8/17/2011

Care of the Patient

Receiving Blood Products

Blood Transfusion
Nursing Implications
Know the P and P at agency
Patient must have a Type and Crossmatch performed
May premedicate the patient- depends on patient
history of reaction
Need at least a 19g IV for PRBC transfusion to
prevent hemolysis

Blood Transfusions (cont)

All blood must be filtered (special blood
transfusion tubing)
Most tubing are Y type to allow saline flush
Only isotonic saline (0.9%) is recommended
for use with blood components.

8/17/2011

Blood Transfusion
If no reaction occurs in the first 15 minutes, the rate
may be increased
Red Blood Cells: two hours unless the patient can
tolerate only gradual expansion of the intravascular
volume
Infusion time should not exceed 4 hours for any
component.
Vital signs should be monitored frequently.

Transfusion Reactions
There are 5 major types of reactions:
1) Hemolytic: caused by incompatibility between
patients blood and donors blood
2) Febrile: caused by sensitivity of the patients blood
to WBCs, platelets, or plasma proteins
3) Allergic: sensitivity to plasma proteins or an
antibody-antigen reaction; may be minor or major
4) Circulatory Overload: caused by blood being
administered faster than the circulation can
accommodate
5) Sepsis: caused by contaminated blood; very rare

Transfusion Reactions
A MAJOR reaction is defined as life
threatening and is a medical emergency. A
hemolytic reaction is the most common major
reaction.
A MINOR reaction is relatively common and is
not life threatening. Febrile and allergic
reactions are the most common minor
reactions

8/17/2011

Signs and Symptoms of a Transfusion

Reaction

Chills
Fever
Headache
Backache
Dyspnea
Cyanosis
Chest pain

Itching
Wheezing
Tachycardia
Hypotension
Anxiety
Flushing

When a Reaction Is Suspected

Stop the transfusion immediately
Change tubing and keep the vein open with
Normal Saline
Send the remaining blood, a sample of the
patients blood, and possibly, depending on
severity of reaction, a urine sample to the lab
Notify the MD and the lab STAT
Monitor VS and I&Os
Complete the Report of Transfusion Reaction
form and return to lab with the blood

If a Transfusion Reaction is Suspected

Stop the transfusion
Maintain the IV.
Notify Health Care Provider
Follow Provider orders for determination of
type of reaction
Save bag and tubing and send to blood
bank for testing

8/17/2011

Critical Thinking
You are administering a platelet transfusion to your
patient who has a nosebleed during the transfusion.
Your priority nursing intervention would be:
1.
2.
3.
4.

Stop the transfusion

Hold slight pressure on the bridge of the nose
Draw a stat platelet count
Call the healthcare provider.