Blood Transfusion Procedure Nursing | Reaction Types, Complications (Hemolytic/Febrile) NCLEX

this is cereth registered nurse re and calm and in this video i'm going to be going over blood transfusions which will include the nurses role and as always I've been to this YouTube video you can access the free quiz that will test you on this procedure so let's get started what is a blood transfusion it is where as a nurse we will transfuse a patient who is low on red blood cells with new red blood cells via a venous access of some type now this is most commonly done through donated red blood cells so a patient needs them some ones donated them to the blood bank and as a nurse we will hang a bag of red blood cells for the patient and transfuse them to replace those low red blood cells which answers the question why would a patient need a blood transfusion because they're low on red blood cells and what can cause a person to be low on red blood cells well number one blood loss and they've had some type of surgery or trauma they can lose a lot of blood so we have to replenish them with red blood cells or they're anemic they can have anemia so bad that they need blood transfusions at some point like because they don't produce enough red blood cells and this can happen in conditions like renal failure cancers just to name a few because the body is not producing enough substances to produce or maintain those red blood cells now what's the importance of red blood cells they are very vital for our survival and how our body works so in other words our body can't function very well without them so what a red blood cells do with the help of hemoglobin it carries oxygen it receives from the lungs throughout our body in addition it removes carbon dioxide co2 and it will take that take it to the lungs so the lungs can't exhale it therefore whenever your patient is low on red blood cells they're going to have some side symptoms that can present especially if they're really low they'll be very pail I've seen patients they literally look white as a sheet before the transfusion and then after the transfusion I've told all my patients man you look like you got a tan because they their skin color is back to where it should be so it's really interesting you transfuse blood make sure you look at that another thing is they can feel very fatigued they can be short of breath any activity they're just like really wore out and they can have an increased heart rate be tachycardic because that heart is trying to pump that blood because consents of the oxygen is low so it's like I got to get more blood everywhere else so it can overwork itself so when is a patient transfuse well this really depends depends on what's going on with the patient their vital signs how are they tolerating that low blood level and recent guidelines by the American Association of blood banks recommends transfusing blood when hemoglobin levels fall to 7 to 8 grams per deciliter so then what is a normal hemoglobin level well depends if you're male or female Mel's it's 14 to 18 grams per deciliter in females it's 12 to 16 grams per deciliter now let's look at the nurses roll with transfusing blood now transfusing blood is very common in the hospital setting and you not only need to know this for NCLEX your Nursing lecture exams but you need to know it for the job okay the first thing before a patient is even transfused is a lot of prep work that is super important and essential because our prep work helps prevent transfusion reactions so we want to make sure we follow exactly what we need to and hospitals have in place protocols that whenever you become a new grad you start working you want to read over there protocol and make sure that you follow it exactly now most hospitals require that you're a registered nurse in order to transfuse the blood so again follow your Hospital protocol with that so let's say you got an order for patient to be transfused with two units of packed red blood cells what's the very first thing that's going to be done the patient is going to be type and cross-match either you'll be drawing the blood or your phlebotomist will be drawing it and this is the part where you've got to pay special attention to everything from what you write down to how you identify the patient you place the blood band everything must be done perfectly because we don't want do too like some type of clerical error to cause a transfusion reaction because someone messed up which tends to be the most common reason for a transfusion reaction so always take care whenever this has to be done next send the blood labs going to type in blood bank will match the blood with a donor and we'll prepare the amount of blood that you're going to need now it's also important that as the nurse you know the patient's compatibility and their Rh factors what blood they can receive what blood they can't receive and I have a whole video where I went over that in depth with you and you can access that and take a quiz that can test you on that but just a quick review who is the universal donor who can donate to all types that's oh now who is the universal recipient they can take from everyone that's a B next you'll want to get informed consent tell the patient what they're going to be receiving assess their understanding of it also this is a good time to ask about their allergies and if they have received any blood transfusions in the past and if they have how many because if they have received a lot of blood transfusions in the past they're at risk for febrile nan hemolytic transfusion reaction where their body has just built up these antibodies from all those previous transfusions and they can start running a fever and things like that so a lot of times physicians like to pre medicate them and you'll want to let the physician know if they do have a history of that and sometimes they're pre-medicated with benadryl or Tylenol acetaminophen before hand orally or when about 30 minutes before you start the transfusion and that will help prevent that also look at the health status of your patient are you giving a patient who is in fluid overload or congestive heart failure has renal failure and but they really need blood you need to be looking at that because they may be at risk for circulatory overload where you can put them in fluid overload because you're putting all this blood inside of their body so a lot of times physicians may order lasix some type of loop diuretic before the transfusion or in between the units or after the transfusion so you want to be aware of that as well next you want to make sure your patient has IV access we have to get this blood in then and you typically want an 18-gauge or larger IV site some hospitals again it's varies on protocols they'll allow you to transfuse through a twenty engage and why is that well as those red blood cells are shooting through they're going into the system if that cannula is not large enough those red blood cells can break open they can lysis and you're just breaking them up and they're not really going into the patient's body so you want good IV access another thing you really want to consider is you know it takes anywhere between two to four hours for a unit of blood to transfuse well if you have to hang some antibiotics on this patient or they're gonna need some IV drugs you can't use that IV access that is being used for the blood transfusion so you need a second access so keep that in mind it's always good to just have a good two sites while a patient's needing blood next is supplies whenever you transfuse blood you use special tubing which is called Y tubing with an inline filter which helps filter some of those substances out of the blood before it actually goes to the patient and keep in mind again it depends on hospital protocol a lot of protocols say only one set of Y tubing per unit that you transfuse so you'll have to you're going to transfuse the patient with more than one unit multiple sets or some hospitals say it's only good for four hours so keep that in mind when you need to change your filter your tubing next you'll want to grab a bag of normal saline 0.9 percent of normal saline this is the only only solution you ever use whenever transfusing blood you never use any met other medications or any other fluids only saline remember that because say you gave it with a dextrose containing solution dextrose and red blood cells don't get along it can cause them to clump up together so only 0.9% normal saline and we will be using that saline to prime that why tubing whip and then to flush that tubing with afterwards once the blood is done transfusing and in addition just whenever everything's wrapped up you're ready to take that tubing down you'll need to get a red biohazard bag to dispose of it properly again fall your Hospital protocols for holiday dispose of their blood products but um you never ever put it in the regular trash now let's talk about transfusing okay done all your prep work the blood bank calls you and says hey your blood is ready let us know whenever you're ready for us to send it to you because they're keeping it refrigerated for you so some key things you want to remember you will be giving one unit at a time patient needs two units you're gonna give one unit now and then whenever that's done call blood bank and say send me the other unit and then they'll send it to you so one at a time and from the time that the person brings you your blood or you go and collect it you need to start transfusing no later than within twenty to thirty minutes and it needs to be done that unit needs to be done within two to four hours so why is this well from the time that that blood bag leaves the refrigerator it needs to be in the patient's body within no more than four hours because there's a risk of it developing bacteria and we can give the patient septicemia so you want to transfuse it in that time frame also another thing you just want to consider one throw this out there is notify the blood bank that you're ready for the blood when you're ready because you need to get this in and as a nurse you get your blood so you have mission discharge you have a patient that is just not doing good that 30 minutes flies fast and you have this blood and you haven't even given it and now it's like 35 minutes later well you can't give it you're gonna have to send it back to the blood bank and blood is expensive so notify the blood bank whenever you're ready to start that transfusion now blood wormers blood warmers can be used if the patient needs large amounts of blood quickly and they're at risk for experiencing hypothermic response so you're not gonna warm the blood up by using a microwave or anything like that you want to use a special device if need be next before you even start the transfusion you're gonna be doing this verification process so as the nurse you're gonna be getting another nurse it's usually to our ends cuz ourian's are usually the ones who can transfuse and then you're gonna do another verification process with another orient and you're going to be looking at the following things before the transfusion together you're going to be verifying that physician's order you're going to be looking at the patient's identification versus the blood banks information making sure everything matches up perfectly you're gonna look look at the patient's blood type versus the donors tie and the Rh factor you're gonna make sure that they're compatible next you're gonna look at the expiration day on the blood make sure it's not expired you're gonna look at the blood make sure it doesn't have any clots are abnormal substances in the blood or it's damaged in any way and everything must match perfectly and if there's a discrepancy you'll need to notify the blood bank immediately and just from personal experience this has happened with one of my patients I was doing the whole verification process with another nurse and we were looking at the blood bag looking at the patient's ID band looking up and there was one letter that they had did a clerical error on so I had to send the blood and we had to go through the whole process again so this does happen so always make sure you verify everything also before transfusing you're going to be getting baseline vital signs which is going to include the temperature the blood pressure respirations and heart rate you want to make sure those are within normal limits and especially that temperature if you have a temperature greater than a hundred degrees Fahrenheit you'll want to notify the physician and make sure they just want to still proceed with the blood transfusion then again before you actually transfuse you want to explain to your patient if they're alert and oriented they can talk to you what you're about to do and for them to notify and report to you if they feel any of the signs and symptoms I'm fixing to describe because it can be a transfusion reaction like sweating chills chest pain itching short of breath headache backache or nausea and vomiting and if this happens you'll immediately want to stop the transfusion okay now it's actually time to start the transfusion so you're gonna have your blood ready hung and it's going to be controlled by an infusion pump which will deliver it to the patient and you want to start the transfusion slowly about two milliliters per minute for those first 15 minutes in addition you want to stay with that patient at their bedside looking at them monitoring them for those first 15 minutes and why is that why are you doing that well you're writing up slowly because we want to minimize the amount of blood that the patient's going to receive in case they do have a possible transfusion reaction we can turn that blood off and we want to stay with them during the first 15 minutes because that's when most transfusion reactions occur so we're gonna be watching their bottle signs throughout so you're gonna stay with them after five minutes of starting the transfusion you're going to get bottle signs and again this is depending on your hospital protocol and then after that you'll get them at 15 minutes after the transfusion has started and if the patient's okay they're tolerating it well this is the time that you can increase the rate and remember you want to make sure that that unit that bag of blood goes in within four hours no more than four hours then you'll get it to 30 minutes again and then hourly until done and then one hour after the transfusion and throughout that blood transfusion you're going to be monitoring them for of course a transfusion reaction and transfusion reaction that word is like an umbrella term for a lot of different reactions the patient can have and here in a moment we're gonna go in-depth over those but it's where the recipient that patients immune system is interacting with the donors blood so you can have a hemolytic transfusion reaction where what's happening is that the patient's blood and the donors blood are not compatible and immune system is attacking that donors red blood cells that they're receiving and this is dangerous it can lead to death also allergic they can have a febrile which is non hemolytic or GVHD which is graft-versus-host disease and have an Astra cry this because this tends to happen days two weeks after a blood transfusion it's rare and it's deadly if it does happen and in addition you want to monitor your patient for what's called circulatory overload and which patients do you think would be at risk for this think of any patient that's at risk for whenever you put extra fluid volume in their blood they'll have trouble with it like patients who have heart problems like congestive heart failure their heart muscles weak and you just throw that extra fluid in it it can't do well with it so the fluid starts backing up into the lungs and into the tissues they have breathing trouble things like that also patients who have renal failure you know these patients need blood but their risk for being able to tolerate all that fluid going in there so you want to keep that in mind you do have to transfuse these patients who have that in addition we want to monitor them for septicemia now it's in a way on how we can remember all those big signs and symptoms that your patient may be having a transfusion reaction so to help us to remember those major signs and symptoms let's remember the word reaction okay r4 rash they may have a rash or fives efore elevated temperature and what you want to do is you want to look at that baseline temperature and you need to ask yourself how's it increase and if you're measuring in Fahrenheit has it increased 1.8 degrees or if you're recording in Celsius has it increase one degree from baseline if so think transfusion reaction a 418 is your patient saying I have a backache all of a sudden or I'm having chest pain or my head is hurting that's a red flag c-4 chills t4 tachycardia especially if it's really increased from baseline I for increased respirations same thing with that increase from baseline oh for all glory so you really want to be looking at your patients urinary output during this blood transfusion and after are they putting out low or are they just putting out no urine at all are they an Urich and then look at the color what does it look like are they experiencing a condition called hemoglobinuria where there's free hemoglobin in the urine it will have like this purplish color so watch the earring closely and then in for nausea GI issues like diarrhea then when the transfusions done your patients tolerated it well you'll want to flush that remaining blood out of that line with that saline that's hanging on that Y tubing then dispose of your tubing properly and then collect post vital signs one hour after that transfusion now let's take a closer look at those various transfusion reactions and then talk about what you're going to do as a nurse if your patient does have a transfusion reaction during a blood transfusion okay first hemolytic this is where the immune system is killing the donors red blood cells so what's happened antibodies in the recipients blood match that antigens on the donors blood cells so hence they've been missed tight and this can lead to di C and renal failure and even death and a lot of times what's going to happen is you're gonna see a fever chills anxiety back pain chest pain hemoglobinuria where you have that purplish look to the urine also they can be tachycardic and have a low blood pressure another type is called allergic and this is where the recipients immune system is reacting to the proteins found in the donors blood leading to like rashes hives and itching and it can actually progress to in a flexus and the patient with this can have hives rashes respiratory issues like wheezing oral swelling things that you expect whenever someone's having an anaphylactic reaction to something another type is febrile and this is non hemolytic so you don't have the breaking up of those red blood cells like you did in hemolytic but this is where the recipients white blood cells or reacting with the donors white blood cells and this causes the body to build antibodies so you can see that increased temperature like one degree Celsius or one point eight degree in Fahrenheit from the baseline and this is actually the most common transfusion reaction that you tend to see especially in patients who have received blood in the past because their body has created these antibodies so that's what you want to ask them have you received a lot of transfusions before and you can see chills headache increase heart rate and fever with that and another transfusion reaction you can have is the GVHD the graft-versus-host disease and again like I said this is rare but it's deadly and it tends to occur days to weeks after the transfusion so this is where the donors T lymphocytes cause an immune response in the recipient but actually in grasping in the marrow of the recipient and attacking the recipients tissue so these T lymphocytes are usually killed by the recipients body but however maybe the patient has a suppressed immune system and they didn't attack these t lymphocytes whenever they're getting the transfusion and these hea lymphocytes from the donors start attacking that marrow and what can happen is they can have a fever and this really peculiar rash all over the body it'll be on the hands and the feet as well with GI issues diarrhea nausea inflammation of the liver and you want to talk you want to tell your patient you know if you start having this rash from head the this fever diarrhea all this stuff for several weeks after you've had this blood transfusion you want to report that to your doctor other complications that can arise that really aren't immune related it's like septicemia where the blood is contaminated so as a nurse again it's really important that you start that transfusion promptly after receiving it from the blood bank or the blood is contaminated with a disease now this isn't as common because we have strict screening guidelines but there can be a risk for hepatitis B C or HIV etc also that circuit or e overload we are talking about or developing high iron levels and this happens with people who've had frequent blood transfusions now let's talk about if your patient does have a blood transfusion reaction and I have seen this this does happen so keep it in the back of your mind so the first thing what you want to do is stop the transfusion and you want to note mentally what time this occurred what time you stopped it because you'll be documenting this later on also you're going to disconnect the blood tubing at the access side and replace it with new tubing and have some point nine percent normal saline running to keep the vein open then you're going to notify the doctor and the blood bank of what's going on but during all this you're going to be staying with the patient at their bedside you need be watching them you need your eyes on them so this is a great time to call in other people on the floor to be helping you make these phone calls to be doing these things next you're going to be monitoring those vital signs every five minutes looking at them watching them looking at that respiratory status it's not compromised or they have an allergic response what's going on now whenever you contact the physician depending on what type of reaction they suspect the patient's having or how severe it is what's going on they may order some medication so it varies some things they can orders like corticosteroids which is going to suppress that immune response along with fluids helping flush out that free hemoglobin that's in the body getting it out we want out of the body anti hit anti histamines to decrease that immune response anti-pirate ik stu decrease that temperature vasopressors this can help if there have an allergic response like epinephrine to open up the airways there's a lot of time those Airways clamp down and they can't breathe or like dopamine to increase renal blood flow or diuretics also some labs are going to be ordered they want to look at those claudine levels because remember if this is hemolytic type because a lot of times they don't know what type of reaction this patient is having they want to look at those clotting factors because they're at risk for di C where all their clotting factors are just going to be depleted and they can bleed out and die looking at those electrolytes looking at the renal function how's our kidneys and other blood levels in addition you'll be collecting urine urine on them looking for the free hemoglobin that's came from those red blood cells I have lysis and whenever you are disconnecting your tubing over here do not throw it away don't throw any of it away because you'll be sending that one with the leftover blood and any other documentation to the blood bank who's going to test it look out and see what went wrong and of course you're going to document you want to document the time it happened what actions you took what the patient was given if you gave them anything what labs you drew all that and how the patient is currently doing okay so that wraps up this review over blood transfusion thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos

Channel: RegisteredNurseRN

Views: 782,119

Keywords: blood transfusion, blood transfusion procedure nursing, blood transfusion nursing, blood transfusion reaction, blood transfusion procedure, blood transfusion lecture, blood transfusion reaction nursing, blood transfusion complications, blood transfusion nclex, blood transfusion types, blood transfusion procedure for nurses, hemolytic reaction to blood transfusion, febrile reaction blood transfusion

Id: v4PHCwvkH24

Length: 25min 33sec (1533 seconds)

Published: Tue Mar 20 2018