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Check that the patients blood has been typed and cross-matched
Check the ABO group and Rh type compatibility
Use blood within 30 minutes after its arrival from the blood bank Establish a baseline
Obtain vital signs Auscultate lungs Assess for JVD
Informed consent
Patient identification number Patient name Blood group and type
Expiration date
Inspection of blood product for clots or unusual color
Infuse blood within 4 hours after its arrival from the blood bank to prevent risk for bacterial contamination Monitor vital signs at regular intervals
3.
4.
TRANSFUSION REACTIONS
Signs and Symptoms Hives Itching Urticaria Flushing Anaphylaxis Type of Reaction Allergic reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Administer antihistamine parenterally as necessary
TRANSFUSION REACTIONS
Signs and Symptoms Fever Chills Headache Malaise Type of Reaction Febrile reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Treat symptoms
TRANSFUSION REACTIONS
Signs and Symptoms Immediate onset Flushing Fever Chills Headache Low back pain Apprehension Dyspnea Hypotension Shock Type of Reaction Hemolytic reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Collect blood sample from site 4. Collect first voided urine sample 5. Treat shock if present 6. Send unit, tubing, and filter to lab
TRANSFUSION REACTIONS
Signs and Symptoms Dyspnea Orthopnea Tachycardia Sudden anxiety JVD Dry cough Crackles at the base of lungs Hypertension Pulmonary edema Type of Reaction Circulatory overload Nursing Actions 1. Slow or stop transfusion 2. Monitor vital signs 3. Notify MD 4. Elevate head of bed and lower feet
TRANSFUSION REACTIONS
Signs and Symptoms Fever Chills Hypertension Dry, flushed skin Abdominal pain Type of Reaction Bacterial reaction Nursing Actions 1. Stop transfusion 2. Collect blood culture from patient and return blood bag 3. Monitor vital signs 4. Notify MD 5. Administer antibiotics
References
Blood transfusion bag [Online image]. (2009). Retrieved from http://americaninvetors.blogspot.com/ 2009/02/blood-transfusion.html Blood transfusions [Online image]. Retrieved from http://magazine.nursing.jhu.edu/2012/05/bloodtransfusion IV normal saline [Online image]. Retrieved October 20, 2013 from http://www.keyhostnet.com/ safetynett5/index.php?route=product/product&product_id=153 Nurses at the heart of transfusion safety [Online image]. (2011). Retrieved from http:// thebloodytruth.com/nursing-the-art-and-science-of-safe-transfusion Redding, D. J. (2006). 060427-M-0000C-001 [Online image]. Retrieved October 20, 2013 from http:// www.1stmlg.marines.mil/Photos/tabid/8621/igphoto/252242/Default.aspx Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths Textbook of Medical-Surgical Nursing (12th ed., pp. 967-972). China: Wolters Kluwer Health. Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of Nursing (7th ed., pp. 1458-1460, 1482-1485). Philadelphia, PA: Wolters Kluwer Health. [Untitled image of blood bag and patient]. Retrieved from http://www.daviddarling.info/ encyclopedia/B/blood_transfusion.html [Untitled image of sharps container]. Retrieved October 20, 2013 from https:// www.armstrongmedical.com/index.cfm/go/product.detail/sec/1/ssec/8/cat/5/scat/ 14/fam/2305