Return Test by:
NYGH
BLOOD ADMINISTRATION
SELF LEARNING PACKAGE
for Nurses
Page 1 of 23
Revised June 2013
The objective of this learning package is to support staff nurses (RN and
RPNs) to adhere to consistent practice standards associated with the procurement,
administration and documentation of blood /blood products at North York General
Hospital.
RPNs can initiate blood transfusions to stable patients with predictable outcomes as
per CNO.
This learning package is the second part of a two part process intended to
facilitate bedside nursing practice. The first part is a Computer based training
(CBT) module entitled “Blood Transfusion” part 1 & 2 which is located on My
Learning Edge on the NYGH Learning Management System.
Process for Competency includes:
1) Initiation of this package after successfully completing the Blood Module 1 &
2 on ‘my learning edge’.
2) Reviewing this package and completing the post test at the end of the
package. A mark of 80% minimum is considered a pass. Return the test to
the Clinical Nurse Educator.
3) One successful return demonstration to a RN or a competent RPN (who has
successfully completed the process outlined). Demonstration requires
documentation on the skills checklist provided. Return the complete
checklist to the Clinical Nurse Educator
Nurses administering blood products at NYGH should abide by the procedures
outlined in the;
•
NYGH Blood Administration policy
•
NYGH Blood guidelines for nurses
Page 2 of 23
Revised June 2013
CONTENT OUTLINE
Process for ordering blood products…………..…………………………… pg 4
Prior to obtaining blood/blood products.……………………………..…..pg 5
Picking up blood products..…………………………………………………………..pg 5
Transfusion practices……………………………………………………………….….pg 6
Handling blood products. ………………………………………………………….…pg 7
Infusion methods …………………………………………………………………….…..pg 8
Blood administration sets ……………………..…………………………………..pg 8
Filter changes & Transfusion solutions,, ………………………………..pg 8
Verification process………………………………… …………………………….....pg 9
Nursing monitoring during infusion…………………………………….……pg 10
Documentation………………………………………………………..……………….... pg. 12
Competency checklist………………………………..…………………………….. pg. 18
Post Test…….. ……………………………………………………………………………. pg 19
Page 3 of 23
Revised June 2013
According to Perry and Potter (2006), “transfusion therapy is the intravenous (IV)
administration of whole blood or blood products for therapeutic purposes. These
transfusions, requiring a doctor’s order, are intended to restore the oxygen-carrying
capacity of blood by replacing packed red blood cells (pRBCs), to replace clotting factors
and/ or platelets and to reverse coagulopathy or to replace white blood cells in neutropenic
clients” (p. 966).
Blood donated, whether allogenic or autologous, should only be received by a patient after
their informed consent is obtained, a suitable intravenous site is established and
appropriate equipment is obtained.
Process for ordering blood products from Blood Transfusion
Department:
Blood/blood products are obtained from the Blood Transfusion department (located in
the 4th floor Laboratory).
To submit an electronic request to the Lab for blood / blood products follow this
process;
1. In the patient’s chart click on the
button
2. To order all blood products EXCEPT red blood
cells, type in “Obtain” to generate list.
3. Select appropriate item and click
.
4. Then process order as usual.
To submit an electronic request to the Lab for
packed Red Blood Cells only, use a Transfuse Red Blood Powerform or;
1.
Click on the
Order button and type in “Prepare” to generate the list.
2. Select “Prepare Packed Red Cell Units”
Page 4 of 23
Revised June 2013
3.
Then click on
and process order as usual.
Prior to obtaining the blood/blood product
•
•
•
•
•
•
•
A physicians order is required to administer blood or a blood products
The patient’s Consent for Blood is valid, correct and complete. (Note: Consent
must be obtained by a physician).
The patient has been cross-matched by Transfusion Medicine
The adult patient has a patent, large bore (18 or 20 gauge) IV catheter insitu.
A large bore (18 to 20 gauge) peripheral site is needed for adult patients
receiving blood transfusions because (1) the administration of the blood
product will be slowed by a narrow catheter, and (2) a small bore angiocath
will damage the components in the blood
All blood/blood products transfusions will be infused through the appropriate
tubing
No drugs must ever be added to blood/blood product transfusions
All patients receiving a blood transfusion must have an identification
wristband in place which includes first name, surname, date of birth and
medical record number (MRN)
Picking up blood products:
When a blood or blood product is ordered online, a paper request will print on the Blood
Transfusion department printer, notifying them of your pending request. Under normal
conditions, routine blood orders usually arrive to the floor 1 - 2 hours after the request is
submitted. Stat blood orders are prepared so they arrive to the floor as soon as possible.
•
“the status of the request” can be monitored and confirmed in Cerner. A
“completed status” indicates that the crossmatch is ready and the blood
product is ready for pick up by a porter or nurse
•
call Portering services and indicate your request for blood to be picked up. The
porter will come to your unit to pick up ‘the patient’s Admission Sheet and/or
Emergency Admission Sheet’ they will present this to the technologist in the blood
transfusion department and bring the blood/blood back to your units nursing station.
Page 5 of 23
Revised June 2013
•
The information cross checked includes; the patient’s name and hospital number, the
unit or lot number, blood group and Rh factor. The patient documents that are crosschecked include:
•
•
•
•
Admission/ Emergency record
Transfusion record
Unit or lot number
Computerized system
Transfusion practices
1. Blood transfusion requires ongoing nursing care and assessment to ensure
unanticipated adverse reactions are promptly detected and addressed. Subsequently
all patients receiving blood should remain on their care unit for monitoring, except
when scheduled for a diagnostic test. In this case a
handover report must be given to the receiving nurse
to ensure ongoing care is in place.
2. The transfusion of all blood/ blood products should occur
immediately after its release from the Blood Transfusion
department refrigerator to the patient care unit.
3. If a blood/ blood product is not going to be used within 20 minutes, it should be
returned to Blood Transfusion department immediately.
4. Once a transfusion of blood/ blood product is started it should be completed within
a 4 hour period. Otherwise the unused portion must be discontinued and/ or
discarded in a biohazard garbage receptacle.
5. Likewise any unused portion of blood/ blood products should be discarded in a
biohazard garbage receptacle.
6. Albumin is to be kept at room temperature, and can be returned to the lab if
unopened or unused.
7. Blood Transfusion department will only issue more than one unit of blood if there is
an emergency and the patient has more than one IV line available to allow both units
to be hung at the same time.
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Revised June 2013
Handling Blood products
1. To avoid heating and damaging blood cells, the nurse should keep the blood/ blood
product away from over-bed lights. Never place blood or blood products in a
refrigerator or next to a source of heat.
2. Before hanging a unit of blood, the nurse should mix the blood by gently rotating the
bag.
3.
When a blood factor (i.e. VII, VIIa, IX, XI) is ordered to be administered via bolus
administration, only nurses having the knowledge, skill and judgment should
administer it. For nurses not competent in this skill, consider notifying the ordering
physician promptly.
Infusion methods
1. Blood transfusions should be administered through an infusion pump, unless
otherwise stated. An infusion pump (see diagram to the right), with blood tubing, is
the preferred system because it allows blood/ blood products to be safely
administered at a precise rate without damage to the blood components.
2. Blood administration through gravity tubing requires more frequent nursing
assessment to ensure the rate remains unchanged.
3. Under special circumstances a blood warmer maybe used by a nurse (i.e. in the CrCU,
PAC) specially trained to use and troubleshoot this equipment. It is essential that
strict control of this equipment be exercised because red blood cells can be
damaged by temperatures above 38 degrees Celsius.
4. In critical circumstances a pressure infusion device maybe used to transfuse blood
products rapidly. A pressure bag device should only be used by a nurse (i.e. in the
Emergency department) specially trained to use and troubleshoot this equipment.
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Blood Administration sets
1. Blood / blood products should always be administered through sterile intravenous
(IV) administration tubing.
2. Blood products in glass vials (i.e. blood factors, cryoprecipitate, albumin and
immunoglobulin) should be administered through vented gravity tubing.
3. When administering blood and blood products through an
infusion pump, the appropriate blood administration tubing
must be used. Prepare this pump tubing by completely filling
the chamber to remove the air (prevents air embolism).
h
4. When administering blood and blood products via Gravity administration, the drip
chamber of the blood gravity tubing should be kept at least two thirds full to
avoid injury to the blood cells.
Filter changes
1. The transfusion of red blood cells, platelets and plasma requires blood tubing
containing a 170-260 micron filter to capture fibrin debris.
2. The blood IV administration set should be changed after the second unit of
blood and after the completion of the transfusion. Changing the tubing at
prescribed intervals decreases the risk of bacterial sepsis.
3. In units, such as CrCU or Emergency, critical patients may require many units of
blood. In these units, PALL filters are attached to the filtered blood
administration sets, thereby allowing patients to receive blood therapy in a timely
and safe manner (A single PALL filter can filter up to 10 units of blood).
Transfusion solution
1. For All Blood Products, except immune globulin: a main intravenous of 0.9%
normal saline must be in place during administration.
♦ In the event the flow of transfusion is impeded, the IV normal saline
solution can be infused to dilute the blood product and enhance infusion
of the transfusion.
2. For Immune Globulin: A main intravenous of 5% dextrose in water solution
must be in place during administration. In the event the flow of transfusion is
impeded, the % D5W solution can be infused to dilute the IVIG solution.
It is recommended that the manufactures information sheet be reviewed.
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No intravenous solution other than the approved solutions should be infused with blood
products
Infusion Rates
The following infusion rates should be adhered to during a blood/ blood product
transfusion:
• Albumin 5% (250- 500ml); Initiate slowly for first 15 minutes, then increase
to rate of 1-10ml/min
• Albumin 25% (50- 100ml); Initiate slowly for first 15 minutes, then increase
to rate of 0.2-0.4ml/min
• Do not exceed 2 - 4 mL/minute in patients with normal plasma volume. In
Day Medicine, rate should not exceed 2mL/minute
• Do not exceed 5 -10 mL/minute in patients with hypoproteinemia
• Do not exceed 1 mL/minute in patients with normal plasma volume; 2 - 3
mL/minute in patients with hypoproteinemia
• 1 unit of Cryoprecipitate (5- 15 mls or pooled as 100 mls ) should be initially
transfused slowly. Then increased to 1 unit/10 kg body weight at 1-2 ml/min
up to as rapidly as tolerated. Recommended infusion time is 10 – 30 minutes
per dose.
• 1 unit of pRBCs (300- 350ml); Transfuse slowly (50mL/hr) for the first 15
minutes. Then increase to infuse over 2- 3 hours and not longer than 4 hours,
based on patient’s clinical condition.
• 1 unit of Plasma (200-250ml); Transfuse slowly for first 15 minutes unless
massive blood loss, then increase to infuse within 4 hours
• 1 unit of Platelets (40- 70ml [pooled], 200-250ml [donor]); Transfuse slowly
for first 15 minutes, then increase to infuse over 1- 4 hours.
3. Perry & Potter, (2006), p. 971
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What must be checked prior to Initiating the transfusion
Prior to the initiation of blood / blood product,
two nurses (RN or RPN) are required to
independently verify the patient and
the blood/blood product at
the bedside before administration.
The patient must be wearing a armband
The following must be checked:
Against the Admission sheet check
• The ID wristband
Patient’s first and last name
a. Date of birth
b. MRN number
In addition:
The Bag or blood product label must be checked
with the Blood Transfusion Collection Form (sticker)
a. Patient first and last name
b. MRN number
c. Blood unit number
d. Blood group and Rh factor
e. Expiry date
The Blood Transfusion Collection Form (sticker)
Date: 16/Oct/2012
JONES, BOB
Hospital#: 678903
ABO/Rh patient: O-POS
Component type: P.Cells-BC
Unit# co78767754666LP
Crossmatch: compatible
ABO/Rh Donor: O-POS
Blood Product Label
Date: 16/Oct/2012
JONES, BOB
Hospital#: 678903
ABO/Rh patient: O-POS
Component type: P.Cells-BC
Unit# co78767754666LP
Crossmatch: compatible
ABO/Rh Donor: O-POS
Checked by: 1_______________
2________________
Time Started_____________
Time terminated______________
Transfusion reaction Y ( ) N( )
If yes call transfusion medicine
At 6239
Any discrepancies must be discussed with the
Blood bank before the transfusion is started.
Once verified both nurses must sign their names on the appropriate spaces on the Blood
Transfusion Collection form along with the start time.
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Revised June 2013
Nursing Care during a Blood Transfusion
During the transfusion of blood or a blood product, the nurse (RN / RPN) administering the
blood/ blood product must monitor and record:
1.
The patient’s vital signs( blood pressure, pulse, respirations, temperature) :
a.
b.
c.
d.
e.
Prior to initiating the transfusion (this will avoid disposing of blood product
if vitals are found to be abnormal)
15 minutes after the initiation of the transfusion
upon completion of the transfusion
as needed, when an adverse reaction arises, and
as ordered by the physician
Minimal changes in vital signs may occur but major changes should be cause for concern.
2. The RN / RPN should monitor the patient closely for signs of a Transfusion reaction
(i.e. back pain, chest pain, pain at the IV site, hives, chills and an increase in temperature,
pulse and\or respirations) during;
a. the first 15 minutes after of starting the blood
transfusion
b. after completion of the blood transfusion
2. Nurses administering cryoprecipitate, plasma and platelets,
should also monitor the patient for signs of Transfusion Related Acute Lung
Injury/ TRALI (i.e. shortness of breath, dyspnea, cyanosis, hypotension, chills,
fever, pulmonary edema)
a. the first minutes after the transfusion is started
b. during the blood product transfusion
c. up to 6 hours after the completion of the blood product
Transfusion Reaction
If a Blood Transfusion reaction (including TRALI) is suspected, the nurse should;
1. Stop the blood transfusion promptly.
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Revised June 2013
2. Prime another blood tubing set with normal saline and replace the existing
tubing with the new one, at the IV angiocath site. . Do not discard the blood bag
or tubing.
3. Infuse the new primary line of normal saline at TKVO.
4. Takes the patient’s vital signs and treat the symptoms ( i.e. provide oxygen
therapy if dyspnea or TRALI is suspected)
5. Notify physician immediately and inform Transfusion Medicine (ext. 6239) if
the physician requests the transfusion to be stopped.
6. Document your assessments and nursing actions taken
7. Continue to monitor the patient’s status and treat symptoms, as needed.
8. Have the phlebotomist draw a pink top blood tube (Group + Screen) from the
patient.
9. Notify Transfusion Medicine of the patient’s symptoms and return the unused
blood bag and tubing to them.
10. Send a routine urine specimen to Biochemistry.
11. Document the incident on the Blood Administration powerform
a. Time when reaction noted
b. Volume of blood infused before transfusion was stopped
c. Patient’s vital signs and symptoms observed.
d. Action taken including notification of physician.
12. Initiate an SLIP Report if the physician orders the transfusion to be
discontinued. Under type of incident, specify “Intravenous/ Blood VarianceAllergic / Adverse Reaction”.
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Documentation during Blood transfusions
Nursing care provided during a blood transfusion must be timely and appropriate and
this level of care should be evident in the documentation by the nurse. In
powerchart, the 2 main powerforms used will be:
1) Blood Administration Initiation powerform
2) Blood Administration Transfusion powerform
In addition:
The Blood Transfusion Collection Form (sticker) provided by the blood bank must be
signed by both the nurses doing the verification and the start time entered. Upon
completion of the blood transfusion the time terminated (completed) is to be
entered on this same form.
Note: If there is a transfusion reaction there is a section on this form to check off
also.
The blood transfusion collection form (sticker) is to be peeled and placed on a
(plain) piece of paper in the Laboratory section of the patients paper chart to
capture the verification that occurred. Any subsequent blood transfusion stickers
can be added to this same piece of paper.
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1) The Blood Administration Initiation powerform (see below) allows the nurse
to describe the care provided when the blood transfusion is initiated.
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2) The Blood Administration Transfusion powerform (see below) allows the nurse
to describe the care provided during the transfusion of blood / blood
products.
Page 15 of 23
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Reference:
London Laboratory Service Group (2009) Blood Transfusion Resource Manual. Retrieved on
August 7, 2009 at www.lhsc.on.ca/lab/bldbank/assets/BTRManual.pdf
North York General Hospital. (2008). Saline Lock: Self Learning Package. Toronto; North
York General Hospital.
North York General Hospital Transfusion Medicine (2009). Processes for patient
receiving blood products for the first time. Conversation with Manuel Girardo
September 1 2009.
Page 16 of 23
Revised June 2013
APPENDIX ONE: Canadian Blood Services Label
Date: 16/Oct/2012
JONES, BOB
Hospital#: 678903
ABO/Rh patient: O-POS
Component type: P.Cells-BC
Unit# co78767754666LP
Crossmatch: compatible
ABO/Rh Donor: O-POS
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Blood Transfusion Skills Checklist
Name: _________________________________
Unit __________
S= Satisfactory; U = Unsatisfactory
The RPN must have the first attempt witnessed and be successful to be competent
1.
2.
3.
4.
Criteria
Verify the physician’s order is present & clear
Verify that the Consent for Blood is complete & current
Ensure patient has a patent IV with an appropriate sized cannula
Appropriate blood tubing and solution has been obtained primed and set up at
patient’s bedside
Set up a infusion pump if appropriate
Explain the procedure to the patient and answer questions
Take patient’s vital signs prior to starting transfusion
1
Comments
5.
6.
7.
8 Two nurses are required to independently verify the patient & the blood/blood product at
the bedside before administration.
The following must be checked:
• The patients ID wrist band must be read & checked against the Admission sheet and
the Blood Transfusion Collection Form for the following:
a. Patient’s first and last name
b. Date of birth (admission sheet and armband)
c. MRN number
The Bag or blood product label must be checked
for the following:
f. Patient first and last name
g. MRN number
h. Blood unit number
i. Blood group and Rh factor
j. Expiry date
9
10
11
12
13
14
15
16
Spike blood product with IV sterile tubing aseptically and sterilely connect to
indwelling IV tubing
Blood/blood product was checked and initiated within 20 minutes of arriving on unit
Ask patient to report any changes in condition
immediately
Start transfusion slowly for first 15 minutes
15 minutes post initiation of transfusion take patient’s vital signs again
If patient’s condition is stable, increase transfusion rate as per NYGH guideline
Take vitals signs when blood transfusion is complete.
Documentation if completed on both powerforms & sticker placed in paper chart
Name of nurse supervising:________________________________
Date completed:________________________
Page 18 of 23
Revised June 2013
Blood Transfusion Post-Test
Name:____________________Unit_____________
Date:______________
Multiple choice questions: Circle the most correct answer
1. To obtain blood from the Blood Bank, the following must be done first:
a. The patient must have had a cross and type done by the lab
b. A Consent to blood transfusion must have been obtained by the
physician and be current.
c. The patient has a patent IV with appropriate sized cannula
d. All of the above
e. a + b only
2. During the administration of blood/ blood product, when should vital signs be
taken:
a.
b.
Just prior to starting the transfusion
15 minutes after the initiation of the transfusion
c.
Q 30 minutes during the transfusion
d.
upon completion of the transfusion
e.
as needed & when an adverse reaction arises
f.
all of the above
g.
a,b,d,e only
3. The Blood bank will issue more than one unit of packed red blood cells:
a. When more than 1 unit of packed red blood cells is ordered to be given
b. In an emergency & patient has 2 IV sites so both units can be hung at the
same time
c. This should never be required
d. none of the above
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4. Intravenous fluid/s used while transfusing blood and blood products:
a. Normal saline is to be used for all blood/blood products
b. Normal saline for PRBC, plasma, platelets
c. Dextrose 5% water for Immune Globulin
d. The physician always orders the solution
e. a only
f. b,c only
g. None of the above
5. Shortness of breath, dyspnea, pulmonary edema, cyanosis, hypotension, chills,
fever, are indicative of:
a. T.R.A.L.I.
b. A Transfusion reaction
c. Anaphylatic reaction
d. All of the above
6. Back pain, chest pain, pain at the IV site, hives, chills are symptoms of:
a. T.R.A.L.I.
b. A Transfusion reaction
c. Anaphylatic reaction
d. None of the above
7. The label on a unit of blood will include:
a.
Patient’s address and phone number
b. Patient’s first & last name & MRN
c.
Unit number
d. Blood type and Rh factor ( if applicable) both the patients & donor
e. b, c , d
f.
All of the above
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8. What are 2 reasons why a unit of blood should never be infused alone/ as a
primary IV solution?
a. With a primary solution in place this prevents the IV from going dry
and air entering the line when the transfused volume is completed.
b. Blood/blood products are too thick and block most lines.
c. In the event of a reaction the blood product as a secondary line can
quickly be removed and the primary line is available to KVO.
d. All of the above
e. a, c only
9. A unit of packed red blood cells, is delivered for transfusion to your unit
a. You can put it in the unit fridge if you are unable to transfuse it
immediately
b. You have 4 hours to complete the infusion
c. You should use blood tubing and a infusion pump for safe, precise rate
administration
d. All of the above
e. b, c only
10. When initiating a blood transfusion the nurse will
a. Ensure there is a order for the transfusion
b. Ensure there is IV access with an appropriate sized cannula
c. Ensure the patients vital signs are taken just prior to the initiation of
the transfusion, abnormal vital signs are reported to & MD and orders
obtained if transfusion is to progress or to be cancelled
d. Ensure 2 nurses independently check the blood transfusion collection
form, the patients ID wristband, and the blood product label
e. All of the above
11. If a physician orders a unit of platelets to be given stat and the patient has a
saline lock with a large IV catheter (i.e. 18 or 20 gauge) there is no need to
change the IV catheter
TRUE
or
FALSE
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12. If blood received from the Blood bank at 1300 hours isn’t transfused by 1320
hours it should be returned to the Blood Bank ASAP before it increased in
temperature and has to be discarded
TRUE
or
FALSE
13. Rotating the unit of blood, to even out the cells suspended in the fluid
before hanging it, is a myth
TRUE or FALSE
14. Since blood factors (i.e. Factor VII, VIIa, IX, XI) are only administered via
direct administration/ bolus, patients are at greater risk if adverse effects
develop due to the fast rate of infusion
TRUE or
15.
FALSE
Blood tubing has a 170-260 micron filter to capture fibrin debris and should
be changed after 2 units have been transfused, to decrease the risk of
bacterial sepsis.
TRUE or
16.
FALSE
When administering a unit of packed red blood cells, you note an order to
administer Lasix IV now, you can hang this medication with the blood to the
lowest port of the blood transfusion
TRUE or FALSE
17.
When verifying the blood product prior to the initiation of the transfusion,
2 nurses must:
a. Perform the verification at the nursing station
b. Check the patients armband
c. Check the blood transfusion collection form (sticker)
d. Check the blood product label
e. All of the above
f. b, c, d
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18. When a blood transfusion reaction is suspected you should:
a. Stop the transfusion
b. Run the main solution to kvo
c. Take the vital signs and Treat the symptoms
d. Notify the MD and clarify if the transfusion is to be stopped
e. Notify the blood bank, have blood drawn and a urine specimen
f. Return unused blood product and tubing to blood bank
g. Document in the blood powerform and other forms as appropriate
h. Complete a SLIP
i. All of the above
19.
Handling blood products:
a. Albumin is kept at room temperature
b. Before hanging a unit of blood, the nurse should mix the blood gently
by rotating the bag
c. When a blood factor products(VII,VIIa, IX) are ordered any nurse can
administer this via IV push
d. A blood warmer is routinely used as blood needs to be heated prior
to administration
e. None of the above
f. a and b only
20.
When administering albumin you need to consider the following:
a. It comes in a glass bottle and needs to be administered through vented
tubing
b. it should be administered with a infusion pump
c. it is compatible only with 5% dextrose in water
d. it must be administered with a filter
e. a, c,d
f. a,b only
g. none of the above
Total Marks (20)
Page 23 of 23
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