SKILL CHECKLISTS FOR FUNDAMENTALS OF NURSING: THE ART AND SCIENCE OF PERSON-CENTERED NURSING CARE, 8TH EDITION

Excellent Satisfactory Needs Practice SKILL 39-6 Administering a Blood Transfusion Goal: The patient receives the blood transfusion without any evidence of a transfusion reaction or complication. Comments 1. Verify the medical order for transfusion of a blood product. Verify the completion of informed consent documentation in the medical record. Verify any medical order for pretransfusion medication. If ordered, administer medication at least 30 minutes before initiating transfusion. 2. Gather all equipment. 3. Perform hand hygiene and put on PPE, if indicated. 4. Identify the patient using 2 patient identifiers. 5. Close the curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about previous experience with transfusion and any reactions. Advise the patient to report any chills, itching, rash, or unusual symptoms. 6. Prime the blood administration set with the normal saline IV fluid. 7. Put on gloves. If patient does not have a venous access in place, initiate peripheral venous access. Connect the administration set to the venous access device via the extension tubing. Infuse the normal saline per facility policy. 8. Obtain the blood product from the blood bank according to agency policy. Scan for bar codes on blood products if required. 9. Two nurses compare and validate the following information with the medical record, patient identification band, and the label of the blood product: ● Medical order for transfusion of the blood product ● Informed consent ● Patient identification number ● Patient name ● Blood group and type ● Expiration date ● Inspection of blood product for clots, clumping, gas bubbles 10. Obtain a baseline set of vital signs before beginning transfusion. Copyright © 2015 by Wolters Kluwer. Skill Checklists for Fundamentals of Nursing: The Art and This study source was downloaded by 1S0c0i0e0n0c8e73o81f 8P1e32rsforonm-CCeonurtseerHeedroN.cuormsionng1C1-a17re-2,0823th11e:d33it:i3o5nG, bMyTC-0a6r:o00l Taylor, Carol Lillis, and Pamela Lynn. Excellent Satisfactory Needs Practice SKILL 39-6 Administering a Blood Transfusion (Continued) Comments 11. Put on gloves. If using an electronic infusion device, put the device on “hold.” Close the roller clamp closest to the drip chamber on the saline side of the administration set. Close the roller clamp on the administration set below the infusion device. Alternately, if using infusion via gravity, close the roller clamp on the administration set. 12. Close the roller clamp closest to the drip chamber on the blood product side of the administration set. Remove the protective cap from the access port on the blood container. Remove the cap from the access spike on the administration set. Using a pushing and twisting motion, insert the spike into the access port on the blood container, taking care not to contaminate the spike. Hang the blood container on the IV pole. Open the roller clamp on the blood side of the administration set. Squeeze the drip chamber until the in-line filter is saturated. Remove gloves. 13. Start administration slowly (no more than 25 to 50 mL for the first 15 minutes). Stay with the patient for the first 5 to 15 minutes of transfusion. Open the roller clamp on the administration set below the infusion device. Set the flow rate and begin the transfusion. Alternately, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the blood and function of the infusion device. Inspect the insertion site for signs of infiltration. 14. Observe the patient for flushing, dyspnea, itching, hives or rash, or any unusual comments. 15. After the observation period (5 to 15 minutes), increase the infusion rate to the calculated rate to complete the infusion within the prescribed time frame, no more than 4 hours. 16. Reassess vital signs after 15 minutes. Obtain vital signs thereafter according to facility policy and nursing assessment. 17. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the patient’s overall condition, keeping in mind the outer limits for safe administration. Ongoing monitoring is crucial throughout the duration of the blood transfusion for early identification of any adverse reactions. Copyright © 2015 by Wolters Kluwer. Skill Checklists for Fundamentals of Nursing: The Art and This study source was downloaded by 1S0c0i0e0n0c8e73o81f 8P1e32rsforonm-CCeonurtseerHeedroN.cuormsionng1C1-a17re-2,0823th11e:d33it:i3o5nG, bMyTC-0a6r:o00l Taylor, Carol Lillis, and Pamela Lynn. Excellent Satisfactory Needs Practice SKILL 39-6 Administering a Blood Transfusion (Continued) Comments 18. During transfusion, assess frequently for transfusion reaction. Stop blood transfusion if you suspect a reaction. Quickly replace the blood tubing with a new administration set primed with normal saline for IV infusion. Initiate an infusion of normal saline for IV at an open rate, usually 40 mL/hour. Obtain vital signs. Notify the primary care provider and blood bank. 19. When transfusion is complete, close the roller clamp on the blood side of the administration set and open the roller clamp on the normal saline side of the administration set. Initiate infusion of normal saline. When all of the blood has infused into the patient, clamp the administration set. Obtain vital signs. Put on gloves. Cap the access site or resume the previous IV infusion. Dispose of blood-transfusion equipment or return it to the blood bank, according to facility policy. 20. Remove equipment. Ensure the patient’s comfort. Remove gloves. Lower the bed if not in the lowest position. 21. Remove additional PPE, if used. Perform hand hygiene. 22. Monitor and assess the patient for one hour after the transfusion for signs and symptoms of delayed transfusion reaction. Provide patient education about signs and symptoms of delayed transfusion reactions. 23. Documentation: Completion time, type of blood product, patients condition throughout the transfusion including any pertinent information (VS, breath sounds, subjective response, complications or no complications, IV site, volume of product and IVF intake on I & O)