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• NOTES
• EXAM
Blood transfusion therapy involves transfusing whole blood or blood components
(specific portion or fraction of blood lacking in patient). One unit of whole blood
consists of 450 mL of blood collected into 60 to 70 mL of preservative or anticoagulant.
Whole blood stored for more than 6 hours does not provide therapeutic platelet
transfusion, nor does it contain therapeutic amounts of labile coagulation factors
(factors V and VIII).
Blood Transfusion Therapy
Blood components include:
1. Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of
plasma originally present in one unit of whole blood), indicated to
increase the oxygen-carrying capacity of blood with minimal expansion
of blood.
2. Leukocyte-poor packed RBCs, indicated for patients who have
experience previous febrile no hemolytic reactions.
3. Platelets, either HLA (human leukocyte antigen) matched or unmatched.
4. Granulocytes ( basophils, eosinophils, and neutrophils )
5. Fresh frozen plasma, containing all coagulation factors, including
factors V and VIII (the labile factors).
6. Single donor plasma, containing all stable coagulation factors but
reduced levels of factors V and VIII; the preferred product for reversal of
Coumadin-induced anticoagulation.
7. Albumin, a plasma protein.
8. Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor
XIII, and fibronectin.
9. Factor IX concentrate, a concentrated form of factor IX prepared by
pooling, fractionating, and freeze-drying large volumes of plasma.
10. Factor VIII concentrate, a concentrated form of factor IX prepared
by pooling, fractionating, and freeze-drying large volumes of plasma.
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11. Prothrombin complex, containing prothrombin and factors VII, IX,
X, and some factor XI.
Advantages of blood component therapy
12. Avoids the risk of sensitizing the patients to other blood
components.
13. Provides optimal therapeutic benefit while reducing risk of volume
overload.
14. Increases availability of needed blood products to larger
population.
Principles of blood transfusion therapy
15. Whole blood transfusion
o 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.
16. Packed RBCs
o 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%.
17. Platelets
o 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.
18. Granulocytes
o 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.
19. Plasma
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o 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.
20. Albumin
o 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.
21. Cryoprecipitate
o Indicated for treatment of hemophilia A, Von Willebrand’s disease,
disseminated intravascular coagulation (DIC), and uremic
bleeding.
22. Factor IX concentrate
o Indicated for treatment of hemophilia B; carries a high risk of
hepatitis because it requires pooling from many donors.
23. Factor VIII concentrate
o Indicated for treatment of hemophilia A; heat-treated product
decreases the risk of hepatitis and HIV transmission.
24. Prothrombin complex-Indicated in congenital or acquired
deficiencies of these factors.
Objectives
25. To increase circulating blood volume after surgery, trauma, or
hemorrhage
26. To increase the number of RBCs and to maintain hemoglobin
levels in clients with severe anemia
27. To provide selected cellular components as replacements therapy
(e.g. clotting factors, platelets, albumin)
Nursing Interventions
28. Verify doctor’s order. Inform the client and explain the purpose of
the procedure.
29. Check for cross matching and typing. To ensure compatibility
30. Obtain and record baseline vital signs
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31. Practice strict Asepsis
32. At least 2 licensed nurse check the label of the blood transfusion
o Check the following:
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▪ 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.
33. Warm blood at room temperature before transfusion to prevent
chills.
34. Identify client properly. Two Nurses check the client’s
identification.
35. Use needle gauge 18 to 19. This allows easy flow of blood.
36. Use BT set with special micron mesh filter. To prevent
administration of blood clots and particles.
37. 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.
38. Monitor vital signs. Altered vital signs indicate adverse reaction.
39. Do not mix medications with blood transfusion. To prevent
adverse effects
o Do not incorporate medication into the blood transfusion
o Do not use blood transfusion lines for IV push of medication.
40. Administer 0.9% NaCl before; during or after BT. Never administer
IV fluids with dextrose. Dextrose causes hemolysis.
41. Administer BT for 4 hours (whole blood, packed RBC). For plasma,
platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor
can easily be destroyed.
42. Observe for potential complications. Notify physician.
Complications of Blood Transfusion
43. Allergic Reaction it is caused by sensitivity to plasma protein of –
donor antibody, which reacts with recipient antigen.
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o Assessments:
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▪ Flushing
▪ Rush, hives
▪ Pruritus
▪ Laryngeal edema, difficulty of breathing
44. 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
o Assessments:
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▪ Sudden chills and fever
▪ Flushing
▪ Headache
▪ Anxiety
45. Septic Reaction it is caused by the transfusion of blood or –
components contaminated with bacteria.
o Assessment:
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▪ Rapid onset of chills
▪ Vomiting
▪ Marked Hypotension
▪ High fever
46. Circulatory Overload it is caused by administration of blood –
volume at a rate greater than the circulatory system can accommodate.
o Assessment:
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▪ Rise in venous pressure
▪ Dyspnea
▪ Crackles or rales
▪ Distended neck vein
▪ Cough
▪ Elevated BP
47. Hemolytic reaction. It is caused by infusion of incompatible blood
products.
o Assessment:
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▪ 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
48. Clinical manifestations of transfusions complications vary
depending on the precipitating factor.
49. Signs and symptoms of hemolytic transfusion reaction include:
o Fever
o Chills
o low back pain
o flank pain
o headache
o nausea
o flushing
o tachycardia
o tachypnea
o hypotension
o hemoglobinuria (cola-colored urine)
50. Clinical signs and laboratory findings in delayed hemolytic
reaction include:
o fever
o mild jaundice
o gradual fall of hemoglobin
o positive Coombs’ test
51. Febrile non-hemolytic reaction is marked by:
o Temperature rise during or shortly after transfusion
o Chills
o headache
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o flushing
o anxiety
52. Signs and symptoms of septic reaction include;
o Rapid onset of high fever and chills
o vomiting
o diarrhea
o marked hypotension
53. Allergic reactions may produce:
o hives
o generalized pruritus
o wheezing or anaphylaxis (rarely)
54. Signs and symptoms of circulatory overload include:
o Dyspnea
o cough
o rales
o jugular vein distention
55. Manifestations of infectious disease transmitted through
transfusion may develop rapidly or insidiously, depending on the
disease.
56. Characteristics of GVH disease include:
o skin changes (e.g. erythema, ulcerations, scaling)
o edema
o hair loss
o hemolytic anemia
57. Reactions associated with massive transfusion produce varying
manifestations
Possible Nursing Diagnosis
58. Ineffective breathing pattern
59. Decreased Cardiac Output
60. Fluid Volume Deficit
61. Fluid Volume Excess
62. Impaired Gas Exchange
63. Hyperthermia
64. Hypothermia
65. High Risk for Infection
66. High Risk for Injury
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67. Pain
68. Impaired Skin Integrity
69. Altered Tissue Perfusion
Planning and Implementation
70. Help prevent transfusion reaction by:
o Meticulously verifying patient identification beginning with type
and cross match sample collection and labeling to double check
blood product and patient identification prior to transfusion.
o Inspecting the blood product for any gas bubbles, clothing, or
abnormal color before administration.
o 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).
o Transfusing blood within 4 hours, and changing blood tubing
every 4 hours to minimize the risk of bacterial growth at warm
room temperatures.
o Preventing infectious disease transmission through careful donor
screening or performing pretest available to identify selected
infectious agents.
o 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.
o Preventing hypothermia by warming blood unit to 37 C before
transfusion.
o 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.
71. On detecting any signs or symptoms of reaction:
o Stop the transfusion immediately, and notify the physician.
o Disconnect the transfusion set-but keep the IV line open with 0.9%
saline to provide access for possible IV drug infusion.
o Send the blood bag and tubing to the blood bank for repeat typing
and culture.
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o Draw another blood sample for plasma hemoglobin, culture, and
retyping.
o Collect a urine sample as soon as possible for hemoglobin
determination.
72. Intervene as appropriate to address symptoms of the specific
reaction:
o Treatment for hemolytic reaction is directed at correcting
hypotension, DIC, and renal failure associated with RBC hemolysis
and hemoglobinuria.
o Febrile, nonhemolytic transfusion reactions are treated
symptomatically with antipyretics; leukocyte-poor blood products
may be recommended for subsequent transfusions.
o In septic reaction, treat septicemia with antibiotics, increased
hydration, steroids and vasopressors as prescribed.
o 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.)
o For circulatory overload, immediate treatment includes
positioning the patient upright with feet dependent; diuretics,
oxygen and aminophylline may be prescribed.
Nursing Interventions when complications occurs in Blood
transfusion
73. If blood transfusion reaction occurs. STOP THE TRANSFUSION.
74. Start IV line (0.9% Na Cl)
75. Place the client in fowler’s position if with SOB and administer O2
therapy.
76. The nurse remains with the client, observing signs and symptoms
and monitoring vital signs as often as every 5 minutes.
77. Notify the physician immediately.
78. The nurse prepares to administer emergency drugs such as
antihistamines, vasopressor, fluids, and steroids as per physician’s
order or protocol.
79. Obtain a urine specimen and send to the laboratory to determine
presence of hemoglobin as a result of RBC hemolysis.
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80. Blood container, tubing, attached label, and transfusion record are
saved and returned to the laboratory for analysis.
Evaluation
81. The patient maintains normal breathing pattern.
82. The patient demonstrates adequate cardiac output.
83. The patient reports minimal or no discomfort.
84. The patient maintains good fluid balance.
85. The patient remains normothermic.
86. The patient remains free of infection.
87. The patient maintains good skin integrity, with no lesions or
pruritus.
88. The patient maintains or returns to normal electrolyte and blood
chemistry values.
