distress secondary to transfusion cardiogenic pulmonary edema. This reaction is most reactions. common in patients already in a fluid-overloaded state, such as congestive heart failure or acute renal failure. Diagnosis is based on symptom onset within 6 to 12 hours of receiving a transfusion, clinical evidence of fluid overload, pulmonary edema, elevated brain natriuretic peptide, and response to diuretics. Preventive efforts and treatment include limiting the number of transfusions to the lowest amount necessary, transfusing over the slowest possible time, and administering diuretics before or between transfusions. ● Allergic Reaction. It often manifests as urticaria and pruritis and occurs in less than 1% of transfusions. More severe symptoms, such as bronchospasm, wheezing, and anaphylaxis, are rare. Allergic reactions may be seen in patients who are IgA deficient, as exposure to IgA in donor products can cause a severe anaphylactoid reaction. This can be avoided by washing the plasma from the cells prior LectureDiscussion 10 minutes Laptop LCD projector Power point Presentation Simple Recall ● ● ● to transfusion. Mild symptoms, such as pruritis and urticaria can be treated with antihistamines. More severe symptoms can be treated with bronchodilators, steroids, and epinephrine. Fatal Hemolysis. This is extremely rare, occurring only in 1 out of nearly 2 million transfusions. It results from ABO incompatibility, and the recipient’s antibodies recognize and induce hemolysis in the donor’s transfused cells. Patients will develop an acute onset of fevers and chills, low back pain, flushing, dyspnea as well as becoming tachycardic and going into shock. Treatment is to stop the transfusion, leave the IV in place, intravenous fluids with normal saline, and keep urine output greater than 100 mL/hour, diuretics may also be needed. Cardiorespiratory support may be provided as appropriate. A hemolytic workup should also be performed, including sending the donor blood and tubing and post-transfusion labs from the recipient to the blood bank. Infections. These are potential complications. However, the risk of infections has decreased due to the screening of potential donors, so hepatitis C and human immunodeficiency virus risk are less than 1 in a million. Bacterial infection can also occur, but does so rarely, about once in every 250,000 units of red cells transfused. Febrile Reactions. If this occurs, the transfusion should be halted, and the patient evaluated, as a hemolytic reaction can initially appear similar and consider performing a hemolytic or infectious workup. The treatment is with acetaminophen and, if needed, diphenhydramine for symptomatic control. After treatment and exclusion of other causes, the transfusion can be resumed at a slower rate. Show all the steps Materials in blood ● Unit of whole blood, packed RBCs, or other component transfusion. ● Blood administration set ● IV pump, if needed ● 250 mL normal saline for infusion ● IV pole ● Venipuncture set containing a #14- to #22-gauge catheter (if one is not already in place) ● Alcohol swabs ● Tape ● Clean gloves Preparation ● If the client has an IV solution infusing, check whether the IV catheter and solution are appropriate to administer blood. The IV catheter size ranges between #14 and #22 gauge, and the solution must be normal saline. Dextrose (which causes lysis of RBCs), Ringer's solution, medications LectureDemonstration 40 minutes Laptop LCD projector Power point Presentation Skill Performance Checklist using the rating scale: 5Outstanding 4 - Very Satisfactory 3Satisfactory 2 - Needs Improvement Return Demonstration ● and other additives, and hyperalimentation solutions are incompatible. If the client does not have an IV solution infusing, check agency policies. In some agencies an infusion must be running before the blood is obtained from the blood bank. In this case, perform a venipuncture on a suitable vein and start an IV infusion of normal saline. Steps 1. Prior to performing the procedure, introduce self and verify the client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, back pain, or other unusual symptoms. 2. Provide for client privacy and prepare the client. 3. Perform hand hygiene and observe other appropriate infection prevention procedures. 4. Prepare the infusion equipment. 5. Prime the tubing. 6. Start the saline solution. 7. Obtain the correct blood component for the client. a. Order: Check the blood or component against the primary care provider's written order. b. Transfusion consent form: Ensure the form is completed per 1 - Not Observed facility policy. c. Client identification: The name and identification number on the client's identification band must be identical to the name and number attached to the, unit of blood. d. Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit must agree. e. Blood type: The ABO group and Rh type on the primary label of the donor unit must agree with those recorded on the transfusion form. f. Expiration: The expiration date and time of the donor unit should be verified as acceptable. g. Compatibility: The interpretation of compatibility testing must be recorded on the transfusion form and on the tag attached to the unit. h. Appearance: There should be no discoloration, foaming, bubbles, cloudiness, clots, or clumps, or loss of integrity of the container. 8. Prepare the blood bag. 9. Establish the blood transfusion. 10. Observe the client closely for the first 15 minutes. 11. Document relevant data. 12. Monitor the client. 13. Terminate the transfusion. 14. Follow agency protocol for appropriate disposition of the used supplies. 15. Document relevant data. References: Berman, A., Synder, S. J., & Frandsen, G. (2018). Kozer & Erb’s Fundamentals of Nursing 10th Edition Volume 2. Lotterman, S., & Sharma, S. (2023, June 20). Blood Transfusion. Nih.gov; https://www.ncbi.nlm.nih.gov/books/NBK499824/ StatPearls Publishing.