Nsg: Blood Transfusions Flashcards
What is a blood transfusion?
The administration of platelets,WBC’s, packed RBC’s or plasma.
Reasons for a blood transfusion?
- Post Sx and lost a lot of blood
- Anemic (chronic condition)
- Hemorrhaging
- Has bleeding disorder.
Which blood type is the Universal Recipient?
AB Can reveive any type
Which blood type is the Universal Donor?
O Can give to any type.
Steps of a blood transfusion
1)Inform pt and explain reason for transfusion.
Inform of s/s to report.
2)Start IV with a LARGE IV (18-19) gauge.
16 for children.
3)Use tube specfic for blood transfusions and prepare w/ NS
4)Obtain baseline VS before.
5)Get blood from blood bank ONLY once ready for administration
6)Identify blood + pt w/ 2 RN’s @ bedside.
7)Start transfusion slowly (50ml/hr)
8)Then after 15min maintain prescribed transfusion rate
9)Take Vs q15min x 4, q30min x 2, q1hr.
And monitor for transfusion reaction.
If any reaction, respond immediately.
10)Document: time started, finished, pt response, reactions and actions taken (if any).
Why use a 19, 18, or 16(ideal) gauge needle for blood transfusions?
Small needles can damage the cells in the blood.
Though, smaller needles can be used on children (16 gauge)
How long can you hang blood transfusions for?
No longer than 4 hours b/c theres an increased risk of MCO build up that could result in infection/sepsis.
Can you infuse other solutions into the same line as the blood transfusions?
No.
Because they can induce RBC hemolysis.
Can also cause clots in the tubing and prevent flow of blood.
Can only use same tubing if tubing was first flushed with Saline Solution.
What to do before you start transfusion?
1)Start transfusion with large gauge needle
2)Double check w/ 2 RN’s
3)Inform pt of procedure and reason
consent
4)Inform pt of s/s to report
5)VS before transfusion (for baseline measure)
How fast to infuse infusion at first
50ml/hr b/c the first 15 min is the highest risk for transfusion reactions to occur.
Monitor closely.
If any reactions occur, infuse no more than 2ml/hr.
What are some Blood Transfusions reactions?
1) Hemolytic Transfusion Reaction
2) Febrile Non-Hemolytic Transfusion Reaction
3) Allergic Reaction (Ex:Anaphylaxis)
4) Trali: Transfusion Related Acute Lung Injury)
5) Fluid Overload
6) Infection
**What is the nursing response to ALL transfusions?
1) Stop infusion immediately
2) use new tubing and flush NS to KVO
3) Assess pt (VS, resp assessment, U/O, Pt’s experinces s/s)
4) Notify MD (He will Dx type of reaction and decides the Tx)
5) Notify blood bank + send blood bag + tuing to lab
6) Document
What are the Secondary Antigens?
Antigens on blood.
Ex: Rh factor is a secondary Antigen. Ex A+ (Rh factor is there)
ABO identicle blood can be imcompatible b/c of other antigens on the RBC’s.
the difference w/ secondary antigens is that the pt will not develop antibodies to these until they are exposed to them.
What to do if pt experiences chest pain?
1) Stop infusion
2) Change tubing
3) Clear w/ NS
4) Give O2
How to prevent Rh- pt’s from developing antibodies.
1) Rh- pt’s are given only Rh- blood.
2) RhoGAM is administered to Rh- mothers who have Rh+ babies (the med destroys the Rh+ antigens transfered to the mother diring childbirth, so she won’t deliver antibodies.
Ex: If given pt who is Rh- the wrong blood (Rh+), the pts antibodies will react with the antigens causing hemolysis.
