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25 Cards in this Set
- Front
- Back
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FIRST
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Check consent form
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At time of transfusion unit is checked by
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2 RN's (started by, checked by - both full signatures)
Date and time started |
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CHECK
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Arm band against bag
Exp. date ABO & RH type Donor number Physicians order Verbal name confirmation w/ PT |
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Before beginning
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Explain procedure to client
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Prime blood filter tubing with
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100cc NS
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Prepare a separate infusion of NS for
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Use in the event of a reaction
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Do not infuse blood components with
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Any other IV solution
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Venipuncture needle gauge
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18 or 19
*infuse with a small amount of NS slowly to keep vein open |
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Blood can be returned to the bank for up to
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30 min.
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Obtain blood from the bank before or after venipuncture
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After (to avoid delay)
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it seems
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ка'жется (кому)
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Needed for baseline comparison
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Temp. & BP (document on monitor sheet)
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Hang unit _____ above PT's heart
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3-4 feet
*Allow to run through transfusion set, shut off NS primer and begin transfusion |
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How much should be allowed to transfuse at first?
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20cc for first 5-15 min
*No reaction? increase rate slowly |
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Check vital signs
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At 5min., 15min. and 30min.
Then at 30min. intervals *Stay w/ PT for first 5-30min. & record VS on monitor sheet |
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Signs of transfusion reaction
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Chills
Fever Restlessness Dyspnea Tachycardia Hemoglobinurea Severe uticaria Erythemia Headache/Backache |
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If any reaction occurs
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1. Stop infusion
2. Keep vein open with NS 3. Notify physician & blood bank 4. Document |
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What to document in the event of a reaction
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1. Date and Time
2. PT response 3. NSG intervention 4. Notification of physician/bank 5. Reaction report generated 6. Orders received |
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In the event of a reaction, check VS
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Q15min. till stable (document)
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What to do with unit and tubing n the event of a reaction
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Return to bank for culture
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Time to allow for each unit to be infused
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2 - 2 1/2 hrs.
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Change tubing with blood filter after
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Every 2 units
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Document in nurses notes
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Time transfusion started
By whom VS Rate of flow PT response Amount infused on I&O sheet |
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Max amount of time a unit can be left to infuse for
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4 hours
*If longer time is needed, unit will be split by the bank. |
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When to use a leukocyte filter
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1. Physician order
2. PT receiving platelets who has had a reaction in the past (PRBC's are already filtered - no filter necessary) 3. Facility protocol |
