NURSING SKILLS

BLOOD TRANSFUSION/ IV THERAPY

Lecturer: Mark Fredderick R. Abejo RN, MAN

______________________________________________

Blood Transfusion

Blood Compatibility

Compatible Incompatible
A A/O AB / B
B B/O AB / A
AB A / B / AB / O
O O A / B / AB
Note:
Type AB “ Universal Recipient”
Type O “ Universal Donor”

Blood Products for Transfusion:

Product Uses
Whole Blood Not commonly used except for
extreme cases of acute
hemorrhage.
Replaces blood volume and all
blood products
PRBC Used to increase the oxygen-
carrying capacity of blood
Platelets Replaces platelets in client with
bleeding disorder or platelet
deficiency
Fresh Frozen Expands blood volume and
Plasma provides clotting factor.
Note:
Does not need to be typed and
cross-matched, contains no
RBCs
Albumin and Blood volume expander
plasma protein Provide plasma proteins
fraction
Clotting factor and Used for client with clotting
cryoprecipitate deficiencies
Cryoprecipitate also contains
fibrinogen
Lecture Notes on Blood Transfusion Therapy & IV Therapy
Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

Purposes: Nursing Intervention:

1. To administer required blood component by Verify doctor’s order. Inform client and explain the
the patient purpose of the procedure.
2. To restore the blood volume Check for cross-matching and blood typing. To
3. To improve oxygen-carrying capacity of the ensure compatibility
blood. Obtain and record baseline VS
Note: If patient has fever do not transfuse
Equipment: Practice strict, ASEPSIS
- Unit of blood At least 2 nurses check the label of the blood
- Normal saline ( PNSS) transfusion, Check the following:
- Blood transfusion set - Serial Number
- Venipuncture set containing needle gauge of #18 or - Blood component
#19 - Blood type
- Alcohol and povidone-iodine swabs - Rh factor
- Tape - Expiration date
- Clean gloves - Screening test
Check the blood for gas bubbles and any unusual
color or cloudiness

Note: Gas bubbles indicate bacterial growth Unusual

color or cloudiness indicate
hemolysis

Warm blood at room temperature before

transfusion.
Identify client properly, two nurses check the
client’s identification
Set up the infusion equipment, use BT set with
filter. To prevent administration of blood clots and
other particles.
Prepare the blood bag, expose the port on the blood
bag and insert the BT set, open the clamp let blood
flow to the tube up the needle.
To remove air in the tubing
Note:
Blood is transfuse as a side drip to PNSS. Direct
transfusion is done during emergency situation and as
ordered.

Blood Shelf Life

WBC Warm at
PRBC room 4 degree C
temperature
transfused
immediately
Washed RBC Transfused
within 1 ½ 4 degree C
hours
FFP Use
immediately - 18 degree C
Cryoprecipitate upon
Platelets thawing 20 degree C
Lecture Notes on Blood Transfusion Therapy & IV Therapy
Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

BLOOD TRANSFUSION REACTION

Reaction Cause Clinical Signs Nursing Intervention

Hemolytic Reaction Incompatibility between Chills, fever STOP transfusion
client’s blood and the Headache, backache KVO with PNSS
donor’s blood Dyspnea Send remaining blood, a sample of
Cyanosis client blood and urine sample to the
Chest pain laboratory.
Tachycardia Notify the physician
Hypotension Monitor VS
Monitor I & O
Febrile Reaction Sensitivity of the client’s Fever, Chills STOP transfusion
blood to WBC, platelets Warm, flushed skin Give antipyretics
or plasma protein Headache Notify the physician
Anxiety KVO with PNSS
Muscle pain
Allergic Reaction
Mild Sensitivity to infused Flushing STOP transfusion
plasma proteins Itching Notify the physician
Urticaria Administer antihistamine as
Brochial wheezing ordered

Severe Antibody-antigen reaction Dyspnea STOP transfusion

Chest pain KVO with PNSS
Circulatory collapse Notify the physician immediately
Cardiac arrest
Monitor VS
Administer CPR as needed
Administer medication / oxygen as
needed
Circulatory Blood administered faster Cough STOP or SLOW the transfusion
Overload than the circulation can Dyspnea Place the client upright, with feet
accommodate Crackles dependent
Distended neck veins Administer diuretics and oxygen as
Tachycardia needed
Hypertension Notify physician
Sepsis Contaminated blood High fever, chills STOP transfusion
administration Vomiting Send remaining blood to laboratory
Diarrhea Notify the physician
Hypotension Obtain a blood specimen from the
client for culture
Administer IV fluids and
antibiotics
KVO with PNSS
Lecture Notes on Blood Transfusion Therapy & IV Therapy
Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

there should be no children

INTRAVENOUS INSERTION discomfort while
solution is flowing.
( I.V Insertion )
Wash hands and
perform appropriate
infection control
Purposes: Open and prepare
To supply fluids when clients are unable to the infusion set
take adequate volume of fluids by mouth. - Remove tubing from
To provide salts needed to maintain electrolyte the package and
balance straighten it out.
To provide glucose, the main fuel for - Slide the clamp just
metabolism below the drip chamber
To provide water-soluble vitamins and and close it.
medications. - Leave the ends of the This will maintain the
To establish a lifeline for rapidly needed tubing covered with sterility of the ends of
medications. plastic caps tubing.
Spike the solution/
Equipment: IV fluids
- Infusion set - Remove the protective
- Solu set ( if needed ) cover of the container
- IV pole of IV fluids.
- Adhesive tape - Remove the cap of the
- Clean gloves spike and insert the
- Tourniquet spike on the insertion
- Antiseptic swab or cotton with alcohol site of the container
- IV catheter Properly labeled the
- Sterile gauze dressing solution:
- Arm splint ( if needed ) - Name of Patient
- Towel or pad - Kind of IVF
- Infusion device or pump ( if required ) - Meds Incorporated
- No. of drops/min
- Date/Time Started
- Date/Time to be
consumed
Hang the solution on Enable gravity to
the pole about 3 ft overcome venous
above the clients pressure and facilitate
head flow of the sol.
Partially fill the drip
chamber by
squeezing it gently
until half full
Prime the Tubing
 Remove the
Steps / Procedure Rationale protective cap and
Identify and inform hold the tubing over
the client and explain To allay anxiety the container
the procedure.  Release the clamp To prevent the
- A venipuncture can Note: and let the fluid run introduction of air to
cause discomfort, but Use dolls to explain to through the tubing the client
Lecture Notes on Blood Transfusion Therapy & IV Therapy
Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

until all air are Note: Insert the catheter and initiate the infusion
remove Air bubbles smaller  If desired and permitted
than 0.5 ml usually do by policy inject .05 ml of
not cause problems in 1% lidocaine ID over the
the line. puncture site. Allow 5-10
 Reclamp the tubing sec. to take effect
and replace the  Use the nondominant This stabilizes the
tubing cap. hand to pull the skin vein
If indicated was below the entry site
hands again  Holding the over-the-
Select Venipuncture Site needle catheter at 15 to
Guidelines in Vein Selection: 30 degree angle bevel up,
Use distal veins of the arm first insert through the skin
and into the vein.
Use the client’s nondominant arm as
 Once blood appears in
possible.
the lumen of your needle,
Select a vein that is: advance the needle and
- easily palpated and feels soft and full catheter approx. .5-1 cm
- naturally splinted by bone  Holding the needle
- large enough to allow adequate circulation portion steady, advance
Avoid using veins that are the catheter until the hub
- in areas of flexion is at the venipuncture site
- highly visible  Release the tourniquet
- damage by previous use  Remove the protective
- distended, knotted or tortuous cap from the tubing and
- surgically compromised or injured hold it ready to attach to
extremity the catheter
Dilate the chosen vein Distending the vein  Attach the end of the
- Place the extremity in a makes easier to insert infusion tubing to the
dependent position, lower the needle catheter hub
than the client’s heart  Initiate the infusion
- Apply a tourniquet Gravity slow the Tape the catheter
firmy 6-8 inches above venous return
Dress and label the
the venipuncture site venipuncture site and
To obstruct the
tubing according to
Note: venous flow
agency policy
If vein is not sufficiently
Ensure appropriate
dilated;
infusion flow
a. Massage or stroke the
vein distal to the site, in Label the IV tubing
the direction of the heart. Document relevant data
b. Encourage the client to and assessment
clench and unclench the
fist.
c. Slightly tap the vein
with your fingertips
Put on clean gloves
and clean the site with Circular motion
alcohol / antiseptic sol. carries
in circular motion and microorganism away
let it dry from the site of entry
Lecture Notes on Blood Transfusion Therapy & IV Therapy
Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor