OUR LADY OF FATIMA UNIVERSITY

BLOOD TRANSFUSION A.Y. 2021- 2022

FUNDAMENTALS OF NURSING PRACTICE ZAPANTA, VIA KRISTEL U.

BLOOD TRANSFUSIONS DONATE

→ Introduction of whole blood or components of the blood) Rh (+) Rh (-)
plasma, RBC, WBC, or platelets) into the venous Rh (+) ✓ ✖
circulation RECEIVE
→ An adult human has about 4–6L of blood Rh (+) Rh (-)
circulating in the body.
→ Massive hemorrhage
Rh (+) ✓ ✓
→ Rib transfusion – Hemoglobin problem Rh (-) ✖ ✓
A → Antigen A and Antigen B antibody WHO CAN RECEIVE?
BLOOD GROUPS

A+ A+, AB
B → Antigen B and Antigen A antibody
A A both and ab both
AB → Universal receipients B+ B+, Ab+
→ Antigen AB and neither A/B antibody B B+, B- , AB+ , AB-
Ab+ AB+
O → Neither antigen A nor B and Anti – A or Ab- Ab+, Ab-
Anti B antibodies O+
AGGLUTINATION UNIVERSAL DONOR
→ The formation of clumps of cells or inert particles by O-
specific antibodies to surface antigenic components
A B AB O HEMATOLOGIC SYSTEM
A Anti B ✖ ✓ ✓ ✖ Wbc (leukocytes) SYSTEM
B Anti A ✓ ✖ ✓ ✖ 4500-1100/cu mm
AB None ✖ ✖ Neutrophils 45-73% Prevents and limits bacterial
O Anti – A ✓ ✖ ✖ ✖ infection
Anti- B Monocytes As macrophages, highly
✓ - Agglutination 2-8% phagocytic, fungus
✖ - No agglutination Monocytopenia
o Surface antigens- already attached in rbc Eosinophils Allergic reactions
o Antigen promotes agglutination 0-4% Parasitic
o Clamping of RBCS and formation of clamp Cancer
Increase – all
o Possible manifestations:
Decrease – stress
o Hematoma
Basophils – 0-1% Contains histamine
o Bleeding with mucosal lining
Lymphocytes Integral component of immune
RH FACTORS system
20-40%
→ Another consideration when matching blood Lymphocytosis – increase
components Lymphocytopenia – decrease
→ Refers to another antigen in RBC membranes T-Lymphocytes Cell mediated immunity
o Rh(+) has an rh antigen recognizes material as foreign
o Rh (-) does not produce antibody body
o Rh (-) has no Rh antigen
Rh (-) produces antibody B lymphocytes Humoral immunity, form
o Rh + - common rh factor antibodies
RBC 120 DAYS
M- 4.6-6 M/ cumm
F- 4.2-5.4
PLATELETES 10 DAYS
150000- 4-0000

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BLOOD TRANSFUSION
 OUR LADY OF FATIMA UNIVERSITY
BLOOD TRANSFUSION A.Y. 2021- 2022
FUNDAMENTALS OF NURSING PRACTICE ZAPANTA, VIA KRISTEL U.

BLOOD PRODUCT USE PURPOSES OF BLOOD TRANSFUSION

Whole blood Replaces blood volume and all 1. To increase 02 carrying capacity of blood as in anemia
(FRESH WHOLE blood products 2. To replace circulating blood volume or as volume
BLOOD/FWB) expansion (WB) for cases of hemorrhage
RBC To increase blood oxygen levels 3. Provision of protein
in anemia and surgeries; 4. Provision of coagulation factors (CYRO, FFP, WB)
contain hemoglobin, the iron-
containing protein carrying
oxygen throughout the body NURSING MGT
which gives blood its red color 1.Proper refrigerated
(oxygen carry capacity of blood 2. Proper typing and cross matching
in 1unit PRBC = 1 unit FWB = 2-3% NURSING CARE
increase in hematocrit levels in 1. Asses history of allergy
an average adult)
2. Ensure that IV CATHETHER is gauge 18 or 19
Platelets Replaces platelets from clients
3. Use .9% NaCl (sodium chloride) – to prevent formation
with bleeding disorder or
platelets deficiency of emboli
150k – 400k – normal value 4. Verify the blood
Crossmatching is not required, 5. Take baseline vital signs
but s done due to patient safety 6. Start transfusion slowly – so that if there are reactions,
Fresh frozen Expands blood volume and there are no major problem
plasma provide clotting factors 7. Stay with the client during the initial 15 mins – reaction
Requires cross matching
occur in 15
200-250 mL
Autologous RBC Use blood replacement following 8. Maintain the transfusion rate
planned elective surgery FWB – 3-4 hours
4-5 weeks prior to surgery PRBC – 2-4 hrs.
Clotting factors Used to clients with clotting FFP, PLATELET, CYRO – immediate
and factors deficiencies 9. Monitor adverse reaction
cryoprecipitate 10. Document the ff
Albumin and Blood volume expander s
a. Blood component and number
plasma protein 5 years
fraction b. Infusion
c. Client reaction
HEMOGLOBIN MALE FEMALE MATERIAL NEEDED
13- 18 gram 12-16 gram 1. IV TRAY
per deciliter per deciliter 2. Compatible BT set
3. IV catheter/ needle gauge 18/19
HEMATOCRIN 42- 52 35-47 4. Plaster
5. Tourniquet
6. Blood product
7. Plain NSS (.9 Sodium Chloride)
8. IV Stand
9. Gloves

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BLOOD TRANSFUSION
 OUR LADY OF FATIMA UNIVERSITY
BLOOD TRANSFUSION
FUNDAMENTALS OF NURSING PRACTICE
INITIATION OF BLOOD THERAPY
ASSESSMENT
o Verify health care provider’s order for specific blood or
blood product and all pertinent information
o Assess the readiness of the client]
o Obtain patient’s transfusion history, noted known
allergies and previous transfusion reaction, verifies
that the typing and
o Verify that IV Canula was patent and with
complications, administered blood or blood
components
o Assess laboratory values such as hematocrit,
coagulation values, platelet count, and potassium
o Check that patient had completed and signed
transfusion
o Know indication or reasons for a transfusion, packed
RBC if necessary
o Obtained and recorded pretransfusion baseline vital
signs notify health care provider if patient is febrile
o Assess patient’s need for IV fluid or education while
transfusion was infusing
o Assess patent’s understanding of procedure and
rationale
PLANNING
o Identify expected outcomes
IMPLEMENTATION
1. Perform pre - administration protocol
→ Obtain blood component following agency protocol
→ Check blood bags signs of contamination and presence
of leaks
a. Identify patient using at least 2 identifies
b. Matched transfusion record number and patient’s ID
number
c. Ensured patient patient’s name
d. Checked unit no. on blood bag with blood bank,
checked expiration date and time
e. Ensue blood type matched transfusion
f. Checked expiration date
g. Checked patient id info with blood unit label
h. Revied [purpose of transfusion and ask the patient to
report any changes he or she may feel
i. Had a patient urine drainage collection container o
applied gloves and emptied for him/her
A.Y. 2021- 2022
ZAPANTA, VIA KRISTEL U.
→ Never warm blood products
→ Just use warming device and should be use in
emergency
→ Room temp for 30 mins pag wala
a. Perform hand hygiene, gloves
b. Opened y-tubing blood administration set, used
multiset if needed
c. Set all clamps to off position
d. Spiked normal saline IV bag with spike hung bag on
pole, primed tubing, opened upper clamp on saline
side of side of tubing squeezes drip chamber
e. Maintained clamp on blood products side of tubing in
off position, open common tubing clamp, close clamp
when tubing was filled in saline, maintained protective
sterile cap
f. Prepare blood components for administration
g. Maintained asepsis
h. Opened tubing clamp regulate blood flow properly
i. Monitored patient’s vital signs
j. Regulate rate appropriately if there is no reaction
k. Cleaned IV Line with saline, discard blood bag
appropriately
l. Dispose all supplies appropriately
m. Monitor vital signs every 15 mins for first hour during
transfusion
EVALUATION
1. Observe IV site and status of each time
2. Observe for change in vital signs
3. Identified unexpected outcomes
RECORDING AND REPORTING
1. Record pre-transfusion medication, vital signs, location
and condition of IV site, and patient education
2. Record type and volume of blood component;
unit/donor/recipient identification, compatibility and
exp. date and patient’s response
3. Record volume of normal saline
4. Record amount of blood received by auto transfusion
and patient’s response
5. Record vital signs before and after initiation and after
transfusion
6. Document evaluation of patent learning
7. Report signs of transfusion reaction
8. Report any in transfusion/posttransfusion deterioration
in cardiac, pulmonary and renal status
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BLOOD TRANSFUSION
 OUR LADY OF FATIMA UNIVERSITY
BLOOD TRANSFUSION A.Y. 2021- 2022
FUNDAMENTALS OF NURSING PRACTICE ZAPANTA, VIA KRISTEL U.

COMPLICATIONS OF BLOOD PYROGENIC REACTION

→ Fever and chills due to sensitivity
1. HEMOLYTIC REACTION NURSING MGT
→ Donor blood is incompatible 1. Stop BT
→ Most fatal and deadly 2. Notify physician
→ Present chills diaphoresis and back pains 3. Flush PNSS
→ Headaches dizziness dyspnea 4. Administer antipyretics, antibiotics
→ Palpitation and tachycardia 5. Send blood
→ Lumbar/sternal/flank pain 6. Obtain urine and blood samples
→ Hypotension 7. Motor vs and io
→ Flushed skin 8. Tepid sponge bath – increase in temp
→ Red urine
NURSING MGT IN HEMOLYTIC REACTION CIRCULATORY OVERLOAD
1. Stop BT – remover and change the tubing SX:
2. Notify doc → Dyspnea
3. Flush with plain NSS → Orthopnea
4. Administer isotonic solution to counteract shock → Crackles
5. Send blood unit to blood bank for re-examination → Tachycardia
6. Obtain urine and blood samples o High fowler
7. Vital signs and allergic reactions NURSING MGT
→ Stop BT and place client upright with feet dependent
ALLERGIC REACTION → Notify doc
→ Rashes and itchiness, dyspnea, bronchospasm die to
sensitivity in foreign proteins in plasma SEPSIS
Sx: → Contaminated blood administration
Fever → High fever chills vomiting diarrhea hypotension
Urticaria MGT
NURSING MGT → STOP KVO WITH NSS
1. Stop BT → NOTIFY DOC
2. Notify Doc → ADMINISTER ATIBIOTICS
3. Flush Plain NSS
4. Administration of anti-histamine – diphenhydramine 1 Hemolytic reaction due to hypotension-
PRIORITY

HCL (Benadryl) attend to destruction of HGB brain damage

CASES

5. If hypotensive – anaphylactic shock administers 2 circulatory overload

epinephrine 3 allergic reaction
6. Send blood to blood bank 4 pyrogenic
7. Obtain urine and blood samples
8. Monitor vital signs 2. ISLAM
9. Administer – antihistamine → Consumption of food containing blood is forbidden by
10. Tepid sponge bath Islamic dietary laws; derived from the statement in the
Qur'an, sura Al-Ma'ida (5:3): "Forbidden to you (for food)
RELIGIOUS AFFILIATION CONSIDERATIONS
are: dead meat, blood, the flesh of swine, and that on which
1. JUDAISM
hath been invoked the name of other than Allah."
→ Blood cannot be consumed even in the smallest quantity;
this is reflected in Jewish dietary laws (Kashrut)
3. JEHOVAH’ S WITNESSES
→ Do not eat blood or accept transfusions of whole blood
or its four major components; members are instructed
to personally decide whether or not to accept fractions,
and medical procedures that involve their own blood

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BLOOD TRANSFUSION