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Learning Objectives ⬇

After completing this chapter, the reader will be able to:

Glossary ⬆ ⬇

Introduction ⬆ ⬇

To ensure the delivery of safe transfusion therapy, nurses must possess a knowledge and understanding of the blood system, basic immunohematology, and the theory and practical management of the transfusion of blood components. Today, patient blood management (PBM) is an international standard of care aimed at optimizing the care of patients who might require a blood transfusion.

The manufacture and distribution of blood products is overseen by the U.S. Food and Drug Administration (FDA), although the FDA does not directly inspect transfusion services. Rather, the FDA accepts inspections sanctioned by the Centers for Medicare & Medicaid Services (CMS), which are most often based on certificates of accreditation from an approved organization. The AABB (Association for the Advancement of Blood & Biotherapies) is an international organization aimed at making transfusions and biotherapies safe, available, and effective worldwide (https://www.aabb.org).

Safe transfusion practices are critical. Transfusion errors are likely to occur in three areas: labeling of the pretransfusion sample, patient identification at the bedside (a major nursing responsibility), and the initial decision to transfuse (i.e., appropriateness for transfusion).

The first part of this chapter presents the fundamental concepts of immunohematology and blood grouping, along with the criteria for donor blood, including allogeneic, designated, and autologous donation followed by further discussion about PBM. Blood components, administration equipment and techniques for transfusing blood, and identification and management of transfusion reactions are presented in the second part of the chapter.

Nursing Process ⬆ ⬇

The nursing process is a six-step process for problem-solving to guide nursing action (see Chapter 1 for details on the steps of the nursing process related to vascular access). The following table focuses on nursing diagnoses, nursing outcomes classification (NOC), and nursing interventions classification (NIC) for patients receiving transfusion therapy. Nursing diagnoses should be patient specific and outcomes and interventions individualized. The NOC and NIC presented here are suggested directions for development of specific outcomes and interventions.

Nursing Diagnoses Related to Transfusion TherapyNursing Outcomes Classification (NIC)Nursing Interventions Classification (NOC)
Anxiety related to: Stressors, threat to current status (need for transfusion)Anxiety level; anxiety self-controlAnxiety reduction; calming technique
Fatigue related to: AnemiaEnergy conservationEnergy management restorative interventions
Impaired gas exchange related to: Ventilation perfusion imbalance, decreased oxygen-carrying capacity of the bloodGas exchange, ventilationAcid-base management
Hypothermia related to: Exposure to cool or cold bloodThermoregulationTemperature regulation
Risk for infection related to: Environmental exposure to pathogens; immunosuppression, invasive procedures, altered skin integrityRisk control: Infectious process, immune statusInfection control; infection protection
Deficient knowledge related to: Purpose of blood component therapy; signs and symptoms of complicationsKnowledge of disease process; transfusion component risk and benefitsTeaching: Disease process, treatment regimen (transfusion)
Ineffective protection related to: Abnormal blood profilesHealth-promoting behavior, blood coagulation, immune statusBleeding precautions, infection prevention, infection protection

Source: Herdman et al., 2021; Ackley et al., 2020

Chapter Highlights ⬆ ⬇

Thinking Critically: Case Study

At the beginning of your shift, you check on a unit of PRBCs that was hung 3 hours prior to your shift. The unit of RBCs is infusing slowly, with approximately 200 mL left.

Case Study Questions

    1.What do you do?

    2.What are the risks to the patient?

    3.What assessments should have taken place prior to hanging this blood component?

Media Link: Chapter post tests and answers are provided on FADavis.com, along with case studies and critical thinking activities.

References ⬆

PROCEDURES DISPLAY 11-1
Initiation of Transfusion

Equipment Needed

This procedure cannot be delegated. A licensed vocational/practical nurse (LVN/LPN) or nursing assistive personnel (NAP) can assist by monitoring vital signs. Note: In California the LVN can administer blood and blood products through a peripheral line if state IV certified and supported by agency policy.

ProcedureRationale

    1.Verify the provider's order and that informed consent is obtained in accordance with organizational policy.

    1.A written order is a legal requirement. Informed consent is required for blood product administration.

    2.Confirm blood is available from the transfusion service.

    3.Introduce yourself to the patient.

    3.Establishes the nurse-patient relationship

    4.Verify patient identity using two forms of identification.

    4.Patient safety

    5.Review patient understanding of the procedure and provide the patient with the opportunity to ask questions and express any concerns.

    5.The patient who is well informed is better able to cope with the treatment regimen.

    6.Perform hand hygiene throughout procedure.

    6.Single most important aspect of infection prevention

    7.Gather and organize needed supplies.

    8.Verify patency of existing IV catheter or place new peripheral IV catheter before obtaining blood from transfusion services.

    8.The blood component must be started within 30 minutes from removal from transfusion service.

    9.Assess patient condition, including baseline vital signs. Notify the provider if temperature is elevated 1°F above normal. The transfusion may be held.

    9.Vital signs serve as baseline for the identification of changes that may transpire during the transfusion.

    10.Obtain and open Y-tubing blood administration set:

      a.Close all clamps.

      b.Spike 0.9% sodium chloride bag with one extension of Y tubing and prime tubing.

      c.Maintain clamp on other Y-tubing extension in closed position.

      d.Initiate slow infusion of 0.9% sodium chloride.

    10.Prepare for transfusion.

    11.Obtain the blood component from transfusion service and:

      a.Inspect the component and its container for clots, bubbles, leaks in the bag, or discoloration.

      b.Compare ABO group and Rh type on the blood label to the tag attached to it and ensure that they match.

      c.Check the expiration date.

      d.Return to the unit with blood component.

    11.Most serious reactions are the result of clerical errors. There is shared accountability between the nurse obtaining the component and the transfusion services. The presence of clots, bubbles, leaks in the bag, or discoloration may indicate bacterial contamination or inadequate anticoagulation of the unit and should not be used.

    12.Perform blood component verification in the presence of the patient. Verify the following:

      a.Patient identification is correct using at least two patient identifiers.

      b.Patient name is correct on all documents.

      c.Blood component is what was ordered (e.g., platelets).

      d.The numbers on the patient's identification band correlate with those on the laboratory form and component.

      e.Blood type matches on transfusion records and blood bag.

      f.Patient is compatible with donor ABO and Rh type.

      g.Expiration date has not passed.

      h.Any product modification (e.g., irradiation)

    12.Less probability of error when two people verify the needed information. One person should read all of the information to the other as the second person verifies it.

    13.Perform hand hygiene and don gloves.

    13.Infection prevention and standard precautions

    14.Spike the blood component bag with the other extension of Y tubing and prime tubing; close clamp to 0.9% sodium chloride container and open the clamp to blood component to initiate the transfusion at the rate of approximately 2 mL/min.

    14.Transfusions are initiated slowly so that minimal blood is transfused in the event of a reaction.

    15.Remain near patient for 15 minutes, checking vital signs within 5 to 15 minutes after starting transfusion and comparing to baseline.

    Stop transfusion immediately if any signs or symptoms of a transfusion reaction are present; disconnect the blood administration set from the catheter hub and start a new primed administration set with 0.9% NaCl.

    15.Most transfusion reactions occur within the first 15 minutes.

    16.Complete RBC/platelet transfusion within 4 hours; plasma within 1 hour.

    16.Increased risk for bacterial growth with longer transfusion times

    17.On completion of the transfusion, close the clamp to the blood product, open the clamp to the saline bag, and infuse 0.9% sodium chloride to clear the IV catheter at the prescribed rate. If another unit of blood is required, a new administration set must be added. Only one administration set can be used in 4 hours.

    17.Clears the remaining blood product that is in the tubing and maintains patency of the IV catheter

    18.Discard the empty blood container and administration set in biohazard container.

    18.Standard precautions

    19.Continue to monitor patient and instruct patient in signs and symptoms to report.

    19.Reactions may occur posttransfusion.

    20.Document pretransfusion assessment and vital signs, vascular access device assessment, blood component, blood unit/donor/recipient identification, compatibility, and expiration date; vital signs and assessment during transfusion, volume of blood component, 0.9% NaCl administered, transfusion start and completion times; patient education.

    Transfusion reaction: If a transfusion reaction occurs, notify the provider immediately; do not discard the blood container—return to transfusion services. Complete the transfusion record and place in the patient's permanent medical record. Draw posttransfusion laboratory samples as ordered. Follow agency policy on transfusion reaction. Document signs and symptoms, component administered, amount infused, time provider notified and response, time of transfusion service notification, medication and treatment ordered and administered, patient's response, and patient outcome.

    20.To maintain the legal record. Immediate reactions can occur within 2 hours of completion of a transfusion. To maintain proper documentation and communicate that transfusion was administered. The remainder of the blood must be sent to the laboratory transfusion service, where it can be analyzed to determine the cause of the reaction. Medication and treatment will vary depending on the type of reaction.

Sources: Gorski et al., 2016b; Jorgenson, 2020.