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Review and carry out the Standard Steps listed in Appendix 6. Assessment (Data Collection) 1. ACTION See that the patient has a patent cannulaat least 19 gauge in place. Plasma products may beinfused via a 22-gauge cannula. RATIONALE Aneedle smaller than 19 gauge may break up red cells. Planning 2. ACTION Gather the equipment, verify that the pa-tient is ready, and obtain the blood product fromthe blood bank. (Packed red cells are the compo-nent used for this example.) RATIONALE Saves time; administration of the blood product must begin within 30 minutes of thetime the product leaves the blood bank. Implementation 3. ACTION With another nurse, verify the bloodcomponent, and compare the donor numbers andthe ABO group and Rh type on the request slipwith the label and numbers on the blood compo-nent bag. One nurse should read the numbersfrom the blood bank transfusion record slip whilethe other checks the numbers on the blood compo-nent bag. Verify the expiration date on the bloodcomponent bag; check the bag for clots. RATIONALE For safety, two nurses must verifythe order, and match the numbers on the bloodcomponent with those on the transfusion record Skill 3-6 Administration of Blood Products Blood components are administered for a variety of reasons. The most common component trans-fused is packed red cells, which are given for acute or chronic anemia. Platelets and fresh frozenplasma are transfused to replenish platelets and provide clotting factors. There is no margin forerror when administering blood products because adverse reactions can be considerable andlife threatening. Per the JCAHO 2005 safety goals, the nurses must use two identifiers for pa-tient identity and room number or location cannot be one. The patient name and number on theID bracelet, or verbally given name and birth date are suitable identifiers. Most agencies requirethat two nurses verify the ordered blood component with the component the blood bank suppliesand correctly match up the patient numbers with the blood component unit numbers. In emer-gency situations, the blood may need to be administered with a pump so that it will flow into thepatient more quickly. Asigned consent is needed before a blood product administration begins.Special tubing with a filter is used for blood components. An extra filter on the bag is required forsome blood products. A“Y” tubing set is commonly used for transfusion of packed red cells. Supplies ✓ Blood product administration set ✓ Alcohol swabs ✓ Normal saline 0.9% IV solution ✓ Physician’s order ✓ Blood bank slip ✓ Ordered blood component ✓ Tape ✓ Glovesslip. The blood component may not be transfusedafter the expiration date. If the unit contains clots,it should be returned to the blood bank. 4. ACTION Close all clamps on the “Y” administra-tion set. Spike a normal saline container. Prime thefilter and tubing with normal saline by openingthe slip clamp below the drip chamber of the nor-mal saline and the lower roller clamp. Spike the From deWit, S.C. (2005). Fundamental Concepts and Skills for Nursing (2nd ed.). Philadelphia: Elsevier Saunders. STEP 4 blood component bag. For packed red cells, invertand lower the packed red cell bag, open the clampto the bag, and open the slip clamp to the normalsaline while keeping the roller clamp closed. Al-low about 50 mLof saline to run into the packedred cells. Close the clamps. RATIONALE A“Y” set is always to be used for blood component infusion. Priming the filter andtubing with normal saline removes air and eases theway for blood flow. Combining a small amount of saline with packed red cells, if within agency proto-col, decreases the viscosity and helps the blood in-fuse more easily. Care is taken to close clamps sothat none of the blood product is accidentally lost. 5. ACTION Take the administration set to the pa-tient’s room; properly identify the patient, com-paring the full name and hospital identificationnumber on the patient’s wristband with the trans-fusion record information. Compare the blood bracelet identification number with the number onthe blood component. RATIONALE It is mandatory that all identifyinginformation and numbers match exactly. If discrep-ancies occur, notify the blood bank. Transfusionsare not begun until the discrepancy is resolved. 6. ACTION Don gloves and face shield, and connectthe “Y” administration set to the indwelling can-nula. Start the normal saline to clear the cannula,and verify the patency of the site. RATIONALE Gloves must be used when contactwith blood is likely. The patency of the site must beverified before beginning the transfusion. 7. ACTION Obtain baseline vital signs. If the pa-tient’s temperature is over 100°F, consult thephysician. Assess the patient’s physical status,particularly looking for signs or symptoms thatmimic a transfusion reaction. RATIONALE Baseline data are essential. Knowingthe patient’s baseline physical status helps deter-mine later if a transfusion reaction is occurring. 8. ACTION Clamp off the saline, and open the clampto the blood. Set the flow rate at 2 mL/minute forthe first 15 minutes. Remain with the patient for atleast the first 5 minutes. Reassess the patient andtake vital signs at the end of 15 minutes. If thereare no signs of an adverse reaction, the infusionrate may be increased to the calculated flow rate.Take vital signs at the end of 30 minutes and thenevery 30 minutes until the transfusion is complete.Follow your agency’s protocol. Ask the patient totell you if she feels “funny,” or has chills, backpain, itching, or shortness of breath. Watch forflushing. Blood must be infused within 4 hours of release from the blood bank. RATIONALE Begins the transfusion. Adverse reac-tions occur most frequently during the first 5 min-utes, although delayed reactions can occur. The pa-tient must be monitored throughout the transfusionfor any signs of an adverse reaction. It is essentialthat the patient understand the importance of re-porting any symptoms that differ from normal.Average infusion time is 2 hours per unit. 9. ACTION When the blood component has been in-fused, flush the line with normal saline. Reinsti-tute IV fluid orders with a new solution and tub-ing, or maintain saline at a “keep vein open” rate(50 mL/hr) until you are certain that the patient isstable and has had no reaction, then convert to aPRN lock, or discontinue the IV site per orders. RATIONALE Previously hanging IV solution andtubing are considered contaminated and must bediscarded. Evaluation 10. ACTION Monitor vital signs and assess for short-ness of breath, rash, back pain, apprehension,fever, tachycardia, nausea and vomiting, and othersigns of transfusion reaction. RATIONALE Evaluates whether a reaction hasoccurred. Documentation 11. ACTION Document the infusion on the IV flowsheet. Add the amount infused to the IV intakerecord. Attach the label from blood bag with num- bers of the unit and crossmatch identification STEP 8 From deWit, S.C. (2005). Fundamental Concepts and Skills for Nursing (2nd ed.). Philadelphia: Elsevier Saunders.From deWit, S.C. (2005). Fundamental Concepts and Skills for Nursing (2nd ed.). Philadelphia: Elsevier Saunders. numbers with the donor type and Rh type; notevolume infused, date and time, any reaction signsand symptoms, and your signature. Adverse reac-tions must be charted in the nurse’s notes. RATIONALE Documents the transfusion and pa-tient response. Example 11/301440Vital signs: T. 98.4°F; BP, 132/86 mm Hg;P74; R 16. First unit of packed RBCs via 18 Angiocathin rt. forearm. Begun at 20 gtt/minute. No signs of ad-verse effects in 15 min. Vital signs: T 98.4°F, BP136/86 mm Hg; P76, R 16. Rate increased to 100 mL/hour.Patient voiced no complaints.______________________1600Transfusion complete; line flushed with normalsaline. No adverse effects noted.________________________________________(Nurse’s signature) Special Considerations ✓ Ablood product infusion should begin within 30 minutes of leaving the blood bank. ✓ Ablood warmer may be used if the patient is incritical condition or is feeling chilly before infusion. ✓ Blood transfusion should be checked every 15 to 30 minutes to ensure that it is running on time. ✓ Blood components that are still hanging after 4 hourswithout refrigeration must be discontinued. ✓ In the postinfusion period, the patient’s urine isobserved for signs of hematuria, indicating atransfusion reaction. ✓ If a transfusion reaction occurs, stop the blood, startthe saline, stay with the patient, and immediatelynotify the physician. If shortness of breath occurs,start low-flow oxygen per agency protocol. Returnthe blood component bag to the blood bank withthe transfusion reaction form. CRITICAL THINKING QUESTIONS 1.How long before you are ready to administer a blood product can you obtain the blood productfrom the blood bank and bring it to the nursing unit?2.You are infusing packed red cells and the patientcalls you to the room and says that she is feelingshort of breath and is itching; what would you do? From deWit, S.C. (2005). Fundamental Concepts and Skills for Nursing (2nd ed.). Philadelphia: Elsevier Saunders. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1. Carries out Standard Steps A, B, C, D, and E as need indicates. 2. Verifies size of IV catheter in place. 3. Obtains blood using proper procedure. 4. Double-checks the blood with another nurse. 5. Attaches the “Y” administration set and sets up normal saline solution. 6. Spikes the blood component bag correctly. 7. Properly identifies the patient and checks the blood identification bracelet with the transfusion record numbers. Uses two identifiers. 8. Dons gloves and connects the blood component to the administration set. 9. Obtains baseline vital signs. 10. Primes administration set with normal saline. 11. Begins the blood administration, remains with patient for first 5 minutes, and checks the patient every 15 minutes for first half hour. 12. Monitors vital signs every 30 minutes. 13. Flushes line with normal saline at end of infusion. 14. Carries out Standard Steps X, Y, and Z. S U Skill 3-6 Administration of Blood Products Student: _________________________________________________Date: ___________________________________________________ Successfully completed Needs practice and retesting Comments:Instructor: ___________________________________ S: Satisfactory PerformanceU: Unsatisfactory Performance
