MONITORING AN INTRAVENOUS INFUSION Definition: An important nursing responsibility is to monitor an IV infusion so that the flow of the correct solution

is maintained at the correct rate. Indications: 1. To maintain prescribed flow rate. 2. To prevent complications associated with IV therapy. Assessment Focus 1. Appearance of infusion site; patency of system. 2. Type of fluid being infused and rate of flow. 3. Response of the client. special consideration: 1. Assess the whole infusion system at least every hour to ascertain problems. 2. Maintain asepsis. 3. Ensure that the correct type and amount of fluid is infused within the specified time period. 4. Prevent or identify early: a. fluid infiltration b. phlebitis c. circulatory overload d. bleeding at the venipuncture site e. blockage of the infusion flow

PROCEDURE 1. From the physicians order determine he type and sequence of solutions to be used. 2. Determine the rate of flow and infusion schedule. 3. Ensure that the correct solution is being infused. If the solution is incorrect, slow the rate of flow to a minimum to maintain the patency of the catheter.

RATIONALE IV infusion should only be performed with support of a physicians order.

Stopping the infusion may allow a thrombus to form in the IV catheter. If this occurs, the catheter must be removed and another venipuncture should be performed before the infusion can be resumed

4. Change

the

solution

to

correct

one.

Document and report the error according to agency protocol.

PROCEDURE 5. Observe the rate of flow every hour. Compare the rate of flow regularly. 6. If the rate is too fast, slow it so that the infusion will be completed at the planned time. 7. Assess the client for the manifestations of hypervolemia including and its complications, rapid, labored dyspnea;

RATIONALE

Infusions that are off schedule can be harmful to a client.

breathing; cough; crackles in the lungs bases; tachycardia; and bounding pulses. 8. Check if the rate is too slow. 9. Inspect the patency of the tubing and needle. solution administered to quickly may cause a significant volume. increase in circulating may blood in Hypervolemia result

pulmonary edema and cardiac failure.

10. Observe

the

position

of

the

solution

container. If it is less than 1 m (3ft) above the IV site, readjust it to the correct height of the pole. 11. Observe the drip chamber. If it is less than half full, squeeze the chamber to correct amount of fluid to flow in. if the container is too low, the solution may not flow into the vein because there is insufficient gravitational pressure to overcome the pressure of the blood within the vein. 12. Open the drip regulator and observe for a rapid flow of fluid the from drip the solution to container into the drip chamber. Then partially close regulator reestablish the prescribed rate of flow. 13. Inspect tubing for pinches or kinks or obstructions to flow. Arrange the tubing so that it is lightly coiled and under no pressure. If it is dangling below the venipuncture, coil it carefully on the surface of the bed. Rapid flow of fluid into the drip chamber indicates patency of the IV line. Closing the drip regulator to the prescribed rate of flow prevents fluid overload.

PROCEDURE 14. Lower the solution container below the level of the infusion site and observe for a return flow of blood from the vein. 15. Check for leakage. Locate the source. If the leak is at the catheter connection, tighten the tubing into the catheter. 16. If the leak cannot be stopped, slow the infusion as much as possible without stopping it, and replace the tubing with a new sterile set. 17. Inspect the infusion site for fluid

RATIONALE The solution may not flow upward into the vein against the force of gravity.

Absence of blood return may indicate that the needle is no longer in the vein or the tip of the catheter is partially obstructed.

To ascertain the presence of infiltration

infiltration a. Palpate the surrounding tissue for edema. b. Feel the surrounding skin for

changes in temperature c. If the tubing does not have a backcheck valve, lower the infusion bottle below the venipuncture site. d. Use a sterile syringe of saline to withdraw fluid from the rubber at the end of the tubing near the venipuncture site. Discontinue the IV infusion if blood does not return. e. Try to stop the flow by applying a tourniquet above the 10-15 cm (4-6 site in.) and insertion to see if blood returns. Blood may indicate that the IV needle is still in the vein.

opening the roller clamp. 18. Inspect for the presence of phlebitis. The clinical signs are redness, warmth, and swelling at the IV site and burning pain along the course of a vein. a new venipuncture site is usually selected, and he injured vein is not used for further infusions.

PROCEDURE 19. Be alert to signs of circulatory overload.

circulatory normal.

RATIONALE overload means

that

the

circulatory system contains more fluid than

20. Inspect for bleeding at the IV site.

Bleeding into the surrounding tissues can occur while the infusion is freely flowing.

21. If the client is able, teach him or her when to call for assistance, e.g., if the solution stops dripping or the venipuncture site becomes swollen.

EVALUATION FOCUS 1. Amount of fluid infused according to the schedule. 2. Intactness of IV system. 3. Appearance of IV site. 4. Urinary output compared to urinary intake. 5. Tissue turgor; specific gravity of urine. 6. Vital signs and lung sounds compared to baseline data.

CHANGING AN INTRAVENOUS CONTAINER AND TUBING Indications: 1. To maintain the flow of required fluids. infection. 3. To maintain patency of the IV tubing. 4. To prevent infection at the IV site and the introduction of microorganisms into the bloodstream. Assessment Focus: 1. Presence of fluid infiltration, bleeding, or phlebitis at IV site. 2. Allergy to tape 3. Infusion rate and amount absorbed 4. Appearance of the dressing for integrity, moisture, and need for change. 5. The date and time of the previous dressing change. Special Considerations: 1. Intravenous solution container are changed when only a small solution of the fluid remains in the neck of the container and fluid still remains in the drip chamber. However, all IV bags should be changed every 24 hours, regardless of how much solution remains, to minimize the risk of contamination. 2. IV tubing is changed every 48 to 96 hours, depending on agency protocol, as is the site dressing. 3. Determine allergies to tape or iodine. 4. Select the correct solution. 5. Prime the tubing before attaching it to the IV needle. 6. Wear gloves when there is possibility of contact with the body secretions. 7. Prevent needle dislodgement when disconnecting and connecting the IV tubing and when cleaning the venipuncture site. 8. Make sure the IV system is intact and the correct flow rate is established. 9. Inspect and clean the venipuncture site appropriately. 10. Secure the needle appropriately with the tape and apply an appropriate dressing. 11. Label the container, tubing, and dressing appropriately. Patient Education: Teach the client ways to maintain the infusion system, like: 1. Avoid sudden twisting or turning movements of the arm with the needle. 2. Avoid stretching or placing tension on the tubing. 3. Try to keep the tubing from dangling below the level of the needle. 4. Notify a nurse if a. The flow rate suddenly changes or the solution stops dripping. b. The solution container is nearly empty. c. There is blood in the IV tubing. d. Discomfort or swelling is experienced at the IV site. 2. To maintain sterility of the IV system and decrease the incidence of phlebitis and

Equipments: Container with the correct kind and amount of sterile solution Administration set, including sterile tubing and drip chamber Timing label Sterile gauge square for positioning the needle Alcohol swab Clean glove Tape

PROCEDURE A. Changing IV Container 1. Review physicians order for changes in fluid administration. 2. Obtain the correct solution container and make sure it is properly labeled. Check for sterility and integrity. 3. Prepare to change solution when it only remains in the neck of the bottle and make sure the drip chamber is half full. 4. Wash hands.

RATIONALE

to prevent medication error

prevents air from entering tubing

-reduces transmission of microorganisms 5. Verify the physicians order. Prepare all necessary materials for changing IV solution and place it on an IV tray. 6. Identify the patient and explain what you are going to do, why is it necessary, and how he can cooperate. 7. Move the roller clamp to reduce flow rate. prevent solution remaining in drip chamber from emptying while changing the solution. ensures correct client undergoes procedure. for faster, organized and smooth change

8. Remove the protective cover from the entry site of the new IVF bottle and disinfect rubber port with cotton and alcohol.

to maintain sterility of the solution.

PROCEDURE 9. Remove old solution from IV pole. 10. Quickly remove spike from old IV solution, and without touching tip, spike it to the new solution bottle while kinking the tubing below the drip chamber. 11. Invert the IV bottle and hang to IV pole. 12. Check the tubing for air. If with air, remove air from the tubing. 13. Regulate IV to prescribed rate. 14. Observe system for patency and the response of the client to the therapy.

RATIONALE brings work to eye level. prevent solution inside the drip from running dry and maintain sterility.

allows gravity to assist with the delivery of fluid into the drip chamber then to the tubing. prevent air embolism

maintain measures to restore fluid balance provides ongoing evaluation of response to therapy

B. Changing IV Tubing 1. Determine the need to change the IV tubing. a. tubing should be changed 48-96 hours, depending on agency protocol. b. puncture of infusion tubing. c. Contamination of tubing. can allow entry of bacteria into bloodstream. d. Occlusion of tubing. 2. Assemble the equipment. 3. Explain the procedure to the patient. ensures efficient and safe procedure. promotes cooperation and prevents movement of extremity, which could dislodge needle or catheter. results in leakage of fluid. tubing should be changed according to agency protocol.

4. Do hand washing. 5. Open the administration set and attach it to the container, using sterile technique.

reduces transmission of microorganisms. provides nurse with ready access to new infusion set and maintains sterility of infusion set.

PROCEDURE 6. Tighten the clamp and hang the container on the pole if it is not already hung. 7. Remove the protective cap from the end of the tubing, and prime the tubing. Clamp the tubing and replace the cap.

RATIONALE to avoid spillage of fluid as tubing is removed.

replacing the cap maintains the sterility of the end of the tubing.

8. Don gloves. Remove the tape and the dressing carefully from around the needle. Take care not to dislodge the needle from the vein. 9. Place a sterile swab under the hub of the catheter to absorb any leakage that might occur when the tubing is disconnected. Clamp the old tubing.

10. While holding the hub of the needle with the fingers of one hand, remove the tubing with the other hand, using a twisting, pulling motion. Place the end of the tubing in the kidney basin or other receptacle. 11. Continue to hold the needle, and grasp the new tubing with the other hand. Remove the protective cap, and maintain sterility, insert the tubing end tightly into the needle hub. 12. Open the clamp to start the solution flowing. 13. Clean the venipuncture site, working from the insertion point outward in a circular manner.

holding the needle firmly but gently maintains its position in the vein.

attaches new, primed infusion tubing to hub of angiocatheter.

permits the solution to enter catheter or tubing. minimize spread of microorganisms.

PROCEDURE 14. Apply a sterile dressing over the site and tape the needle in place. Apply a labeled tape over the dressing. The label should include the date and time the dressing is applied; the original date and time of the venipuncture; the size of the catheter or needle; and your initials, as the nurse who changed the dressing.

RATIONALE

15. Tape a label on the new tubing with the date and time of the change and your initials. 16. Regulate the flow of the solution according to the order on the chart. 17. Record the change of the tubing in the appropriate place on the clients chart. maintains infusion flow at prescribed rate.

EVALUATION FOCUS 1. Status of IV site. 2. Patency of IV system. 3. Accuracy of flow.

DISCONTINUING AN INTRAVENOUS INFUSION Definition: When an IV infusion is no longer necessary to maintain the clients fluid intake or to provide a route for medication administration, the infusion is discontinued.

Indications: 1. To discontinue an intravenous infusion when the therapy is complete or when the clients oral fluid intake and hydration status are satisfactory. 2. The medications administered via IV route are no longer necessary. 3. There is a problem with the infusion that cannot be fixed (e.g. thrombophlebitis, etc.). Assessment Focus: 1. Appearance of IV catheter. 2. Amount of fluid infused. 3. Any bleeding from infusion site. 4. Appearance of the venipuncture site. SPECIAL CONSIDERATIONS: 1. Maintain asepsis. 2. Prevent discomfort to the client. 3. Prevent bleeding and hematoma formation. 4. Make sure a catheter is removed intact. 5. Wear gloves to prevent contamination by the clients body secretions. Equipment: Clean glove Waste receptacle tray Dry or antiseptic-soaked swabs Plaster Sterile dressing

1. Verify

PROCEDURE written doctors

RATIONALE order to

discontinue IV infusion. 2. Wash hands. reduces anxiety and promotes cooperation

3. Prepare all necessary equipments. 4. Close the roller clamp of the IV

reduces transmission of microorganisms

administration set.

PROCEDURE 5. Put on the clean glove.

RATIONALE clamping the tubing prevents the fluid from flowing out of the needle onto the client or bed

6. Moisten adhesive tapes around the IV catheter using cotton balls with alcohol; remove plaster gently while holding the needle firmly and applying counteraction to the skin.

prevents direct contact with patient blood

7. Gently remove the needle or catheter by pulling it out along the line of the vein.

movement of the needle can injure the vein and cause discomfort to the client. Counteraction prevents pulling the skin and causing discomfort

8. Immediately apply pressure to the site, using the cotton swab, for 2 to 3 minutes.

pulling it out in line with the vein avoids injury to the vein

9. Hold the clients arm or leg above the body if any bleeding persists. 10. Inspect the catheter for completeness.

pressure

stops

bleeding

and

prevents

hematoma formation. raising the limb decreases blood flow to the area.

11. Report a broken catheter to the nurse in charge immediately.

if a piece of tubing remains in the clients vein it could move centrally (toward the heart or lungs) and cause serious problems.

12. If a broken piece can be palpated, apply a tourniquet above the insertion site. 13. Cover the venipuncture site by application is notified. of tourniquet decreases the

applying a sterile dressing.

possibility of a piece moving until a physician

14. Discard the IV solution container, if infusions are being discontinued, and discard the used supplies appropriately.

the

dressing

continues

the

pressure

and

covers the open area in the skin, preventing infection.

PROCEDURE 15. Document all relevant information a. the amount of fluid infused b. type of solution c. container number d. time of discontinuance e. the clients response to the procedure

RATIONALE

EVALUATION FOCUS 1. Appearance of the venipuncture site. 2. The pulse 3. Respirations, skin color, edema, sputum, cough and urine output. 4. And how the client feels physically and psychologically.

STARTING AN INTRAVENOUS INFUSION Definition: It is one of the commonest invasive procedure in hospitals and is administered either by the peripheral or central route. It is the aseptic instillation of fluids, electrolytes, nutrients, or medications through a needle into a vein. Indications: 1. To supply fluid when clients are unable to take in an adequate volume of fluids by mouth. 2. To provide salts needed to maintain electrolyte balance. 3. To provide glucose (dextrose), the main fuel for metabolism. 4. To provide water-soluble vitamins and medications. 5. To establish a lifeline for rapidly needed medications. 6. To provide nutrition while resting the gastrointestinal tract. 7. To monitor central venous pressure. 8. To restore acid-base balance. 9. To restore volume of blood components. Patient Education: Educating the patient is one of the best complication prevention measures that can be done!!! All procedures should be explained to the patient with regard to why, what, complications, and signs and symptoms about which to call a nurse. Preparation Of Patient: 1. Explain procedure and answer all questions to decrease anxiety. 2. Describe the patients participation and the importance of holding still during the procedure. 3. Assist in positioning the patient in a comfortable position that allows easy access to the desired site. 4. Show the patient the equipment. 5. Touch the patient to assess the skin. 6. Anxiety can cause vasoconstriction. 7. If site selected is hairy, clip or shave. 8. Ensure patient is not allergic to skin prep agent. Special Considerations: 1. Maintain asepsis. 2. Select the correct solution. 3. Prime the tubing. 4. Label the container appropriately. 5. Label the IV tubing with the date and time of attachment.

Types of Solutions: 1. Isotonic solution A solution that exert the same osmotic pressure as that found in plasma. It has no effect on the cell/expand intravascular compartments only. Ex. 0.9% NaCl (normal saline), Lactated Ringers (a balanced electrolyte solution), D5W (5% dextrose in water), Blood components. 2. Hypotonic solution A solution that exert less osmotic pressure than that of blood plasma. Cell size increases and extracellular fluid (ECF) volume decreases; fluid and electrolytes shift out of intravascular compartment, hydrating intracellular and interstitial compartment. Ex. 0.45% NaCl, 0.2% NaCl, 0.33 NaCl, 2.5% Dextrose. A solution that exert higher osmotic pressure than that of blood plasma. Cell size decreases and ECF volume increases; fluid and electrolytes are drawn into intravascular compartment, dehydrating intracellular and interstitial compartments. Ex. D5NS (5% dextrose in normal saline), D5 1/2NS (5% dextrose in 0.45% NaCl), D5LR (5% dextrose in lactated ringers), D10W, D20W. Kinds of Needles and Catheters Butterfly Needles (Wing-tipped needle) Used in short-term IV therapy Easy to insert, infiltrate easily Most common Cannula is over needle: allows ease of insertion Catheter of 14- to 19-gauge inside the needle Rarely used because of advances in midline and central catheters Shearing of catheter is a major risk 3. Hypertonic solution -

Over-the-needle Cannula (Angiocatheter) -

Inside-the-needle Catheter -

Site Selection Guidelines: (Take into account available vein condition, patient comfort, and type and duration of IV therapy) 1. Start distally and move proximally. Use lower extremities as a last resort. 2. Use the clients non domi nant arm whenever possible to increase patient mobility. 3. Use smallest catheter that accomplishes the purpose. 4. Dorsal metacarpal veins of the hand provide the most comfortable insertion site (skin on back of the hand is less sensitive). 5. Select a vein that is Easily palpated and feels soft and full Naturally splinted by bones Large enough to allow adequate circulation around the catheter

6. Avoid using veins that are a. In areas of flexion/joints ( e.g. the antecubital fossa) b. Highly visible, because they tend to roll away from the needle c. Damaged by previous use, phlebitis, infiltration, or sclerosis d. Continually distended with blood, or knotted or tortuous e. In a surgically compromised or injured extremity, because of possible impaired circulation and discomfort for the client. 7. The median basilica and cephalic veins are not recommended for chemotherapy administration due to potential for extravasation and poor healing resulting in impaired joint movement. Age-Related Considerations: PEDIATRIC 1. Dorsal surfaces of hands and feet are most frequently used. 2. Dorsal vein of hand allows child the greatest mobility. 3. Always select site that will require the least restraint. 4. Scalp veins are very fragile and require protection so they are not infiltrated easily (used for neonates and infants) 5. Foot, scalp and antecubital sites are most commonly used in infant through toddler age-group. GERIATRIC 1. Skin becomes paper-thin. Anchor catheters carefully to avoid tears and infiltrations. 2. Insert catheter without a tourniquet if skin is fragile and veins are palpable and visible. 3. Vascular disease, obesity, and dehydration may limit venous access. Equipments: Infusion set as ordered Intravenous solution as prescribed by physician Intravenous catheter IV pole IV tray containing - Adhesive or nonallergic tape - Clean glove - Tourniquet - Antiseptic swab - Sterile gauge dressing or transparent occlusive dressing - Arm splint, if required - Towel or pad

PROCEDURE 1. Verify the physician order for type and amount of solution to use and the flow rate. 2. Observe the 10 rights in preparing and administering medications. 3. Identify client and explain the procedure, secure consent if necessary.

RATIONALE Serious errors can be avoided by careful checking.

IV solutions are medications and should be doubled checked to reduce risk of error. to facilitate cooperation and alleviate clients anxiety.

4. Do hand washing. 5. Prepare necessary materials for the

reduces transmission of microorganisms. to avoid delay

procedure. 6. Check the sterility and integrity of the IV solution, IV set and other devices. 7. Place IV label on IVF bottle duly signed by RN who prepared it. a. patients name b. room number c. IV solution d. drug incorporation (if any) e. bottle sequence f. drop rate g. time started h. date started For proper documentation. Crack or leak would indicate contamination.

8. Open and prepare the infusion set. a. Remove the tubing from the Close proximity of roller clamp to drip container and straighten it out. Slide the roller clamp along the tubing until it is just below the drip chamber. b. Move roller clamp to off position. c. Leave the ends of the tubing To prevent spillage of fluid. This will maintain sterility of the ends of the tubing. chamber allows more accurate regulation of flow rate.

covered with the plastic caps until the infusion is started.

PROCEDURE 9. Spike the solution container a. Remove the protective cover from the entry site of the IVF bottle and disinfect rubber port with cotton and alcohol. b. Remove the cap from the spike and insert the spike into the insertion site of the IVF bottle.

RATIONALE To maintain sterility of the solution.

10. Invert the IV bottle and hang to IV pole. Adjust the pole so that the container is suspended about 1 m (3 ft.) above the clients head. 11. Fill the drip chamber with solution.

Height

is

needed

to

enable

gravity

to

overcome venous pressure and facilitate flow of the solution to the vein.

creates chamber.

suction

effect;

fluid

enters

drip

Squeeze the chamber gently until it is half full of solution.

12. Prime the tubing. Remove the protective cap and release the roller clamp to allow the fluid to travel from drip chamber through the tubing until all the bubbles are removed. Tap the tubing if necessary with your fingers to help the bubbles move. 13. Reclamp the tubing and replace the tubing cap, maintaining sterile technique. 14. Then prepare to assist the IV therapist in IV insertion.

Tubing is primed to prevent the introduction of air into the client which can act as emboli.

To maintain system sterility.

BLOOD TRANSFUSION Definition: Blood transfusion is the introduction of whole blood or blood components (such as serum, plasma, platelets, or erythrocytes) into the venous circulation. Indications: 1. To restore blood volume after severe hemorrhage. 2. To combat infection due to decreased or defective white cells or antibodies. 3. To restore the capacity of the blood to carry oxygen. 4. To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates, which prevents or treat bleeding. Special Considerations: 1. Confirm that there is a physicians order and assigned consent from the client. 2. Have two health care professionals confirm that the client name and ID #, and crossmatching result are correct. 3. Maintain asepsis. 4. Keep blood cold until ready for use. 5. Blood should be stored in the blood bank and not in the nurses station. 6. Do not use blood if released from blood bank for more than 30 minutes. 7. Give pre-med 30 minutes before transfusion as prescribed. 8. Dont use blood with bubbles and has been discolored. 9. Wear gloves before performing venipuncture, transfusing the blood, and when terminating blood and disposing of equipment. 10. Administer all blood products through the correct filter for prevention of emboli. 11. Monitor patient carefully throughout blood transfusion. 12. Crystalloid solutions other than 0.9% saline and all medications are incompatible with blood products. They may cause agglutination and or hemolysis. 13. Do not transfuse a unit of blood more than 4 hours. 14. Assess the client closely for transfusion reactions. Types Of Transfusion Reactions: 1. Hemolytic reaction: incompatibility between clients blood and donors blood. 2. Febrile reaction: sensitivity of the clients blood to white blood cells, platelets or plasma proteins. 3. Allergic reactions (mild): sensitivity to infused plasma proteins. 4. Allergic reaction (severe): antibody-antigen reaction. 5. Circulatory overload: blood administered faster than the circulation can accommodate. 6. Sepsis: contaminated blood administered.

Blood Products For Transfusion: 1. Whole blood - Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors. 2. Red blood cells Used to increase the oxygen-carrying capacity of blood in anemias surgery, disorders with slow bleeding. One unit raises hematocrit by approximately 4%. 3. Autologos red blood cells Used for blood replacement following planned elective surgery. Client donates blood for autologos transfusion 4-5 weeks prior to surgery. 4. Platelets replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets most effective. 5. Fresh frozen plasma Expands blood volume and provides clotting factors. Does not need to be typed and crossmatched (contains no RBC). 6. Albumin and plasma protein fraction Blood volume expander; provides plasma protein. 7. Clotting factors and cryoprecipitate Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contain fibrinogen. Assessment Focus: 1. Clinical signs of reaction (sudden chills, fever, nausea, itchiness, low back pain, dyspnea). 2. Manifestations of hypervolemia. 3. Status of infusion site. 4. Any unusual symptoms. Equipments: Unit of blood that has been correctly crossmatched Blood administration set 500 ml or 250 ml of normal saline solution for infusion IV pole # 18 or # 19-guage needle or catheter (if one is not already in place) Alcohol swab Plaster Clean glove Tourniquet

PROCEDURE 1. Verify doctors written order for blood transfusion. 2. Obtain clients consent before the for and

RATIONALE Serious errors can be avoided by careful checking. basis for legal purposes.

transfusion. explaining transfusion, alternatives.

Informed medical benefits,

consent risks,

involves

indications

PROCEDURE 3. Explain the procedure and its purpose to the patient. Instruct the client to re[port promptly any sudden chills, nausea, itching, rash, dyspnea, backpain, or other unusual symptoms. 4. If the client has an IV solution infusing, check whether the needle and solution are appropriate to administer blood. The needle should be gauge # 18 or # 19, and the solution must be normal saline. 5. If the client does not have an IV solution infusing, you will need to perform a venipuncture on a suitable vein and start an IV infusion of normal saline. 6. Request prescribed blood/blood

RATIONALE reduces anxiety and promotes cooperation.

to achieve maximal flow rate. Normal saline is isotonic and reduces hemolysis.

safe storage of the blood is only limited to 35 days after extraction from he donor since the BC deteriorates after this time causing in allergic reaction when given.

component from the blood bank to include blood typing and X-matching result, the expiration of he blood and blood result of transmissible disease. 7. Using a clean tray, get the compatible blood from the laboratory or blood bank. 8. With another nurse, compare the

to check for correct blood to infuse.

laboratory blood record with a. The clients name and identification number. b. The serial # on the blood bag label. c. The ABO group and Rh type on the blood bag label or check crossmatching form. 9. Check blood bag for bubbles, cloudiness, dark color or sediments. these signs indicate bacterial contamination.

10. Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting the transfusion.

RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. Lysis of RBCs releases potassium into the bloodstream, causing hyperkalemia.

PROCEDURE 11. Verify the clients identity by asking the full name and/or checking the arm band for name and ID number. 12. Get the baseline V/S: BP, RR,

RATIONALE to make sure you are doing the procedure to the correct patient.

to establish baseline data. V/S beyond normal may result to the postponement of the transfusion.

Temperature before transfusion and refer to M.D accordingly. 13. Give pre-med 30 minutes before

prevents allergic reaction.

transfusion as prescribed. 14. Do hand hygiene before ad after the procedure. 15. Prepare equipment needed for the for efficiency of work and accessibility of needed materials. prevents spread of microorganism.

procedure. 16. Set up the transfusion equipment. a. Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood components to be transfused. 17. If the main line is with dextrose 5% initiate an IV line with appropriate IV catheter with plain NSS on another site, anchor catheter properly and allow a small amount of solution to infuse to make sure there are no problems with the flow or the venipuncture site. 18. Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma. 19. Expose the port on the blood bag by pulling back the tabs.

Blood filters have a surface area large enough to allow the blood components through easily but are designed to trap clots.

Infusing a normal saline before initiating the transfusion also clears the IV catheter of incompatible solutions or medications.

Rough handling can damage the cells.

20. Spike blood bag port carefully and hang the unit. Be sure blood clamp is closed.

PROCEDURE 21. Gently squeeze the flexible sides of the drip chamber to reestablish the liquid level with drip chamber one-third full. sure filter is submerged in the blood. 22. Open the clamp and prime tubing and remove air bubbles if any. Use needle G 18 or G 19 for side drip (for adults) or G 22 (for pediatrics). Make

RATIONALE

tubing is primed to prevent the introduction of air into the client which can act as emboli.

23. Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and secure with adhesive tape. 24. Shut off the primary IV and begin the blood transfusion. 25. Run the blood slowly for the first 15 minutes at 20 gtts/min. Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or tachycardia. 26. Observe the client for the first 5 to 10 minutes of transfusion. 27. Remind the client to call a nurse allows passage of blood components into the vein. the earlier the transfusion occurs, the more severe it tends to be. Identifying such reactions promptly helps to minimize the consequences. early identification of reaction facilitates

prompt intervention.

immediately if any unusual symptoms are felt during the transfusion. 28. Document relevant data. Record time for documentation of relevant information and future reference for legal purposes.

blood was started, V/S, type of blood, blood serial #, sequence # (e.g. #1 of three rate. ordered units), site of the venipuncture, size of the needle, and drip

29. Swirl the bag hourly. 30. Check the V/S of the client 15 minutes after initiating transfusion. If there are no signs of reaction, establish the required flow rate.

to mix the solid with the plasma. Most adults can tolerate receiving one unit of blood in 1 & hours. Do not transfuse blood more than 4 hours.

PROCEDURE 31. Assess the client every 30 minutes or more often, depending on the health status, until 1 hour post-transfusion. 32. If any untoward reaction or signs occur, stop the transfusion immediately and notify the physician ASAP. 33. When blood is consumed, don glove, close the roller clamp of BT set and disconnect from IV line. Flush the line with saline solution by opening the mainline and adjust the drip to desired rate. 34. Re-check Hgb, Hct, bleeding time, serial platelet count within specified time as prescribed &/or per institutions policy. 35. Discard the administration set according to agency practice. Needles should be placed in a labeled puncture-resistant container designed for such disposal. Blood bags and administration sets should be bagged and labeled before being sent for decontamination and processing. 36. Remove glove.

RATIONALE

to check the effect of the blood transfusion.

37. Document

the

procedure,

pertinent

documentation of relevant information and serves as future reference for legal purposes.

observations and nursing intervention and endorse accordingly. 38. Remind patient the had doctor several about units of the blood

to maintain cardiac function and prevent hypocalcaemia toxicity. that may lead to citrate

administration of Calcium Gluconate if transfusion 93-6 or more units of blood).

EVALUATION FOCUS 1. Changes in vital signs or health status. 2. Presence of chills, nausea, vomiting, or skin rash.