Week 9: Administering a Blood Transfusion

Question 1

Pre-Transfusion Steps

Answer 1

• verifies that informed consent has been obtained (physicians responsibility to get it signed, nurses responsibility to be the witness)
• verifies the prescription, noting the indication, rate of infusion, and any pre-transfusion medications
• administer any pre-transfusion medications as prescribed
• Ensures patient has a patent IV line or lock
• gather supplies
• if everything is good, obtain the blood product

Question 2

Pre-procedure Assessment

Answer 2

• confirm the patients need for blood products by assessing vital signs, urine output, and laboratory studies
• check the patients history for previous blood transfusions and reactions and verify her blood type
• assess patency of the existing IV catheter and make sure that it is the proper size for blood product administration
• assess for allergy to tape

Question 3

What size gauge catheter would you use for an infusion?

Answer 3

nurses often use a 20 gauge catheter for blood administration

• however, for routine transfusion, a 22-gauge or even a 24-gauge catheter can be used
• you would need an 18 or 20 gauge catheter when large amounts of blood must be transfused rapidly
• the primary consideration should be the size of the patients veins and not an arbitrary catheter size

Question 4

Once Blood Product is Obtained Steps

Answer 4

• verifies that the blood product matches the prescription/order
• inspects the blood for color, clots, leakage
• verify the patient and blood product identification with another staff member

Question 5

When inspecting the blood:

Answer 5

• pink plasma indicates hemolysis
• the red cells should be red, not purple or black
• there should be no large clots visible
• there should be no leakage

Question 6

With another qualified staff member, verify the patient and blood product identification as follows:

Answer 6

-has patient state full name and date of birth (if able to) and compare it with the name and date of birth located on the blood bank form and patients ID band
-compares patient name and hospital identification number on patients ID bracelet with patient name and hospital ID number on the blood bank form attached to the blood product
-compares the unit identification number on the blood bank form with the identification number printed on the blood product container
-compares patients blood type on the blood bank form with the blood type on the blood product container
>if all verifications are in agreement, both staff members must sign the blood bank form attached to the blood bank container

Question 7

After the 2 staff verify the patient and blood product, the nurses must

Answer 7

• sign the blood bank form attached to the blood product when all verification are in agreement
• document on the blood bank form the date and time that the transfusion was started
• make sure that the blood bank form remains attached to the blood product container until administration is complete

Question 8

Before beginning a transfusion what should the nurse do?

Answer 8

obtain and record vital signs , including temperature, pulse and blood pressure
-establishes a baseline to help monitor for transfusion reactions

Question 9

During the Transfusion

Answer 9

• stay for the first 5-15 minutes (per policy) at the bedside to obtain the first set of vital signs
• repeat vital signs per policy (usually at 30 minutes ad then hourly)
• ensure that the patients call bell is available and tell them to alert the nurse immediately of any signs or symptoms of a transfusion reaction such as back pain, chills, itching, or SOB

Question 10

After the transfusion is done

Answer 10

• when blood transfusion is done close the roller clamp to the blood product and run normal saline through to flush the administration set
• blood and blood product infusions must be completed within 4 to 6 hours; PRBCs can hang no longer than 4 hours, some may be good up to 6

Question 11

When do most transfusion reactions occur?

Answer 11

occur during the first 5 minutes or first 50mL of blood product

Question 12

How often do you take vital signs?

Answer 12

before administration

• after the first 5 minutes
• again in 15 minutes
• then again in 30 minutes
• and then hourly

Question 13

Transfusion reactions

Answer 13

• allergic
• bacterial
• febrile
• hemolytic reactions
• circulatory overload

Question 14

Blood and Blood products must be completed within?

Answer 14

4 to 6 hours

• PRBCs can hang only up to 4 hours
• come products good up to 6 hours

Question 15

What if two individuals are not available to verify that the blood and the patient are a match, and the blood must be hung now?

Answer 15

if it is available, an automated identification technology (e.g. bar coding) may be used

Question 16

Equipment for a blood transfusion

Answer 16

• clean non-sterile gloves
• blood product
• normal saline IV solution; 250 mL
• blood administration set (with a 200 micrometer filter and luer-lock connection); if there is no filter on the tubing, you must attach one
• IV pole
• Watch with a second hand
• Thermometer
• blood pressure cuff with sphygmomanometer
• stethoscope
• an infusion pump if available and blood warmer if necessary

Question 17

Why do we use normal saline solution?

Answer 17

normal saline solution is the only solution that is compatible with blood products
-other IV solutions cause hemolysis of blood cells (isotonic solution)

Question 18

Delegation

Answer 18

do not delegate this procedure to a LPN or NAP, because blood product administration requires advanced assessment and critical-thinking skills

Question 19

In the pre-procedure assessment why do we check the patients history for previous blood transfusions and reactions and verify her blood type?

Answer 19

if the patient has a history of a blood transfusion reaction, precautions must be taken before she receives additional transfusions
ex: she may need premedication with acetaminophen, a corticosteroid, and diphenhydramine, specially treated blood products, and the use of a specialized administration set with greater filtering capabilities

Question 20

What is required for blood product administration, as for any invasive or risk-breaing procedures?

Answer 20

informed consent

Question 21

When verifying the medical prescription, what are you noting?

Answer 21

• the indication for the prescription (reason why)
• rate of infusion
• and any medications (administer them as prescribed)

Question 22

When is blood discarded?

Answer 22

after it has been out of refrigeration for 30 minutes

-this is why some blood banks require a pickup slip

Question 23

How often does do administration sets and add on filters need to be changed?

Answer 23

every 4 hours

-the same administration set can be used for two units of blood or per policy

Question 24

How to manage a transfusion reaction

Answer 24

• stop the transfusion immediately; do not flush the tubing
• disconnect the administration set from the IV; call for help; obtain vital signs; and auscultate heart ad breath sounds
• maintain patency of the IV catheter by hanging a new infusion of normal saline solution, using new tubing
• notify the primary care provider as soon as you have stopped the blood, assessed the patient, and hung the new normal saline solution
• place the administration set and the blood product container, with the blood bank form attached, inside a biohazard bag; send bag to the blood bank immediately
• obtain blood (in extremity opposite to the infusion site) and urine specimen according to policy
• continue to monitor vital signs frequently, at least every 15 minutes
• administer medications as prescribed depending on the transfusion reaction type