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11 Cards in this Set
- Front
- Back
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What steps are taken first by the nurse in the blood pre-transfusion process?
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• Check physician’s order to type & cross and transfuse
• Check if patient will accept blood – Jehovah Witness will not • Ensure informed consent – if policy – have a consent signed • Obtain blood sample for type & crossmatch • Teach patient about the transfusion, report any symptoms to RN • Gather equipment: i. 18 or 19 gauge IV access ii. NSS solution (only acceptable IV solution w/blood, others will cause RBC hemolysis) iii. Y blood tubing & blood filter • Purge blood tubing of air using NSS solution • Obtain baseline VS & assess patient lungs. Inform Dr of any abnormalities prior to blood administration • Premedicate or post medicate, if ordered i. Acetaminophen ii. Diphenhyramine (Benadryl) iii. Steroids iv. Furosemide (Lasix) • Obtain the blood from the blood bank i. Don’t put blood in the refrigerator on unit, if you can’t get to the transfusion ASAP then return to blood bank until ready. ii. Administer blood as soon as it is brought to patient – be ready |
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What solution is the only acceptable one to use with blood transfusions? and why?
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NSS Other solutions will call hemolysis of RBCs.
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Describe the importance of a clerical check for blood.
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2 RNs have to do the clerical check together to ensure and verify the correct product is given to the correct patient. Document this process. 90% of transfusion reactions are caused by improper ID.
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Describe the components of the clerical check.
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Confirm transfusion information: Blood product, unit number, expiration date, blood type, patient name, patient identification number.
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What is the maximum amount of time a blood transfusion can hang?
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No more than 4 hrs
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What is the rationale used for pre or post transfusion medicating of a patient receiving blood:
• Acetaminophen |
to prevent blood transfusion reactions (febrile-sudden chills, fever, headache, flushing)
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What is the rationale used for pre or post transfusion medicating of a patient receiving blood:
• furosemide |
to prevent fluid overload (circulatory overload)
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What is the rationale used for pre or post transfusion medicating of a patient receiving blood:
• diphenhydramine |
to prevent blood transfusion reactions (allergic/anaphylactic)
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What is the rationale used for pre or post transfusion medicating of a patient receiving blood:
• steroids |
to prevent severe blood transfusion reactions (allergic/anaphylactic)
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What actions are performed by the nurse when initiating a blood transfusion after the clerical check is completed?
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•inspect blood bag – don’t transfuse discolored, gas present in bag
•administer according to institution policy i.use filter ii.tubing good for 2 units only iii.use blood warmers if multiple (3 or more) units are infused •record when transfusion was started •start infusion slowly (30-50 ml during the first 15 minutes) •stay with patient •assess patient’s response •increase flow rate after 15 minutes to prescribed rate •reinforce w/patient the need to report any unusual signs & symptoms immediately •perform or delegate VS checks as per policy •never allow a unit of blood to hang more than 4 hours |
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Describe nursing actions for S&S of blood transfusion reactions.
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•Stop transfusion!
•Maintain the IV •Notify MD & blood bank •Recheck ID tags & numbers •Monitor VS & urine output •Treat symptoms as per Dr orders •Save blood bag & tubing & return them to blood bank. •Complete transfusion reaction documentation •Collect blood & urine specimens |
