P. 1
BT Pprocedure

BT Pprocedure

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Published by Nylanne V-cabidog

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Published by: Nylanne V-cabidog on Jul 13, 2012
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1.Definition Is the introduction of whole blood or component of the blood, e.g. plasma or erythrocytes into venous circulation. 2.

Blood Group Human blood is classified in to four main groups (A, B, AB and O) on the basic of polysaccharide antigen on the erythrocyte surface. These antigens type A and Type B, commonly cause antibody reaction and are called agglutinogens. In other words group A blood contain type A agglutinogen, group B blood contain type B agglutinogen, group AB contain both A & B agglutinogens, and group O blood containe neither agglutinogen. In addition to agglutinogens on the erythrocytes agglutinin (antibody) are present in the blood plasma. No individual can have agglutinin and agglutinogen of the same type, that person's system would attack its own cells. Then group A blood does not contain agglutinin A but does contain agglutinin B. Group B blood does not contain agglutinin B but does contain agglutinin A. Group AB blood contain neither agglutinin and group O contain both anti A and anti B agglutinin. Blood transfusion must be match to the patient blood type in term of compatible agglutinogen mismatch blood will cause hemolytic reaction. Rhesus (Rh) and other factors Rh antigen also on the surface of erythrocytes are present in about 85% of the population are can be a mayor cause of hemolytic reaction. Persons who possess the Rh factor are referred to as Rh positive those who do not are referred to as Rh negative. Unlike the A and B agglitinogen, the Rh factor cannot cause a hemolytic reaction on the first exposure to mismatched blood, because the Rh antibody is not normally present in the plasma of Rh negative person. 3.Transfusion reaction Transfusion reaction can be categorized as hemolytic, febrile, circulatory over load and allergic. The nurse must asses a client closely for reactions. Sign of an acute reaction include sudden chills or fever, low back pain, drop in blood pressure, nausea, flushing agitation or respiratory disorders. Sign of less severe allergic reaction include hives and itching but no fever. Nursing management for transfusion reaction: •Stop the transfusion. Maintain the intravenous line with normal saline solution through new intravenous tubing, administered at a slow rate. •Asses the patient carefully, compare the vital sign with those from the base line assessment. •Notify the physician of the assessment findings and implement any order obtained. •Notify the blood bank that a suspected transfusion reaction has occurred. •Send the blood container and tubing to the blood bank for repeat typing and culture, the identifying tag and number are verified. Before commencing a blood transfusion determine: 1.Base line data regarding blood pressure, temperature, pulse and respiration. 2.Any previous reaction to a blood transfusion. 3.The request for blood transfusion form has been completed and send specimen for typing and cross matching, 3 ml in plain tube/red without wax or gel and 2 ml in CBC tube. 4.Purpose 1.Restore blood volume after hemorrhage 2.Maintain hemoglobin levels in severe anemia 3.Replace specific blood component. 5. Assessment focus Clinical signs of reaction (e.g. sudden chills, nausea, itching rash, dyspnea) status of infusion, site, any unusual symptoms.

Obtain the correct blood component for the patient.Wear gloves.Alcohol swab 7. •The number on the blood bag label •The patient’s blood group and label. Note specific signs related to the client's pathology and reason for transfusion (e.Procedure 1. an anemic client. •Asses base line data: Temp. clots and excess air •Make sure that the blood is left at room temperature for no more than 30 minutes before starting the transfusion. 4.Assemble the equipment and bring to the patient 5. or if blood is to be administered quickly no 16 needle or a larger. •Ensure that doctor’s counter check and sign •With another nurse (RN) compare the laboratory blood type round with : •The client's name and identification number. See that doctor check and write to start. give before transfusion 3.Vena puncture set containing a 18 needle or catheter. 2. RBCs deteriorate and lose their effectiveness after 2 hours at room temperature. amount of blood. .Equipment 1. and desired outcome of transfusion. blood type and Rh group the blood donor number. the risk of bacterial growth also increases.IV dressing 5. Ask the patient to state the full name as a double check.g. delay transfusion if baseline temperature is greater than 38.Blood administration set either a straight line or a Y set ( Y set is preferred) 3.Wash and dry hands 2. approximate length of time. •Check the physician's order with the requisition. •Check the requisition form and the blood bag label with a specially check the patient name. As blood component warm.Unit of whole blood 2. gas bubles dark color or cloudiness. •Check blood for any abnormalities. identification number. and the expiration date of blood.Prepare the patient •Identify the patient and explain the procedure and its purpose to the patient such as blood product to be transfused. calculate and adjust. Rational : If the patient’s Clinical status permits.Disposable gloves (Sterile) 6. Pulse. Respiration and Blood Pressure. 6. Agencies may designate different times at which the blood must be returned to the blood bank if it has not been started. Maintaining and Terminating a Blood Transfusion * Nursing Intervention a.Obtain patient’s base line data before the transfusion.Normal saline solution 4.Tape 8.Pre Procedure 1. note the hemoglobin level less than 10g/L). •Determine any known allergies or previous adverse reaction to blood.Initiating.50 C b.If any pre medication order.

volume transfused. •Product identification number •Name of individual verifying. Ringer's Solution. Report sign and symptoms of reaction immediately to physician to minimize consequences. save the set for further investigations) Rational : Rationale it must be possible to trace each transfusion product to the original blood donor.e. patient ID. name of person starting and ending transfusion. The needle should be no. nausea. rate. •Patient assessment findings and tolerance to procedure.Start infusion slowly at 2 ml/mnt. Dextrose which causes lysis of RBCs. It is strongly recommended that two qualified individuals perform this task. Rational : The majority of acute fatal transfusion reaction are caused by clerical errors. in the case you will need to perform veni puncture on a suitable vein. Start the prescribed intravenous infusion 10. Select a large vein that allows patient some degree of mobility and place bed protector under the site. Document procedure in patient's medical record including: •Product . report to doctor. medication and other additives and hyper alimentation solution are incompatible. Acute reaction may occur at anytime during the transfusion. Remain at bed side for 5-30 minutes.Positioning the patient comfortably 7. If solution is not compatible remove it and dispose of it according to hospital policy. . site infused. Establish the saline infusion See that the set used in appropriate. Do not proceed with the transfusion if there is any discrepancy.If patient does not have an intravenous solution infusing.6. •Monitor patient for response to and effectiveness of the procedure. blood type Rh.Prime the tubing with saline solution. If there are not sign of circulatory overloading. save urine and observe.Establish the blood transfusion.Observe the patient closely for chilling. If any reaction. as sometimes attached filteris not suitable for some product 8.If any reaction: close clamp & run normal saline. vomiting.If the patient has an intravenous solution infusing check whether the needle and solution are appropriate to administer blood. Invert the blood bag gently several times to mix the cell within the plasme 11. the infusion rate may be increased 12. Terminate the transfusion Discard administration set according to policy procedure. skin rashes tachycardia as they early sign and symptom reaction and check vital sign at least hourly until 1 hour post transfusion. (i. Contact the blood bank immediately cPost procedure Obtain vital sign and compare with base line assessment. Patient and product verification is the single most important fucntion of the nurse. 9. 18 gauge or larger and the solution must be saline.

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