Blood Administration N300 Flashcards
Rh factor
(-) Rh can only take (-) Rh blood
(+) Rh can only take (+) and (-) blood
Rh(-) mom WILL need Rhogam
Blood typing vs. cross matching
Typing: blood tests that determines blood type
Cross matching: blood test that indicates compatibility between blood of donor and recipient… Determines if any clumping; if NO CLUMPING = patient can have blood => compatible !
Both done prior to patient getting blood
Blood administration : factors in blood
Whole blood Packed RBC Platelets Granulocytes Fresh frozen plasma Anti- hemophillic factor 8 Cryoprecipitate Albumin Immune serum globulins
What are the protocols and nursing care for Blood Admin.?
What are the Protocols and Nursing Care for Blood Admin…. Part 2
-Administer blood as soon as it arrives to floor (NO longer than 2-4 hours= longer blood sits around, cells release K+ —> heart issues)
-minimal handling of bag
-VS at start of infusion,15 minutes into infusion
-stay with patient for first 15 minutes
-Administer VERY SLOW for first 15 minutes
(Check VS again- okay- turn bag up to actual ml/ hr order)
What is the number one rule with blood administration?!
Hint: solution type
ONLY USE NSS, (0.9 Nacl or LR )
NO Dextrose anything
Post transfusion (4 things)
VS/ necessary assessments at end of transfusion (flush)
Document findings after transfusion
Complete adverse rx forms of needed
Monitor lab values (check hbg and hct)
What to do with a blood transfusion Rx?
STOP infusion (if some bring happened or u think something happened) Maintain patency of cannula -KVO Monitor VS and urine output Notify physician Emergency equipment at bedside Implement appropriate interventions Written documentation Follow protocol for reporting incident
3 KEY responsibilities in transfusion Rx
STOP BLOOD AND IV GOES TO NSS (turn on / connect to patient) AND CALL RAPID
Acute Hemolytic Rx.
ABO incompatibility (getting blood and dying )
Ab in recipients plasma attach to ag on transfused RBC= RBC DESTRUCTION …. “Domino affect”= all RBC diminish / cardiovascular collapse*
Most dangerous
Acute hemolytic Rx: S/S & Nursing Actions
Chills, fever, LOW BACK PAIN, chest tight, dyspnea, acute kidney injury, vascular collapse, cardiac arrest, death
ACTIONS: STOP BLOOD, NSS- give fluids, treat shock, RED urine on next void- COLLECT, collect blood specimen to analyze broken down RBC , check BUN & Cr.. CALL RAPID
Allergic Rx and anaphylactic
Can be mild--> severe Results from recipient sensitivity to donor plasma proteins Flushing/ itching/ urticaria Antihistamines/ corticosteroids Monitor close Leads to anaphylaxis
STOP BLOOD- start process all over::: VS- FLUSH NSS-RESTART BLOOD
… Steroids / Benadryl
Acute Rx: Circulatory Overload
Is the problem the blood or the amount ?
Problem = AMOUNT
Blood administration is too rapid and circulatory system can’t accommodate
S/S: cough, SOB, tachy, HTN, RESTLESSNESS, pulmonary edema
ACTIONS: STOP BLOOD increase HOB IV NSS to KVO Notify MD... Order Lasix then restart blood @ slower rate
Sepsis Rx: ACUTE
Blood sits around too long or contaminated set up (Transfusion of bacteria lot infected blood components)
RAPID onset of chills, high fever, vomiting, diarrhea, hypotension, shock
ACTIONS: STOP BLOOD
NSS to KVO
Notify MD
Blood bag and tubing sent back to lab for examination.
Transfusion- Related Acute Lung Injury (TRALI)
Rx: DELAYED
Is pulmonary edema related to fluids or inflammation?
What is the Tx.?
Possible Rx.between recipients leukocyte sand donors ab = pulmonary INFLAMMATION & capillary LEAK. —-> sudden noncardiogenic pulmonary edema
Inflammation related / Tx: Steroids
2-6 h after infusion
S/S: fever, hypotension, tacypnea, SOB, frothy sputum… Won’t see in first 15 minutes
ACTIONS: STOP BLOOD, O2, STEROIDS, IV KVO
