Before administration of packed red blood cells to a client which is the nurses priority action

Blood transfusion (BT) therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). Learn the concepts behind blood transfusion therapy and the nursing management and interventions before, during and after the therapy.

• Advantages
• Principles
• Blood Components
• Objectives
• Nursing Interventions
• Complications
• Assessment findings
• Nursing Diagnosis
• Planning and Implementation
• Nursing Interventions
• Evaluation

Advantages

1. Avoids the risk of sensitizing the patients to other blood components.
2. Provides optimal therapeutic benefit while reducing risk of volume overload.
3. Increases availability of needed blood products to larger population.

Principles

Whole blood transfusion

Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.

Packed RBCs

Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hemactocrit 3%.

Platelets

Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.

Granulocytes

May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.

Plasma

Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.

Albumin

Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma oncotic pressure.

Cryoprecipitate

Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic bleeding.

Factor IX concentrate

Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from many donors.

Factor VIII concentrate

Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.

Prothrombin complex

Indicated in congenital or acquired deficiencies of these factors.

Blood Components

Objectives

1. To increase circulating blood volume after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia
3. To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, albumin)

Nursing Interventions

1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
2. Check for cross matching and typing. To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the label of the blood transfusion. Check the following:
   • Serial number
   • Blood component
   • Blood type
   • Rh factor
   • Expiration date
   • Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.
6. Warm blood at room temperature before transfusion to prevent chills.
7. Identify client properly. Two Nurses check the client’s identification.
8. Use needle gauge 18 to 19 to allow easy flow of blood.
9. Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)
12. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.
13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose based IV fluids cause hemolysis.
14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
15. Observe for potential complications. Notify physician.

Complications

1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.

Assess for:

• Flushing
• Rash, hives
• Pruritus
• Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion

Assess for:

• Sudden chills and fever
• Flushing
• Headache
• Anxiety

3. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria.

Assess for:

• Rapid onset of chills
• Vomiting
• Marked Hypotension
• High fever

4. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.

Assess for:

• Rise in venous pressure
• Dyspnea
• Crackles or rales
• Distended neck vein
• Cough
• Elevated BP

5. Hemolytic reaction – it is caused by infusion of incompatible blood products.

Assess for:

• Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
• Chills
• Feeling of fullness
• Tachycardia
• Flushing
• Tachypnea
• Hypotension
• Bleeding
• Vascular collapse
• Acute renal failure

Assessment findings

1. Clinical manifestations of transfusions complications vary depending on the precipitating factor.
2. Signs and symptoms of hemolytic transfusion reaction include:
   • Fever
   • Chills
   • low back pain
   • flank pain
   • headache
   • nausea
   • flushing
   • tachycardia
   • tachypnea
   • hypotension
   • hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in delayed hemolytic reaction include:
   • fever
   • mild jaundice
   • gradual fall of hemoglobin
   • positive Coombs’ test
4. Febrile non-hemolytic reaction is marked by:
   • Temperature rise during or shortly after transfusion
   • Chills
   • headache
   • flushing
   • anxiety
5. Signs and symptoms of septic reaction include;
   • Rapid onset of high fever and chills
   • vomiting
   • diarrhea
   • marked hypotension
6. Allergic reactions may produce:
   • hives
   • generalized pruritus
   • wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory overload include:
   • Dyspnea
   • cough
   • rales
   • jugular vein distention
8. Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
9. Characteristics of GVH disease include:
   • skin changes (e.g. erythema, ulcerations, scaling)
   • edema
   • hair loss
   • hemolytic anemia
10. Reactions associated with massive transfusion produce varying manifestations

Nursing Diagnosis

1. Ineffective breathing pattern
2. Decreased Cardiac Output
3. Fluid Volume Deficit
4. Fluid Volume Excess
5. Impaired Gas Exchange
6. Hyperthermia
7. Hypothermia
8. High Risk for Infection
9. High Risk for Injury
10. Pain
11. Impaired Skin Integrity
12. Altered Tissue Perfusion

Planning and Implementation

Help prevent transfusion reaction by:

• Meticulously verifying patient identification beginning with type and crossmatch sample collection and labeling to double check blood product and patient identification prior to transfusion.
• Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
• Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
• Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
• Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
• Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
• Preventing hypothermia by warming blood unit to 37 C before transfusion.
• Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20-40-um size) in the blood line to remove these aggregates during transfusion.

On detecting any signs or symptoms of reaction:

• Stop the transfusion immediately, and notify the physician.
• Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
• Send the blood bag and tubing to the blood bank for repeat typing and culture.
• Draw another blood sample for plasma hemoglobin, culture, and retyping.
• Collect a urine sample as soon as possible for hemoglobin determination.

Intervene as appropriate to address symptoms of the specific reaction:

• Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
• Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions.
• In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as prescribed.
• Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but at a slower rate.)
• For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions

1. If blood transfusion reaction occurs:  STOP THE TRANSFUSION.
2. Start IV line (0.9% NaCl)
3. Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy.
4. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician’s order or protocol.
7. Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
8. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.

Evaluation

1. The patient maintains normal breathing pattern.
2. The patient demonstrates adequate cardiac output.
3. The patient reports minimal or no discomfort.
4. The patient maintains good fluid balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin integrity, with no lesions or pruritus.
8. The patient maintains or returns to normal electrolyte and blood chemistry values.

What should you do first before you administer blood transfusion?

What are the nursing responsibilities before blood transfusion?

What is the first action by the nurse when transfusion reaction occurs?

Which is the first nursing priority in case of blood transfusion reaction?