HANDOUT on NURSING MANAGEMENT FOR CLIENT RECEIVING BLOOD TRANSFUSIONBy: John Arbie T. Tattao, RN

• Blood GroupsA. Erythrocytes carry antigens, which determine the different blood groups.B. Blood-typing systems are based on the many possible antigens, but the most important are antigens of the ABO and Rh blood groups because they are most likely to be involved I transfusion reactions.

1. ABO typing Antigens of system are labelled A and Absence of both antigens results in type O blood Presence of both antigens is type AB Presence of either A or B results in type A and type B respectively Nearly half the population is type O, the universal donor

Antibodies are automatically formed against the ABO antigens not on person’s own RBC’S; transfusion with mismatched or incompatible blood results in a transfusion reaction

2. Rh typing Identifies presence or absence of Rh antigen (Rh positive or Rh negative). Anti-Rh antibodies not automatically formed in Rh-negative person, but if Rh-positive blood is

given, antibody formation starts and a second exposure to Rh antigen will trigger a transfusion reaction.

Important for Rh-negative woman carrying Rh-positive baby; first pregnancy not affected, but in a subsequent pregnancy with an Rh-positive positive baby, mother’s antibodies attack baby’s RBCs.

Blood Transfusion and Component TherapyBLOOD TRANSFUSION – the introduction of whole blood components of the blood (plasma, serum, erythrocytes, or platelets) into the venous circulation.

Purposes:a. To increase the circulating blood volume as in shock due to haemorrhageb. To increase red cell volume of hemoglobin content of the blood as in anemiac. To increase WBC content of the blood as in agranulocytosis and leucopeniad. To increase the quantity of protein malnutrition, excessive loss of protein from burns or

vesicular skin diseases

A. Blood and blood products1. Whole blood: provides all components

> 500 ml: 200 ml RBC and 300 ml Plasmaa. Large volume can cause difficulty: 12-24 hours for Hgb and hct to riseb. For massive blood loss and exchange transfusion in neonatesc. Complications: volume overload, transmission of hepatitis or AIDS, transfusion reaction, infusion of excess potassium and sodium, infusion of anticoagulant (citrate) used to keep stored blood from clotting.

2. Packed Red blood cells> 350 – 400 ml: 200 – 250 ml RBC and 150 ml Plasma and additive solution (saline, glucose, mannitol)

a. Provide twice the amount of Hgb as an equivalent amount of whole blood.b. Indicated in cases of blood loss, pre and post-op clients, and those with incipient congestive failurec. Complications: transfusion reaction (less common than with whole blood due to removal of plasma protein)

3. Fresh frozen plasma> 200 – 250 ml: contains all coagulation factors and 250 mg of fibrinogen

a. Contains all coagulation factors including V and VIIIb. To expand plasma volume, treat post operative hemorrhage or shock and correct coagulation factor deficienciesc. Can be stored frozen for 12 months; takes 20 minutes to thawd. Hang immediately upon arrival to unit (Rationale: loses its coagulation factors rapidly)

4. Platelets> 30 – 60 ml: half of the number of platelets originally found in 1 unit whole blood

a. Will raise recipient’s platelet count by 10,000/mm3

b. For thrombocytopenia, acute leukemia, to restore platelet count preoperatively.b. Pooled from 4-8 units of whole bloodc. Single-donor platelet transfusions may be necessary for clients who have developed antibodies; compatibility testing may be necessary

5. Factor VIII fractions (cryoprecipitate): contains Factors VIII, fibrinogen, and XIII> Frozen 20 ml unit contains mostly coagulation factor VIII and 250 mg fibrinogen

a. For hemophilia A

6. Volume expanders: albumin; percentage concentration varies (50-100 ml/unit)> Serum albumin and Plasma Protein Fraction (PPF)> 25% albumin in 50 ml and 100 ml units> 5% albumin and PPF comes in 250 ml unitsa. For hypovolemia and hypoproteinuriab. Hyperosmolar solutions should not be used in dehydrated clients

7. Granulocytes> Contains mostly granulocytes and RBC’s, plasma, and plateletsa. For severe gram negative infection or severe neutropenia, unresponsive to routine forms of therapy in immunosuppressed patients

B. Nursing Interventions for patients receiving Blood Transfusion:

Nursing Responsibility Prior to Blood Transfusion1. Verify doctor’s order and make a treatment card

Rationale: To avoid mistakes2. Assess client for history of previous blood transfusions and any adverse reactions.

3. Request blood/blood component from hospital blood bank to include blood typing and cross matching

4. Ensure that the adult client has an 18- or 19- gauge IV catheter in placeRationale: Large bore needle is indicated for BT since blood is viscous.

5. Initiate an IV line with appropriate IV catheter with 0.9% NaCL (PNSS).Rationale: To flush out tubing and Keep IV open (KVO)

6. Ensure that the blood should be transfused not more than 20 minutes from the time it arrives from the blood bankRationale: To prevent untoward blood reaction

7. Have a doctor and a nurse or at least two nurses countercheck the compatible blood to be transfused:a. Name and Identification numberb. Client’s blood group and Rh typec. Donor’s blood group and Rh typed. Cross-match compatibilitye. Blood unit and serial componentf. Expiration date of blood product

Rationale: To prevent any problem in relation to transfusion8. Take baseline vital signs before initiating transfusion.

Rationale: To compare any change in vital signs before and during the BT9. Give pre medications 30 minutes before transfusion if any is ordered

Rationale: To prevent minor allergic reaction

Nursing Responsibility during Blood Transfusion:1. Start transfusion slowly (2 ml/minute)2. Stay with the client during the first 15 minutes of the transfusion and take vital signs frequently

Rationale: Transfusion reactions occurs during the first 10 – 15 minutes of transfusion3. Maintain the prescribed transfusion rate

a. Whole blood: approximately 3-4 hoursb. RBCs: approximately 2-4 hoursc. Fresh frozen plasma: as quickly as possibled. Platelets: as quickly as possiblee. Cryoprecipitate: rapid infusiond. Volume expanders: volume-dependent rate

4. Observe the patient for any untoward signs and symptoms (ICEFUD)a. Itchinessb. Chillsc. Elevated temperatured. Flushed skine. Urticariaf. Dyspnea

If any occurs, institute (SPR) STOP transfusion, OPEN IV line with PNSS, and REPORT to the physician

5. Swirl the bag once in a whileRationale: To mix the solid and liquid elements of the blood. RBC tends to settle at the bottom of the solution while the plasma rises to the top as the blood bag hangs

6. If blood is consumed, close roller clamp of BT set then disconnect from IV line then regulate the IVF as ordered

Nursing Responsibility after Blood Transfusion1. Continuously monitor the patient for signs of blood transfusion reactions.2. Carry out post BT order such as re-check Hgb and Hct level, bleeding time,RBC and platelet

count3. Document observations and interventions done

a. Blood component unit number (apply sticker if available)b. Date infusion starts and endsc. Type of component and amount transfusedd. Client reaction and vital signs e. Signature of transfusionist

C. Blood Transfusion Reactions (HAPCAT)A. Hemolytic Reaction

1. Causes:a. ABO incompatibilityb. Rh incompatibilityc. Use of dextrose solutions

2. Mechanisma. Antibodies in recipient plasma react with antigen in donor cells. Agglutinated cells block capillary blood flow to organs.

3. Occurrence: a. Acute: first 5 min after completion of transfusionb. Delayed: days to 2 weeks after

4. Signs and symptomsa. Headacheb. Lumbar or sternal painc. Nausea and vomitingd. Fever and chillse. Flushing and heat along veinf. Restlessness g. Dysnea h. Signs of shock; renal shutdowni. DIC

5. Nursing Interventiona. Stop transfusion (Standard Operating Procedure-SOP)b. Continue saline IVc. Notify Physiciand. Send blood unit and client blood sample to labe. Administer isotonic fluid solution as ordered. To prevent acute tubular necrosis and counteract shockd. Watch for hemoglobinuria e. Treat or prevent shock, DIC, and renal shutdownf. Monitor Vital signs and intake and output

B. Allergic Reaction1. Causes

a. Transfer of an antigen or antibody from donor to recipientb. Allergic donors

2. Mechanisma. Immune sensitivity to foreign serum protein

3. Occurrencea. Within 30 min of start of transfusion

4. Signs and symptomsa. Urticaria b. Laryngeal edemac. Wheezing d. Dyspnea e. Brochospasm f. Headacheg. Anaphylaxis

5. Nursing Interventiona. Stop transfusionb. Flush with PNSSc. Notify Physiciand. Administer antihistamine as ordered

If (+) hypotension – signals anaphylactic shock – administer epinephrinee. Send blood unit to blood bankf. Obtain urine and blood samples – send to labg. Treat life-threatening reactionsh. Monitor VS and I and O

C. Pyrogenic Reaction 1. Causes

a. Recipient possesses antibodies directed against WBCs b. Bacterial contaminationc. Multitransfused clients

2. Mechanisma. Leukocyte agglutinationb. Bacterial organisms

3. Occurrencea. Within 15-90 min after initiation of transfusion

4. Signs and symptomsa. Fever and chillsb. Flushingc. Palpitationsd. Tachycardiae. Occasional lumbar pain

5. Nursing Interventiona. Stop transfusionb. Flush with PNSSc. Notify Physician

d. Administer antipyretics, antibiotics as orderede. Treat temperature – Tepid sponge bathf. Transfuse with leukocyte-poor blood or washed RBC

D. Circulatory overload1. Cause

a. Too rapid infusion in susceptible clients2. Mechanism: Fluid volume overload3. Occurrence: During and after transfusion4. Signs and symptoms

a. Dyspnea b. Tachycardiac. Orthopnea d. Increased blood pressuree. Cyanosisf. Anxiety

5. Nursing Interventiona. Slow infusion rateb. Use packed cells instead of whole bloodc. Monitor CVP through a separate line

E. Air embolism1. Cause: blood given under air pressure following severe blood loss2. Mechanism: bolus of air blocks pulmonary artery outflow3. Occurrence: anytime4. Signs and symptoms

a. Dyspnea b. Increased pulsec. Wheezingd. Chest paine. Decreased blood pressuref. Apprehension

5. Nursing Interventiona. Clamp tubingb. Turn client on left side

F. Thrombocytopenia1. Cause: Use of large amounts of banked blood2. Mechanism: Platelets deteriorate rapidly in stored blood3. Occurrence: When large amounts of blood given over 24 hr4. Signs and symptoms

a. Abdominal bleeding5. Nursing Interventions

a. Assess for signs of bleedingb. Initiate bleeding precautionsc. Use fresh blood