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13 Cards in this Set
- Front
- Back
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Indications for Whole Blood transfusion
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Treatment of acute, massive blood loss(> 25% to 30% of persons total blood volume)
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Signs and symptoms associated with the need for whole blood transfusion related to massive blood loss
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decreased hematocrit, decreased hemoglobin, dyspnea, hypotension, pallor
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Indications for Packed Red Blood cells transfusion
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anemic patients who do not need fluid volume expansion, such as those with remal failure or cardiac problems, yet need to increase the oxygen carrying ability to their blood.
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Signs and symptoms associated with the need for Red Blood Cell trasfusion owing to acute or chronic blood loss
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Decreased hemotocrit, decreased hemoglobin, dyspnea, fatigue, pallor, tachycardia
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When NOT to transfuse RBC's
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Should not be transfused for the following purposes: Fluid Volume expansion, Hematinic substitution, Enhanced wound healing, Improved general well being
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Indications for platelet transfusion
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A. indicated for the prophylaxis(A measure taken for the prevention of a disease or condition)or control of bleeding disorders associated with deficiencies in the number or function of platelets. B. As a preventive measure, can be administered when counts are in the 10,000 to 20,000 range and spontaneous bleeding is not a problem. C. Also are given to control active bleeding for counts below 50,000
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Signs and symptoms associated with the need for platelet transfusions
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A. Blood in the stool
B. Ecchymoses (The skin discoloration caused by the escape of blood into the tissues from ruptured blood vessel) C. Gum Bleeding D. Hematuria (blood in urine) E. Petechiae ( Pinpoint flat round red spots under the skin surface caused by intradermal hemorrhage (bleeding into the skin) F. Platelet Count < 20,000 |
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Vital Signs with transfusions
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vital signs must be taken and recorded for a baseline before transfusion begins. Then should be taken every
5 minutes 3 times, and then again in 30 minutes, and every 30 minutes until transfusion is complete. |
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Adminstration Guidelines for WHOLE BLOOD
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A.IV give as fast as patient can tolerate, should not exceed 4 hours.
B. Cannula Size - 16-20 gauge C. Compatible with 0.9% NS |
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Adminstration Guidelines for
PACKED RBC'S |
A. IV as fast as patient can tolerate 1-3 hours, should not exceed 4 hours
B. Cannula Size - 16-20 gauge C. Compatible with 0.9% NS |
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Adminstration Guidelines for
Platelets |
A. IV Determine by volume tolerance, not to exceed 4 hours
B. Cannula Size - 16-20 gauge C. Compatible with 0.9% NS |
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Nursing Interventions for Transfusion Reactions
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A. Stop the transfusion immediately, but do not discontinue IV line.
B. Connect new IV tubing to the cannula hub and keep the line open with 0.9% NS. C. Stay with the patient and moniter Vital signs. D. Notify the physician E. Follow medical orders regarding symptomatic treatment. F. Notify the bolld service. G. Notify the lab to collect blood and urine samples specified by blood administration services. H. Check the tags and numbers on the blood containers to verify correlation with the patients blood identification bracelet and document this verification. I. Sent th blood bag with its administration set and all attached labels to the blood transfusion service. J. Document all assessment data, nursing interventions, and patient responses in the medical record and fill out a transfusion reaction report. |
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Transfustion of Blood Components
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A. Verify the prescribers order.
B. Verify informed consent. C. Verify the patients identity. D. If patient is ambulatory, it is recommended to have patient to void. E. Assemble all equipment and start infusing 0.9% NS, if ordered, using the proper adminstration set. F. Premedicate the patient with anithistamines, antipyretics or diuretics, as ordered by the MD. G. Verification: prior to the start of the transfusion, the nurse must strictly adhere to the follwing protocols: 1. Recheck the physicians orders 2. Obtain the component from the transfusion service and record the name of the person issuing it, as well as date and time of issue. Record in medical record. 3. Inspect the blood components for abnormalities. 4. Compare the ABO group and the Rh type on the blood label and the tag attached to it with the type and crossmatching info in the chart. 5. Read the instructions on the product label and check the date and time of expiration. 6. With another LICENSED nurse, compare the name and ID # of the blood bag and its tag with those of the patients ID bands and with the transfusion forms to verify they are the same. 7. Ask patient to state name, if possible 8. Document the name of the person(s) who verified with you the patient and the component to be transfused H. Reassess the patients condition. Take vital signs, and LOC I. Initiate transusion J. Monitor the patient K. Discontinue when transfusion complete L.Document |
