Step1 identify what?
identify client, order for transfusion, client allergies, and previous transfusion reaction
Step 2 Provide what?
Provide education to client regarding reasons for ordered transfusion, transfusion complications
Step 3 obtain what?
Obtain consent, ensure Type and cross match completed, and blood bank arm band on the client
Step 4 Ensure what?
Ensure patent IV #18g.
Step 5 Obtain what?
Obtain Vital signs
Step 6 Identify what?
Identify proper blood products infusion set, prime blood products infusion set with 0.9% NS to include back priming of Y connection
Step 7 Request what?
Request blood products from blood bank (ordered throught IMED) and complete transfusion criteria form
Step 8 Complete what at the bedside?
- Complete bedside identification with 2 RN or and RN and LPN
- - Client name
- - DOB
- - Blood type
- - Blood tag
- - Client admission armband
- - unit number on the blood transfusion form and blood bag tag match the blood bag number
- - the blood bag number must remain on the blood bag until the transfusion is terminated
- - both nurses sign the blood transfusion sheet
- - if any discrepancy, return blood to blood bank immediately within 10 minutes
- - You MUST START THE BLOOD TRANSFUSION WITHIN 10 MINUTES OF RECEIVING BLOOD FROM BLOOD BANK
Step 9 Obtain what?
Obtain vital signs and document on transfusion sheet
Step 10 Start what now?
- Start blood transfusion at a slow rate (25-50ml per hour), remaining with client for the first 15 minutes
- - rate can be adjusted after the first 15 minutes- blood products must be infused within 4 hours
- if not infused with 4 hours, products must be discarded
Step 11 What do you teach the client?
- client education-
- - tell client to immediately report the occurence of transfusion reaction symptoms.
Step 12 Obtain what now?
Obtain vital signs as indicated on transfusion sheet
Step 13 How often do you you assess the patient
assess patient frequently
Step 14 Upon completion of what, do what?
Upon completion of tranfusion, clamp off blood and infuse NS
Step 15 Complete what?
- Complete blood transfusion record- leave no blanks
- - place original on chart
- - send copy marked "blood bank" to blood bank
Step 16 Continue what?
Continue to monitor client for S/S of adverse reaction
Step 17 Transfusion is immediately stopped when what happens?
- transfusion is immediately stopped an MD and blood bank notified if any other the following occur
- - urticaria (a transient condition of the skin, usually caused by an allergic reaction, characterized by pale or reddened irregular, elevated patches and severe itching; hives)
- - chills
- - fever- 2 degree change from baseline
- - nausea
- - backache/ flank pain
- - dyspnea (difficult or labored breathing)
- - hypotension
- - apprehension, anxiety, feelings of impending doom
Step 18 In the event of....?
- In the event of transfusion reaction
- - Stop transfusion immediately, maintaining patent IV with new IV tubing infusiion NS- Notify MD
- - Notify blood bank
- - Complete transfusion reaction consultation form
- - obtain urine specimen
- - hand carry blood bag, urine specimen and complete form to blood bank.