Chapter 41: Blood and Blood Product Transfusions

Chapter 41: Blood and Blood Product Transfusions

Replace blood volume or components due to blood loss or blood disorders

Blood Components

• Packed RBCs

• Washed RBCs (WBC-poor RBCs)

• White blood cells (granulocytes)

• Fresh frozen plasma (FFP)

• Albumin

• Clotting factors

• Cryoprecipitate

• Platelets

Indications by Diagnosis

Excessive Blood Loss

• Packed RBCs

Anemia

• Packed RBCs

• Hgb less than 6 or 6 to 10 g/dL depending on findings

Kidney Failure

• Packed RBCs

Coagulation Factor Deficiencies (e.g., Hemophilia)

• Fresh frozen plasma

Thrombocytopenia or Platelet Dysfunction

• Platelets

Hemophilia A

• Cryoprecipitate

Burns or Hypoproteinemia

• Albumin

ABO Blood Type Compatibility

Blood Type	Antigen	Antibodies Against	Can Receive
A	A	B	A, O
B	B	A	B, O
AB	A, B	None	A, B, AB, O
O	None	A, B	O

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching?

a

“You should make an appointment to donate blood 10 weeks prior to the surgery.”

b

“If you need an autologous transfusion, the blood a a sibling donates can be used.”

c

“You can donate blood each week if your hemoglobin is stable.”

d

“Any unused blood that is donated can be used for other clients.”

c “You can donate blood each week if your hemoglobin is stable.”

When taking actions and teaching a client about autologous blood donations, the nurse should teach the client that beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if their Hgb and Hct remain stable.

A charge nurse is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

a

Inserts an 18-gauge IV catheter in the client.

b

Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP).

c

Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion.

d

Obtains vital signs every 15 min throughout the procedure.

d

Obtains vital signs every 15 min throughout the procedure.

Transfusion Types

Standard (Allogeneic) Donation

• Transfusion from a compatible donor

Autologous Transfusion

• Client donates own blood before elective surgery

• Can donate up to 6 weeks preop

• Weekly donations if Hgb and Hct stable

• Blood used only for that client

Intraoperative Blood Salvage

• Sterile blood lost during surgery is collected, filtered, and reinfused

• Reinfusion must occur within 6 hr of collection

Platelet Transfusion

Key Points

• Blood type matching not required

• Volume: 200 to 300 mL

Nursing Actions

• Infuse immediately once delivered

• Administer over 15 to 30 min

• Use special transfusion set with small filter and short tubing

• Vital signs before infusion, 15 min after start, and at completion

Plasma Transfusion (FFP)

Key Points

• Frozen immediately after donation

• Thawed just before use

• Transfuse as soon as thawed to preserve clotting factors

• ABO compatibility required

Nursing Actions

• Infuse 200 mL rapidly over 15 to 30 min

• Use regular Y-set or straight filtered tubing

White Blood Cell Transfusion (Granulocytes)

Key Points

• Rare due to high risk of severe reaction

• Used in immunocompromised clients

• Separate amphotericin B and WBC transfusion by 4 to 6 hr

Nursing Actions

• Infuse WBCs in 400 mL plasma over 45 to 60 min

• Monitor vital signs every 15 min

• Provider presence may be required

Washed RBCs (WBC-Poor Packed RBCs)

Indications

• History of transfusion reactions

• Hematopoietic stem cell transplant recipients

Nursing Actions

• Infuse 200 mL over 2 to 4 hr

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 6 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?

a

Obtain consent from the client for the transfusion.

b

Assess for an acute hemolytic reaction.

c

Explain the transfusion procedure to the client.

d

Obtain blood culture specimens to send to the lab.

b Assess for an acute hemolytic reaction.

The nurse should plan to generate solutions to address the potential for blood transfusion reactions while receiving packed RBCs. The nurse should plan to assess for an acute hemolytic reaction during the first 15 min of the transfusion. This type of a reaction can occur following the transfusion of as little as 10 mL of blood product,

Blood and Blood Product Transfusions Considerations

Preprocedure

Compatibility

• Major risk is incompatibility

• Strict protocol adherence required

Testing

• Packed RBCs require type and cross-match

• Plasma typed for ABO only

• Blood typing based on antigen presence

Rh Factor

• Rh-negative clients do not have Rh antigen

• Sensitization leads to reactions with Rh-positive blood

Nursing Actions

• Explain procedure

• Obtain consent if required

• Baseline vital signs and temperature

• Review labs pretransfusion

• Verify provider prescription

• Assess transfusion history

• Obtain compatibility samples

• Initiate large-bore IV access

  • 18 to 20 gauge preferred

• Inspect blood for discoloration, bubbles, cloudiness

• Two-nurse verification of client and blood product

• Prime tubing with 0.9% normal saline only

• Use Y-tubing with filter

• Start transfusion within 30 min of obtaining blood

Older Adult Considerations

• No larger than 19-gauge needle

• Assess kidney function, fluid status, circulation

• Increased risk for fluid overload

• Use blood less than 1 week old

• Explain rationale clearly

Intraprocedure Nursing Actions

• Stay with client first 15 to 30 min

• Monitor vital signs per policy

• Older adults

  • Vital signs every 15 min

  • Transfuse over 2 to 4 hr

  • Hold other IV fluids

• Watch for reaction signs

• Notify provider immediately if reaction suspected

Postprocedure Nursing Actions

• Obtain final vital signs

• Dispose of tubing per policy

• Complete documentation

• Document client response

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction?

Select all that apply.

a

Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F)

b

Current blood pressure 178/90 mm Hg

c

Heart rate change from 88/min pretransfusion to 120/min

d

Client report of itching

e

Client appears flushed

c

Heart rate change from 88/min pretransfusion to 120/min

e

Client appears flushed

Blood and Blood Product Transfusions Complications

Acute Hemolytic Transfusion Reaction

Onset

• Immediate or during subsequent transfusions

• Can occur after as little as 10 mL infused

Cause

• Incompatible blood type or Rh factor (immune destruction of RBCs)

Key Findings

• Chills

• Fever

• Low back or flank pain (hemolysis in kidneys)

• Chest pain or tightness

• Tachycardia

• Hypotension

• Tachypnea

• Nausea

• Anxiety

• Hemoglobinuria (dark urine)

• Sense of impending doom

• Can progress to DIC or circulatory collapse

Priority Nursing Actions

• Stop the transfusion immediately

• Remove blood tubing from IV access

• Infuse 0.9% normal saline with new tubing

• Monitor vital signs and fluid status

• Send blood bag and tubing to lab for testing

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Febrile Transfusion Reaction

Onset

• Within 2 hr of starting transfusion

Cause

• Anti-WBC antibodies

• More common with multiple prior transfusions

Key Findings

• Chills

• Temperature increase of 1°C or more from baseline

• Hypotension

• Tachycardia

Nursing Actions

• Stop the transfusion

• Initiate 0.9% normal saline with new tubing

• Administer antipyretics as prescribed

• Use WBC filter for future transfusions

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Allergic Transfusion Reaction

Onset

• During transfusion or up to 24 hr after

Cause

• Sensitivity to plasma proteins or additives

Mild Reaction

Findings

• Pruritus

• Urticaria

• Flushing

Nursing Actions

• Stop the transfusion

• Initiate 0.9% normal saline with new tubing

• Administer antihistamine (e.g., diphenhydramine)

• Restart transfusion slowly if prescribed

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Anaphylactic Reaction

Findings

• Bronchospasm

• Laryngeal edema

• Hypotension

• Shock

Nursing Actions

• Stop the transfusion

• Remove blood tubing from IV access

• Initiate 0.9% normal saline with new tubing

• Administer epinephrine, corticosteroids, vasopressors, oxygen

• Initiate CPR if indicated

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Bacterial Transfusion Reaction

Onset

• During transfusion or several hours after

Cause

• Transfusion of contaminated blood products

Key Findings

• Wheezing

• Dyspnea

• Chest tightness

• Cyanosis

• Hypotension

• Shock

Nursing Actions

• Stop the transfusion

• Initiate 0.9% normal saline with new tubing

• Administer antibiotics as prescribed

• Send blood culture specimen to lab

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Circulatory Overload (TACO)

Onset

• Can occur at any time during transfusion

High-Risk Clients

• Older adults

• Heart failure

• Renal impairment

• Rapid infusion rate

Key Findings

• Crackles

• Dyspnea

• Cough

• Anxiety

• Jugular vein distention

• Tachycardia

• Pulmonary edema

Nursing Actions

• Slow or stop transfusion

• Position client upright with feet dependent

• Administer oxygen

• Administer diuretics and morphine as prescribed

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if the client develops manifestations of an allergic transfusion reaction?

Select all that apply.

a

Stop the transfusion.

b

Monitor for hypertension.

c

Maintain an IV infusion with 0.9% sodium chloride.

d

Position the client in an upright position with the feet lower than the heart.

e

Administer diphenhydramine.

a

Stop the transfusion.

c

Maintain an IV infusion with 0.9% sodium chloride.

e

Administer diphenhydramine.