Which is the correct nursing procedure for administering a blood transfusion?
All health care practitioners who administer blood or blood products must complete specific training for safe transfusion practices and be competent in the transfusion administration process. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. These guidelines apply to adult patients only. Show The transfusion of blood or blood products (see Figure 8.8) is the administration of whole blood, its components, or plasma-derived products. The primary indication for a red blood cell (RBC) transfusion is to improve the oxygen-carrying capacity of the blood (Canadian Blood Services, 2013). A health care provider order is required for the transfusion of blood or blood products. RBC transfusions are indicated in patients with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with bone marrow suppression may be candidates for RBC transfusion. In patients with acute blood loss, volume replacement is often more critical than the composition of the replacing fluids (Canadian Blood Services, 2013). Transfusions can restore blood volume, restore oxygen-carrying capacity of blood with red blood cells, and provide platelets and clotting factors. The most common type of blood transfusion is blood that is donated by another person (allogeneic). Autologous transfusion is the transfusion of one’s own blood (Perry et al., 2014). Figure 8.8 Red blood cells and blood IV tubingTransfusion therapy is considered safe, and stringent precautions are followed in the collection, processing, and administration of blood and blood components. However, transfusions still carry risks such as incompatibility, human error, and disease transmission, and blood transfusion must be taken seriously at all times. Incompatibility can be decreased by using irradiated red blood cells or leukocyte-reduced blood. The majority of blood transfusion complications are a result of human error (Perry et al., 2014). Compatibility testing is vital for all recipients of blood or blood products. Recipients must be transfused with an ABO group specific to their own blood type or ABO group-compatible. There are three types of blood typing systems: ABO, Rh, and human leukocyte antigen (HLA). For more information on these, refer to the online resources at the end of this chapter. It is vital to understand what types of blood groups are compatible for transfusions (Canadian Blood Services, 2013). When administering blood and blood products, it is important to know the patient’s values and beliefs regarding blood products. Some groups of individuals, mainly Jehovah Witnesses, will refuse blood transfusions or blood products based on religious beliefs. These individuals will refuse transfusion of whole blood and primary blood components but may accept transfusion of derivatives of primary blood components such as albumins solutions, clotting factors and immunoglobulins. Always assess each individual preference to establish if a blood component is an acceptable treatment to manage their illness or condition (Canadian Blood Services, 2007). When managing blood transfusions, it is important to prevent complications from occurring and to identify issues promptly to manage reactions effectively. Transfusion reactions (mild to life-threatening) may occur despite all safety measures taken. All transfusion reactions and transfusion errors must be reported to the hospital’s transfusion services (blood bank). It is imperative to know what signs and symptoms to look for, and to educate your patient on what to report and when to report potential transfusion reactions. Mild to severe reactions may include (Canadian Blood Services, 2011):
For more information on types of reactions, signs and symptoms, and treatments, review the article adverse events related to blood transfusions, or see the online resources at the end of this chapter. If patient has a blood transfusion reaction, always follow agency policy to manage mild to severe blood reactions. In general, if a reaction occurs, follow the steps outlined in Checklist 73. Disclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Stop transfusion immediately.The severity of a blood transfusion reaction is related to the amount of product infused and the amount of time it has been infusing.2. Keep IV line open with 0.9% saline.Keeps IV site patent for emergency medications if required.3. Complete cardiovascular and vital signs assessment.Assessment monitors the type and severity of reaction. In addition to assessment:
Documentation includes, but is not limited to:
In preparation for a blood or blood product transfusion (Alberta Health Services, 2015a, 2015b; Perry et al., 2014; Vancouver Coastal Health, 2008), the steps listed in Checklist 74 must be completed. These steps must be completed before obtaining the blood or blood product from the blood bank. Checklist 74: Preparing for a Blood or Blood Product TransfusionDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Verify the physician’s order for the specific blood or blood product.Order must be verified for the type of product; the amount, date, time, and rate and duration of infusion; any modifications to a blood component (e.g., irradiation); specific transfusion requirements; and possible sequence in which multiple components are to be transfused.Physician orders for a blood transfusion2. Verify the health care provider’s orders for any pre- or post-transfusion medications to be administered.Some patients may require Benadryl IV or Tylenol pretransfusion or Lasix post-transfusion.3. Obtain the patient’s transfusion history, and note any known allergies and previous transfusion reactions.Past complications may require patient to have pre- and post-transfusion medications to prevent further transfusion reactions.4. Verify that type and cross-match (also known as a G & S) have been completed within the past 96 hours.Verification allows for the identification of any newly developed antibodies, and ensures current compatibility between donor red blood cells and recipient’s plasma. If G & S is outdated or not available, initiate process for new G & S sample.5. Verify patency of IV site.The patient’s IV cannula must be patent and without complications, such as infiltration or phlebitis. The size of cannula (#18 to #20) must match the guidelines set by Canadian Blood Services.Assess patency of IV site6. Ensure appropriate patient identification band is available and legible.To complete all safety identification checks, proper identification must be on the patient.7. Assess laboratory values, such as hematocrit, coagulation values, and platelet count.This ensures the transfusion is appropriate for the patient.8. Check that the patient has properly completed and signed the transfusion consent form.Assess patient’s understanding of the procedure and its rationale. Consent is required for the transfusion of blood and blood components and products. All blood products must have a consent form signed prior to the transfusion.Example of a consent formConsent is mandatory for all blood and blood product transfusions. Follow agency policy if patient is unable to sign or consent to blood or blood product transfusions. 9. Know the indications for the transfusion.Know why the patient is receiving the transfusion.10. Obtain and record the patient’s pretransfusion baseline vital signs, including temperature, pulse, respiration, blood pressure, and oxygen saturation level. If the patient is febrile, which means the patient’s temperature is higher than 37.8°C (100°F), notify the health care provider before initiating the transfusion.Pretransfusion vital signs are a mandatory component of blood administration.Pre-assessment of vital signs11. Have emergency equipment available at the bedside (oxygen, suction, etc.).Be prepared for potential complications, as prompt intervention may be required to prevent serious complications.Emergency equipment check at bedside12. Complete all documentation as required per agency policy.Proper documentation provides evidence that all required procedures have been followed to prepare for a transfusion.Data source: Alberta Health Services, 2015b; Canadian Blood Services, 2011; Perry et al., 2014; Vancouver Coastal Health, 2008Checklist 75 provides steps to administering blood and blood products safely in the acute care setting. Checklist 75: Transfusion of Blood and Blood ProductsDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Verify physician orders and all preparation steps as listed in Checklist 74.2. Assess or initiate venous access.Appropriate needle gauge is based on clinical status of patient, urgency of transfusion, and venous access:
Transfusion set must be Luer-locked to a 2.0 ml maximum extension tubing, either directly to cannula or through a Max Plus positive pressure cap. Saline lock3. Initiate primary infusion at TKVO.Prime an IV line following Checklist 66.
Refer to blood product fact sheets for all other products. a. Compare the transfusion medical services (TMS) documentation with the patient record to verify:
b. Compare the TMS documentation with the product label attached to the product tab and verify:
Must be completed by two trained staff members competent in blood transfusion administration process as set out by the agency. Confirm the patient blood type and Rh are compatible with the donor blood type and Rh. If there are any discrepancies, stop the process and contact the TMS for resolution and direction. Do not proceed. Ensure the blood product matches the physician’s orders (red blood cells or platelets). TMS record8 Administer pre-medications as ordered.Medications must be administered through an IV infusion set, and the IV site cleared with 0.9% NS.9. Final verification (must be completed by the same two staff members as noted in Step 7).Compare the patient’s first and last name and unique identifier number using all of the following:
Only after recipient identification and product check is confirmed, invert product 5 to 10 times and insert spike of the blood administration set into the blood product container. All verification numbers must match exactly. If there are any discrepancies, stop the process and contact the TMS for resolution and direction. Do not proceed.Identify patientPatients who are alert and oriented should be asked to:
All identifying information attached to the blood bag must remain attached at least until completion of transfusion. 10. Perform hand hygiene. Prime the blood product administration set:
Some agencies use an EID to administer blood transfusions. Always check agency policy prior to transfusion. For each and every unit:
Most transfusion reactions occur within first 15 minutes of a transfusion. Infusing small amounts of blood component initially minimizes volume of blood to which patient is exposed, thereby minimizing severity of reaction. What is the correct procedure for blood transfusion?The blood transfusion procedure begins when an intravenous (IV) line is placed onto the patient's body. It is through the IV that the patient will begin to receive the new blood. Depending on the amount of blood, a simple blood transfusion can take between 1-4 hours.
Which step must be done first when administering a blood transfusion?Safe transfusion requires a final patient identity check at the patient bedside before blood administration. This is vital to ensure the right blood is given to the right patient. Two clinicians must independently complete the patient and blood product identification check at the bedside.
What is the most important nursing consideration in administering blood transfusion?Obtain the patient's blood pressure, heart rate, respiratory rate and temperature. Obtaining an accurate temperature is important since febrile reactions are the most common reaction to blood transfusions. An increased temperature may be one of the first signs of impending reaction.
What are the expected nursing responsibilities of a nurse prior to blood transfusion?The nurse must take baseline vital signs just prior to the infusion of blood or a blood product and then the nurse should remain with and monitor the client for at least 15 minutes after the transfusion begins at a slow rate since most serious blood reactions and complications occur shortly after the transfusion begins ...
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