Transfusion Therapy Chapter 34 Practice Flashcards

Objectives and Clinical Goals of Transfusion Therapy

• Increasing the Number of Red Blood Cells (RBCs): One of the primary goals is to elevate the count of circulating erythrocytes to ensure adequate oxygen-carrying capacity.

• Maintaining Hemogl obin (Hgb) Levels: Proper transfusion therapy aims to sustain appropriate hemoglobin concentrations within the patient's system.

• Provision of Cellular and Pl asma Co mponents: Therapies are utilized to provide specific blood constituents, such as:

  • Platelets

  • Albumin

  • Clotting factors

• Volume Restoration: Transfusions are critical for increasing total blood volume following major physiological stressors, including:

  • Surgery

  • Trauma

  • Hemorrhage

Blood and Blood Product Classifications

• Whole Blood: This component contains all blood elements but is noted as being rarely used in modern clinical practice.

• Packed Red Blood Cells (PRBCs): These are primarily used to restore blood volume and oxygen-carrying capacity.

• Platelets: These are administered specifically to restore platelet levels in patients who are hemorrhaging or have thrombocytopenia.

• Fresh Frozen Plasma (FFP): This component contains essential coagulation factors used to treat clotting deficiencies.

• Albumin: A protein derived from plasma used for volume expansion and protein replacement.

Laboratory Testing: Type & Screen versus Type & Crossmatch

• Type and Screen:

  • This procedure determines the patient’s ABO blood group and Rh type.

  • It includes a screen for clinically significant alloantibodies in the event the patient requires blood in the future.

• Type and Crossmatch:

  • This involves all the steps of a Type and Screen but includes an additional, critical final step.

  • A crossmatch is performed between the patient’s specific serum sample and a specific unit of donor blood to prepare a product for immediate transfusion.

  • Clinical Guideline: A type and crossmatch should only be ordered if there is a high likelihood of an immediate transfusion.

Pretransfusion Responsibilities and Protocols

• Physician’s Order: A valid medical order must be present before initiating the procedure.

• Informed Consent: A separate, specific consent form must be obtained from the patient before a transfusion is performed.

• Equipment Requirements:

  • Use a Blood Administration Set that includes a built-in blood filter.

  • The only fluid compatible for infusion with blood products is $0.9\%\text{ Normal Saline}$.

  • Establish venous access using a $20\text{-gauge}$ needle.

• IV Access Considerations: If the patient requires other medications or fluids simultaneously, additional IV access must be established, as blood cannot be mixed with other substances.

Administrative Verification and Safety Procedures

• Dual Verification: Two registered nurses (RNs) must verify the product at the bedside.

• Required Verification Data: The following must be checked against the patient's identity band, the blood band, and the unit from the lab:

  • Patient Name

  • Blood Bank (BB) Number

  • Donor Number

  • Unit Expiration Date (must note the expiration time)

  • ABO and Rh Compatibility

  • Correctness of the blood component ordered

• Significance of Verification: Checking these details is vital because human error is cited as the most common cause of incompatibility reactions.

Infusion Monitoring and Implementation

• Initial Infusion Rate: Start the infusion at a slow rate to monitor for early signs of a reaction.

• First $15-30\text{ minutes}$: The nurse must remain with the patient during the first $15-30\text{ minutes}$ of the infusion.

• Vital Sign Schedule:

  • Assess vital signs immediately before the infusion.

  • Assess vital signs $15\text{ minutes}$ after starting the infusion to identify indications of a reaction.

  • Monitor throughout the remainder of the infusion at intervals dictated by agency policy and patient condition.

• Volume Control: Infuse the product at the prescribed rate to avoid the complication of circulatory/fluid overload.

• Patient Education: Instruct the patient to report unusual sensations immediately, including:

  • Chills

  • Shortness of breath

  • Hives or itching

  • Back pain

Documentation Requirements

• Following the infusion, every aspect of the procedure must be documented, including:

  • The type of blood product administered

  • The specific product number

  • The total volume infused

  • The duration of the infusion

  • All sets of vital signs

  • Any adverse reactions observed

Immunohematology: ABO and Rh Systems

• Antigens: Found on the surface of the red blood cell (A or B).

• Antibodies: Found within the plasma.

• The ABO Blood Groupings:

  • Type A: Contains A antigens and anti-B antibodies.

  • Type B: Contains B antigens and anti-A antibodies.

  • Type AB: Contains both A and B antigens; contains no anti-A or anti-B antibodies.

  • Type O: Contains neither A nor B antigens; contains both anti-A and anti-B antibodies.

• The Rh Factor:

  • An Rh-negative person must only be transfused with Rh-negative blood.

  • An Rh-positive person can receive both Rh-negative and Rh-positive blood.

• Universal Compatibility:

  • Universal Donor: Type O-negative ($O-$).

  • Universal Recipient: Type AB-positive ($AB+$).

Blood Composition and Cellular Sizing

• Plasma: Makes up $55\%$, of whole blood; contains proteins, electrolytes, water, and dissolved gases.

• White Blood Cells (WBCs) and Platelets: Make up $1\%$, of whole blood.

  • WBC diameter: $7-18\,\mu m$

  • Platelet diameter: $2-3\,\mu m$ (at greatest diameter)

• Red Blood Cells (RBCs): Make up $44\%$, of whole blood.

  • RBC diameter: $6.2-8.2\,\mu m$,

  • RBC thickness: $2-2.5\,\mu m$

Specific Component Considerations

• Platelets:

  • Fragility: Platelets are fragile and must be infused immediately upon arrival.

  • Equipment: A special transfusion set with a smaller filter and shorter tubing is required.

  • Filtration: Platelet filters remove WBCs for patients with a history of febrile reactions or those requiring multiple transfusions.

• Fresh Frozen Plasma (FFP):

  • Must be infused immediately after thawing while clotting factors are still active.

  • ABO compatibility is required because FFP contains the donor's ABO antibodies.

• Packed Red Blood Cells (PRBCs) and Electrolytes:

  • Transfusions can cause electrolyte imbalances, specifically Hyperkalemia.

  • As cells are damaged during the process, they release potassium, raising the serum potassium level above normal.

Transfusion Reactions and Symptom Matrix

• Types of Reactions:

  • Febrile Reaction: Characterized by temperature increase.

  • Hemolytic Reaction: Characterized by temperature increase, chest pain, and Hematuria ($\text{blood in urine}$).

  • Allergic/Anaphylactic Reaction: Characterized by chest pain, Shortness of Breath (SOB), and welps/hives.

  • Bacterial Reaction: Caused by contaminated products.

  • Circulatory Overload: Characterized by SOB and crackles heard upon lung auscultation.

• Warning Signs for Patients: Advise patients to report any change in physical or emotional status, such as feeling "uneasy," feeling unwell, nausea, or new-onset joint, abdominal, chest, or back pain.

Emergency Protocol for Reactions

• If any reaction is suspected:

  1. Stop blood immediately.

  2. Obtain a full set of vital signs.

  3. Maintain IV access with fresh normal saline (do not use the saline in the blood-contaminated tubing).

  4. Perform repeat checks to ensure the right unit was given to the right patient.

  5. Notify the healthcare provider.

  6. Return the blood bag and all associated tubing to the blood bank for analysis.

Key Safety and Special Populations

• Solution Restriction: Only use Normal Saline ($NS$) with blood products.

• Medication Contraindication: Never administer any medications through the same line while blood products are infusing.

• Older Clients and Cardiac Patients: Transfuse blood products more slowly to these populations to minimize the risk of fluid overload.

• Timing: Always remain with the client during the first $15\text{ minutes}$ of any blood product infusion.