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NURSING SKILLS BLOOD TRANSFUSION/ IV THERAPY Lecturer: Mark Fredderick R. Abejo RN, MAN ______________________________________________ Blood Transfusion Blood Compatibility Compatible Incompatible A A/O AB / B B B/O AB / A AB A / B / AB / O O O A / B / AB Note: Type AB “ Universal Recipient” Type O “ Universal Donor”Blood Products for Transfusion: Product UsesWhole Blood Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood productsPRBC Used to increase the oxygen- carrying capacity of bloodPlatelets Replaces platelets in client with bleeding disorder or platelet deficiencyFresh Frozen Expands blood volume andPlasma provides clotting factor. Note: Does not need to be typed and cross-matched, contains no RBCsAlbumin and Blood volume expanderplasma protein Provide plasma proteinsfractionClotting factor and Used for client with clottingcryoprecipitate deficiencies Cryoprecipitate also contains fibrinogen
Lecture Notes on Blood Transfusion Therapy & IV TherapyPrepared By: Mark Fredderick R Abejo R.N. MAN Clinical InstructorPurposes: Nursing Intervention: 1. To administer required blood component by Verify doctor’s order. Inform client and explain the the patient purpose of the procedure. 2. To restore the blood volume Check for cross-matching and blood typing. To 3. To improve oxygen-carrying capacity of the ensure compatibility blood. Obtain and record baseline VS Note: If patient has fever do not transfuseEquipment: Practice strict, ASEPSIS- Unit of blood At least 2 nurses check the label of the blood- Normal saline ( PNSS) transfusion, Check the following:- Blood transfusion set - Serial Number- Venipuncture set containing needle gauge of #18 or - Blood component#19 - Blood type- Alcohol and povidone-iodine swabs - Rh factor- Tape - Expiration date- Clean gloves - Screening test Check the blood for gas bubbles and any unusual color or cloudiness Note: Gas bubbles indicate bacterial growth Unusual color or cloudiness indicate hemolysis Warm blood at room temperature before transfusion. Identify client properly, two nurses check the client’s identification Set up the infusion equipment, use BT set with filter. To prevent administration of blood clots and other particles. Prepare the blood bag, expose the port on the blood bag and insert the BT set, open the clamp let blood flow to the tube up the needle. To remove air in the tubing Note: Blood is transfuse as a side drip to PNSS. Direct transfusion is done during emergency situation and as ordered. Blood Shelf Life WBC Warm at PRBC room 4 degree C temperature transfused immediately Washed RBC Transfused within 1 ½ 4 degree C hours FFP Use immediately - 18 degree C Cryoprecipitate upon Platelets thawing 20 degree C
Lecture Notes on Blood Transfusion Therapy & IV TherapyPrepared By: Mark Fredderick R Abejo R.N. MAN Clinical Instructor BLOOD TRANSFUSION REACTION Reaction Cause Clinical Signs Nursing InterventionHemolytic Reaction Incompatibility between Chills, fever STOP transfusion client’s blood and the Headache, backache KVO with PNSS donor’s blood Dyspnea Send remaining blood, a sample of Cyanosis client blood and urine sample to the Chest pain laboratory. Tachycardia Notify the physician Hypotension Monitor VS Monitor I & OFebrile Reaction Sensitivity of the client’s Fever, Chills STOP transfusion blood to WBC, platelets Warm, flushed skin Give antipyretics or plasma protein Headache Notify the physician Anxiety KVO with PNSS Muscle painAllergic ReactionMild Sensitivity to infused Flushing STOP transfusion plasma proteins Itching Notify the physician Urticaria Administer antihistamine as Brochial wheezing orderedSevere Antibody-antigen reaction Dyspnea STOP transfusion Chest pain KVO with PNSS Circulatory collapse Notify the physician immediately Cardiac arrest Monitor VS Administer CPR as needed Administer medication / oxygen as neededCirculatory Blood administered faster Cough STOP or SLOW the transfusionOverload than the circulation can Dyspnea Place the client upright, with feet accommodate Crackles dependent Distended neck veins Administer diuretics and oxygen as Tachycardia needed Hypertension Notify physicianSepsis Contaminated blood High fever, chills STOP transfusion administration Vomiting Send remaining blood to laboratory Diarrhea Notify the physician Hypotension Obtain a blood specimen from the client for culture Administer IV fluids and antibiotics KVO with PNSS
Lecture Notes on Blood Transfusion Therapy & IV TherapyPrepared By: Mark Fredderick R Abejo R.N. MAN Clinical Instructor there should be no childrenINTRAVENOUS INSERTION discomfort while solution is flowing. ( I.V Insertion ) Wash hands and perform appropriate infection controlPurposes: Open and prepare To supply fluids when clients are unable to the infusion set take adequate volume of fluids by mouth. - Remove tubing from To provide salts needed to maintain electrolyte the package and balance straighten it out. To provide glucose, the main fuel for - Slide the clamp just metabolism below the drip chamber To provide water-soluble vitamins and and close it. medications. - Leave the ends of the This will maintain the To establish a lifeline for rapidly needed tubing covered with sterility of the ends of medications. plastic caps tubing. Spike the solution/Equipment: IV fluids- Infusion set - Remove the protective- Solu set ( if needed ) cover of the container- IV pole of IV fluids.- Adhesive tape - Remove the cap of the- Clean gloves spike and insert the- Tourniquet spike on the insertion- Antiseptic swab or cotton with alcohol site of the container- IV catheter Properly labeled the- Sterile gauze dressing solution:- Arm splint ( if needed ) - Name of Patient- Towel or pad - Kind of IVF- Infusion device or pump ( if required ) - Meds Incorporated - No. of drops/min - Date/Time Started - Date/Time to be consumed Hang the solution on Enable gravity to the pole about 3 ft overcome venous above the clients pressure and facilitate head flow of the sol. Partially fill the drip chamber by squeezing it gently until half full Prime the Tubing Remove the Steps / Procedure Rationale protective cap and Identify and inform hold the tubing over the client and explain To allay anxiety the container the procedure. Release the clamp To prevent the- A venipuncture can Note: and let the fluid run introduction of air tocause discomfort, but Use dolls to explain to through the tubing the client
Lecture Notes on Blood Transfusion Therapy & IV TherapyPrepared By: Mark Fredderick R Abejo R.N. MAN Clinical Instructor until all air are Note: Insert the catheter and initiate the infusion remove Air bubbles smaller If desired and permitted than 0.5 ml usually do by policy inject .05 ml of not cause problems in 1% lidocaine ID over the the line. puncture site. Allow 5-10 Reclamp the tubing sec. to take effect and replace the Use the nondominant This stabilizes the tubing cap. hand to pull the skin vein If indicated was below the entry site hands again Holding the over-the-Select Venipuncture Site needle catheter at 15 toGuidelines in Vein Selection: 30 degree angle bevel up, Use distal veins of the arm first insert through the skin and into the vein. Use the client’s nondominant arm as Once blood appears in possible. the lumen of your needle, Select a vein that is: advance the needle and - easily palpated and feels soft and full catheter approx. .5-1 cm - naturally splinted by bone Holding the needle - large enough to allow adequate circulation portion steady, advance Avoid using veins that are the catheter until the hub - in areas of flexion is at the venipuncture site - highly visible Release the tourniquet - damage by previous use Remove the protective - distended, knotted or tortuous cap from the tubing and - surgically compromised or injured hold it ready to attach to extremity the catheter Dilate the chosen vein Distending the vein Attach the end of the- Place the extremity in a makes easier to insert infusion tubing to thedependent position, lower the needle catheter hubthan the client’s heart Initiate the infusion- Apply a tourniquet Gravity slow the Tape the catheterfirmy 6-8 inches above venous return Dress and label thethe venipuncture site venipuncture site and To obstruct the tubing according toNote: venous flow agency policyIf vein is not sufficiently Ensure appropriatedilated; infusion flowa. Massage or stroke thevein distal to the site, in Label the IV tubingthe direction of the heart. Document relevant datab. Encourage the client to and assessmentclench and unclench thefist.c. Slightly tap the veinwith your fingertips Put on clean gloves and clean the site with Circular motion alcohol / antiseptic sol. carries in circular motion and microorganism away let it dry from the site of entry
Lecture Notes on Blood Transfusion Therapy & IV TherapyPrepared By: Mark Fredderick R Abejo R.N. MAN Clinical Instructor