Complications, NursingInterventions and PreventiveMeasures of Blood TransfusionInfiltrationThrombophlebitisCirculatory OverloadAir EmbolismCatheter embolism infectionTransfusion Reaction
Infiltration – A substance (blood) that passes into the tissues and forms an accumulation of the blood to the skinManifestations: – Blanching of skin – Swelling, pain at site – Cool to touch – Decreased infusion rate
Nursing Interventions: – Discontinue IV – Restart in a new site – Apply warm compress to increase fluid absorptionPreventive Measures: – Check the IV site before starting the transfusion – Monitor the site during the transfusion – Inspect the site thoroughly. – Make sure that a main line is set before starting the transfusion.
Thrombophlebitis – Inflammation of a vein with formation of a thrombus / clotManifestations: – Redness, heat & swelling at site – Possible pain – Red line along course of vein
Nursing Interventions: – Discontinue IV – Restart in a new site – Apply warm compress to sitePreventive Measures: Measures – Check the site before transfusion – Monitor and inspect the site during and after the transfusion – Inquire and tell the patient to notify you if any sudden awkward feeling is felt – Check the integrity of the IV line and patency
Circulatory Overload – Too rapid infusion of the blood causing fluid volume overload to the patient Manifestations: – Apprehension, shortness of breath – Coughing, frothy sputum, crackles – Engorged neck veins – Increased central venous pressure and jugular vein pressure – Increased blood pressure and pulse
Nursing Interventions: – Stop the infusion / Slow down IV rate – Inform the doctor at once. – Monitor CVP through a separate line – Maintain the I.V. infusion with normal saline solution – Administer oxygen. – Elevate the patient’s head. Preventive Measures: – Always monitor the patient’s vital signs before, during and after blood transfusion – Transfuse blood slowly. – Don’t transfuse more than 2 units of blood in 4 hours. – Have oxygen readily available at the bedside of the patient.
Air Embolism – Obstruction of the circulation by air that has gained entrance to veins usually caused by empty IV lines and sets – Blood given under air pressure following severe blood lossManifestations: – Dyspnea, cyanosis, hypotension, tachycardia – Loss of consciousness – Wheezing, chest pain
Nursing Interventions: – Stop infusion immediately – Clamp tubing – Turn client to the left with his left down – Administer oxygen – Inform the doctorPreventive Measures: – Have a clamp accessible at the bedside – Check the patient and site and line every now and then – Monitor the time of the transfusion.
Catheter Embolism InfectionClogging of the catheter set causing obstruction of a blood vessel by a clot or particle that leads to development of infectionManifestations: – Fever, shills, flushing, tachycardia
Nursing Interventions: – Stop the transfusion at once. – Replace the whole set. – Inform the doctor. – Open the main line
Preventive Measures: – Monitor patient’s vital signs. – Use a blood set with filter and check the patency of the whole set before transfusion. – Assess patient for occurrence of signs and symptoms of fever. – Inspect the blood before the transfusion. – Change the blood tubing and filter every 4 hours. – Infuse each unit of blood over 2 to 4 hours; terminate the infusion if the time period exceeds 4 hours. – Maintain sterile technique when administering blood products.
Nursing Interventions: – Stop the IV at once. – Continue main IV – Inform the doctor – Give medicines as prescribed – Send blood and urine specimen for work-up Preventive Measures: – Have a thorough assessment of the patient before hand. Take note of the occurrence of any allergies. – Monitor patient’s vital signs. – Always check the line, site, and set for the validity and availability of the company…
Citrate Intoxication – Large amounts of citrated blood in patients with decreased liver function.Manifestations: – Neuromascular irritability – Bleeding due to decreased calcium – Cardiac arrhythmias – Hypotension – Muscle cramps – Nausea and vomiting – Seizures – Tingling in the fingers
Nursing Interventions: – Monitor and treat hypocalcemia – Encourage patient to eat foods rich in calcium – Monitor how many blood bags already infused to the patient. – Monitor calcium and citrate level if with multiple transfusions Preventive Measures: – Remind the doctor about how many blood bags already infused to the patient – Avoid using citrated blood – Monitor liver function – Have calcium gluconate available in your unit.
WHAT TO DO IF TRANSFUSIONREACTION OCCURS…When they do occur, it is usually because of ABO incompatibility between patient and donor during transfusion of red cells.Ensure that the intended recipient is getting the intended unit at the time of transfusion.
Acute Transfusion Reactions signs and symptoms will usually appear within the first 5- 15 minutes after the transfusion is started, but can happen anytime during the transfusion. Types of Acute Transfusion Reactions: – Acute hemolytic Transfusion Reaction – Febrile nonhemolytic Transfusion Reaction – Mild allergic (Urticarial) – Anapylactic – Transfusion Associated Circulatory Overload – Transfusion – Related Acute Lung Injury – Septic Transfusion Reaction
Symptoms you might see during an acute transfusion reaction include: – Temperature increase of more than 1°C or 2°F – Bloody urine – Chills – Hypotension – Severe low back, flank, or chest pain – Low or absent urine output – Nausea and vomiting – Dyspnea, wheezing – Anxiety, "sense of impending doom" – Diaphoresis – Generalized bleeding, especially from punctures and surgical wounds.
Should any of these symptoms occur, discontinue the unit immediately, hang normal saline (on a new tubing) to maintain vascular access, and call for assistance. Closely monitor the patient’s vital signs and symptoms. Notify the physician and obtain further orders to address the patient’s symptoms. Recheck the patient’s identifying information against the transfusion record and blood bag. All bags, tubings, filters, and paperwork should be retained and forwarded per hospital policy.
Importance of Giving Health Education to Patients and FamilyIt can establish rapport to you and the patient and family.Tension will be lessen on their part and anxiety will be alleviated.To enlighten them the real concept of blood transfusion therapy.It serves as a channel and communication between you and your patient.
The client’s major concern is likely to be the safety of the transfusion, specifically the risk of contracting AIDS.Provide accurate information for the client, and begin efforts to ensure a safe and effective transfusion before the blood or component is collected.
DOCUMENTING BLOODTRANSFUSIONS Date and time the transfusion was started and completed Name of the health care professional who verified the information of the patient and the blood Catheter type and gauge Total amount of the transfusion Patient’s vital signs before and after the transfusion
Infusion device used Flow rate and if blood warming was used Vital signs obtain prior to, during, and after the transfusion Name of the component, unit number Evidence of possible transfusion reaction. – Document interventions done and to whom you notified. Patient’s outcome.
Date Time12/12/0 2:00 D = Patient reports nausea and chills8 pm = Cyanosis of the lips noted at 1:50 pm, with PRBCs transfusing A = Infusion stopped. Approximately 100 mL infused. = Tubing changed of 1,000 mL of D5NSS infusing at KVO rate in right arm. = Notified Dr. X. = BP:170/90, Pulse Rate: 104, Respiratory Rate: 25, Temperature: 36.0°C. = Blood sample taken from PRBCs. Urine specimen also sent out to lab for urinalysis. = Gave patient diphenhydramine 50mg via IV as prescribed by the doctor. = Two blankets placed on patient. R = Patient reports he’s getting warmer and less nauseated. = BP: 148/80; Pulse Rate: 80; Respiratory Rate: 20; Temperature: 36.8°C. = Patient no longer complaining of nausea or chills. ---------------------------------------------------------------- Ram M. Mar, R.N.
TWELVE SIMPLE STEPS NECESSARY IN CARING FOR A PATIENT RECEIVING BLOOD TRANSFUSIONSTEP 1: OBTAIN PATIENT’S TRANSFUSION HISTORYSTEP 2: SELECT A LARGE GAUGE NEEDLE OR CATHETERSTEP 3: CONSIDER THE TUBING & FILTER’S PORE SIZESTEP 4: FOLLOW PROTOCOL TO OBTAIN THE BLOOD PRODUCT ACCORDING TO HOSPITAL POLICYSTEP 5: IDENTIFY THE BLOOD PRODUCT & THE PATIENTSTEP 6: OBTAIN BASELINE VITAL SIGNS & RECORD
STEP 7: USE 0.9% NORMAL SALINE FOR THE STARTER SOLUTIONSTEP 8: START THE TRANSFUSION SLOWLYSTEP 9: MAINTAIN THE PRESCRIBED TRANSFUSION RATESTEP 10: MONITOR PATIENT’S V/S & DOCUMENTSTEP 11: OBSERVE FOR ANY ADVERSE REACTIONSTEP 12: COMPLETE THE NECESSARY PAPERWORK
Computations of flow and drip ratesCalculation of IV Flow Rates Calculation of cc/hr is essential in most IV therapy. Volume = cc/hr # of hrs E.g. 1 L over 8 hrs = 125 cc/hr 50 cc over 20 minutes = 150 cc/hr
Calculation of gtt/min (Long Method)STEPS : 1. Need to know cc/hr to calculate 2. Gtt factor = gtt / ml gtt factors : macrodrip 10, 15, 20 gtts/ml microdrip 60 gtt/mlEXAMPLE : LONG METHOD Doctors Order : Run 1L D5W over 8 hours Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr 125 cc x 60 gtt/ml = 125 gtt/ml 60 min 1 10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min 60 min 1 15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min 60 min 1 20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min 60 min 1
SHORT METHOD cc / hr ÷ 6 for 10 gtt / min cc / hr ÷ 4 for 15 gtt / min cc / hr ÷ 3 for 20 gtt / min cc / hr = gtt / min for microdrip set
10 Rights in Safe Drug Administration • Right DRUG • Right PATIENT • Right DOSE • Right ROUTE • Right TIME • Right DOCUMENTATION • Right PATIENT’S HISTORY • Right DRUG ALLERGIES • Right DRUG-DRUG, DRUG-FOOD INTERACTION • Right HEALTH EDUCATION
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