Blood Transfusion

Question 1

Blood group

Answer 1

• Red blood cells are covered by proteins that make up a person’s blood group. The four major blood groups are O, A, B, and AB.
• About 85 percent of the people in the United States have a substance on their red blood cells called the “Rh factor.” These people are “Rh positive.” The remaining 15 percent of Americans are called “”Rh negative” because they do not have the Rh factor.
  — This is why a person’s blood may be referred to as “A positive” (group A, Rh positive) or “O negative” (group O, Rh negative).

Question 2

Whole blood:

Answer 2

• Blood with all blood components intact
• contains all blood components: RBCs, WBCs, Platelets, Plasma, Clotting factors, Immunoglobulins
• transfused 24 hours after collection due to degradation of clotting factors

Question 3

Whole blood Indication:

Answer 3

• (rarely used) to rapidly restore blood volume and oxygen-carrying capability of blood, as in cases of blood loss from hemorrhage

Question 4

Whole blood Administration:

Answer 4

Give whole blood or packed RBCs through a Y-type I.V. set with a 170-micron filter unless a 20- to 40- micron filter (for microaggregates from degenerating platelets and fibrin strands) is ordered.

Question 5

Red blood cells (RBCs):

Answer 5

• Whole blood with 80% of plasma removed & platelets removed; volume usually 250 mL
• contain hemoglobin

Question 6

Red blood cells (RBCs) Indication:

Answer 6

• to maintain or boost oxygen-carrying capability of the blood, as in cases of:
  — blood loss from GI bleeding or surgery
  — RBC destruction from chemotherapy
• contain hemoglobin

Question 7

Red blood cells (RBCs) Administration:

Answer 7

Give whole blood or packed RBCs through a Y-type I.V. set with a 170-micron filter unless a 20- to 40- micron filter (for microaggregates from degenerating platelets and fibrin strands) is ordered.

Question 8

Leukocyte-poor RBCs:

Answer 8

Same as RBCs but with about 95% of leukocytes removed; volume about 200 mL

Question 9

Leukocyte-poor RBCs Indication:

Answer 9

for treatment of febrile nonhemolytic transfusion reaction caused by WBC antigens reacting with a patient’s WBC antibodies or platelets

Question 10

leukocyte-poor RBCs Administration:

Answer 10

Administer leukocyte-poor RBCs with a straight-line or Y-type I.V. set to infuse blood over 1 1/2 to 4 hours. Use a 40-micron filter suitable for hard-spun leukocyte-poor RBCs.

Question 11

Hemoglobin

Answer 11

Each unit of whole blood or RBCs contains enough hemoglobin (Hb) to raise the Hb level in an average- size adult by 1 g/dL (about 3%)

Question 12

White blood cells (WBCs, also called leukocytes):

Answer 12

Whole blood with all RBCs and about 80% of plasma removed; volume usually 150 mL

Question 13

White blood cells (WBCs, also called leukocytes) Indication:

Answer 13

• to treat sepsis that is unresponsive to antibiotics (especially if the patient has blood cultures positive for sepsis or a persistent fever that exceeds 101° F [38.3° C] and granulocytopenia [granulocyte count usually less than 500/μL])
• When administering WBCs, premedicate with diphenhydramine (Benadryl), as prescribed.

Question 14

WBC Administration:

Answer 14

Administer WBCs using a straight-line I.V. set with a standard in-line blood filter to provide 1 unit daily for 5 days or until the infection resolves.
- Because a WBC infusion induces fever and chills, administer an antipyretic if fever occurs. Don’t discontinue the transfusion; instead, reduce the flow rate, as ordered, for patient comfort.
- Agitate the WBC container to prevent settling, thus preventing the delivery of a bolus infusion of WBCs

Question 15

Platelets

Answer 15

Fragments of large bone marrow cells (called megakaryocytes) that help with clotting; volume 35 to 50 mL/unit

Question 16

Platelets Indication:

Answer 16

to treat thrombocytopenia caused by decreased platelet production, increased platelet destruction, or massive transfusion of stored blood; to treat acute leukemia and marrow aplasia; and to improve platelet count preoperatively in a patient whose count is 100,000/μL or less

Question 17

Platelet Administration:

Answer 17

• Platelets require a component drip administration set to infuse 100 mL over 15 minutes. As prescribed, premedicate with an antipyretic and an antihistamine if the patient’s history includes a platelet transfusion reaction. If the patient has a fever before administration, notify the practitioner for probable delay of the transfusion.
• Prepare to draw blood for a platelet count, as ordered, 1 hour after platelet administration to determine platelet transfusion increments.

Question 18

Fresh frozen plasma (FFP):

Answer 18

Uncoagulated plasma separated from RBCs and rich in coagulation factors V, VIII, and IX; 5,8,9
volume 200 to 250 mL

Question 19

Fresh frozen plasma (FFP) Indication:

Answer 19

• to correct an undetermined coagulation factor deficiency
• to replace a specific factor when it isn’t available
• to correct factor deficiencies resulting from hepatic disease
• WARNING!: FFP is no longer indicated for use as a volume expander because of its high load of clotting factors. It’s also contraindicated as prophylaxis after cardiopulmonary bypass surgery or with massive blood transfusions.

Question 20

Fresh frozen plasma (FFP) Administration:

Answer 20

• For FFP, use a straight-line I.V. set, and administer the infusion rapidly.
• Keep in mind that large-volume transfusions of FFP may require correction for hypocalcemia because citric acid in FFP binds calcium.

Question 21

Cryo: Cryopercipitate:

Answer 21

often referred to as Cryo is the precipitated material obtained from FFP when thawed. It contains coagulation factors VIII and XIII;
8 & 13,
Bogen, von Willebrand factor, and fibronectin. It is given to prevent or control, bleeding in patients with hemophilia, von Willebrand disease, to correct low fibrinogen levels, and for other clotting disorders

Question 22

Albumin 5% (buffered saline) and albumin 25% (salt-poor saline):

Answer 22

Small plasma protein prepared by fractionating pooled plasma; volume of 5%, 12.5 g/250 mL; volume of 25%, 12.5 g/50 mL

Question 23

Albumin Indication:

Answer 23

• to replace volume lost because of shock from burns, trauma, surgery, or infections; to replace volume and prevent marked hemoconcentration; and to treat hypoproteinemia (with or without edema)
• WARNING! : Keep in mind that albumin is contraindicated in patients with severe anemia and must be administered cautiously to those with cardiac or pulmonary disease because of the risk of heart failure from circulatory overload.

Question 24

Albumin Administration:

Answer 24

For albumin, use a straight-line I.V. set with rate and volume dictated by the patient’s condition and response.

Question 25

Factor VIII:

Answer 25

Insoluble portion of plasma recovered from FFP; volume about 30 mL (freeze-dried)

Question 26

Factor VIII Indication:

Answer 26

Factor VIII to treat hemophilia A, to control bleeding associated with factor VIII deficiency, and to replace fibrinogen or deficient factor VIII

Question 27

Factor VIII Administration:

Answer 27

For factor VIII, use the administration set supplied by the manufacturer. Administer with a filter; the standard dose recommended for the treatment of acute bleeding episodes in patients with hemophilia is 15 to 20 units/kg.

Question 28

Factors II, VII, IX, and X complex (prothrombin complex): 2,7,9,10

Answer 28

Lyophilized, commercially prepared solution drawn from pooled plasma

Question 29

Factors II, VII, IX, and X complex Indications:

Answer 29

• to treat a congenital factor V deficiency and other bleeding disorders resulting from an acquired deficiency of factors II, VII, IX, and X
• WARNING!: Factors II, VII, IX, and X complex transfusions are contraindicated in patients with hepatic disease resulting in fibrinolysis and in patients with disseminated intravascular coagulation who aren’t undergoing heparin therapy.
• Draw blood for a coagulation assay before administering factors II, VII, IX, and X complex and at suitable intervals during treatment.

Question 30

factors II, VII, IX, and X complex Administration:

Answer 30

• Administer factors II, VII, IX, and X complex with a straight-line I.V. set, basing the dose on the desired factor level and the patient’s weight, as ordered.
• Note that the half-life of factor VII is 8 to 10 hours, which necessitates repeated transfusions at specified intervals to maintain normal levels.

Question 31

Alternatives to blood transfusions

Answer 31

when specific blood components are adequate but volume has been lost, alternatives are:
- normal saline
- lactated Ringer solution
- albumin
- purified protein fractions
- hydroxyethyl starch
- dextrans

Question 32

Cross-matching

Answer 32

Before your transfusion, your blood will be drawn for cross-matching. During cross-matching, a sample of your blood is mixed with a sample from a blood donor. If the blood cells do not clump together, your blood is compatible, and the transfusion can be given.

Question 33

Typenex bracelet

Answer 33

• When your blood is drawn for cross-matching, a special red Typenex bracelet will be placed on your wrist. This bracelet will be checked by your nurse before your transfusion begins.
• Please do not remove the bracelet until after your transfusion.

Question 34

Informed consent

Answer 34

• Before you get your transfusion, you will be asked to read and sign an Informed Consent for Transfusion of Blood or Blood Components. (If an emergency arises and you have not had the chance to sign this form, you will still get the blood you need.) This form explains why the transfusion is needed, as well as risks, benefits, and choices about where the blood or blood components come from.
• For example, some patients prefer to be given their own blood (autologous donation).
  — Autologous blood is donated by a patient who qualifies to donate before a planned procedure. You can donate blood weeks before your surgery, either at NIH or at your local hospital. If you choose not to donate blood at NIH, your blood will be shipped in time for your surgery. Others wish to be given a transfusion from someone of their choosing (directed donation). Many patients choose directed donation, but there is no evidence that it is safer than getting blood from a volunteer community donor.

Question 35

Pretreatment Care

Answer 35

• Explain to the patient and family or caregiver the reason for the transfusion and the steps in the procedure.
• Unless the transfusion is an emergency, verify that the patient has signed an appropriate informed consent form.
• Make sure the patient’s religious beliefs don’t prohibit blood transfusion therapy.
• Record the patient’s baseline vital signs.
• Follow your facility’s policy for continued monitoring of vital signs during the transfusion.
• Obtain the blood product from the blood bank no more than 30 minutes before starting the transfusion.
• WARNING!:
  — Never store blood in a non-blood bank refrigerator. Return blood to the blood bank refrigerator if you anticipate a delay of 30 minutes or more.
• Check the expiration date on the component bag, and inspect for abnormal color, clumping, gas bubbles, and extraneous material.
• Return outdated or abnormal components to the blood bank.

Question 36

2 nurse Prep Check:

Answer 36

• According to The Joint Commission’s standards and most facilities’ policies, two nurses or practitioners are required to Use a two-person verification process to match the blood or blood component to the practitioner’s order and to match the patient to the blood component before transfusion to prevent errors and a potentially fatal reaction.
• Perform identification of blood and blood products at the patient’s bedside with another licensed professional, according to facility policy.
  — One of the people conducting the verification must be the qualified person, usually a registered nurse, who will administer the blood or blood component to the patient.
  — The second person conducting the verification must be qualified to participate in the process, as determined by your facility’s policy.
• Compare/check:
  — Pt
  — name
  — medical record number on the identification band
  blood bank identification number
• Check the component bag label
  — blood bank identification number
  — ABO blood group
  — Rh compatibility
• WARNING!
  — ABO incompatibility from mistakes in blood product labeling or patient identification is the major cause of fatal hemolytic transfusion reactions.

Question 37

Procedure

Answer 37

• The transfusion will be given either in your room or in the outpatient clinic.
• If the patient doesn’t have an I.V. line in place, perform a venipuncture using a 20G or larger catheter (18G) or the transfuse through central venous line
• Prepare a bag of normal saline solution to flush the line before and after transfusion or to keep the vein open during a reaction or between transfusions.
• Obtain an infusion pump suitable for administering blood, according to your facility’s policy.
  — Obtain a blood warmer, if ordered, to prevent hypothermia from rapid infusion of large volumes of blood.
• Only normal saline solution is compatible with blood and plasma products.
• Vital signs (pulse, respiration, temperature) will be taken before, during, and after the transfusion.
• If you have had transfusion reactions, you may be given medication (Tylenol and Benadryl) 30 minutes before your transfusion.
• Unless you are on a special diet, you may eat or drink what you like during the transfusion.
• You may also get up and move around. Just make sure to keep your movements slow and easy so that the needle and tubing do not come loose.
• If you feel any discomfort from the needle, please let your nurse know right away.
• Transfusing one unit of red blood cells takes about 1 1/2 to 2 hours, but other blood components, such as platelets, take less time to give. Often, electronic pumps are used to regulate the speed of a transfusion.

Question 38

Geriatric consideration

Answer 38

• Elderly patients require a smaller-diameter catheter, such as 20G, for RBC transfusion because they have smaller veins.
• Prepare a bag of normal saline solution to flush the line before and after transfusion or to keep the vein open during a reaction or between transfusions.
• Obtain an infusion pump suitable for administering blood, according to your facility’s policy.
• Obtain a blood warmer, if ordered, to prevent hypothermia from rapid infusion of large volumes of blood.

Question 39

Normal Saline!:

Answer 39

• Only normal saline solution is compatible with blood and plasma products.
• Never start a transfusion in an I.V. line that has been used for another infusion without completely flushing the line with saline solution.
  — Only normal saline solution is isotonic and calcium-free. Calcium binds with the citrate anticoagulant in the blood bag and promotes clotting in the tubing.
  — Excess glucose causes hemolysis and shortens RBC survival.
• Also, do not piggyback a blood administration set into a main line that has been used for any solution other than normal saline solution.

Question 40

IV Rate beginning procedure:

Answer 40

• Monitor the patient closely and adjust the flow rate to no greater than 2 mL/minute for the first 15 minutes of the transfusion to observe for a possible transfusion reaction.
• Remain with the patient and frequently reassess vital signs and blood pressure, facial color, and any complaints for the first 15 minutes.
• If no signs of a reaction appear within 15 minutes, adjust the flow to the ordered infusion rate, which should be as rapid as the circulatory system can tolerate.
• Observe the patient at least every 30 minutes during the transfusion to identify early signs and symptoms of a possible transfusion reaction and to monitor the I.V. insertion site for signs of infiltration.

Question 41

IV Rate after procedure:

Answer 41

• After completion, flush the administration set and I.V. catheter with normal saline solution.
• Remove and discard the infusion equipment and reconnect the original I.V. fluid, if necessary, or discontinue the I.V. access.
• Discard the blood bag, tubing, and filter in an appropriate hazardous waste container.
• Monitor and assess the patient for signs and symptoms of a delayed transfusion reaction for 4 to 6 hours after the transfusion. (GVHD)
• If the patient isn’t under direct observation after the transfusion (for example, if the patient receives a transfusion as an outpatient), provide patient teaching about signs and symptoms of a delayed transfusion reaction and the importance of reporting them.

Question 42

First steps if Transfusion reaction happens:

Answer 42

• If signs of a reaction develop, immediately stop the transfusion and record the patient’s vital signs.
• Infuse normal saline solution through a new I.V. line at a keep-vein-open rate, and notify the practitioner.
• Save the blood product bag for return to the blood bank. Do not throw away.
• Obtain urine and blood samples, and send them to the laboratory.

Question 43

After the procedure

Answer 43

• After the transfusion, you may do your normal activities.
• Though it is uncommon, delayed transfusion reactions can occur days or weeks after the procedure.
• Symptoms of a delayed transfusion reaction are fever, muscle aches, and dark urine. If you think you are having a delayed reaction to your transfusion, notify a member of your health care team right away

Question 44

Posttreatment Care

Answer 44

• If necessary, change the blood or blood component administration set, using sterile technique, after infusing each unit or after 4 hours.
• Change it immediately if you suspect contamination or if the integrity of the product or system becomes compromised.
• Change the filter whenever you change the tubing, unless otherwise indicated by the manufacturer’s instructions.
• If a hematoma develops at the I.V. site, immediately stop the transfusion and remove the I.V. cannula.
• Notify the practitioner and prepare to apply ice to the site intermittently for 8 hours. Then apply warm compresses, according to your facility’s policy.
• Monitor the patient’s intake and output as well as lung status, and watch for edema to prevent fluid overload.
• After completing the transfusion, adhere to standard precautions and remove and discard the used infusion equipment in a biohazard materials receptacle.
• Reconnect the original I.V. fluid, if necessary, or discontinue the I.V. infusion.
• Return the empty component bag to the blood bank if facility policy dictates.
• Record the patient’s vital signs.

Question 45

Reactions to the transfusion

Answer 45

• During, or right after the transfusion, some patients have a “transfusion reaction.” Symptoms are usually mild and include hives, itching, rashes, fever, chills, muscle aches, back pain, chest pain, headache, and heat where you got the transfusion or along the vein. If you have these symptoms, or feel anything unusual, tell your nurse immediately. If you have had a transfusion reaction in the past, please let your doctor or nurse know before you get a transfusion.

Question 46

Patient Teaching

Answer 46

Be sure to include the patient’s family or caregiver in your teaching, when appropriate.

Question 47

General

Answer 47

• Teach the patient to immediately report the following symptoms:
  — flushing, feverish feeling chills, nausea, or headache (transfusion reaction)
  — palpitations (with hypotension, arrhythmia, shaking, or chills may be a sign of hypothermia)
  — difficulty swallowing or breathing (possible anaphylaxis)
  tingling in the fingers, muscle cramps, nausea, vomiting, or faintness (with hypotension, arrhythmias, and seizures, may signal hypocalcemia from citrate toxicity or liver impairment)
  — intestinal colic, diarrhea, or muscle weakness (with irritability, oliguria, T-wave changes on electrocardiogram, and bradycardia, may signal hyperkalemia from large-volume transfusions).
  — graft vs. host disease: happens days - weeks after infusion
  —- rash head to toe
• Explain to the patient that additional transfusions may be needed.
• Inform the patient that you may need to collect specimens to evaluate the effectiveness of therapy.

Question 48

Complications

Answer 48

• Transfusion reaction
• Infectious disease transmission
• Hepatitis C
• Circulatory overload
• Hemolytic reactions
• Coagulation disturbances
• Citrate intoxication
• Hyperkalemia
• Acid-base imbalance
• Allergic, febrile, and pyogenic reactions
• Hypothermia
• Acute lung injury

Question 49

Nursing Diagnoses

Answer 49

• Activity intolerance
• Deficient fluid volume
• Deficient knowledge: Disease process
• Risk for decreased cardiac tissue perfusion
• Risk for ineffective cerebral tissue perfusion
• Risk for ineffective renal perfusion
• Risk for injury

Question 50

Expected Outcomes

Answer 50

• The patient will:
  — demonstrate an increased ability to perform activities of daily living
  — maintain adequate fluid volume
  — verbalize an understanding of the need for the transfusion and the steps involved
  — maintain adequate cardiac tissue perfusion
  — demonstrate an alert level of consciousness
  — exhibit adequate renal perfusion
  — remain free from complications, including a transfusion reaction.

Question 51

Universal donor

Answer 51

type O

Question 52

universal recipient

Answer 52

type AB

Question 53

Call MD if baseline temp is

Answer 53

> 100 F

Question 54

start transfusion/ vs:

Answer 54

• slow; 2ml/min (120mL/hr) for the first 15 min
• 5 min into transfusion: take vital signs
• 15 mins after transfusion: take vital signs; if stable, increase IV rate to finish within 2-4 hours)
• 30 min into transfusion: take vital signs if stable switch VS frequency to 1 hourly until done
• 1 hour after transfusion: VS

Question 55

Transfusion reaction:

Answer 55

• rash
• fever (increase of 1° C or 1.8° F)
• Most common; people who have received blood in the past.
• body creates antibodies
• Aches
• Chills
• Tachycardia
• tachypnea
• UOP Low (hemoglobinuria: purple color
• NVD

Question 56

Transfusion reaction labs:

Answer 56

• Clotting; DIC
• Electrolytes
• Renal blood levels
• urine: free hemoglobin

Question 57

900mL PRBC to infuse over 4 hours

Answer 57

• 1st 15 min:
  — 2ml/min = 30 ml/ 15 min @ 120ml/hr
• next 3.75 hours:
  — 870mL remaining = 870mL infused @ 232ml/hr