Nsg: Blood Transfusions Flashcards Preview

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Flashcards in Nsg: Blood Transfusions Deck (28)
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1
Q

What is a blood transfusion?

A

The administration of platelets,WBC’s, packed RBC’s or plasma.

2
Q

Reasons for a blood transfusion?

A
  • Post Sx and lost a lot of blood
  • Anemic (chronic condition)
  • Hemorrhaging
  • Has bleeding disorder.
3
Q

Which blood type is the Universal Recipient?

A

AB Can reveive any type

4
Q

Which blood type is the Universal Donor?

A

O Can give to any type.

5
Q

Steps of a blood transfusion

A

1)Inform pt and explain reason for transfusion.
Inform of s/s to report.
2)Start IV with a LARGE IV (18-19) gauge.
16 for children.
3)Use tube specfic for blood transfusions and prepare w/ NS
4)Obtain baseline VS before.
5)Get blood from blood bank ONLY once ready for administration
6)Identify blood + pt w/ 2 RN’s @ bedside.
7)Start transfusion slowly (50ml/hr)
8)Then after 15min maintain prescribed transfusion rate
9)Take Vs q15min x 4, q30min x 2, q1hr.
And monitor for transfusion reaction.
If any reaction, respond immediately.
10)Document: time started, finished, pt response, reactions and actions taken (if any).

6
Q

Why use a 19, 18, or 16(ideal) gauge needle for blood transfusions?

A

Small needles can damage the cells in the blood.

Though, smaller needles can be used on children (16 gauge)

7
Q

How long can you hang blood transfusions for?

A

No longer than 4 hours b/c theres an increased risk of MCO build up that could result in infection/sepsis.

8
Q

Can you infuse other solutions into the same line as the blood transfusions?

A

No.

Because they can induce RBC hemolysis.
Can also cause clots in the tubing and prevent flow of blood.

Can only use same tubing if tubing was first flushed with Saline Solution.

9
Q

What to do before you start transfusion?

A

1)Start transfusion with large gauge needle
2)Double check w/ 2 RN’s
3)Inform pt of procedure and reason
consent
4)Inform pt of s/s to report
5)VS before transfusion (for baseline measure)

10
Q

How fast to infuse infusion at first

A

50ml/hr b/c the first 15 min is the highest risk for transfusion reactions to occur.
Monitor closely.

If any reactions occur, infuse no more than 2ml/hr.

11
Q

What are some Blood Transfusions reactions?

A

1) Hemolytic Transfusion Reaction
2) Febrile Non-Hemolytic Transfusion Reaction
3) Allergic Reaction (Ex:Anaphylaxis)
4) Trali: Transfusion Related Acute Lung Injury)
5) Fluid Overload
6) Infection

12
Q

**What is the nursing response to ALL transfusions?

A

1) Stop infusion immediately
2) use new tubing and flush NS to KVO
3) Assess pt (VS, resp assessment, U/O, Pt’s experinces s/s)
4) Notify MD (He will Dx type of reaction and decides the Tx)
5) Notify blood bank + send blood bag + tuing to lab
6) Document

13
Q

What are the Secondary Antigens?

A

Antigens on blood.
Ex: Rh factor is a secondary Antigen. Ex A+ (Rh factor is there)

ABO identicle blood can be imcompatible b/c of other antigens on the RBC’s.

the difference w/ secondary antigens is that the pt will not develop antibodies to these until they are exposed to them.

14
Q

What to do if pt experiences chest pain?

A

1) Stop infusion
2) Change tubing
3) Clear w/ NS
4) Give O2

15
Q

How to prevent Rh- pt’s from developing antibodies.

A

1) Rh- pt’s are given only Rh- blood.
2) RhoGAM is administered to Rh- mothers who have Rh+ babies (the med destroys the Rh+ antigens transfered to the mother diring childbirth, so she won’t deliver antibodies.

Ex: If given pt who is Rh- the wrong blood (Rh+), the pts antibodies will react with the antigens causing hemolysis.

16
Q

What is a Hemolytic Transfusion Reaction?

A

The most severe reaction

  • usually occurs in first 15 min
  • D/t ABO incompatability.
  • Reaction of antibodies and antigens
17
Q

S/s of Hemolytic Transfusion Reaction

A
  • SOB
  • Chills
  • Sweats
  • Fever
  • Shivering
  • Chest pain
  • Hypotension
  • Vomiting
  • Tachycardia
  • Anxiety
18
Q

Tx of Hemolytic Transfusion Reaction

A

Same as response to all reactions

19
Q

What is Febrile Non-Hemolytic Transfusion Reaction?

A

A sudden increase in Temperature with no other s/s

-D/t pts antibodies reacting against donor leukocytes still in the unit of blood.

20
Q

Tx of Febrile Non-Hemolytic Transfusion Reaction

A

Same as all other reactions
plus:

Antipyretic
Notify MD
Pt will need leukocyte reduced (washed) blood products in the future

21
Q

S/s and Tx of an Allergic Reaction to the blood transfusion

A

Mild: Rash (hives) and itching
Tx: Antihistamine + may continue transfusion if MD says so.

Severe: Anaphylaxis, respiratory distress
Tx: Epinephrine (Vasoconstrictor), O2, life support prn, Notify MD

22
Q

What is TRALI?

A

Transfusion Related Acute Lung Injury

-Reaction b/w transfused antileukocyte antibodies and recipients leukocytes causing pulmonary inflammation and capillary leak, which could lead to death.

23
Q

S/s of TRALI

A
  • Sudden resp distress during transfusion or in 6hr following
  • Hypoxemia w/ O2 sat <90%
  • Bilateral infiltrates on CxR
  • No evidence of vol overload or other pulmonary lesions.
24
Q

S/s of Fluid overload from blood transfusion

A
  • HTN
  • Tachycardia
  • SOB
  • Adventicous sounds in lungs
25
Q

Why does fluid overload happen in blood transfusions?

A

It happens b/c of volume administration and oncotic “pull” of fluid from tissues into the vascular system.

It effects the elderly and ppl with cardiac Hx.

26
Q

Tx of Fluid overload

A
  • Diuretics
  • Check lung sounds
  • Inform MD, he may order lasix.
27
Q

Why may an infection occur?

A
  • Contaminated blood
  • Transmission of infectious organisms (Hepatitis, HIV, west nile virus)
  • All donors are screened and blood is tested for infectious agents
  • small risk if donor is infected but antibodies have not yet formed in donors blood for detection by testing. (overall, always a small risk)
28
Q

What are some s/s the pt should know to report?

A

Lower back pain
Itching
SOB
Feeling of light headedness