Professional Documents
Culture Documents
PATIENT-CENTERED CARE
When administering blood products, you need to consider a
patients values and cultural beliefs about blood therapy. A persons
perception of his or her disease or health condition affects how
receptive he or she is to receiving blood. Blood transfusion is often
equated to severity of illness. Allay patient anxieties when possible.
Some religions do not allow blood transfusions. For example,
Safety Guidelines
1 Administration of blood and blood components requires meticulous attention to detail (e.g., preparation, administration, and
monitoring) to prevent life-threatening transfusion reactions
(Table 29-3).
2 Ensure that each blood unit is correctly labeled; check against
patients identification.
3 Review agency policy and procedure regarding administration
of blood or blood products.
4 Two nurses should verify correct unit and correct patient before
administration.
Mechanism
Onset
Prevention
Nursing Intervention
Febrile,
nonhemolytic
(most
common)
30min after
initiation to
6hrs after
completion
of
transfusion
Use leukocyte-reduced
blood products in
patients who have
experienced febrile
nonhemolytic
reactions in the past.
Stop transfusion.
Administer antipyretics
as ordered. Monitor
temperature every
4hrs.
Acute hemolytic
transfusion
reaction
ABO, Rh
incompatibility;
causes intravascular
destruction of
transfused RBCs as
antibodies in
recipients plasma
attach to antigens on
donor RBCs.
Within 15
minutes of
transfusion
initiation
Stop transfusion.
Remove blood product
and tubing. Maintain IV
access. Notify health
care provider. Monitor
vital signs at least every
15min. Administer
ordered therapy
to correct arterial
blood pressure and
coagulopathy. Insert
Foley catheter. Monitor
intake and output
hourly. Assess for
shock. Dialysis may be
required. Obtain blood
and urine samples and
send to laboratory with
unused portion of unit
of blood. Document
reaction according to
agency policy.
741
Mechanism
Onset
Prevention
Nursing Intervention
Delayed
hemolytic
transfusion
reaction
Immune response
mounted by recipient
against non-ABO
donor antigens;
usually the result
of destruction of
transfused RBCs by
alloantibodies not
detected during
cross-match
2-14 days
Unexplained fever,
unexplained decrease
in Hgb/Hct, increased
bilirubin levels,
jaundice
Careful cross-matching
of donor and recipient
blood. Has potential
to be missed because
it may occur several
days after transfusion.
Allergic reaction
(mild-tomoderate)
Caused by recipient
allergy to a plasma
protein in donors
blood
During
transfusion
to 1hr after
transfusion
May administer
antihistamines before
transfusion if
prescribed.
Allergic reaction
(severe)
Caused by recipient
allergy to a donor
antigen (usually IgA)
Agglutination of RBCs
obstructing capillaries
and blocking blood
flow, causing
symptoms to all
major organ systems
Within
5-15min of
initiation of
transfusion
Coughing, nausea,
vomiting, respiratory
distress, wheezing,
hypotension, loss
of consciousness,
possible cardiac arrest
This is a life-threatening
reaction. Stop
transfusion. Maintain IV
access. Notify health
care provider and blood
bank. Administer
antihistamines,
corticosteroids,
epinephrine, and
antipyretics as ordered.
Measure and document
vital signs until stable.
Initiate cardiopulmonary
resuscitation if
necessary.
Graft-versushost disease
Donor lymphocytes
are destroyed by
recipients immune
system. In
immunocompromised
patients the donor
lymphocytes are
identified as foreign;
however, patients
immune system is
not capable of
destroying, and in
turn patients
lymphocytes are
destroyed.
Days to weeks
Administer irradiated
blood and/or
leukocyte-depleted
RBC products as
prescribed.
Administer methotrexate
and corticosteroids as
ordered.
Continued
742
Mechanism
Onset
Prevention
Nursing Intervention
Circulatory
overload
Occurs with
transfusion of
excessive volume or
excessively rapid
rate; can lead to
pulmonary edema.
Anytime
during or
within
1-2hrs after
transfusion
Dyspnea, cough,
crackles at lung
bases, tachypnea,
headache,
hypertension,
tachycardia, increased
central venous
pressure, distended
neck veins
Administer blood or
component at
prescribed rate,
usually no greater
than 2-4mL/kg/hr;
pay particular
attention to rate and
volume in older adults,
young children, and
patients with cardiac
and renal disorders.
Administer PRBCs
instead of whole
blood. Minimize
amount of saline
infused with
transfusion.
Infectious
disease
transmission
Microorganism
contamination of
infused product
During
transfusion
to 2hrs after
transfusion
Complete
transfusion
within 4hrs
Stop transfusion.
Remove blood product
and tubing. Maintain IV
access. Notify health
care provider. Monitor
and document vital
signs. Obtain samples
for blood culture and
Gram stain from
recipient. Administer IV
fluids, broad-spectrum
antimicrobials,
vasopressors, and
steroids as ordered.
Iron overload
May occur
with multiple
transfusions
or chronic
transfusion
therapy
Cardiac dysfunction,
SOB, arrhythmias,
heart failure,
increased serum
transferrin, increased
liver enzymes,
jaundice
Chelation, phlebotomy,
monitor serum iron
levels.
Data modified from Alexander M, et al.: Infusion nursing: an evidence-based approach, ed 3, St Louis, 2010, Mosby; and American Association of Blood Banks:
Standards for blood banks and transfusion services. ed 27, Bethesoa, Md, 2011, The Association.
HF, Heart failure; Hct, hematocrit; Hgb, hemoglobin; IV, intravenous; PRBCs, packed red blood cells; RBC, red blood cell; SOB, shortness of breath.
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