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01.06 Blood Transfusions (Administration)

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Overview

  1. Four types of products
    1. Packed Red Blood Cells (PRBCs)
    2. Cryoprecipitate
    3. Fresh Frozen Plasma
    4. Platelets
  2. Administered under close observation
    1. Type and cross process
    2. Frequent vital signs
    3. Policies are hospital-specific
  3. Must match donor type
    1. ABO type
    2. Rh status
    3. Special antibodies

Nursing Points

General

  1. PRBCs
    1. “Unit of Blood”
    2. Given for anemia
      1. Typically, Hgb < 7.0 g/dl
      2. Caused by hemorrhage or disease process
  2. FFP
    1. Contains clotting factors
    2. Can be used prophylactically
    3. Most commonly used in Mass Transfusion Protocols (MTP)
  3. Platelets
    1. Thrombocytopenia
      1. Bone marrow suppression
      2. Liver disorders
      3. Hypothermia
    2. Often given pre-procedure for patients with Platelets <50
    3. Re-check 1 hour post-transfusion
  4. Cryoprecipitate
    1. Fibrinogenemia
    2. Most common uses
      1. Hemorrhage
      2. Disseminated Intravascular Coagluation (DIC)
    3. Fibrinogen present in FFP, so cryo is not always needed
  5. Prepare to transfuse
    1. Type and crossmatch/screen
    2. Pre-transfusion vitals
    3. Administration materials
      1. Special blood IV tubing
      2. 0.9% normal saline
      3. Access to emergency medications
  6. Begin transfusion
    1. Independent double-check
      1. Must be completed by two RNs
    2. Verify
      1. Type
      2. Antibody status
      3. Expiration date
    3. Initiate infusion at slow rate, first 10-15 minutes
    4. Monitor for Reaction
  7. Tranfusion Reactions
    1. Present similarly to anaphylaxis
    2. Can occur up to 24 hours after transfusion
  8. Delayed Transfusion Reactions
    1. Caused by antibody mis-match
    2. Potentially fatal

Assessment

  1. Transfusion reactions
    1. Most commonly occur in first 10-15 minutes
    2. Symptoms
      1. Pruritis
      2. Rash
      3. Fever
      4. Chills
      5. Anxiety
    3. Life threatening if unnoticed, untreated
    4. Monitoring during transfusion focused on catching early
  2. Delayed Transfusion Reactions
    1. Occur in patients who have received transfusions before
    2. Undetectable antibodies below threshold of screening
  3. Post-Transfusion
    1. Re-draw Complete Blood Count (CBC)
    2. Report results to MD/APP per orders

Therapeutic Management

  1. Transfusion Reactions
    1. Immediately stop transfusion
    2. Treatment similar to anaphylaxis
      1. Notify provider
      2. Anti-histamines
      3. Diphenhydramine
      4. Acetaminophen
      5. Consider furosemide
        1. Fluid overload
        2. Maintain kidney function
    3. Monitor airway patency
    4. Maintain IV access
    5. Report to blood bank
  2. Post-Transfusion
    1. Final set of vital signs
    2. Laboratory values, as appropriate
  3. Massive Transfusion Protocols (MTP)
    1. For patients with active hemorrhage and/or critically low blood volume
    2. Fixed ratio of PRBCs : Plasma : Platelets
      1. Can vary by institution
      2. Typically 1:1:1
      3. Helps to replenish clotting factors lost to hemorrhage not present in PRBCs
    3. Still need independent double check by 2 RNs for each component

Nursing Concepts

  1. Clotting
    1. Indication for products may be due to lack of clotting/hemorrhage
    2. Products help to replace body’s natural clotting factors
  2. Lab Values
    1. Monitor Complete Blood Count (CBC)
      1. Hemoglobin/Hematocrit
      2. Platelets
      3. Differential
  3. Fluid/Electrolyte Balance
    1. Can cause fluid overload, especially in MTP
    2. Hypovolemia side effect of hemorrhage/blood loss

Patient Education

  1. Signs/Symptoms of Reaction
    1. Similar to anaphylaxis
      1. Fever
      2. Itching
      3. Flushing
      4. Anxiety
      5. Feeling of throat closing up
  2. Patient History
    1. Patients with history of reaction should report to nurse with each transfusion
      1. May be related to specific antigen
      2. Can lengthen type and screen process
    2. History of Sickle Cell Disease or multiple transfusions increases risk of reaction

Reference Links

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Video Transcript

Hey there, it’s Meg again! Today we’re going to talk about administering blood products. Let’s dive in!

So when we talk about administering blood products, there are four main types that we give to our patients. The thing that all four of those types have in common is that we want to be monitoring for reactions; it is always going to be safety first when we’re talking about blood products. Because of that, there are many checks and balances that go into preparing to administer blood products to our patients, and we’ll be sure to talk about that. And then we’ll also do a brief blood typing review. Let’s go to that first.

So we have the ABO type, the Rh status, and an antibody screen. These things comprise the type and cross. Now when I talk about safety first, making sure that you draw the correct type and cross on the correct patient ensures your patient safety. Throughout this process, if you sent down the wrong blood, it’s possible that when you go to administer those blood products to the patient, it’s the wrong type, which can cause a massive reaction that can result in DIC or even death. So when I say that it safety first, it is for a good reason.

Now when we talk about ABO type and Rh status and administering blood products, for the most part, we’re looking for an exact match. But if you’ve taken the blood typing lesson, you know there are some inter-compatibilities. When we talk about the antibody screen, the important thing to understand is that it is not a hundred percent effective– it’s possible that your patient could have titers of antibodies that are below the threshold for the typical antibody screen that we do when we’re doing a type and cross. And so this is how even if we give patients a unit of blood that we think is quote/unquote a perfect match, it’s still possible that they could have a transfusion reaction. Understanding the way that things work is going to help you advocate for your patients and keep them safe. All right, let’s move on.

So now we know a little bit about blood types. Now we need to talk about types of blood products. First, we’re going to have PRBCs, that’s the packed red blood cells. This is what we call a unit of blood. This is the most common blood product that we give to patients. Second, there are platelets, that is replacing a very specific clotting component. Then we have what we call Cryo or cryoprecipitate, and that is replacing fibrinogen. And then finally we have FFP or fresh frozen plasma, and that is replacing all of your clotting factors, or most of them.

All of these things are related in one way or another. But the important thing for you to know is that RBCs are packed red blood cells, they don’t contain the clotting factors that a patient’s whole blood would have, which is why I say if we have a hemorrhaging patient, it’s not effective to give them just PRBCs because it would be like pouring water into a bucket with holes in the bottom. If we don’t stop up those holes, your patient’s just going to continue to lose blood. Understanding the indications for use for each of these things is incredibly important, as well as knowing the thresholds for transfusing.

So when we talk about PRBCs, we are correcting anemia. We’re going to be looking at the patient’s hemoglobin or Hermatocrit depending on the provider’s preference. Next we have platelets, platelets, we’re looking at the patient’s platelet count. If the patient is going to be undergoing any sort of procedure, then we want their platelets at least 50,000. Sometimes in oncology patients, we’ll wait to transfuse until they are less than 10, but as a general rule of thumb, your patient’s clotting and bleeding risk increases exponentially after you get below 50, so that’s kind of our target point. Next we have cryo. There’s no exact way to measure the amount of fibrinogen in your patient’s blood level. There is something called a TEG study, but that’s not being widely viewed widely used yet. Then we have FFP, which is going to be replacing our “clotting-factor-emia.” Again, there’s no real word for having no clotting factors and the only way to perfectly measure it as a TEG study.

So let’s talk about the blood administration process. As with any nursing process, preparation is arguably the most important phase because a misstep here can actually lead to the wasting of blood products and skipping a step can cause harm to your patient. So we want to make sure that we are being very thoughtful throughout the preparation process. The most important supply is going to be normal saline. That is the only IV fluid compatible with blood products. And if your patient has a transfusion reaction, having that at the bedside and being able to just flip it open will help keep the IV line patent, and we’re going to need that IV access to administer emergency medications.

Next, we need to get vital signs. We want our vital signs to be within normal limits. If not, you need to notify the MD. Especially, we want our patients a febrile. One of the signs of a transfusion reaction is a fever. If the patient already has a fever, it makes it much harder for us to detect the transfusion reaction early on. Now, I do want to pause and say that a patient that is severely anemic might have vital signs outside of normal limits. They could especially be tachycardic or hypotensive, so you need to look at that whole clinical picture and ask yourself. “the way that my patient looks right now, are these vital signs appropriate?” That’s where the nursing judgment comes in.

Next, we have verification. There are three main things that you need to verify before you even send a request to the blood bank. For a blood product, we need to make sure we have a type and cross. The patient needs to sign a consent and you need an order to transfuse.

Now in an emergency, sometimes we’ll skip these steps. But, I’ve worked in an emergency department and even in a trauma patient, we are going to check off as many boxes of this as we can before we administer blood to the patient. Because the last thing that a trauma patient needs is a hemolytic, or a blood transfusion, reaction. So even in that case, safety is still number one.

And then finally, education. We need to educate our patients on what a transfusion reaction looks like because they’re going to be able to tell us how they’re feeling. And a lot of times I’ve had patients report to me that they felt like something was going wrong before they had any physical symptoms of a transfusion reaction. So we have our patient prepared, let’s go onto administration.

So the administration process starts with an independent double-check by two RNs. And this looks very much like the medication administration process in that there are some key things that we need to check before we administer the blood. First, we want to make sure that it’s the correct blood type. We need to make sure it’s the correct patient. We need to make sure it’s the correct blood product and we need to check the expiration date because we don’t want to be giving our patients expired blood products.

Now, when we talk about how long you need to stay with the patient after you’ve initiated the transfusion, you need to refer to your hospital policy because not only does that dictate how long you should stay with your patient, it’s also gonna have a much more comprehensive outline of the steps they want you to take to ensure that your patient is safe during those first 10 to 15 minutes.

After you initiate the transfusion, you are monitoring for a reaction. Signs of a reaction are going to be anxiety. I list that first because both times I’ve had a patient have a large transfusion reaction, the first sign they showed was anxiety. Your that was your patient’s body telling you or telling me rather something doesn’t feel right. So they were anxious before they had a rash before they started itching, before they were tachycardic before they had a fever– they were anxious. And then, of course, we could have fever, itching, redness, and rash.

And then vital signs are going to continue even after the first 10 to 15 minutes. And again, you need to refer to your hospital policy on that. I’ve worked places where patients getting blood get vitals every hour, and I’ve worked places where patients getting blood have had vitals every 15 minutes. It’s very important to make sure that you’re sticking to your hospital’s policy on this because it’s a specialty procedure and everything is put in place with your patient’s safety in mind.

Now we enter the observation process. So we’re after the initial 10 to 15 minutes, we’re monitoring our patient’s vital signs per policy like we just talked about, and then the blood administration period is over and we need to get a final set of vital signs. We want these to be within normal limits. Of course, we want our patients afebrile. But, we also want to see if–we gave a patient packed red blood cells because they’re anemic– ideally, we would start to see their heart rate come down and their blood pressure comes up. If you’re not seeing the vital signs improve, that could be your first clinical indication that the patient might need some other sort of intervention. And then of course, we want you to pass it on to report because reactions can occur 24 hours after the transfusion ends.

We also want to make sure that we’re following up and getting a follow-up CBC, especially if your patients still appears unstable. Depending on which blood product you gave your patient, their provider will want the CBC at a different time. In general, if we’re giving our patients a unit of blood or a packed red blood cells, they’re gonna want it about two hours after the transfusion. It’s important to look at your orders very closely so that you’re following them correctly.

All right, so let’s talk a little bit more about transfusion reactions. I know we talked about them a little bit and the administration phase. Okay, so they are the most common in the first 10 to 15 minutes, which is why it is so important to stay with your patient. Even if something is going on with another one of your patients, you need to stay with your patient, so you might need to delegate that to another RN. We’re going to treat it similarly to anaphylaxis, so the patient’s probably going to get epi. They’re going to get some diphenhydramine, and then also probably some of Acetaminophen, especially if they’re febrile.

Remember, this can happen within 24 hours post-transfusion, and that’s even more common if your patient has had multiple transfusions. So especially our patients with sickle cell disease, because they often have more interestingly specific antibodies, and then also remember, remember those oncology patients, they often have had multiple blood transfusions in their care continuum for their cancer diagnosis.

Again, it’s going to look like an allergic reaction. We’re going to look for rash, we’re gonna look for itching. We’re going to look for fever, and then remember anxiety. You cannot discount the way that the reaction makes your patient feel. As with any other medical emergency, we’re also going to remember our ABCs. We want to make sure that our patient’s airway remains patent throughout the reaction, that they’re breathing, and that they have adequate circulation. This circulation also includes IV access. We want to make sure that we maintain our IV access during the reaction period because we need that to give our patient these lifesaving meds. So maintaining IV access is critical in this period.

Okay, so we’re also going to briefly touch on massive transfusion protocol because this is no longer something that just happens in the ED for traumas. We also do it sometimes following surgery and even internal hemorrhage. Actually, the first time I had a patient go undergo MTP, it was for internal bleeding that I found on just a routine assessment on the med surg floor. I saw some bruising on the back that I thought looked suspicious. So always remember, do your full head to toe assessments! So again, this is an emergency and so when we’re talking about any sort of specialized protocol, we want a trained RN at the bedside.

Alright, so let’s do our priority nursing concepts for a patient undergoing blood product administration. Clotting- blood administration helps to supplement clotting. But if we only give our patients PRBcs, then we could actually be diluting their clotting factors. So we need to understand the indications for all of our different types of blood products because that will help you to guide your patient’s plan of care. Next, the fluid and electrolyte balance. Not only are we monitoring for hypovolemia, but we can also fluid overload our patients if we give them too many successive transfusions, so they might need a diuretic. And then finally, lab values. Make sure you’ve set aside some time to learn the normal ranges in a complete blood count so you can better understand the thresholds for transfusion for all of our different types of blood products.

Okay. Time to wrap up with some key points. First, remember there are four types of products that replace deficiencies that can be created by a whole multitude of disease processes. Next, we need to monitor our patients closely for transfusion reactions, and also prevent them by making sure we complete every single step of our blood administration process. And finally, we will monitor our patients for signs of late reaction and monitor them for the need for potentially more blood products.

All right, folks, that is it for our lesson on blood administration, and that was a lot of content. Be sure to check out your complete blood count, normal values, and the blood typing lesson if you haven’t already. Now go out, be your best selves today, and as always, happy nursing!

 

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