Reviewed 8/31/2013 Susan Parrish MSN RN
After completion of this self study packet, the nurse should be able to: Identify the required components of the physician's order for blood transfusion products. Discuss the blood products used for transfusion. Describe the procedure for administration of blood products. List the signs/symptoms of a transfusion reaction. Describe the procedure/treatment for a transfusion reaction.
Refer to Nursing Policies on the Infoweb for step-bystep instructions. Refer to Administrative Policies on the Infoweb for Consent Policy.
The average RBC lifespan is 120 days. Red blood cell volume is 250-350mL per unit. RBCs are infused slowly for the 1st 15 minutes except in an emergency. Standard infusion rate is as the patient can tolerate, but less than 4 hours. If a slower infusion is required, notify the Blood Bank to split the unit.
Platelets are kept at room temperature and NEVER refrigerated. Platelets are administered to treat bleeding for thrombocytopenia or dysfunctional platelets. Administer as rapidly as tolerated. Consider primary and underlying diagnoses for infusion time to prevent fluid volume overload. Standard infusion rate is 15 30 minutes. Crossmatching is not necessary.
Fresh frozen plasma is administered for coagulopathy. May be transfused without crossmatch but must be compatible with recipient s blood group (A, B, O, AB). Rh compatibility is not necessary (positive or negative). Administer as rapidly as tolerated with consideration for primary and underlying diagnoses to prevent fluid volume overload. Standard infusion rate is 30 60 minutes.
Cryoprecipitate is administered for: Hemophilia A von Willebrand s disease Factor XIII deficiency Standard infusion rate is 15 30 minutes.
Complete an Informed Consent/Refusal for Transfusion of Blood or Blood Components and place it in the patient s medical record. If the patient lacks capacity, or is unable to give informed consent, or is under the age of 18 - refer to Section II of the Consent Policy. Telephone Consent, if necessary, shall be obtained and witnessed by a second party. (Consent Policy, Section VI).
A signed Consent or Refusal is valid for the entire hospitalization or until the patient (or an authorized person to sign for the patient) changes his/her decision about receiving blood. In the case of a series of outpatient visits, the Consent or Refusal is valid for the duration of the treatment.
The LIP ordering the blood product will explain to the patient (or an authorized person to sign for the patient) the potential risks, benefits, and alternatives of blood/blood component transfusion. The nurse will then confirm consent by the signature of the patient or other legally responsible person.
All transfusion refusals shall be witnessed by a second party and documented on the Informed Consent/Refusal for Transfusion of Blood or Blood Components. When a patient or family member refuses blood products and the refusal is signed and witnessed: Place a NO BLOOD armband on the patient Apply a NO BLOOD sticker on the chart
The venipuncture site should be started prior to picking up the blood product from Transfusion Services. The site should be in a vein large enough to accommodate a 16-18 gauge catheter or larger (in an adult patient). With some products, large amounts of fluid can be infused through a 20 gauge catheter; where there is limited vein access, a 22 gauge may be attempted.
Only registered nurses and Advisory Statement Competent LPNs may administer blood products. An exception is made during LifeLink transports. LifeLink EMT-Paramedics may: Serve as one of the two persons required to verify appropriate transfusion identification; 2 nd person must be RN Discontinue blood in the event of infiltration or an allergic reaction Restart a blood transfusion
The Adult Non-Urgent Blood/Blood Components Transfusion Order Set or the Pediatrics Non Urgent Blood/Blood Components Transfusion Order Set should be used for all transfusion orders that are nonemergent. If the physician has not completed all the required sections, the nurse must contact the physician for the necessary information.
If more than one blood product is ordered, the LIP must clarify the order in which the products are to be given. An order to Type and Crossmatch is not an order to transfuse the blood!
Nursing staff reviews Blood/Blood Component Transfusion Order Set to ensure it is complete: Patient ID label or Patient s first name, middle initial, and last name, Medical Record Number, and Date of Birth Special Requirement questions answered Verify blood component ordered and number of units Sequence of transfusion if multiple products are ordered Verify at least 1 indication for each blood product Verify LIP signs order, prints name, documents date, and time
For each product that is ordered, the relevant information in that section must be addressed (i.e.: current lab; physiologic signs, symptoms, and rationale for transfusion). An omission will result in delay of the blood product in order to complete the missing information. A copy of the Transfusion Order Set must be sent to the blood bank with the nurse s signature for each blood product that is ordered.
The orders for testing and blood components will be entered into ValleyLink. RNs, LPNs, NAs, US may obtain blood products from Transfusion Services or by the PEVCO pneumatic tube system. Transfusion Services must receive a copy of completed Adult (or Pediatric) Non-Urgent Blood/Blood Components Transfusion Order Set.
In the patient's presence, and using: the patient s armband; and the blood product label. 2 RN's (or 1 RN and 1 LPN) must compare for accuracy: Patient full name Date of Birth Medical Record Number Blood product type Donor Identification Number (DIN) Unit expiration date/time ABO/Rh type (if applicable) Signature of both nurses
Notify Transfusion Services immediately for identification inconsistencies. Do NOT administer product until the inconsistencies are resolved. Both nurses are to verify the correct information and sign the Blood Transfusion Record. CFV does not use R (Recipient) number armbands for blood/patient identification.
The blood label contains all relevant identifying information. Discard into biohazard waste when transfusion is completed.
A licensed staff member must remain with the patient during the first 15 minutes of the transfusion, starting from the time the blood reaches the hub of the catheter. Age Specific Considerations: Pediatric: Infuse 1 st 50 ml of blood slowly. Gerontological: Older adults have decreased cardiac function and require slower infusion to prevent fluid overload.
Vital signs consist of TPR, BP, and Pulse Ox. Obtain the above vital signs: Before starting transfusion within 30 min. prior to start of transfusion; 15 minutes after starting transfusion; 55-65 minutes after starting transfusion; At completion of transfusion; 25-35 minutes post transfusion or reaction. Baseline vital signs and the transfusion start time cannot be documented as the same time!
Begin administration of the ordered blood product prior to the transfer of the patient except in a critical or emergency situation or if the patient is transferring from an acute care inpatient unit to the Rehab Center.
Nurses are to accompany the patient to the next unit when blood products are transfusing. When the patient is transferred, the transferring and receiving nurses will review the chart for a valid consent and physician s order to ensure accuracy. Patient identifiers and the blood product are to be reviewed at the bedside by both nurses.
Normal saline is the intravenous fluid administered with a blood transfusion. No medications should be given into an IV line through which blood is infusing. If a patient has another IV product due during transfusion, such as antibiotics, start the transfusion in another site. If an arm restriction exists, call the doctor for specific orders.
Blood administration tubing must be used for transfusions. Blood administration tubing may be used for two (2) transfusions as long as total time does NOT exceed four (4) hours.
Complete the Blood Transfusion record: Patient identification process is completed and witnessed Product is identified with donor identification number (DIN), type, and expiration date/time Any reaction and the time the MD and lab notified IV site location and condition Vital signs Indicate if a blood warmer or leukocyte filter was used
Remember to document the blood product administered and any reaction in Valley Link nursing documentation. Remember to document the amount of blood product and normal saline infused!
Carefully observe for signs of a transfusion reaction or complications when administering blood to a comatose, cognitively impaired, or non-communicative patient.
Transfusion reaction is a serious, potentially lifethreatening allergic reaction Signs and symptoms of transfusion reaction include a temperature increase of at least 2 F (1 Celsius) or chills. Fever is one of the most important indicators of an adverse reaction. Significant changes in vital signs such as 2 F rise in temperature, 10 mm Hg drop in SBP, 10 beats per minute rise in pulse, decrease in O2 Saturation indicate a reaction.
Uticaria-hives, itching, or erythema Chest pain Shock Nausea Headache Flushing Perspiration Oliguria, anuria or hemoglobinuria Back Pain Dyspnea IV site pain or oozing Chills
Stop the transfusion immediately Disconnect and remove all blood tubing and solution. Aspirate 2-5 ml at IV site then flush with 3 ml Normal Saline. Keep IV patent with new tubing and new 0.9% Normal Saline solution. Obtain and record vital signs. Notify the LIP. Check all identifying names and numbers on blood product, patient s wristband, and paperwork for any discrepancies.
Notify the Lab (if there is no unit-based phlebotomy) to draw blood samples (clotted and anticoagulated) avoiding mechanical hemolysis. Collect a first voided post-transfusion urine sample or fresh specimen from urinary catheter. Complete the Transfusion Reaction Report Document events as they occurred, interventions, and patient s condition.
Take to Lab: Discontinued blood product Administration Set Attached IV solutions All related forms and labels Transfusion Reaction Report
Patients discharged after transfusion should be instructed that it is necessary to remain in the hospital for 30 minutes after completion of transfusion. Patients should be instructed on the signs and symptoms of reactions including that symptoms may present up to 24 hours post- transfusion. Document instruction in the Patient Education Record.
Assess vital signs more frequently when the patient's condition is unstable or a transfusion reaction is suspected. The Advanced LPN and Paramedics may implement the interventions regarding a transfusion reaction; however, it is the responsibility of the RN to verify that procedures are followed.
TRALI is a life-threatening complication of blood transfusion. TRALI is associated with significant morbidity and has been reported as the most common cause of fatal transfusion reaction. TRALI is most often associated with transfusion of fresh frozen plasma and platelets (although red cells have also been implicated).
The symptoms of TRALI usually begin within 1-2 hours of transfusion, and are present by 4-6 hours. The severity ranges from mild to severe, and related to the degree of hypoxia. Diagnosis of TRALI is based primarily on clinical signs.
TRALI is a syndrome characterized by: pulmonary edema hypoxia tachycardia fever hypotension cyanosis
Signs and symptoms of TRALI include: Dyspnea Cyanosis Hypotension Fever Chills Treatment of TRALI is supportive ventilatory assistance and maintenance of hemodynamic status. Diuretics are contraindicated.
In order to expedite the release of blood in emergencies, blood may be obtained for patients prior to completion of crossmatch. After receiving a written or verbal order from the LIP, nursing staff completes and presents to Transfusion Services with a complete Component Retrieval Form. If order is an emergency release order, send completed Emergency Release form to Transfusion Services within 24 hours.
Transfusion Services must be given the following: Admission Number or Medical Record Number Patient's Name Patient s gender If un-crossmatched blood is used, blood specimens should be drawn for crossmatch and sent to Transfusion Services as soon as possible.
Type specific blood is available within 10 minutes. Complete crossmatched blood takes a minimum of 45 minutes. Emergency Release of un-crossmatched, blood type O is available immediately. O negative (O-) is the universal red cell donor.
Patients who should receive leukocyte-reduced RBCs: Sickle cell Post-op cardiac surgery Oncology patients undergoing active treatment NICU PICU (less than 4 months old) Any patient the MD requests leukocyte reduced
If leukocyte-reduced cells are not available, Pall Filters are stocked in Transfusion Services and distributed with each unit of packed cells per physician's order and based on patient s diagnosis/condition. One filter is used for each unit of blood. All guidelines for blood transfusions will be followed.
The Drip chamber should not be squeezed while the Pall Filter is in place. An airlock will occur, blood will not flow, and a new filter must be obtained. Saline should NOT enter the filter thus preventing release of Leukocytes. Document on the Blood Transfusion Record if a leukocyte reduced filter used.
Blood administration via a pressure bag can be performed by a registered nurse or Advisory Statement Competent LPN. Pump pressure should exert only enough pressure to achieve desired rate of blood administration and SHOULD NOT exceed 300 mg Hg or have pressure indicator extend into the red zone. Air embolism may occur when a transfusion is given under pressure and air is introduced into the system.
Transfusions are not risk-free: Blood born disease and parasites Costs Potentially prolonged healing time Potential for transfusion reactions Increased demand with decreased supplies
JCAHO requires us to offer non-blood alternatives to the patient who refuses blood products. The LIP may elect to treat asymptomatic anemia with dietary/ nutritional supplements or medications instead of relying solely on transfusions to improve the patient s health. Place Inpatient Anemia Orders in all charts of patients with hemoglobin less than 10.