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5: CONTINUUM OF CARE
5.4 BLOOD/BLOOD COMPONENT TRANSFUSION
1. INTRODUCTION Blood transfusion if used correctly can save life and improve health. However, there are risks associated with blood transfusion. The biggest risk associated with transfusion is due to human error. These errors can lead to complications, which can be serious and life threatening. Nurses have to be competent in safely administrating a transfusion of blood/blood products to an individual who has been identified as requiring this procedure and their responsibility is to comply to the safety standards and practices in order to prevent occurrence of adverse transfusion errors / misadventures. This involves confirming pre-transfusion checks to ensure the correct patient receives the correct blood. It also involves supporting and monitoring the patient throughout the transfusion procedure, identifying and responding promptly to indications of adverse reactions, completing relevant documents and proper handling of used blood bags and other used equipment on completion of infusion. Nurses must also know the possible adverse events, which include febrile nonhaemolytic infection. transfusion reaction, acute haemolytic transfusion reaction, anaphylactic reaction, transfusion-associated graft-vs-host disease (GVHD) and
OBJECTIVES 2.1 To ensure blood / blood components is safely administered to patient. 2.2 To ensure reactions related to blood / blood component transfusion is detected, reported and action taken immediately. 2.3. To ensure the nurse documents and complete the relevant records
2.4 To ensure that nurses exhibit the caring component when administering blood / blood components to patients.
STANDARD 3.1. Nurses administer blood/blood component correctly to patient as prescribed. 3.2 Nurses exhibit the caring component during the administration of blood/blood component. 3.3 Nurses document accurately and completely into relevant documents.
CRITERIA Structure Process 1. Greet patient Outcome 1. Patient is informed and aware of possible risks. of the transfusion.
1. Each patient has current legal written prescription transfusion. 2. There is a Nursing Operating Procedure (NOP) for procedure for blood/blood component transfusion.
2. Confirm patient for blood/blood component identification. 3. Confirm prescription. 4. Verify right patient and
2. Patient received blood/blood blood/blood components product as together with the Doctor. prescribed.
5. Complete pre-transfusion 3. Blood reaction check list are detected early and - Verify screening. appropriate measures taken - Verify expiry date. timely 4. Documentation is accurate and complete.
3 The nurse has knowledge and skill on 6. Verify consent taken transfusion practice is competent in administrating blood/blood component transfusion. 4. Nurse has knowledge of transfusion reaction and its measures 5. Consent for blood transfusion. 6. GXM request form. 7. Perform baseline monitoring. 8. Prime line with IV solution 0.9 Normal Saline. 9. Titrate flow rate
10. Observe for reactions and take appropriate measures. 11. Listen, respond to patient/relative promptly and politely. 12. Perform accurate documentation
Structure 7. Transfusion practice guideline MOH 2001/ PDN 2007. 8. PDN Check list. 9. Blood transfusion set 10. Blood card. 11. Patient progress notes/ temperature chart. 12. Intake / output chart 13. Observation chart
AUDIT GUIDE FOR BLOOD / BLOOD COMPONENT TRANSFUSION 5.1. INCLUSION CRITERIA All patients in the ward who require blood / blood components transfusion.
INSTRUMENT Audit Form (E5 AF 5.4) – one audit form for one observation
Methodology 5.3.1 Direct observation of blood / blood component transfusion and also gathering information from documents. 5.3.2 Setting : Medical, Surgical and Orthopedic adult wards
5.4. Sample Size
20 transfusions of blood/blood product from Specialist Hospital and 10 for non-specialist hospital.
5.5. Time Frame One month 6. DEFINITION OF OPERATIONAL TERMS 6.1. Written prescription : 6.1.1. Any legal orders of blood / blood components transfusion Endorse in the patient’s medical records 6.2. Time limit for transfusion: 6.2.1 blood / blood component must be transfused within 30 minutes of removing the pack from refrigeration. 6.2.2 to start transfusion at 10 drops per minute. Nurse is to be at the patient’s bedside and to observe the patient for the first 15 minutes. 6.2.3 appropriate time frame per pack i] whole blood : within 4 hours ii] packed cells : within 4 hours iii] fresh frozen plasma : within 30 minutes iv] cryoprecipitate : within 30 minutes v] platelet concentrate : within 30 minutes
Verify right patient with blood / blood product 6.3.1. Confirm patient’s identity by 2 identifier 18.104.22.168. his name i. Ask patient to confirm name and registration number iii. Verify accuracy of identifier with patient’s medical record. iv. Registration number ii. Cross check with patient’s wrist band for name
6.3.2. Confirm the right blood /blood product by verifying the labels on the blood or blood product with patient’s blood request form to ensure correct match: i ] of blood / blood component ii] ABO grouping & Rhesus factor correspond iii] screening for HbsAg, HIV and VDRL done iv] blood not expired * No. [i] – [iv] to be verified together with the doctor 6.4. Assessment of patient pre-transfusion (baseline), during and post transfusion vital signs and response/reaction: 6.4.1. Nurses need to determine the patient’s status prior to administration by checking: 22.214.171.124 blood pressure, 126.96.36.199 pulse rate 188.8.131.52 temperature. 184.108.40.206 respiration 220.127.116.11 pain assessment 6.4.2 Initial monitoring 15 minutes upon commencement of blood transfusion and followed by hourly until completion 6.4.3 Reactions – e.g. chills, rigors, skin changes [rash], pyrexia, hypo / hypertension, respiratory distress, nausea and vomiting, renal shutdown [oliguria /anuria] abnormal bleeding [haematuria], anaphylaxis, pain [infusion site, chest pain, abdomen, loin]. 6.5 Remedial action /appropriate measures: – stop transfusion immediately, inform doctor urgently and document measures taken 6.6. Nurses when assessing the patient will exhibit the caring component.
6.6.1 communicating well in a respectful manner. 6.6.2 giving the patient the privacy, dignity and modesty. 6.7 Right /proper documentation – implies accuracy and completeness of documentation: 6.7.1 check list and blood card must be completed accurately 6.7.2 document date and time of administration must be indicated in the intake and output chart / patient’s progress notes /temperature chart [date & time of transfusion, blood type, amount transfused] 6.7.3 response to the transfusion, whether any transfusion reactions and appropriate measures taken. 6.7.4 document vital signs in observation chart. 6.7.5 document any identified adverse reaction to the blood /blood product administered. 6.7.6 Document full name/cop, signature and date. 6.8 Transfusion errors include any following : 6.8.1 6.8.2 6.8.3 blood / blood component given not according to prescription blood pack number / blood group / Rhesus Factor not corresponding to GXM request form. name / registration number / identity card number on GXM request form not corresponding to patient’s case notes expired blood transfused did not confirm screening for HbsAg, HIV and VDRL or nonEmergency transfusion transfusion time not complying to appropriate time frame [for non-emergency cases] appropriate measures not taken when complications arise reactions / document the evaluation of the patient
6.8.4 6.8.5 6.8.6 6.8.7
baseline and regular monitoring of vital signs not done inappropriate personnel [e.g. non-qualified staff. Appropriate personnel should have a diploma and above qualification to verify blood).
6.8.10 improper / incomplete documentation * If any one of the errors above occur, it would be considered as transfusion error.* 7. Compliance of blood / blood components transfusion Safety Audit . Every step in the process must be performed. a) Technical identify patient accordingly verify transfusion order. assess patient prior to administration takes the correct blood / blood product and administer accurately – right blood and right patient. administer and ensure patient receives correct blood and amount
Essence of Care (Soft Skills) - greets patient - explain and inform patient - listen, responds promptly and politely to patient’s questions. - exhibit caring component when assessing patient
Documentation - document baseline vital signs and subsequence readings - document blood /blood component administered – blood number, amount, date, time and signature - document adverse reactions identified if any - document appropriate measures taken if adverse reactions
8. AUDIT FORM
NATIONAL NURSING AUDIT MINISTRY OF HEALTH MALAYSIA VERSION 1/08
ELEMENT 5 : CONTINUUM OF CARE
DATE : 1.11.08 TOPIC : 5.4 BLOOD AND BLOOD COMPONENT TRANSFUSION DOCUMENT NO : E5 AF 5.4 PAGE No. 1/3
1. STANDARD: 1.1. Nurses administer blood/blood component correctly to patient as prescribed. 1.2 Nurses exhibit the caring component during the administration of blood/blood component. 1.3 Nurses document accurately and completely into relevant documents. . 2. OBJECTIVES 2.1 2.2
To ensure blood / blood components is safely administered to patients. To ensure reactions related to blood / blood component transfusion is detected, reported and action taken immediately.
To ensure the nurse documents and completes the relevant records accurately.
2.4 To ensure that nurses exhibit the caring component when administering blood / blood components to patients. Date of Audit :………………………………….
Locality :………………………………………… Auditors : 1. …………………………………… 2. …………………………………… N.B. Instructions For Auditors 1. To tick [√] at appropriate column. 2. Item 1.11 is not rated if no specific nursing measures required.
S/N 1 1.1 1.2 1.3 1.4
ITEM TECHNICAL Confirm patient’s identification. Confirm prescription. Verify right blood / blood components with doctor. Verify right blood / blood component for transfusion Verify screening. Verify expiry date. Verify consent.
SOURCE OF INFORMATION
Ask patient his name or check bracelet. Check doctor’s order in patient’s case notes. Observe nurse & check written evidence. Observe nurse and check written evidence. Observe nurse and check written evidence. Observe nurse and check written evidence. Observe nurse and check written evidence SOURCE OF INFORMATION YES NO N/A
1.5 1.6 1.7
Perform baseline monitoring. Observe nurse.
1.9 1.10 1.11 1.12 1.13
Prime line with 0.9% saline
Titrate flow rate accordingly Observe nurse Monitor patient within first minutes 15 of transfusion. Observe nurse
Check vitals signs hourly till Observe nurse transfusion completes. Monitor time limit of transfusion. Identify reactions. Observe nurse / Ask patient / Check written evidence. Observe nurse / Ask patient / Check written evidence.
Take appropriate measures Observe nurse / Ask if required. patient / Check written evidence. DOCUMENTATION Check for accuracy and completeness of documentation. SOFT SKILLS The nurse explains to the Ask the patient. patient prior to procedure: Observe nurse - purpose of blood transfusion - Possible reactions that may occur - When to call for nurse(blood not flowing well, physiological needs, reactions) - Duration of transfusion Listen, responds promptly and politely to patient’s questions. Observe nurse. Ask the patient Observe nurse / Ask patient / Check written evidence.
AUDIT REPORT (Please [√] the appropriate box)
Auditor 1[Name and Signature]: …………………………… Auditor 2 [Name and Signature]: ……………………………
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