The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [287]
2 Check that the patient’s baseline vital signs, temperature, pulse, blood pressure and respirations have been recorded.
To ensure that any transfusion reaction can be immediately identified, due to changes in baseline (E), and managed appropriately (SNBTS 2004, C).
3 Conduct a visual inspection of the component to be used for signs of clumping, discoloration, damage or leaks.
Expired or damaged products must not be used (McClelland 2007, E).
4 If there are any discrepancies at this point do not proceed until they have been resolved.
To ensure an IBCT event does not occur. E
5 Positively identify the patient by asking them to state the following information.
(a) First name
(b) Surname
(c) Date of birth
This is the final check of identity which must be performed next to the patient prior to transfusion and is absolutely vital in minimizing the risk of IBCT errors (BCSH 2009, C; SNBTS 2004, C).
6 Check the details given against the patient’s nameband and the patient details on the blood component.
To minimize the risk of error (SNBTS 2004, C).
7 Check that the information on the compatibility label matches the details on the blood component, checking expiry date, unique component donation number, blood group on the component label against the laboratory-produced label. Check special requirements have been met.
To minimize the risk of error (BCSH 2009, C; SNBTS 2004, C).
If there are any interruptions during this checking procedure, the entire process should be restarted from the beginning.
8 If there are any discrepancies at this point do not proceed until they have been resolved.
To ensure an IBCT event does not occur (SHOT 2008, C).
Procedure
9 Prime the set with blood unless there are concerns about patency of the device, then prime with 0.9% sodium chloride.
Other agents may damage the product components and precipitate transfusion complications (SNBTS 2004, C), for example dextrose should never be used to prime a set or flush the blood administration set following a transfusion as this can cause haemolysis (SNBTS 2004, C).
10 Set up infusion via a volumetric infusion pump if appropriate. Check the infusion pump and settings prior to use.
To ensure the pump is in working order (BCSH 2009, C). Some older infusion pumps can damage the red cells. Blood administration sets for specific infusion pumps must always be used. If none are available the standard blood administration set should be used via gravity and the rate monitored as necessary. E
11 Set the desired infusion rate as indicated by the blood component being used and the patient’s condition.
The rate of administration is indicated by the patient’s clinical condition (SNBTS 2004, C; Weinstein and Plumer 2007, E). Dictated by current guidelines (SNBTS 2004, C).
Either
Red cell administration can range from 5–10 minutes in acute blood loss to the maximum time of 4 hours (from the time the component is removed from storage) in elderly patients (SNBTS 2004).
Or
Platelets, fresh frozen plasma and cryoprecipitate should be transfused over 30–60 minutes and must be completed within 4 hours of puncturing the blood component.
12 Sign the written order ‘prescription’ as the person administering the component. The unique component donation number, the date and start time should be recorded in the patient’s clinical notes.
To ensure documentation and traceability requirements are met (BCSH 2009, C).
13 Fifteen minutes after the commencement of each component, take and record patient observations – blood pressure, temperature, pulse and respiratory rate.
Adverse reactions will often occur during the first 15 minutes of transfusion (Gray and Illingworth 2005, C). Complaints of serious anxiety, transfusion site pain, loin pain, backache, fever, skin flushing or urticaria could be indicative of a serious transfusion reaction (McClelland 2007, E). In such cases the transfusion should be stopped immediately and urgent medical advice sought (SNBTS 2004, C).
14 Observe and monitor the patient