NUR 241: Blood transfusions 29-1

1. NUR 241: Blood transfusions 29-1

2. BLOOD TRANSFUSIONS – There are many different types of blood types! • As a nurse, we must realize there are many different types of blood types. • If a patient accidentally receives the wrong blood type, this could mean the difference between life and death. • The administration of blood & blood products cannot be taken lightly since a majority of the complications, regarding blood transfusion, result from human error!

3. Safety guidelines for BLOOD TRANSFUSIONS • Administration of blood & blood components requires meticulous attention to detail (e.g., preparation, administration, and monitoring) to prevent life-threatening transfusion reactions. • Ensure that each blood unit is correctly labeled; check against patient’s identification. • Review agency policy and procedure regarding administration of blood or blood products. • Two nurses should verify correct unit & correct patient before administration!

4. WHAT ARE SOME TRANSFUSION REACTIONS? What could happen to a patient when they receive a blood transfusion? • Febrile, nonhemolytic (most common): • Mechanism: Accompanies less than 1% of transfusions; possible sensitivity of recipient to leukocytes or platelets in donor’s blood. • Onset: 30 Minutes after initiation to 6 hours after completion of transfusion. • Signs & Symptoms: Fever greater than 1 percent C above baseline, flushing, chills, headache, muscle pain; occurs most frequently in immunosuppressed patient. • Prevention: Use leukocyte-reduced blood products in patients who have experienced febrile nonhemolytic reactions in the past. • NURSING INTERVENTION: Stop transfusion; administer antipyretics as ordered. Monitor temperature every 4 hours.

5. Transfusion reactions – cont’d • The previous reaction, Febrile nonhemolytic, was very detailed. Here are some other transfusion reactions. For a more detailed view, please see the book, Clinical Nursing Skills & Techniques, 8th Edition, Perry, Potter & Ostendorf, page 740. • Other Transfusion Reactions: • Acute Hemolytic Transfusion Reaction • Delayed Hemolytic Transfusion Reaction • Allergic Reaction (mild-to-moderate) • Allergic Reaction (Severe) • Graft-versus-host disease • Circulatory Overload • Infectious Disease Transmission • Iron Overload

6. INITIATING BLOOD THERAPY Blood is administered for different clinical indications & remember, a heath care provider’s order is required for administration of a blood product! • Blood is stored in a refrigerated environment. • In an emergency situation rapid transfusion of cold blood may lead to dysrhythmias & a reduction of core temperature. • Sometimes a blood-warmer machine is used for large transfusions of greater than 50mL/kg/hr or patients with cold agglutinins.

7. TRANSFUSION- CONT’D • The skill of initiating transfusion therapy cannot be delegated to a nursing assistive personnel. • The nurse must keep a close eye on the patient. • Blood products cannot be heated in a microwave or with hot water because this is dangerous and may destroy blood cells!

8. Let’s get started! So, not that you have some knowledge about blood & transfusion reactions, let’s get started on the skill! Blood Warming System: • Assessment: 1. Verify health care provider’s order for specific blood or blood product, date, time to begin transfusion, duration, and any pre-transfusion or post-transfusion medication to administer. 2. Obtain patient’s transfusion history and note known allergies & previous transfusion reactions. Verify that type & cross-match have been completed within 72 hours of transfusion.

9. Blood transfusion – cont’d • 3. Verify that IV cannula is patent & without complications such as infiltration or phlebitis. • A. Administer blood or blood components to an adult, using a 14 to 24 gauge short peripheral catheter. • B. Transfuse a neonate or pediatric patient using a 22-to 24 gauge device. • C. A 1.9 Fr is the smallest central venous access device (CVAD) that can be used. 4. Assess laboratory values such as hematocrit, coagulation, values, platelet count. 5. Check that patient has properly completed & signed transfusion consent before retrieving blood.

10. Blood transfusion – cont’d 6. Know indications or reasons for transfusion (e.g., packed red blood cells (PRBCs) for patient with low hematocrit level from gastrointestinal bleeding or surgery blood loss). 7. Obtain & record pre-transfusion baseline vital signs (temperature, respirations, and blood pressure). If patient is febrile (temperature greater than 37.8 degrees C (100 degrees F), notify health care provider before initiating transfusion. Also: Change from baseline vital signs during infusion alerts nurse to potential transfusion reaction or adverse effect of therapy! • Was there a change in patient’s B/P, for ex.?

11. BLOOD TRANSFUSION – CONT’D • 8. Assess patient’s need for IV fluids or medications while transfusion is infusing • If IV medications need to be administered during transfusion, second IV site is necessary. • No other infusions are to be administered through same IV site as blood transfusion. • Administer blood or blood components only with 0.9% normal saline solutions. • 9. Assess patient’s understanding of procedure & rationale – as this alleviates some of the anxiety a patient may have.

12. IMPLEMENTATION • 1. PRE-ADMINISTRATION PROTOCOL: • A. Obtain blood component from blood bank following agency protocol. • Blood transfusion must be initiated within 30 minutes after release from laboratory or blood bank • B. Check blood bag for any signs of contamination (i.e., clumping / clots, gas bubbles, purplish color) and presence of leaks. • Do not transfuse blood if integrity is compromised. • Air bubbles, clots & discoloration indicates bacterial contamination or inadequate anticoagulation of stored components & are contraindications for transfusion of that product. • Blood serves as medium for bacterial growth. • If you bring blood to patient’s bedside at 31 minutes, the blood is now NO GOOD!

13. IMPLEMENTATION – CONT’D • C. Verbally compare & correctly verify patient, blood product & type with another person considered qualified by your agency (e.g., RN or LPN) before initiating transfusion. Check the following: • 1. Identify patient using two identifiers (i.e., name & birthday or name & account number) according to agency policy. • Compare identifiers in MAR/medical record with information on patient’s identification bracelet and/or ask patient to state name. • 2. Transfusion record number & patient’s identification number match. • Clinical Decision Point: If you notice a discrepancy during verification procedure, do not administer the product. Notify blood bank & appropriate personnel as indicated by agency policy.

14. Implementation – cont’d • 3. Patient’s name is correct on all documents. Check identification number & date of birth on identification band & patient record. • 4. Check unit number on blood bag with blood bank form to ensure that they are the same. • 5. Blood type matches on transfusion record & blood bag. Verify that component received from blood bank is same component that health care provider ordered. (e.g., packed red cells, platelets). • 6. Check that patient’s blood type & Rh type are compatible with donor blood type & Rh type (e.g., Patient A+: Donor A+ or O+). • 7. Check expiration date and time on unit of blood. – NEVER use expired blood because cell components deteriorate & may contain excess citrate irons.

15. Implementation – cont’d • 8. Just before initiating transfusion, check patient identification information with blood unit label information. Do not administer blood to patient without an identification bracelet. • 9. Both individuals verify patient & unit identification record process as directed by agency policy. • D. Review purpose of transfusion & ask patient to report any changes that they may feel during the transfusion. • Remember: Signs & symptoms of transfusion reactions include: Chills, low back pain, shortness of breath, rash, hives, or itching. Prompt notification aids in early intervention! • E. Empty urine drainage collection container or have patient void. • If transfusion reaction does occur, urine specimen containing urine produced after initiation of transfusion will be sent to the laboratory.

16. SOME POINTS TO REVIEW, BEFORE WE CONTINUE! • LET’S GO OVER THE FOLLOWING: • I realize that this is a difficult skill, but you can get through it! 2 nurses checking blood • Transfusing blood is a very important job & one that can’t be taken lightly. • Blood must be administered within 30 minutes & if it’s not, it’s NO GOOD. Blood is not easy to come by, so it is vital that you follow this policy. Also, timely acquisition ensures that product is safe to administer. • If, for any reason, another IV medication needs to be administered, a second IV site is necessary! • Administer blood or blood components only with 0.9% normal saline solution. • Check, Check & triple check that you know the patient’s allergies & if they have had any previous allergic reactions to a blood transfusion, & remember, 2 nurses must verbally compare & correctly verify patient, as well as blood product, before initiating transfusion!

17. Let’s get back to the blood transfusion • ADMINISTRATION: • A. Perform Hand Hygiene • B. Open Y-tubing blood administration set for single unit use. Use multi-set if multiple units are to be transfused. • Y-tubing facilitates maintenance of IV access with normal saline in case patient will need more than 1 unit of blood. • C. Set all clamp(s) to “off” position. • Setting clamps to “off” position prevents accidentally spilling & wasting of the product. D. Spike 0.9% normal saline IV bag with one of Y-Tubing spikes. Hang bag on IV pole & prime tubing. Open upper clamp on normal saline side of tubing & squeeze drip chamber until fluid covers filter & 1/3 to ½ of drip chamber.

18. Implementation – cont’d • E. Maintain clamp on blood product side of Y-tubing in “off” position. Open common tubing clamp to finish priming tubing to distal end of tubing connector. Close tubing clamp when tubing is filled with saline. All three tubing clamps should be closed. Maintain protective sterile cap on tubing connector. • F. Prepare blood component for administration. Gently agitate blood unit bag, turning back & forth, upside down. Remove protective covering from access port. Spike blood component unit with other Y connection. Close normal saline clamp above filter, open clamp above filter to blood unit & prime tubing with blood. Blood will flow into drip chamber. Tap filter chamber to ensure that residual air is removed. • These are the directions, but you will need to practice this skill in the nursing lab. You will not be able to accomplish this skill without practice, no matter how many times you may read this power point presentation. • Also, watch the video – link to follow at the end of the presentation.

19. IMPLEMENTATION – CONT’D • G. Maintaining asepsis, attach primed tubing to patient’s VAD (Ventricular Assist Device). Open common tubing clamp & regulate blood infusion to allow only 2 mL/min to infuse in initial 15 minutes. It goes in slowly in the beginning! • CLINICAL DECISION POINT:Normal Saline is compatible with blood products, unlike solutions that contain dextrose, which causes coagulation of blood. Only use 0.9% normal saline solution to administer blood. No other solutions are to be administered with blood. • Think of the jumping fish as the normal saline & he is jumping into the other bowl, to be alone, so they can be administered with blood.

20. IMPLEMENTATION- cont’d • H. Remains with patient during first 15 minutes of transfusion. Initial flow rate during this time should be 2 mL/min or 20 gtt/min (using macrodrip of 10gtt/mL) • Why is blood transfused slowly during the beginning? • Most transfusion reactions occur within the first 15 minutes of a transfusion. Infusing small amounts of a blood component initially minimizes volume of blood to which the patient is exposed, thereby minimizing the severity of the reaction. • CLINICAL DECISION POINT: If signs of a transfusion reaction occur, stop the transfusion, start normal saline with a new primed tubing directly to the VAD, and notify the health care provider immediately. Do not infuse saline through existing tubing because it will cause blood in tubing to enter the patient! • I. Monitor patient’s vital signs at 5 minutes, 15 minutes & every 30 minute until 1 hour after transfusion or per agency policy. • Frequently monitoring vital signs helps to quickly alert you to transfusion reaction.

21. IMPLEMENTATION – CONT’D • J. If there is no transfusion reaction, regulate rate of transfusion according to health care provider’s orders. Check drop factor for blood tubing. • CLINICAL DECISION POINT: Do not let a unit of blood hang for more than 4 hours because danger of bacterial growth. Administration sets should be changed at the completion of each unit or every 4 hours to reduce bacterial contamination. Never store blood in an agency refrigerator. • CLINICAL DECISION POINT: Never inject medication into the same IV line with a blood component because of the risk for contaminating the blood product with pathogens & the possibility of incompatibility. Maintain a separate IV access if patient requires IV solutions or medications.

22. Implementation – cont’d • K. After blood has infused, clear IV line with 0.9% normal saline and discard blood bag according to agency policy. When consecutive units are ordered, maintain IV patency with 0.9% normal saline at keep vein open (KVO) rate and retrieve subsequent unit for administration. • L. Appropriately dispose of all supplies. Remove gloves & perform hand hygiene. • EVALUATION: • Observe IV site & status of infusion each time vital signs are taken. • Observe for any changes in vital signs & any signs of transfusion reactions such as chills, flushing, itching, dyspnea or rash. • Observe patient & assess laboratory values to determine response to administration of blood component.

23. We are almost at the finish line! • Recording & Reporting: • Record pre-transfusion medications, vital signs, location & condition of IV site & patient education. • Record the type & volume of blood component, blood unit / donor / recipient identifications, compatibility & expiration date according to the agency policy, along with patient’s response to administration of blood.

24. Unexpected outcomes of a blood transfusion • 1. Patient displays symptoms of transfusion reaction! • What do you do? • Stop transfusion immediately • Disconnect blood tubing at VAD hub & cap distal end with sterile connector to maintain sterile system. • Connect normal saline-primed tubing at VAD hub to prevent any subsequent blood from infusing from tubing. • Keep vein open with slow infusion of normal saline at 10 to 12 gtt/min to ensure venous patency and maintain venous access for medication or to resume transfusion • Notify health care provider 2. Patient develops infiltration or phlebitis at venicpuncture site: Remove IV line and insert new VAD. Re-start product if remainder can be infused within 4 hours of initiation of transfusion.

25. END OF SKILL 29-1 • You have now completed reading about skill 29-1, but what about Skill 29-2: Monitoring for ADVERSE TRANSFUSION REACTIONS? • This skill is vital because adverse transfusion reactions may occur any time during a transfusion of blood products. • Life-threatening reactions usually occur within the first 15 minutes of a transfusion. Remain with a patient during this time to monitor physiologic responses. • Some patients who have a history of frequent transfusion may receive premedication with diphenhydramine (Benadryl) to combat acquired sensitivities. • Before a transfusion, each blood unit undergoes extensive serologic testing to reduce the risk for patients acquiring a blood-borne disease.

26. SKILL 29-2: Monitoring for adverse transfusion reactions O.K., you have mastered skill 29-1, but this skill is vital, as well. Again: LIFE-THREATENING REACTIONS USUALLY OCCUR WITHIN THE FIRST 15 MINUTES OF TRANSFUSION! As a nurse, you will need to know what to watch out for during a blood transfusion!

27. MONITORING FOR ADVERSE TRANSFUSION REACTIONS • ASSESSMENT: • 1. With initiation of transfusion, observe patient for fever with or without chills. • Fever indicates onset of an acute hemolytic reaction, febrile nonhemolytic reaction, or bacterial sepsis. 2. Assess patient for tachycardia and / or tachypnea & dyspnea. Indicates acute hemolytic reaction or circulatory overload. 3. Observe patient for drop in Blood Pressure: Hypotension indicates infectious disease transmission, an acute hemolytic reaction & anaphylaxis. • Observe patient for hives or skin rash, including assessment of trunk & back These are early indications of an allergic reaction, anaphylaxis , or graft-versus-host disease, which occur after transfusion.

28. Monitoring for adverse transfusion reactions – cont’d • 5. Observe patient for flushing • 6. Observe patient for gastrointestinal symptoms: Nausea & vomiting are present in acute hemolytic transfusion reactions, anaphylactic reactions or infectious disease transmission. • 7. Observe patient for wheezing, chest pain, and possible cardiac arrest – these are all indications of anaphylactic reaction. • 8. Monitor patient for disseminated intravascular coagulation (DIC), renal failure, anemia, and hemoglobinemia / hemoglobinuria by reviewing laboratory test results (complete blood count (CBC) with differential, hemoglobin (hgb) hematocrit (Hct).

29. Monitoring for adverse transfusion reactions – cont’d • IMPLEMENTATION: • If you suspect transfusion reaction: • Immediately stop transfusion – Severity of reaction is related to the amount of blood component infused & cause of reaction. It is critical to prevent any more blood from infusing into patient. • Remove blood component & tubing containing blood product. Replace them with new bag of 0.9% normal saline and tubing. Connect tubing to hub of intravenous catheter. • Maintain patent IV line using 0.9% normal saline. • Obtain Vital Signs. Remain with patient for continuous monitoring and assessment. Do not leave patient alone. • Notify health care provider • Notify blood bank.

30. Monitoring for adverse transfusion reactions – cont’d • Monitor patient’s V/S every 15 minutes or more, if needed. • Administer prescribed medications according to type and severity of transfusion reaction: • 1. Epinephrine • 2. Antihistamine • 3. Antibiotics • 4. Antipyretics / analgesics • 5. Diuretics / morphine • 6. Corticosteroids • 7. IV fluids • RECORDING & REPORTING: Document the exact time transfusion reaction was first noted, all vital signs & other physiologic assessments, treatments instituted & patient response in medical record.

31. FOR EXIT SKILL OF 241: PLEASE SEE BELOW • 241 IV Exit Skill – 45 minutes total: • I will discuss this in another power-point presentation labeled:241 IV Exit Skill, BUT: • Be prepared for the following: • Students will be required to: • Calculate IV administration rate of medication; e.g. Heparin Drip before beginning • Correctly mix & set up a drip to be piggybacked to an existing IV • Correctly set an IV pump to administer the correct dosage of medication prescribed • Set up for blood administration

32. END OF SKILL • Please go to the website below to watch: Initiating blood transfusion. • If, for any reason, you are having difficulty accessing the web-site, type it into your computer directly & after this is done, please watch the skill. It is approximately 3 minutes long. Watch it several times for the full effect. • http://booksite.Elsevier.com/Perry-Potter/ClilnicalSkills/video36.php • Elsevier: Perry-Potter: Clinical Nursing Skills & Techniques, 8e-29.1: • Initiating Blood transfusion. • Although I have typed everything out for you, you MUST watch this video and practice in the skills lab, with fellow nursing students, in order to pass these skills. • Good Luck!