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 physician’s 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 physician’s 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
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;
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.
Inspect for the presence of phlebitis. tighten the tubing into the catheter. 18. Lower the solution container below the level of the infusion site and observe for a return flow of blood from the vein. Locate the source.
Absence of blood return may indicate that the needle is no longer in the vein or the tip of the catheter is partially obstructed. e. Try to stop the flow by applying a tourniquet above the 10-15 cm (4-6 site in.PROCEDURE 14.
To ascertain the presence of infiltration
changes in temperature c. If the leak is at the catheter connection. If the tubing does not have a backcheck valve.) and insertion to see if blood returns. 15. If the leak cannot be stopped. Feel the surrounding skin for the infusion site for fluid
RATIONALE The solution may not flow upward into the vein against the force of gravity. a new venipuncture site is usually selected. and he injured vein is not used for further infusions. lower the infusion bottle below the venipuncture site. Discontinue the IV infusion if blood does not return. The clinical signs are redness. warmth. Use a sterile syringe of saline to withdraw fluid from the rubber at the end of the tubing near the venipuncture site.
. slow the infusion as much as possible without stopping it. and swelling at the IV site and burning pain along the course of a vein. d. b. Palpate the surrounding tissue for edema. Check for leakage. and replace the tubing with a new sterile set.
opening the roller clamp. 17. 16. Blood may indicate that the IV needle is still in the vein. Inspect infiltration a.
Bleeding into the surrounding tissues can occur while the infusion is freely flowing. Urinary output compared to urinary intake.
RATIONALE overload means
circulatory system contains more fluid than
20. If the client is able.
21. 3. Be alert to signs of circulatory overload. 5. Tissue turgor. Amount of fluid infused according to the schedule. 6.g. e. 4. if the solution stops dripping or the venipuncture site becomes swollen.. Inspect for bleeding at the IV site. Appearance of IV site.
EVALUATION FOCUS 1.PROCEDURE 19. 2. specific gravity of urine. Vital signs and lung sounds compared to baseline data. teach him or her when to call for assistance.
circulatory normal. Intactness of IV system.
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. Label the container. Presence of fluid infiltration. 10. 4. 2. c. b. and dressing appropriately. Select the correct solution. To maintain patency of the IV tubing. like: 1. 8. Prime the tubing before attaching it to the IV needle. To prevent infection at the IV site and the introduction of microorganisms into the bloodstream. Appearance of the dressing for integrity. Avoid stretching or placing tension on the tubing. Allergy to tape 3. all IV bags should be changed every 24 hours. 5. Avoid sudden twisting or turning movements of the arm with the needle. IV tubing is changed every 48 to 96 hours. or phlebitis at IV site. 3. 3. The flow rate suddenly changes or the solution stops dripping.CHANGING AN INTRAVENOUS CONTAINER AND TUBING Indications: 1. There is blood in the IV tubing. Assessment Focus: 1. and need for change. Try to keep the tubing from dangling below the level of the needle. Inspect and clean the venipuncture site appropriately. 4. To maintain sterility of the IV system and decrease the incidence of phlebitis and
. Prevent needle dislodgement when disconnecting and connecting the IV tubing and when cleaning the venipuncture site. bleeding. 11. Make sure the IV system is intact and the correct flow rate is established. Wear gloves when there is possibility of contact with the body secretions. The date and time of the previous dressing change. 2. Special Considerations: 1. 6. 2. Determine allergies to tape or iodine. 2. tubing. To maintain the flow of required fluids. Infusion rate and amount absorbed 4. 4. However. moisture. depending on agency protocol. to minimize the risk of contamination. Patient Education: Teach the client ways to maintain the infusion system. 9. 3. d. regardless of how much solution remains. Discomfort or swelling is experienced at the IV site. infection. 5. 7. Notify a nurse if a. Secure the needle appropriately with the tape and apply an appropriate dressing. The solution container is nearly empty. as is the site dressing.
Identify the patient and explain what you are going to do. why is it necessary. and how he can cooperate. organized and smooth change
. Prepare all necessary materials for changing IV solution and place it on an IV tray. 6. Prepare to change solution when it only remains in the neck of the bottle and make sure the drip chamber is half full. prevent solution remaining in drip chamber from emptying while changing the solution. Obtain the correct solution container and make sure it is properly labeled. Review physician’s order for changes in fluid administration. 2. ensures correct client undergoes procedure. 3. including sterile tubing and drip chamber Timing label Sterile gauge square for positioning the needle Alcohol swab Clean glove Tape PROCEDURE RATIONALE
A. 8.Equipments: • • • • • • • Container with the correct kind and amount of sterile solution Administration set. for faster. 4. Move the roller clamp to reduce flow rate. 7. Check for sterility and integrity. Wash hands. Verify the physician’s order. Remove the protective cover from the entry site of the new IVF bottle and disinfect rubber port with cotton and alcohol. prevents air from entering tubing to prevent medication error
-reduces transmission of microorganisms 5. Changing IV Container
1. to maintain sterility of the solution.
Regulate IV to prescribed rate.
allows gravity to assist with the delivery of fluid into the drip chamber then to the tubing. 2.
RATIONALE brings work to eye level. Assemble the equipment. Check the tubing for air. tubing should be changed according to agency protocol. prevent solution inside the drip from running dry and maintain sterility. If with air. Open the administration set and attach it to the container. d. a. 12. Invert the IV bottle and hang to IV pole. Remove old solution from IV pole. 13. Explain the procedure to the patient. 3. 11. spike it to the new solution bottle while kinking the tubing below the drip chamber. 14. results in leakage of fluid. puncture of infusion tubing. using sterile technique. Observe system for patency and the response of the client to the therapy. which could dislodge needle or catheter. Quickly remove spike from old IV solution. c. 5. and without touching tip. prevent air embolism
maintain measures to restore fluid balance provides ongoing evaluation of response to therapy
B. 10. depending on agency protocol. Do hand washing. reduces transmission of microorganisms. can allow entry of bacteria into bloodstream. promotes cooperation and prevents movement of extremity.PROCEDURE 9. ensures efficient and safe procedure. Contamination of tubing. remove air from the tubing. Determine the need to change the IV tubing. tubing should be changed 48-96 hours. b.
. Occlusion of tubing. Changing IV Tubing
1. provides nurse with ready access to new infusion set and maintains sterility of infusion set. 4.
holding the needle firmly but gently maintains its position in the vein. Place the end of the tubing in the kidney basin or other receptacle. 11. 9. and grasp the new tubing with the other hand. Continue to hold the needle. 10. Place a sterile swab under the hub of the catheter to absorb any leakage that might occur when the tubing is disconnected.
permits the solution to enter catheter or tubing. Clean the venipuncture site.
RATIONALE to avoid spillage of fluid as tubing is removed. While holding the hub of the needle with the fingers of one hand. Clamp the old tubing.
. Open the clamp to start the solution flowing. primed infusion tubing to hub of angiocatheter. 7. Don gloves. pulling motion. 8. minimize spread of microorganisms. and maintain sterility. and prime the tubing. Clamp the tubing and replace the cap. Tighten the clamp and hang the container on the pole if it is not already hung. 13. Remove the protective cap from the end of the tubing. Take care not to dislodge the needle from the vein.
replacing the cap maintains the sterility of the end of the tubing. working from the insertion point outward in a circular manner. remove the tubing with the other hand.PROCEDURE 6.
attaches new. using a twisting. insert the tubing end tightly into the needle hub. Remove the protective cap. Remove the tape and the dressing carefully from around the needle. 12.
maintains infusion flow at prescribed rate. and your initials. Record the change of the tubing in the appropriate place on the client’s chart. Regulate the flow of the solution according to the order on the chart. the size of the catheter or needle. 16.PROCEDURE 14.
EVALUATION FOCUS 1. Apply a labeled tape over the dressing. The label should include the date and time the dressing is applied. 17. Patency of IV system. 3.
. Status of IV site. Tape a label on the new tubing with the date and time of the change and your initials. the original date and time of the venipuncture. 15. as the nurse who changed the dressing. 2. Accuracy of flow. Apply a sterile dressing over the site and tape the needle in place.
3.). 4. 2. 3. Equipment: • • • • • Clean glove Waste receptacle tray Dry or antiseptic-soaked swabs Plaster Sterile dressing PROCEDURE written doctor’s RATIONALE order to
1. Wear gloves to prevent contamination by the client’s body secretions. Wash hands. thrombophlebitis. Prepare all necessary equipments. The medications administered via IV route are no longer necessary. Appearance of IV catheter.g.
. Prevent bleeding and hematoma formation. SPECIAL CONSIDERATIONS: 1. 2. Appearance of the venipuncture site. There is a problem with the infusion that cannot be fixed (e.DISCONTINUING AN INTRAVENOUS INFUSION Definition: When an IV infusion is no longer necessary to maintain the client’s fluid intake or to provide a route for medication administration.
Indications: 1. the infusion is discontinued. 2. Any bleeding from infusion site. Make sure a catheter is removed intact. etc. Amount of fluid infused. Assessment Focus: 1. To discontinue an intravenous infusion when the therapy is complete or when the client’s oral fluid intake and hydration status are satisfactory. Maintain asepsis. 3. Prevent discomfort to the client. 5. 4. 2. 3. Verify
discontinue IV infusion. 4. Close the roller clamp of the IV reduces anxiety and promotes cooperation reduces transmission of microorganisms
11. Hold the client’s arm or leg above the body if any bleeding persists. Report a broken catheter to the nurse in charge immediately. 7. Moisten adhesive tapes around the IV catheter using cotton balls with alcohol. If a broken piece can be palpated. using the cotton swab. Immediately apply pressure to the site. if infusions are being discontinued. Cover the venipuncture site by application is notified.
prevents direct contact with patient’ blood
movement of the needle can injure the vein and cause discomfort to the client. raising the limb decreases blood flow to the area. Counteraction prevents pulling the skin and causing discomfort
possibility of a piece moving until a physician
covers the open area in the skin.PROCEDURE 5. and discard the used supplies appropriately.
12. Inspect the catheter for completeness. remove plaster gently while holding the needle firmly and applying counteraction to the skin. Discard the IV solution container. for 2 to 3 minutes. preventing
. Gently remove the needle or catheter by pulling it out along the line of the vein. 13.
RATIONALE clamping the tubing prevents the fluid from flowing out of the needle onto the client or bed
pulling it out in line with the vein avoids injury to the vein
hematoma formation. apply a tourniquet above the insertion site. 14.
if a piece of tubing remains in the client’s vein it could move centrally (toward the heart or lungs) and cause serious problems. the pressure and of tourniquet decreases the
applying a sterile dressing. Put on the clean glove. 10. the dressing continues infection.
skin color. Document all relevant information a. Appearance of the venipuncture site. the amount of fluid infused b. container number d. edema. cough and urine output. type of solution c. 4. 2.PROCEDURE 15. Respirations. And how the client feels physically and psychologically. time of discontinuance e. the client’s response to the procedure
EVALUATION FOCUS 1.
. The pulse 3. sputum.
5. 4. To establish a lifeline for rapidly needed medications. 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. Prime the tubing. 6. the main fuel for metabolism.
. If site selected is hairy. To monitor central venous pressure. 9. To restore volume of blood components. To restore acid-base balance. nutrients. 2. To supply fluid when clients are unable to take in an adequate volume of fluids by mouth. 3. 8. 7. and signs and symptoms about which to call a nurse. 8. Indications: 1. Describe the patient’s participation and the importance of holding still during the procedure. 6. Label the container appropriately. 4. 3. 3.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. Label the IV tubing with the date and time of attachment. electrolytes. To provide water-soluble vitamins and medications. Maintain asepsis. or medications through a needle into a vein. complications. 4. To provide salts needed to maintain electrolyte balance. To provide nutrition while resting the gastrointestinal tract. Select the correct solution. Preparation Of Patient: 1. clip or shave. Explain procedure and answer all questions to decrease anxiety. 2. Anxiety can cause vasoconstriction. Ensure patient is not allergic to skin prep agent. To provide glucose (dextrose). Special Considerations: 1. 5. 2. 5. Touch the patient to assess the skin. Show the patient the equipment. Assist in positioning the patient in a comfortable position that allows easy access to the desired site. It is the aseptic instillation of fluids. what. 7.
fluid and electrolytes are drawn into intravascular compartment. Isotonic solution A solution that exert the same osmotic pressure as that found in plasma. patient comfort. Cell size increases and extracellular fluid (ECF) volume decreases. Hypotonic solution A solution that exert less osmotic pressure than that of blood plasma.45% NaCl). Ex. Use lower extremities as a last resort. A solution that exert higher osmotic pressure than that of blood –plasma. 0. 0. Ex. Hypertonic solution -
Over-the-needle Cannula (Angiocatheter) -
Inside-the-needle Catheter -
Site Selection Guidelines: (Take into account available vein condition.to 19-gauge inside the needle Rarely used because of advances in midline and central catheters Shearing of catheter is a major risk 3. dehydrating intracellular and interstitial compartments. infiltrate easily Most common Cannula is over needle: allows ease of insertion Catheter of 14. 2. Use the client’s non dominant arm whenever possible to increase patient mobility. Lactated Ringer’s (a balanced electrolyte solution). 3.45% NaCl. 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
. 4.33 NaCl. 0. Cell size decreases and ECF volume increases. 2. Use smallest catheter that accomplishes the purpose. D20W.9% NaCl (normal saline). D5 1/2NS (5% dextrose in 0. Ex. and type and duration of IV therapy) 1. Start distally and move proximally. D5LR (5% dextrose in lactated ringer’s). Kinds of Needles and Catheters • Butterfly Needles (Wing-tipped needle) • Used in short-term IV therapy Easy to insert. 0. D10W. hydrating intracellular and interstitial compartment.Types of Solutions: 1. 5. Dorsal metacarpal veins of the hand provide the most comfortable insertion site (skin on back of the hand is less sensitive).2% NaCl. Blood components. fluid and electrolytes shift out of intravascular compartment. D5NS (5% dextrose in normal saline). It has no effect on the cell/expand intravascular compartments only.5% Dextrose. 2. D5W (5% dextrose in water).
and dehydration may limit venous access.Antiseptic swab . obesity. GERIATRIC 1. 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. or knotted or tortuous e. Scalp veins are very fragile and require protection so they are not infiltrated easily (used for neonates and infants) 5. Highly visible. 3. 2. Foot. Skin becomes paper-thin. if required .Tourniquet . the antecubital fossa) b. Dorsal surfaces of hands and feet are most frequently used. Damaged by previous use. 4.Arm splint. 2. Continually distended with blood. Vascular disease.Adhesive or nonallergic tape . In areas of flexion/joints ( e. Age-Related Considerations: PEDIATRIC 1.6.Sterile gauge dressing or transparent occlusive dressing . 7.Towel or pad
. scalp and antecubital sites are most commonly used in infant through toddler age-group. 3. Always select site that will require the least restraint. Equipments: • • • • • Infusion set as ordered Intravenous solution as prescribed by physician Intravenous catheter IV pole IV tray containing . or sclerosis d. In a surgically compromised or injured extremity. Anchor catheters carefully to avoid tears and infiltrations. Avoid using veins that are a.g.Clean glove . Dorsal vein of hand allows child the greatest mobility. Insert catheter without a tourniquet if skin is fragile and veins are palpable and visible. because of possible impaired circulation and discomfort for the client. infiltration. because they tend to roll away from the needle c. phlebitis.
drop rate g.
covered with the plastic caps until the infusion is started. drug incorporation (if any) e. Identify client and explain the procedure. Check the sterility and integrity of the IV solution. bottle sequence f. 2. time started h. Place IV label on IVF bottle duly signed by RN who prepared it. Move roller clamp to off position. 3. Verify the physician order for type and amount of solution to use and the flow rate. room number c. patient’s name b. Crack or leak would indicate contamination. to avoid delay
procedure. date started 8. reduces transmission of microorganisms. Leave the ends of the tubing To prevent spillage of fluid.
IV solutions are medications and should be doubled checked to reduce risk of error. For proper documentation. Prepare necessary materials for the
RATIONALE Serious errors can be avoided by careful checking. 5. a. Slide the roller clamp along the tubing until it is just below the drip chamber. b. IV set and other devices.
. This will maintain sterility of the ends of the tubing. secure consent if necessary. a. Remove the tubing from the Close proximity of roller clamp to drip container and straighten it out. 4.PROCEDURE 1. Do hand washing. c. chamber allows more accurate regulation of flow rate. IV solution d. to facilitate cooperation and alleviate client’s anxiety. 6. Open and prepare the infusion set. Observe the 10 rights in preparing and administering medications. 7.
Then prepare to assist the IV therapist in IV insertion. 11. b. Fill the drip chamber with solution. Adjust the pole so that the container is suspended about 1 m (3 ft. Remove the protective cover from the entry site of the IVF bottle and disinfect rubber port with cotton and alcohol. Reclamp the tubing and replace the tubing cap. Remove the cap from the spike and insert the spike into the insertion site of the IVF bottle.PROCEDURE 9.
RATIONALE To maintain sterility of the solution. Tap the tubing if necessary with your fingers to help the bubbles move. 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.
creates chamber. Invert the IV bottle and hang to IV pole. Prime the tubing. 12.
Squeeze the chamber gently until it is half full of solution. maintaining sterile technique.) above the client’s head.
overcome venous pressure and facilitate flow of the solution to the vein.
Tubing is primed to prevent the introduction of air into the client which can act as emboli. 10.
To maintain system sterility. Spike the solution container a.
Wear gloves before performing venipuncture. Maintain asepsis. 5. 4. or erythrocytes) into the venous circulation. Crystalloid solutions other than 0. Assess the client closely for transfusion reactions. 6.9% saline and all medications are incompatible with blood products. 9. 3. Give pre-med 30 minutes before transfusion as prescribed. Allergic reaction (severe): antibody-antigen reaction. 10. 2. Allergic reactions (mild): sensitivity to infused plasma proteins. Sepsis: contaminated blood administered. 3. and when terminating blood and disposing of equipment. Indications: 1. transfusing the blood. and crossmatching result are correct. Have two health care professionals confirm that the client name and ID #. Types Of Transfusion Reactions: 1. Administer all blood products through the correct filter for prevention of emboli. which prevents or treat bleeding. 12. To restore the capacity of the blood to carry oxygen. Special Considerations: 1. 7. plasma. 8. such as antihemophilic factor (AHF) or factor VIII. 13. platelets. Blood should be stored in the blood bank and not in the nurse’s station. Febrile reaction: sensitivity of the client’s blood to white blood cells. Monitor patient carefully throughout blood transfusion. They may cause agglutination and or hemolysis. or platelet concentrates. 2.
. 4. To restore blood volume after severe hemorrhage. platelets or plasma proteins.BLOOD TRANSFUSION Definition: Blood transfusion is the introduction of whole blood or blood components (such as serum. 4. Circulatory overload: blood administered faster than the circulation can accommodate. 11. 6. Keep blood cold until ready for use. 2. Hemolytic reaction: incompatibility between client’s blood and donor’s blood. Confirm that there is a physician’s order and assigned consent from the client. Do not transfuse a unit of blood more than 4 hours. 3. 5. Do not use blood if released from blood bank for more than 30 minutes. To provide plasma factors. To combat infection due to decreased or defective white cells or antibodies. Don’t use blood with bubbles and has been discolored. 14.
itchiness. disorders with slow bleeding. 6. Client donates blood for autologos transfusion 4-5 weeks prior to surgery. low back pain. Each provides different factors involved in the clotting pathway.
PROCEDURE 1. fever. One unit raises hematocrit by approximately 4%.
. Manifestations of hypervolemia. Obtain client’s
transfusion. 2. Verify doctor’s written order for blood transfusion. plasma. Clinical signs of reaction (sudden chills. Albumin and plasma protein fraction – Blood volume expander. 3. 4. 2. provides plasma protein. Red blood cells – Used to increase the oxygen-carrying capacity of blood in anemias surgery. fresh platelets. and other clotting factors. Whole blood . Assessment Focus: 1. 4. 2. cryoprecipitate also contain fibrinogen.
consent risks. Autologos red blood cells – Used for blood replacement following planned elective surgery. Fresh platelets most effective. Status of infusion site. nausea.Blood Products For Transfusion: 1. 3. dyspnea). Platelets – replaces platelets in clients with bleeding disorders or platelet deficiency. explaining transfusion. consent before the for and basis for legal purposes. 7. Fresh frozen plasma – Expands blood volume and provides clotting factors. alternatives. 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 RATIONALE Serious errors can be avoided by careful checking. Clotting factors and cryoprecipitate – Used for clients with clotting factor deficiencies. Replaces blood volume and all blood products: RBCs.Not commonly used except for extreme cases of acute hemorrhage.
Informed medical benefits. 5. Any unusual symptoms. Does not need to be typed and crossmatched (contains no RBC). plasma proteins.
laboratory blood record with a. 10. Request prescribed blood/blood
RATIONALE reduces anxiety and promotes cooperation. Explain the procedure and its purpose to the patient. these signs indicate bacterial contamination. rash. If the client does not have an IV solution infusing. itching. c. Using a clean tray. dyspnea. 8. b. check whether the needle and solution are appropriate to administer blood.
component from the blood bank to include blood typing and X-matching result. With another nurse.
to achieve maximal flow rate. The needle should be gauge # 18 or # 19. 6. or other unusual symptoms. the expiration of he blood and blood result of transmissible disease.
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.PROCEDURE 3. 4. Normal saline is isotonic and reduces hemolysis. backpain. you will need to perform a venipuncture on a suitable vein and start an IV infusion of normal saline. compare the
to check for correct blood to infuse. and the solution must be normal saline. The client’s name and identification number. dark color or sediments. If the client has an IV solution infusing. Lysis of RBCs releases potassium into the bloodstream. nausea. Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting the transfusion. 7. Check blood bag for bubbles. 9. cloudiness. The serial # on the blood bag label. get the compatible blood from the laboratory or blood bank. RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. The ABO group and Rh type on the blood bag label or check crossmatching form. 5. causing hyperkalemia. Instruct the client to re[port promptly any sudden chills.
RATIONALE to make sure you are doing the procedure to the correct patient.
to establish baseline data. Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood components to be transfused. 19. Set up the transfusion equipment. V/S beyond normal may result to the postponement of the transfusion. 14.
transfusion as prescribed. prevents spread of microorganism. Get the baseline V/S: BP.
Blood filters have a surface area large enough to allow the blood components through easily but are designed to trap clots. If the main line is with dextrose 5% initiate an IV line with appropriate IV catheter with plain NSS on another site. Prepare the blood bag. 15.
Temperature before transfusion and refer to M. Spike blood bag port carefully and hang the unit. RR.PROCEDURE 11.
Rough handling can damage the cells.D accordingly. Do hand hygiene before ad after the procedure. 12. Give pre-med 30 minutes before
prevents allergic reaction. Verify the client’s identity by asking the full name and/or checking the arm band for name and ID number. Be sure blood clamp is closed. 16.
Infusing a normal saline before initiating the transfusion also clears the IV catheter of incompatible solutions or medications. Prepare equipment needed for the for efficiency of work and accessibility of needed materials. 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. 13. 17. Expose the port on the blood bag by pulling back the tabs. Invert the blood bag gently several times to mix the cells with the plasma.
30. Open the clamp and prime tubing and remove air bubbles if any. Note adverse reactions. 27. skin rash. Use needle G 18 or G 19 for side drip (for adults) or G 22 (for pediatrics). Most adults can tolerate receiving one unit of blood in 1 & ½ hours. Record time for documentation of relevant information and future reference for legal purposes.
blood was started. 26. or tachycardia. the earlier the transfusion occurs. Run the blood slowly for the first 15 minutes at 20 gtts/min. 22.
immediately if any unusual symptoms are felt during the transfusion. ordered units). site of the venipuncture. the more severe it tends to be. Shut off the primary IV and begin the blood transfusion. Observe the client for the first 5 to 10 minutes of transfusion. Check the V/S of the client 15 minutes after initiating transfusion. such as chilling. #1 of three rate. Remind the client to call a nurse Make
tubing is primed to prevent the introduction of air into the client which can act as emboli. vomiting. 28. size of the needle. sure filter is submerged in the blood. nausea. 24. 29. Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and secure with adhesive tape. type of blood. blood serial #. 25.
allows passage of blood components into the vein. Swirl the bag hourly. establish the required flow rate. sequence # (e.PROCEDURE 21. Gently squeeze the flexible sides of the drip chamber to reestablish the liquid level with drip chamber one-third full. If there are no signs of reaction.g. 23.
. early identification of reaction facilitates
prompt intervention. V/S. Do not transfuse blood more than 4 hours. Identifying such reactions promptly helps to minimize the consequences. Document relevant data. and drip
to mix the solid with the plasma.
When blood is consumed. Remove glove.
observations and nursing intervention and endorse accordingly. vomiting. Presence of chills. that may lead to citrate
administration of Calcium Gluconate if transfusion 93-6 or more units of blood). serial platelet count within specified time as prescribed &/or per institution’s policy. Remind patient the had doctor several about units of the blood
to maintain cardiac function and prevent hypocalcaemia toxicity. 36. 2. If any untoward reaction or signs occur. don glove.PROCEDURE 31. until 1 hour post-transfusion. 34. Hct. bleeding time. Re-check Hgb. close the roller clamp of BT set and disconnect from IV line. nausea. Changes in vital signs or health status. Needles should be placed in a labeled puncture-resistant container designed for such disposal. pertinent
to check the effect of the blood transfusion. 37. 38. Blood bags and administration sets should be bagged and labeled before being sent for decontamination and processing. 33.
documentation of relevant information and serves as future reference for legal purposes. Document the procedure. 35. stop the transfusion immediately and notify the physician ASAP. 32. Flush the line with saline solution by opening the mainline and adjust the drip to desired rate. depending on the health status. or skin rash. Assess the client every 30 minutes or more often.
EVALUATION FOCUS 1.
. Discard the administration set according to agency practice.