blood administration process Flashcards
Pre-Prep
HCP orders Blood administration/Consent
Verify Order, Labs, and informed consent
who has to get consent for a blood transfusion from a client?
- the HCP must initiate education for blood administration
- the HCP must obtain consent for blood administration from a client, a nurse may witness the consent.
Pre-Prep
type and cross
to find a compatible blood type for transfusion. the results of blood typing will tell you if the client is type A, B, AB, or O and if the client is Rh negative or positive. the results will tell what blood or blood components will be safe to give.
type and screen: getting blood that matches the pt type and holding it in case of an emergency
Pre-Prep
- IV access start one or verify for patency.
- consider if you need 2nd access
what is the best gauge size for blood administration?
- (18G - 20G)
- 2nd access: if IV Med ordered or potential to give within the duration of the blood transfusion ie. Narcotics, Antibiotics, etc… as NO MEDS should infuse into Blood Products
- need large bore catheter (18-20 gauge); bc smaller bore causes destruction of RBC’s and slow blood administration.
- the only component that should every be administered in the same line as blood or blood products should be normal saline!
Pre-Prep
evaluate labs: H/H, PLTS, BUN/Create, BNP, ect.
- Hgb: (M) 14 - 18 ; (F) 12 - 16
- Hct: (M) 42 - 52 ; (F) 37 - 47
- PLTS: 150k - 400k
- BUN: 10 - 20
- Create: greater than 1.3
- BNP: less than 100
Pre-Prep
pre-medicate
what are the two most common medications that a HCP may order before a blood transfusion? and why?
- diphenhydramine
- to prevent allergic rxns
- acetaminophen
- to prevent febrile non-hemolytic rxns
Pre-Prep
pre-administration VS
1st set of vitals
BP, T, HR, RR
- call HCP if T is greater than 100°
- it is important to get a baseline of vitals to compare to later sets of VS and to be able to tell what is going on with your patient.
you may get an SpO2 if you’d like
Pre-Prep
educate & communicate with the patient:
- on the process (VS, timing, screening, checks)
- S/S to report (sweating, CP, SOB, NV, Chills, HA, BA, fever, Heart racing)
- have they had a blood transfusion before? (any reactions or complications?)
Pre-Prep
equipment:
1st you must have a HCP order
- blood tubing (y tubing with filter)
- NS 250 mL
- VS machine
- IV Pump
Pre-Prep
coverage
- have a 2nd nurse available to take your line of patients if necessary
- most of the time this second person will complete your check offs with you, then cover your other patients on the floor while you complete the blood administration procedure.
Pre-Prep
initiate fluids
- close clamps x2 @Y connector on tubing
- close roller clamp on tubing
- spike NS 250mL
- open NS connector clamp at the Y stem
- squeeze drip chamber 2/3 full (cover filter)
- prime tubing by opening lower clamp
- connect to patient
- start at KVO rate: 20mL/hr
KVO = keep vein open
Lab / Blood Bank
nurse and lab tech
1st check
-
verify the patient: consent & order to requisition form in blood bank
(name, DOB, MR#) -
verify the blood bag to requisition form: blood type and RH factor of donor to patient
(appropriate/match?, expiration date, unit #) - inspect bag: check for bubbles, clots, discoloration
- sign requisition form with lab tech verifying the checks
important inormation about blood administration
blood has to be started within 30” from being signed out of the blood bank
if something changes or you will not be able to administer the blood within 30”, you need to return the blood to the blood bank.
important inormation about blood administration
blood tubing
- blood tubing should only be used for up to 4 hours
- tubing can be used for 2 units of blood if both are given within the 4 hour time frame, otherwise think 1 bag of blood to 1 blood tubing
(you can use the NS bag with the new tubing)
important inormation about blood administration
blood warmers
may be used if giving blood at a fast rate to warm it and prevent chills
Bedside
can be completed by:
- RN:RN
- RN:LPN
2nd check
-
verify the patient: consent & order to requisition form in blood bank
(name, DOB, MR#) -
verify the blood bag to requisition form: blood type and RH factor of donor to patient
(appropriate/match?, expiration date, unit #) - inspect bag: check for bubbles, clots, discoloration
also verify that the order and arm band verification are all the same with the verification form and blood bag.
Bedside
mix before hanging
invert bag to mix components before infusing
Bedside
- close NS connector clamp at the Y stem
- spike blood bag and hang
- squeeze drip chamber to initiate flow
- prime tubing by opening lower clamp
- follow blood through the tube until it has reached the end of tubing and close the roller clamp
- connect to patient (START TIME)
- always clamp NS connection before hanging blood or the blood will back up into NS bag.
- make sure to not waste any blood product
- mae sure to swab the J-loop and tubing connection sites to prevent infection
Bedside
start blood:
- 2 mL/min
- 120 mL /hr
Bedside
when will a hemolytic reaction most likely occur?
- if a hemolytic reaction will occur it will be during the first 50mL of blood infusing
Bedside
nurse stays
the nurse will stay with the patient for first 15 minutes, and then get a set of VS at 15 minutes to evaluate
2nd set of vitals
- the nurse stays with the patient i the first fifteen minutes of begining an infusion because that is when a reaction to the transfusion is most likey to occur
- make sure that you have coverage for the other patients
Bedside
if a patient is unstable;
and has a reaction:
- Immediately stop transfusion
- Remove blood product and tubing
- Replace with new Normal Saline and flush
- Obtain VS and Monitor VS and UO frequently
- Notify HCP & Blood Bank to draw blood sample & obtain Urine Sample
- Return Blood Bag and tubing to Blood Bank for assessment.
- Administer medications as prescribed
- CPR if needed
- Complete transfusion reaction reports
- Prevent ARF with diuretics and fluids (esp. with hemolytic)
Bedside
If patient is stable:
- increase infusion rate
- rate can be 150 mL/hr or higher.
- this depends on if the pt has contraindications such as: CHF, for a patient with CHF you do not want to run it as fast…but to assure it will be in within 4 hours.
- 200mL/hr for non CHF clients
VS Q30 minutes till complete
3rd set of vitals
VS at completion
4th set of vitals
VS 1 hour post transfusion
5th set of vitals
NS Flush at completion:
- clamp blood connector @ y-tubing
- open NS clamp connector @ y-tubing
- let NS flush till 1 hour post transfusion at KVO rate: 20mL/hr or d/c within 15-30 minutes post
why do we do so many checks?
90% of all reactions occur because of mistakes in labeling and verification
nurse: monitor the site and the rate
cna: get vitals if patient has been stable
how should you dispose of equipment after administration?
dispose of tubing and blood bag in biohazard bag
