Blood Transfusions Flashcards
what is one of the most serious errors associated with blood transfusions?
ABO incompatibilities
what are ways to decrease transfusion-related errors?
- bar code technology to prevent ID errors
- radiofrequency transponder microchips: standardize and document key steps in blood collection and confirm recipient-blood unit matching at a pt’s bedside
- advanced lab screening procedures ensure safe transfusion; identifies and decreases pathogen transmission
- blood alternative therapies w pharm developments such as colloids, crystalloids, EPO, antifibrinolytics, and hematinics
how do you determine what type of blood is needed?
pts medical condition
who is responsible for understanding which components are appropriate in various situations?
the nurse
where should blood be stored?
in fridge but NOT on unit!
can blood be cold or warm?
in emergency situations, cold blood may be rapidly transfused which can lead to dysrhythmias and decreased core temp
blood can be warmed in a special machine for large transfusions >50mL/kg/hr, but should never be warmed in microwave or in hot water (dangerous, destroys RBCs, result in hemolysis and severe rxns)
what should the order include?
specific blood or blood product
date
time to begin transfusion
special instructions (irradiated, leukocyte-depleted)
duration
pretransfusion or posttransfusion meds to admin
what premeds may be admin?
antihistamine or antipyretics
what is important to assess for prior to blood transfusion?
A) transfusion hx, allergies, previous transfusion rxns, cross match and type have been completed within 72hrs of transfusion
B) lab values (Hct, coagulation values, K+, platelets)
C) pt needs to sign consent
D) know indications for transfusion
E) pretransfusion VS and note if pt is febrile
F) assess need for IV fluids or meds while transfusion is infusing
G) pt understanding
what needs to be obtained within a specific time period?
blood sample has been collected and sent to lab within 72 hrs for typing and compatibility screening
nursing diagnoses for initiating blood therapy
activity intolerance altered health protection, risk for infection dec CO deficient or excess fluid volume deficient knowledge ineffective peripheral tissue perfusion
expected outcomes
1) pt understands need for therapy
2) pt experiences improved activity intolerance
3) mucous membranes are pink and pt has brisk cap refill
4) pt’s CO returns to baseline
5) pt’s sBP improves and urine output is 0.5-1.0 mL/kg/h
what do you want to check with a blood bag?
clots, clumping, gas bubbles, purple colour, presence of leaks
expiration date and time
what needs to be compatible?
pt’s blood type and Rh type with donor blood type and Rh type
what are basic s&s of transfusion reactions?
chills, low back pain, SOB, rash, hives, or itching
why do you want the pt to void before initiating therapy?
If transfusion rxn occurs, urine specimen containing urine prod after initiation of transfusion will be sent to lab
why is blood therapy time sensitive?
should be initiated within 30mins from time of release from blood bank
blood serves as medium for bacterial growth
what do you do if you cannot admin blood within 30 mins?
if this cannot be completed because of factors such as an elevated temperature, immediately return blood to blood bank and retrieve it when you can administer it.
It is important that the blood bag not be spiked until you ensure that no factors exist preventing transfusion
how should you set up the blood bag?
gently agitate bag by inverting 2-3x to suspends RBCs in anticoagulant. spike at chest level
what rate should blood be run at?
regulate blood infusion to allow only 2mL/min to infuse in initial 15 mins.
Remain with pt during first 15 mins of transfusion.
Initial flow rate during this time should be 1-2mL/min or 10-20gtt/min (using macrodrip of 10gtt/mL)
why do we stay with pt for first 15 mins and run blood at such a slow rate?
Many transfusions reactions occur within 15 mins of transfusion. Infusing small amount of blood component initially minimizes volume of blood to which pt is exposed, thereby minimizing severity of reaction
signs of a blood transfusion are occurring in your pt. what do you do?
stop the transfusion, start 0.9%NS with a new primed tubing attached directly to the VAD hub, and notify the hcp immediately. Do not discard the blood product or tubing because they may need to be returned to the blood bank. Do not infuse saline through existing tubing because it will cause blood in tubing to enter pt
what do we monitor?
Monitor pt’s VS within 5-15mins of initiating transfusion and at completion of transfusion or according to agency policy
how long can blood hang for?
no longer than 4hrs because of danger of bacterial growth. When a longer transfusion time is indicated clinically, the unit may be divided by the blood bank, and the part not being transfused can be properly refrigerated
when should admin sets be changed?
Admin sets should be changed at the completion of each unit or every 4hrs to reduce bacterial contamination
why do we clear line with IV NS after blood therapy is complete?
Infusing IV NS allows remainder of blood in IV tubing to infuse and keeps IV line patent for supportive measures in case of transfusion rxn
evaluation following blood admin
1) Observe IV site and status of infusion each time vital signs are taken.
2) Observe for any signs of transfusion reactions such as chills, flushing, itching, dyspnea, or rash
3) Observe pt and assess lab values to determine response to admin of blood component
unexpected outcomes
1) Patient displays s&s of transfusion reaction such as chills, flushing, itching, dyspnea, or rash
2) Patient develops irritation or phlebitis at venipuncture site
3) Fluid volume overload occurs, and/or pt exhibits difficulty breathing or has crackles on auscultation of lungs
what interventions will you perform if the pt displays s&s of transfusion rxn?
- Stop transfusion immediately
- Disconnect blood tubing and cap IV
- Connect new NS solution and primed tubing directly to VAD hub to prevent any subsequent blood from infusing into pt from tubing
- Keep vein open with slow infusion of NS at 1-2mL/min to ensure venous patency and maintain venous access for medication or to resume transfusion
- Notify hcp
what interventions will you perform if the pt develops irritation or phlebitis at venipuncture site?
• Transfusion should be stopped at first sign of infiltration, and IV line removed
• Insert new VAD in area above previous location or opposite arm
• Restart product if remainder can be infused within 4hrs of initiation of transfusion
-Institute nursing measures to reduce discomfort at infiltrated or phlebitic area
what interventions will you perform if fluid volume overload occurs, and/or the pt exhibits difficulty breathing or has crackles on auscultation of lungs?
- Slow or stop transfusion, elevate HOB, and inform hcp
- Administer diuretics, morphine, and/or O2 as ordered by hcp
- Continue frequent assessments and closely monitor VS and I&O
what pt teaching is done after blood admin?
- Instruct pt and fc to notify nurse if pt experiences itching, swelling, dizziness, dyspnea, low back pain, and/or chest pain because these may indicate a transfusion rxn
- Instruct pt to inform nurse if redness, pain, tenderness, swelling, bleeding, drainage, or leaking from under dressing occurs at IV site
what are peds considerations for blood admin?
- Infuse the first 50mL or 20% of volume (whichever is smaller) of a blood transfusion very slowly in a peds pt. Nurse should stay with the child during this time frame.
- smaller portions of blood are available
what gauge catheter should be used in peds?
22-24 gauge cannula can be used to infuse PRBCs in small veins that do not need rapid flow rates
what type of catheter or catheter placement can be used in infants/peds pts?
Umbilical catheters or catheters placed in the small saphenous veins
what are some gerontological considerations with blood admin?
Some older adults have decreased cardiac function, thus requiring a slower infusion time. Half units may be obtained if a pt is unable to tolerate the volume in a whole unit of blood or blood component
what is a risk with blood transfusions in older adults?
at risk for circulatory overload, so regulate flow rate at 1mL/kg/h
what types of pts are not good candidates for home transfusion?
Pts who have had prior transfusion reactions, acute angina, or heart failure
what teaching needs to be done with home care pts for transfusions?
Instruct pt and fc regarding s&s of a delayed hemolytic transfusion rxn so they can report them and receive treatment if necessary
what is transfusion therapy or blood replacement?
IV administration of whole blood, its components, or a plasma-derived product for therapeutic purposes. Transfusions restore intravascular volume with whole blood or albumin, restore the oxygen-carrying capacity of blood with RBCs, and provide clotting factors and/or platelets
what is the most common method of blood transfusion?
allogeneic blood (blood donated from someone else)
what is autologous transfusion or autotransfusion?
when a pts own blood is collected and reinfused for the purpose of intravascular volume replacement
what is autologous transfusion or autotransfusion ideal for?
preop blood donation, intraoperative cell salvage, and postop blood salvage.
what is the most commonly used type of autologous transfusion?
preop blood donation - pts can donate 4-6wks before surgery via phlebotomy. last donation must occur 72hrs before surgery, and donated blood is stored 1-6C for 35-42 days
what is a commonly used anticoagulant preservative?
Citrate-phosphate-dextrose-adenine (CPDA-1)
what lab test is important to obtain prior to blood admin and why?
K+ level; When blood is stored, RBCs are destroyed continually, which releases potassium from the cells into the plasma
what are the 3 blood typing systems?
ABO, Rh, and human leukocyte antigen (HLA)
HLA
highly immunogenic antigens that can cause serious transfusion complications
most common HLA complx
- Febrile nonhemolytic reaction (FNH)
- Immune-mediated platelet refractories
- Transfusion-related acute lung injury (TRALI)
- Transfusion-associated-graft-versus-host disease (TA-GVHD)
Rh factor
- antigen of RBC membranes
- A person with Rh-negative blood must first be exposed to Rh-positive blood before any Rh antibodies are formed
- A person with Rh-negative blood who is exposed to a large volume (200 mL or more) of Rh-positive blood will develop enough antibodies to cause a severe transfusion reaction with repeat exposure.
D antigen
- widely prevalent, most likely to elicit an IR
- presence or absence determines person’s Rh type
- person with D antigen is (+)
- Rh (-) mother previously exposed to Rh antigen can transfer Rh Ab across placenta to Rh (+) fetus
what can happen if mom is Rh negative and fetus is Rh positive? how do we prevent this?
severe fetal hemolysis; RhoGam is given to mom via IM to prevent this
RhoGam
suppresses or destroys the fetal Rh-positive blood cells that have passed from the fetal to the maternal circulation
what type of pts receive blood transfusions?
pts with hematological d/o, cancer, injury, or surgical intervention
hemolytic reaction
systemic response to the admin of a blood product that is incompatible with that of the recipient
what can you do to prevent sensitivities to blood transfusions for pts who have a hx of frequent transfusions?
may admin premeds with diphenhydramine to combat acquired sensitivities
how long does it take for a delayed transfusion rxn to occur?
days or weeks
what are other possible adverse outcomes?
transmission of diseases, circulatory overload, and transfusion-related acute lung injury (TRALI), characterized by noncardiogenic pulmonary edema with an onset within 6hrs of transfusion
what is the most fatal risk for transfusion-associated death?
erroneous transfusion of ABO-incompatible allogenic units
nursing diagnoses for blood transfusion rxn
acute pain anxiety decreased CO excess fluid volume hyper/hypothermia impaired gas exchange risk for infection
expected outcomes for monitoring for a transfusion reaction
a. Pt’s cardiac parameters return to baseline
Intravascular volume is restored, reaction reversed
b. Pt maintains core body temp of 36-37.2
Helps to confirm absence of transfusion rxn, infection, and sepsis
c. Pt has urine output of 0.5-1mL/kg/h
Reflects optimal fluid status
d. Pt maintains O2 sat greater than 95%
Improved tissue perfusion
e. Pt is comfortable
Absence of transfusion rxn. Appropriate nursing measures keeps pt at ease
2. Pt is able to explain s&s of a transfusion rxn
Calms anxiety and helps pt/fc anticipate nurse’s actions
unexpected outcomes with blood transfusion rxn
pt’s physiological status worsens; interventions depend on type of rxn
which type of blood transfusion products are preferable in peds?
Irradiated RBCs and platelets are preferable in children under 6 yrs of age bc their immature immune systems and to avoid graft-vs-host disease
what is the purpose of injecting Rh immune globulin?
prevents sensitization in the Rh-negative woman who has had a fetomaternal transfusion of Rh-positive fetal RBCs
when do you give Rh immune globulin?
within 72 hrs after birth
who is given Rh immune globulin?
all Rh-negative, antibody-negative women who give birth to Rh-positive infants
what follow up do moms do if they receive Rh immune globulin and a live virus immunization?
they have to be tested in 3 months for immunity
what increases the incidence of transplacental hemorrhage and subsequent isoimmunization?
Multiple gestations, placental abruption, placenta previa, manual removal of the placenta, and C-section birth
erythroblastosis fetalis
immature RBCs (erythroblasts) appear in fetal circulation d/t accelerated rate of erythropoiesis
when can sensitization occur in a pregnant woman?
during the first pregnancy if the woman had previously received an Rh-positive blood transfusion
when would no sensitization occur in a pregnant woman?
In situations in which a strong placental barrier prevents transfer of fetal blood into the maternal circulation
hydrops fetalis
most severe form of erythroblastosis; the progressive hemolysis causes fetal hypoxia; cardiac failure; generalized edema (anasarca); and fluid effusions into the pericardial, pleural, and peritoneal spaces (hydrops)
-The fetus may be delivered stillborn or in severe resp distress
epinephrine
Stimulates SNS to relieve resp distress and combat vasodilation in anaphylaxis
antihistamine
Diminishes some aspects of allergic response by blocking histamine receptors
antibiotics
Admin when bacterial contamination/sepsis is suspected
antipyretics/analgesics
Admin to relieve fever and discomfort in acute hemolytic rxns, febrile nonhemolytic rxns, graft-vs-host disease, and bacterial sepsis
diuretics/morphine
Treats circulatory overload by reducing intravascular volume and decreasing vascular tone
corticosteroids
Stabilize cell membranes, decreasing histamine release. Admin in severe allergic rxns
IV fluids
Counteracts some symptoms of anaphylactic shock
what is in a single unit of whole blood?
450mL blood
50mL anticoagulant
why is PRBCs concentrated?
because plasma is removed; Hct is 70%
what temp is PRBCs stored at?
4 degrees
what temp are platelets stored at and for how long?
room temp; last for 5 days
how is plasma stored and how long does it last?
frozen to maintain activity of clotting factors; last for 1 yr
what are examples of diseases transmitted by blood transfusions?
hepatitis; AIDS; cytomegalovirus; TA-GVHD; creutzfeldt-jacob disease
plasma albumin
- large protein molecule that usually stays within vessels and is a major contributor to plasma oncotic pressure
- expands the blood volume of pts in hypovolemic shock and, rarely, to increase the concentration of circulating albumin in pts with hypoalbuminemia
immune globulin
concentrated solution of the antibody IgG; it contains very little IgA or IgM
what treats hemophilia A?
Factor VIII
