The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [288]
To monitor for any adverse reactions (McClelland 2007, E).
15 Record the finish time of each unit. All units must be completed within 4 hours of removal from storage.
Continuation of a transfusion beyond 4 hours increases the risk of transfusion reaction and complications (BCSH 2009, C).
16 Take and record the patient’s observations on completion of each unit, ensuring that post-transfusion observations are performed within 60 minutes of completion of the unit.
To ensure the patient’s progress is recorded and acts as a baseline for subsequent units (BCSH 2009, C).
Postprocedure
17 Record the time the transfusion finished and the volume of the component transfused on the patient’s fluid balance chart.
To ensure an accurate record of fluid is maintained as fluid balance monitoring can identify fluid overload in at-risk patients (Weinstein and Plumer 2007, E).
18 Carefully file all transfusion documentation in the patient’s clinical record. In line with local policy, return information on the final fate of each blood component to the hospital laboratory manager.
To ensure the transfusion episode has been recorded, maintaining the clinical record for patient safety. To comply with Statutory Instrument No. 50 (Blood Safety and Quality Regulations 2005, C), where the final fate of all blood components must be held for a duration of 30 years.
19 Return any unused blood components to the laboratory promptly.
Unused components may be reallocated if returned in time. Refer to local guidelines. E.
20 Keep all empty blood component bags in the clinical area until the transfusion is completed. Once the transfusion is completed, dispose of in clinical waste.
To ensure transfused bags are available in the event of incident investigation (SNBTS 2004, C).
21 For patients receiving ongoing transfusion support, the blood administration set should be changed at least every 12 hours, or after every second unit transfused. Dispose of used set in clinical waste: refer to local guidelines/protocols.
Minimize risk from bacterial contamination (BCSH 2009, C; McClelland 2007, E; SNBTS 2004, E).
Problem-solving table 8.6 Prevention and resolution (Procedure guidelines 8.14–8.16)
Postprocedural considerations
Immediate care
The patient should be asked to inform a member of staff of any symptoms which may indicate a transfusion-related adverse event, such as feeling anxious, rigors (shivering), flushing, pain or shortness of breath. The patient should be cared for where they can be visually observed and should be shown how to use the nurse call system. The patient should have vital signs monitored as indicated in the procedure guidelines: however, it may be necessary to take additional observations if clinically indicated, such as if the patient complains of feeling unwell or they develop signs of a transfusion reaction (Gray and Illingworth 2005).
Many drugs may cause a pyretic hypersensitivity reaction (BNF 2011). There is at present insufficient evidence to allow guidance on the co-administration of drugs with red blood cell transfusion. A lack of clinical reporting of reactions in patients cannot be taken to indicate safe practice: adverse reactions may be attributed to other causes, subclinical haemolysis or agglutination may occur undetected and serious adverse effects may be masked by pre-existing illness in the patient (Murdock et al. 2009).
Ongoing care
On completion of a blood transfusion episode, observations to include blood pressure, temperature, pulse and respiratory rate should be taken and recorded. The patient’s records should be updated to confirm that the transfusion has taken place, including the volume transfused, whether the transfusion achieved the desired effect (either post-transfusion increment rates or an improvement in the patient’s symptoms) and the details of any reactions to the transfusion. If intravenous fluids are prescribed to follow the transfusion, these should be administered