What are the nursing responsibility during blood transfusion?

Blood transfusions are a life-sustaining and life-saving treatment but they aren’t without risk. Conditions that warrant blood transfusions range from acute trauma to intraoperative blood loss to compromised blood-cell production secondary to disease or treatment. If you’re a nurse on the front line of patient care, you must be adept at administering blood products safely and managing adverse reactions with speed and confidence.

Why reactions occur

Blood transfusion reactions typically occur when the recipients immune system launches a response against blood cells or other components of the transfused product. These reactions may occur within the first few minutes of transfusion (classified as an acute reaction) or may develop hours to days later (delayed reaction). If red blood cells are destroyed, the reaction may be classified further as hemolytic all other types of reactions are broadly classified as nonhemolytic.

Some reactions result from infectious, chemical, or physical forces or from human error during blood-product preparation or administration. (For details on types of reactions, signs and symptoms, appropriate interventions, and prevention methods, see A closer look at transfusion reactions by clicking on the PDF icon above)

Before starting the transfusion

Safe practice starts with accurate collection of pretransfusion blood samples for typing and crossmatching. Some facilities may require a second authorized staff member to witness and sign the form as the phlebotomist obtains the specimen. Also take these other key actions before you begin the transfusion:

• Verify that an order for the transfusion exists.
• Conduct a thorough physical assessment of the patient (including vital signs) to help identify later changes.
• Document your findings. Confirm that the patient has given informed consent.
• Teach the patient about the procedures associated risks and benefits, what to expect during the transfusion, signs and symptoms of a reaction, and when and how to call for assistance.
• Check for an appropriate and patent vascular access.
• Make sure necessary equipment is at hand for administering the blood product and managing a reaction, such as an additional free I.V. line for normal saline solution, oxygen, suction, and a hypersensitivity kit.
• Be sure you’re familiar with the specific product to be transfused, the appropriate administration rate, and required patient monitoring. Be aware that the type of blood product and patients condition usually dictate the infusion rate. For example, blood must be infused faster in a trauma victim who’s rapidly losing blood than in a 75-year-old patient with heart failure, who may not be able to tolerate rapid infusion.
• Know what personnel will be available in the event of a reaction, and how to contact them. Resources should include the on-call physician and a blood bank representative.
• Before hanging the blood product, thoroughly double-check the patients identification and verify the actual product. Check the unit to be transfused against patient identifiers, per facility policy.
• Infuse the blood product with normal saline solution only, using filtered tubing.

Premedication

To help prevent immunologic transfusion reactions, the physician may order such medications as acetaminophen and diphenhydramine before the transfusion begins to prevent fever and histamine release. Febrile nonhemolytic transfusion reactions seem to be linked to blood components, such as platelets or fresh frozen plasma, as opposed to packed red blood cells; thus, premedication may be indicated for patients who will receive these products. Such reactions may be mediated by donor leukocytes in the plasma, causing allosensitization to human leukocyte antigens. Cytokine generation and accumulation during blood component storage may play a contributing role.

Leukocyte-reduced and irradiated blood products

Use of blood products that have been leukocyte-reduced, irradiated, or both has been shown to reduce complications stemming from an immunologic response. In organ transplant candidates, these products reduce the risk of graft rejection.

Administering the transfusion

Make sure you know the window of time during which the product must be transfused starting from when the product arrives from the blood bank to when the infusion must be completed. (See Quick guide to blood products by clicking on the PDF icon above). Failing to adhere to these time guidelines increases the risk of such complications as bacterial contamination.

Detecting and managing transfusion reactions

During the transfusion, stay alert for signs and symptoms of a reaction, such as fever or chills, flank pain, vital sign changes, nausea, headache, urticaria, dyspnea, and broncho spasm. Optimal management of reactions begins with a standardized protocol for monitoring and documenting vital signs. As dictated by facility policy, obtain the patients vital signs before, during, and after the transfusion.

If you suspect a transfusion reaction, take these immediate actions:

• Stop the transfusion.
• Keep the I.V. line open with normal saline solution.
• Notify the physician and blood bank.
• Intervene for signs and symptoms as appropriate.
• Monitor the patients vital signs.

Also return the blood product to the blood bank and collect laboratory samples according to facility policy. If and when clinically necessary, resume the transfusion after obtaining a physician order. Carefully document transfusion-related events according to facility policy; be sure to include the patients vital signs, other assessment findings, and nursing interventions.

Most fatal transfusion reactions result from human error. The most important step in preventing such error is to know and follow your facilities policies and procedures for administering blood products. Be aware, though, that prevention isn’t always possible which means you must be able to anticipate potential reactions and be prepared to manage them effectively. To promote good patient outcomes, you must be knowledgeable about the best practices described in this article.

Selected references

Silvergleid A. Immunologic blood transfusion reactions. UpToDate. October 17, 2008. www.uptodate.com/patients/content/topic.do?topicKey=~EE8E1UGcUSyKQT. Accessed December 22, 2008.

Sabrina Bielefeldt and Justine DeWitt are Oncology Certified Nurses at Georgetown University Hospital in Washington, D.C. Ms. Bielefeldt is the Clinical Manager and Ms. DeWitt is a Clinical Nurse IV on the Inpatient Hematology Oncology unit. Ms. DeWitt also serves as Co-Chair of the hospitals Nursing Practice Council.

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of blood and blood products in order to:

• Identify the client according to facility/agency policy prior to administration of red blood cells/ blood products (e.g., prescription for administration, correct type, correct client, cross matching complete, consent obtained)
• Check the client for appropriate venous access for red blood cell/blood product administration (e.g., correct gauge needle, integrity of access site)
• Document necessary information on the administration of red blood cells/blood products
• Administer blood products and evaluate client response

Blood transfusions are indicated for the client who has hypovolemia secondary to hemorrhage, anemia or another disease process that is associated with a deficiency in terms the client's clotting or another component of blood, for example. Although hypovolemia can be treated with fluid replacement, this fluid does not provide the client with the oxygen carrying components that only blood has. In addition to blood's components in terms of oxygen transporting red blood cells, blood also transports carbon dioxide, and it contains white blood cells to combat infection, clotting factors and essential blood proteins.

There are four blood types each of which has its antigen in its red blood cells. These blood types are A with A antigens, B with B antigens, AB with both A and B antigens, and O which has neither A nor B antigens. People with O type blood are universal donors but they are universal suckers because type O blood can be given to clients with A, B, AB and O blood type clients but the type O blood type client can only receive type O blood. Each blood type also has antibodies, which are referred to as agglutinins. Type A blood has B agglutinins; type B blood has A agglutinins, type AB blood has no antibodies, or agglutinins, and type O blood has both A and B agglutinins.

People also have a rhesus, or Rh, factor antigen or the lack of it. Clients with an Rh positive blood, which is the vast majority of people, have Rh positive blood and people without the Rh factor antigen have Rh negative blood.

Members of the Christian Science religion do not typically accept blood transfusions and members of Jehovah's Witness religion are prohibited from receiving blood. Plasma expanders without any blood or blood products, however, are acceptable to members of both of these religions.

Most clients get blood and blood products that are donate by others through the blood bank, however, some clients can choose to donate their own blood prior to an elective surgery, for example, and then use this blood rather than the blood of a blood donor. This type of blood transfusion is referred to as an autologous blood donation.

Blood and blood components are selected and given as based on the client's specific needs. The different blood products and their components are described below.

• Packed red blood cells: Packed red blood cells are used when the client is in need of increased oxygen transporting red blood cells as may occur post operatively and with an acute hemorrhage.

• Platelets: Platelets are administered to clients who are adversely affected with a platelet deficiency or a serious bleeding disorder, such as thrombocytopenia or platelet dysfunction that requires the clotting factors that are in platelets.

• Fresh frozen plasma: Fresh frozen plasma, which does not contain any red blood cells, is administered to clients who are in need of clotting factors or are in need of increased blood volume as occurs with hypovolemia and hypovolemic shock. Fresh frozen plasma does not have to be typed and cross matched to the client's blood type because plasma does not contain antigen carrying red blood cells.

• Albumin: Albumin is administered to clients who need expanded blood volume and/or plasma proteins.

• Clotting factors and cryoprecipitate: Clotting factors and cryoprecipitate are administered to clients affected with a clotting disorder including the lack of fibrinogen.

• Whole blood: Whole blood is typically reserved for only cases of severe hemorrhage. Whole blood contains clotting factors, red blood cells, white blood cells, plasma, platelets, and plasma proteins.

Identifying the Client According to the Facility or Agency Policy Prior to the Administration of Red Blood Cells and Blood Products

Some blood transfusion reactions and blood transfusion errors occur as the result of inaccurate client identification. Simply stated, client misidentification can be prevented by matching the client to the order, insuring that the blood is accurately matched to the client and the order and by using the two person verification technique that involves two nurses checking the blood, the order and the client's identity using at least two unique identifiers.

The two nurses will check the blood against the order, check the client's identity, check the client's blood type against the type of blood that will be infused, check the expiration of the blood or blood component, and check the client's number against the blood product number. The nurses will also visually inspect the blood for any unusual color, precipitate, clumping and any other unusual signs.

The order for the blood or blood component must be a complete order that specifies exactly what will be administered. The client will also give consent for the transfusion.

The gauge of the intravenous catheter should be 18 gauge and the blood should be administered with normal saline using a Y infusion set that is specifically used for the administration of blood and blood products. Normal saline is compatible with blood; ringer's lactate, dextrose, hyperalimentation and other intravenous solutions with incompatible medications are not compatible with blood and blood products. If a blood filter is used, the filter must be inspected to insure that it is suitable for the specific blood product that the client will be getting.

Blood should not remain in the client care area for more than 30 minutes so it is important that the nurse is prepared to begin the transfusion shortly after the blood is delivered to the patient care area. The nurse must take baseline vital signs just prior to the infusion of blood or a blood product and then the nurse should remain with and monitor the client for at least 15 minutes after the transfusion begins at a slow rate since most serious blood reactions and complications occur shortly after the transfusion begins. All blood and blood products must be administered completely in less than 4 hours.

Only registered nurses and licensed practical nurses can initiate, monitor and maintain blood transfusions. These aspects of care can NOT be delegated to an unlicensed assistive nursing staff member. Additionally, some facilities restrict blood transfusions to only registered nurses, so it is important to check the facility specific policies and procedures relating to the administration of blood and blood products.

Checking the Client for Appropriate Venous Access for Red Blood Cells and Blood Product Administration

The nurse must insure that the intravenous line is patent and they must insure that a 18 or 20 gauge catheter is being used and patent.

Documenting the Necessary Information on the Administration of Red Blood Cells and Blood Products

All aspects of the administration of red blood cells and blood products are documented. This documentation must minimally include:

• The date and time that the blood transfusion began
• The name of the second nurse who did the two person verification process
• The name and amount of the specific type of transfusion such as 1 unit of packed red cells
• The number of the blood product
• Where the IV site was
• Size of the angiocath that was used
• The duration of the transfusion
• The vital signs that were taken and when they were taken
• The fact that the client was informed about when and why to contact the nurse after the initial 15 minute monitoring period

Administering Blood Products and Evaluating the Client's Responses

Whenever blood or a blood product is being administered, the nurse must closely monitor the client for the signs and symptoms of a possible complication. The first thing that the nurse must do when a reaction or a complication is possible is to discontinue the administration of the blood or blood product.

The complications associated with the administration of blood and blood components are discussed below:

Febrile Reactions

Febrile reactions are the most commonly occurring reaction to blood and blood products administration. Although a febrile reaction can occur with all blood transfusions, it is most frequently associated with packed red blood cells and this reaction is not accompanied with hemolysis. The signs and symptoms of this transfusion reaction include fever, nausea, anxiety, chilling and warm flushed skin.

Hemolysis

Hemolysis occurs as the result of an incompatibility of the donor's and recipient's blood which is referred to as an ABO incompatibility. This incompatibility can occur as the result of a laboratory error in terms of typing and cross matching and a practitioner error in terms of checking the blood and matching it to the client's blood type. This complication is signaled when the client has flank pain, chest pain, restlessness, oliguria or anuria, respiratory distress, brown urinary output, hypotension, fever, low blood pressure and tachycardia. The treatment of hemolysis includes the administration of normal saline after the transfusion is stopped and all the tubing is changed to prevent kidney failure and circulatory collapse. Although rare, a delayed, rather than an acute and immediate, hemolytic reaction can occur up to about 4 weeks after the transfusion. This delayed reaction is not as severe as an acute hemolytic reaction and it is characterized with jaundice, discolored urine and anemia.

The intravenous tubing, the blood filter, the blood bag with its remaining contents are retained and sent to the laboratory. A sample of the client's blood and urine are also taken and sent for diagnostic testing.

Allergic Reactions

Allergic reactions to a blood transfusion can range from mild to severe. A mild allergic reaction typically occurs as the result of an allergy to the plasma proteins in the blood, and severe allergic reactions occur from a severe antibody - antigen reaction. Mild allergic reactions are accompanied with possible itching, pruritic erythema, swelling of the lips, tongue or pharynx and eyelids, and flushing of the skin; severe allergic reactions can manifest with chest pain, decreased oxygen saturation, loss of consciousness, flushing, shortness of breath and respiratory stridor. Mild allergic responses are treated with the administration of a corticosteroid and/or antihistamine medication; severe allergic reactions are treated with the administration of supplemental oxygen and medications. At times, a serious allergic reaction can be life threatening.

Sepsis

Sepsis is characterized with fever, hypotension, oliguria, chilling, nausea and vomiting This transfusion reaction occurs as the result of some contaminate in the blood. This complication is treated with intravenous fluids and antibiotics. The intravenous tubing, the blood filter, the blood bag with its remaining contents are retained and sent to the laboratory. A sample of the client's blood and urine are also taken and sent for diagnostic testing as is also done when the client has a hemolytic reaction.

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Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members.

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