Janice Romero, age 24, has recently been diagnosed with acute lymphocytic leukemia (ALL). To provide long-term venous access, she is having an implanted port placed. She had a 21-gauge peripheral IV inserted in her right arm prior to surgery. After her port was placed, Mrs. Romero's health care provider prescribed two units of packed red blood cells (PRBCs). You note a prescribed intervention for the use of a blood warmer for the transfusions. When you talk to Mrs. Romero about the blood transfusion, she tells you that the last time she received blood she had chills and fever during the transfusion.
Prescribed Interventions
- Two units PRBCs via blood warmer stat
- Intravenous fluids: D5 ½ NSS at 50 mL/hr
Developing Clinical Reasoning and Clinical Judgment
- Identify the site you will use to administer blood to Mrs. Romero. Why did you choose this site?
- Describe the technique you will use to administer blood to Mrs. Romero.
- Identify the purposes for warming blood, and describe the safest way to warm blood.
- Considering Mrs. Romero's history and diagnosis, describe the precautions you will implement before giving her blood.
Suggested Responses for Integrated Nursing Care
- Before Mrs. Romero can receive blood, you must select an appropriate site (see Chapter 16). Site selection depends on the gauge of the IV and the fluid infusing in the IV. Use a 20- to 24-gauge PIVC based on vein size for blood transfusion; a large-gauge PIVC is recommended when rapid transfusion is required. Since dextrose will cause hemolysis, blood can be administered only with normal saline. For these two reasons, the optimal site for blood administration is her implanted port (Chapter 16). Before you give her blood through the port, be certain that the port is not dedicated for other infusions, such as chemo.
- Since the implanted port is new, check the patient's health record for indications that the port has been approved for use; confirmation of location of the tip of the port catheter either by postprocedure chest radiograph or by technology used during the placement procedure is required prior to use and should be documented in the patient's health record. Maintain sterile technique when accessing the port and wear a mask (see Chapter 16). Ensure that the port is patent prior to use. Check the port for patency and blood return per facility policy. Infuse the normal saline slowly while you observe the implanted port site for signs of swelling and pain. If the port shows any sign of infiltration, notify the health care provider and choose another site to give her blood.
- Some patients may need to have their blood warmed before it is administered. This includes patients who are at risk for cardiac arrhythmias, patients with unusual immune responses, as well as neonatal and pediatric patients. A health care provider must prescribe warming of blood products during transfusion. Various devices exist to warm blood. Whenever you need to warm blood, always use a blood warmer approved by your facility. Do not use the microwave to warm any blood product.
- Mrs. Romero's history of chills and fever are signs of a possible transfusion reaction; thus, she is at increased risk for a transfusion reaction. Ensure that she has a signed consent form and that she fully understands her need for the blood. The health care provider should be aware of this history of a transfusion reaction. Stay with the patient for at least 15 minutes at the beginning of the transfusion. Assess the patient at least every 30 minutes for adverse reactions (Gorski et al., 2021). Continue to monitor her vital signs frequently per hospital policy (see Chapters 2 and 16). When you leave her room, make sure her call light is available, and instruct her to contact you if she has any symptoms.