Sie sind auf Seite 1von 8

BLOOD TRANSFUSION Definition: Blood transfusion is the introduction of whole blood or blood components (such as serum, plasma, platelets,

or erythrocytes) into the venous circulation. Purposes: 1. To administer required blood component to the patient. 2. To restore the blood volume. 3. To improve oxygen carrying capacity of the blood. Special Considerations: 1. Confirm that there is a physicians order and assigned consent from the client. 2. Have two health care professionals confirm that the client name and ID #, and crossmatching result are correct. 3. Maintain asepsis. 4. Keep blood cold until ready for use. 5. Blood should be stored in the blood bank and not in the nurses station. 6. Do not use blood if released from blood bank for more than 30 minutes. 7. Give pre-med 30 minutes before transfusion as prescribed. 8. Dont use blood with bubbles and has been discolored. 9. Wear gloves before performing venipuncture, transfusing the blood, and when terminating blood and disposing of equipment. 10. Administer all blood products through the correct filter for prevention of emboli. 11. Monitor patient carefully throughout blood transfusion. 12. Crystalloid solutions other than 0.9% saline and all medications are incompatible with blood products. They may cause agglutination and or hemolysis. 13. Do not transfuse a unit of blood more than 4 hours. 14. Assess the client closely for transfusion reactions. Blood Products For Transfusion: 1. Whole blood - Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors. 2. Red blood cells Used to increase the oxygen-carrying capacity of blood in anemias surgery, disorders with slow bleeding. One unit raises hematocrit by approximately 4%. 3. Autologos red blood cells Used for blood replacement following planned elective surgery. Client donates blood for autologos transfusion 4-5 weeks prior to surgery. 4. Platelets replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets most effective. 5. Fresh frozen plasma Expands blood volume and provides clotting factors. Does not need to be typed and crossmatched (contains no RBC). 6. Albumin and plasma protein fraction Blood volume expander; provides plasma protein. 7. Clotting factors and cryoprecipitate Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contain fibrinogen.

4 MAIN BLOOD GROUPS: *A, B, AB, & O ANTIGENS A number of proteins contained by the surface of the red blood cells that are unique for each person - A, B, and Rh are the most important antigens in determining blood group or type - Antigens promote agglutination or clumping of blood cells, they are also known as Agglutinogens The A antigen or agglutination is present on the RBCs of people with blood group A The B antigen is present in people with blood group B Both A & B antigens are found on the RBC surface in people with group AB blood ANTIBODIES are present in the plasma Are often called Agglutinins Blood group A have B antibodies (agglutinins) Blood group B have A antibodies Blood group O have antibodies to both A & B antigens Blood group AB do not have antibodies to either A & B antigens

When blood is transfused, the blood group of the donor must match to avoid an antigen antibody reaction and destruction (hemolysis) of RBCs.

RH FACTOR : Rh Positive (Rh +) blood that contains the Rh factor Rh Negative (Rh -) Rh factor is not present in the blood Exposure to blood containing Rh factor (e.g. a Rh - mother carrying a fetus with Rh+ blood, or transfusion of Rh+ blood into a client who is Rh- ) Rh antibodies develop and place the client at risk for an antigen antibody reaction and hemolysis of RBCs. BLOOD TYPING & CROSSMATCHING: To avoid transfusing incompatible red blood cells, both blood donor and recipient are typed and their blood crossmatched. BLOOD TYPING is done to determine the ABO blood group and Rh factor status.

TYPES OF TRANSFUSION REACTIONS: 1. Hemolytic reaction: incompatibility between clients blood and donors blood. 2. Febrile reaction: sensitivity of the clients blood to white blood cells, platelets or plasma proteins. 3. Allergic reactions (mild): sensitivity to infused plasma proteins. 4. Allergic reaction (severe): antibody-antigen reaction. 5. Circulatory overload: blood administered faster than the circulation can accommodate. 6. Sepsis: contaminated blood administered. Signs of Transfusion Reaction In An Unconscious Patient: Weak pulse Fever Hypotension Visible Hemoglobinuria Increased operative bleeding ( oozing at surgical site) Vasomotor irritability (tachycardia, bradycardia, or hypotension) Oliguria/ anuria

Complications of Blood Transfusion 1. Allergic Reaction it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen. o Assessments: Flushing Rush, hives Pruritus Laryngeal edema, difficulty of breathing Febrile, Non-Hemolytic it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion o Assessments: Sudden chills and fever Flushing Headache Anxiety Septic Reaction it is caused by the transfusion of blood or components contaminated with bacteria. o Assessment: Rapid onset of chills Vomiting Marked Hypotension High fever Circulatory Overload it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate. o Assessment: Rise in venous pressure Dyspnea Crackles or rales Distended neck vein Cough




Elevated BP


Hemolytic reaction. It is caused by infusion of incompatible blood products. o Assessment: Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood. Chills Feeling of fullness Tachycardia Flushing Tachypnea Hypotension Bleeding Vascular collapse Acute renal failure

Nursing Interventions when complications occurs in Blood transfusion 1. 2. 3. 4. 5. 6. 7. 8. If blood transfusion reaction occurs. STOP THE TRANSFUSION. Start IV line (0.9% Na Cl) Place the client in fowlers position if with SOB and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Notify the physician immediately. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physicians order or protocol. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis
REACTION CAUSE Incompatibility between clients blood and the donors blood HEMOLYTIC REACTION CLINICAL SIGNS Chills Fever, backache, Dyspnea, Cyanosis, Chest Pain, Tachycardia, Hypotension NURSING INTERVENTIONS STOP transfusion KVO with PNSS Send remaining blood, a sample of client blood and urine sample to the laboratory


Sensitivity of the clients blood to WBC, platelets, or plasma protein

Fever, Chills, Warm, Flushed skin, Headache, Anxiety, Muscle Pain

STOP transfusion Give antipyretics Notify the physician KVO with PNSS


Sensitivity to infused plasma proteins

Flushing Itching Urticaria Bronchial Wheezing Dyspnea Chest Pain Circulatory collapse Cardiac Arrest

STOP the transfusion Notify the physician Administer antihistamine as ordered


Antibody antigen reaction

STOP Transfusion KVO with PNSS Notify the physician Immediately Monitor V/S Administer CPR as needed Administer medication/ oxygen as needed STOP or SLOW the transfusion Place the client upright, with feet dependent Administer diuretics and oxygen as needed Notify physician


Blood administered faster than the circulation can accommodate

Cough Dyspnea Crackles Distended neck veins Tachycardia Hypertension


Contaminated blood administration

High fever, chills Vomiting Diarrhea Hypotension

STOP transfusion Send remaining blood to laboratory Notify the physician Obtain a blood specimen from the client for culture Administer IV fluids and antibiotics

Before Commencing Blood Transfusion, determine: 1. Baseline data regarding Blood Pressure, temperature, pulse and respirations 2. Any previous reactions to the blood transfusion Assessment Focus: Clinical signs of reaction (e.g. sudden chills, nausea, itching, rash, dyspnea); status of infusion site; any unusual symptoms

Equipments: Procedure: Unit of blood that has been correctly crossmatched Blood administration set 500 ml or 250 ml of normal saline solution for infusion (PNSS) IV pole # 18 or # 19-guage needle or catheter (if one is not already in place) Alcohol swab Plaster Clean glove Tourniquet BP apparatus Stethoscope Thermometer

1. Wash hands. 2. Obtain clients consent before the transfusion. Inform consent involves explaining medical indication for transfusion, benefits, risks, and alternatives. Obtain signed consent form is required. Determine any known allergies or previous adverse reaction to blood. Note specific signs related to the clients pathology or reason for transfusion (e.g. for anemic client, note the hemoglobin level) Rationale: Failure to disclose information and obtain consent from transfusion has resulted in ligitation when transfusion complication occurs. 3. Prepare the client. Explain the procedure and its purpose to the client. Instruct the client to report promptly any sudden chills, nausea, itching, rash, dyspnea, or other unusual symptoms. Rationale: Reduces anxiety If the client has intravenous solution infusing, check whether the needle and solution are appropriate to administer blood. The needle should be #18 gauge or larger, and the solution must be saline. If the infusing solution is not compatible, remove it and dispose it according to agency policy. Rationale: To achieve maximal flow rate. Normal saline is isotonic and reduces hemolysis If the client does not have an intravenous solution infusing, check agency policies. In some agencies, an infusion must be running before the blood is obtained from the blood bank. In this case, you will need to perform a venipuncture on a suitable vein and start an IV infusion of normal saline. 4. Obtain the correct blood component for the client. Rationale: Safe storage of the blood is only limited to 35 days after extraction from the donor since the RBC deteriorates after this time causing an allergic reaction when given. Check the physicians order with the requisition.

Check the requisition form and blood bag label with a laboratory technician or according to agency policy. Specifically, check the clients name, blood type (A, B, AB, or O ) and Rh group, the blood donor number , and the expiration date of the blood. With another nurse/ intern, / resident, compare the laboratory blood type record with a. The clients name. Ask the client to state the full name as a double check. b. The serial number on the blood bag label. c. The ABO group and Rh type on the blood bag label. Check blood bag for bubbles, cloudiness, dark color or sediment. Rationale: These signs indicate bacterial contamination. Check cross matching form. Sign the appropriate form with the other nurse according to agency policy. Warm the blood by letting it stand at room temperature, wrapped with towel for more than 30 minutes before starting the transfusion. Rationale: RBCs deteriorate and lose their effectiveness after 2 hours at a room temperature. 5. Verify the clients identity. Ask the clients full name.

6. Set up the infusion equipment. Ensure that the blood filter inside the drip chamber is suitable for whole blood components to be transfused. Blood filters have surface area large enough to allow the blood components through easily but are designed also to trap clots. Spike a container of 0.9 saline solution with appropriate set and hang on an IV pole about 1 m (36 in) above the planned venipuncture site. 7. Prime the tubing with saline solution. Open the clamp on the normal saline tubing squeeze the drip chamber until it is one third full. Remove the IV tubing needle adapter cover, open the flow rate clamp, and prime the tubing. Close the clamp and replace the needle adapter cover. 8. Perform venipuncture, if required. 9. Establish the saline solution. Connect the prime tubing to the IV needle or catheter. Tape the tubing to the IGV needle securely. Open the saline solution clamp. 10. Obtain baseline data. Check temperature, blood pressure, pulse and respiration before transfusion is started. 11. Establish the blood transfusion. Invert the blood bag gently several times to mix the cells with the plasma. Expose the port on the blood bag by pulling back the tabs. Spike blood bag port carefully and hang unit. Be sure blood clamp on set is closed. Open clamp. Full drip chamber by gently squeezing its flexible sides. Make sure filter is submerged in the blood. Open clamp on tubing, and cap tubing. Swab injection port of the primary administration set with alcohol. Insert needle carefully and tape it into place. Shut off primary IV and begin the blood transfusion. 12. Observe the client closely for 5 10 minutes. Run the blood for the first 15 minutes at 10 15 drops per minute. Note adverse reaction, such as chilling nausea, vomiting, skin rash, or tachycardia. Rationale: The earlier a transfusion reaction occurs, the more severe it tends to be. Identifying such reactions promptly helps to minimize the consequences. Remind the client to call you immediately if any unusual symptoms are felt during the transfusion. If any of these reactions occur, report these to the nurse in charge, and take appropriate nursing action. 13. Document relevant data. Record time blood was started, vital signs, type of blood, blood serial number (e.g. #1 of 3 ordered units), site of the venipuncture, size of the needle, and drip rate. 14. Monitor the client. 15 minutes after initiating the transfusion, check the vital signs of the client. If there are no signs of reaction, establish the required flow rate.. Most adults can tolerate receiving one unit of blood in hours. Assess the client every 30 minutes or more often, depending on the health status, including vital signs. If any severe untoward sign (sudden increase in temperature, severe pain in kidney region), stop transfusion immediately. Notify the physician immediately after stopping Iv for signs of transfusion reaction. 15. Terminate the transfusion.

Don gloves. If no infusion is to allow, clamp the blood tubing and remove the needle. If the primary IV is to be continued, flash the line with saline solution by opening the mainline and adjust the drip to desired rate. Discard the administration set according to agency practice. Needles should be placed in a labeled, puncture resistant container designed for such disposal. Blood bags and administration sets should be bagged and labeled before being sent for documentation and processing. Rationale: Often a normal saline or other solution is kept running in case of delayed reaction to blood. Remove gloves. Again monitor vital signs. 16. Follow agency protocol for appropriate disposition of the blood bag. On the requisition attached to the blood unit fill in the time the transfusion was completed and the amount transfused. Attach one copy of the requisition to the clients record and another to the empty blood bag. Return the blood bag and requisition to the blood bank. 17. Document relevant data. Record completion of the transfusion, the amount of the blood absorbed the blood serial number, and the vital signs. If the primary intravenous infusion was continued, record connecting it. Key Elements of Initiating, Maintaining, and Terminating a Blood Transfusion Confirm that there is an order and signed consent from the client. Have two health care professionals confirm that the client name, blood type, and blood serial number are correct. Check also the expiration date. Make sure the transfusion is started within 30 minutes of arrival at the bedside. Maintain asepsis. Use the appropriate blood filter. Flush the tubing first with normal saline. Mix the blood cells with plasma gently to maintain their integrity. Wear gloves before performing venipuncture, transfusing the blood, and when terminating blood and disposing the equipment. Assess the client closely for reactions to the transfusions. Nursing Interventions: 1. Verify doctors order. Inform client and explain the purpose of the procedure. 2. Check cross matching and blood typing. To ensure compatibility. 3. Obtain record baseline vital signs. Note: If patient has fever do not transfuse. 4. Practice strict ASEPSIS. 5. At least 2 nurses check the label of the blood transfusion, check the following: Serial Number Blood component Blood type Rh Factor Expiration Date Screening Test (VDRL for sexually transmitted diseases; HSbAg for Hepatitis B; Malarial smear for malaria). This is to ensure that the blood is free from blood carried diseases and therefore, safe for transfusion. 6. Check the blood for gas bubbles and any unusual color or cloudiness. Note: Gas bubbles indicate bacterial growth. Unusual color or cloudiness indicates hemolysis. 7. Warm blood at room temperature before transfusion. To prevent chills. 8. Identify client properly, two nurses check the clients identification. 9. Set up the infusion equipment, use Blood transfusion set with filter. To prevent administration of blood clots and other particles. 10. Prepare the blood bag, expose the port on the blood bag and insert the BT set, open the clamp let blood flow to the tube up the needle. To remove air in the tubing. Note: Blood is transfused as a side drip to PNSS. Direct transfusion is done during emergency situation as ordered. 11. Use needle gauge 18 or 19. This allows easy flow of blood. 12. Start infusion slowly at 10 gtts/ min. Remain at bedside for 15 to 30 mins. Adverse reaction usually occurs 15 to 20 minutes

13. Monitor vital signs. Altered vital signs indicates adverse reaction. 14. Do not mix medications with blood transfusion. To prevent adverse effects. Do not incorporate medication into the blood transfusion Do not use the blood transfusion line for IV push of medications 15. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis. 16. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factors can easily be destroyed. 17. Observe for potential complications. Notify physician.