Blood Transfusions in Nursing Practice

Adapted from DepositPhotos.com
Adapted from DepositPhotos.com

 

Administering blood products is a common life-saving procedure in any hospital setting. The nurse should know why the healthcare provider has ordered a specific blood product to be given to a patient as well as the institution’s policies and procedure in administering that product. The nurse must also recognize early signs of adverse reactions to prevent life-threatening complications.

What is a Blood Transfusion?

A blood transfusion is the administration of a component of blood or whole blood intravenously.

What are examples of blood components?

  • Complete or Whole Blood: used to restore blood volume and replace red cell mass.
  • Packed red blood cells: preferred method in replacing red cell mass; contains 80% less plasma volume than whole blood to correct anemia or surgical blood loss.
  • Leukocyte-depleted RBCs: to treat immunocompromised patients and prevent febrile reactions and non-hemolytic transfusion reactions.
  • White blood cells (leukocytes): whole blood with 80% of plasma and all RBCs removed. This is used to treat sepsis.
  • Platelets: treat bleeding caused by low circulating platelet count or functionally abnormal platelets; Used in patients with thrombocytopenia
  • Fresh Frozen Plasma: used to treat postoperative hemorrhage. 
  • Albumin 5% (buffered saline); albumin 25% (salt-poor): used to replace blood volume loss and treat hypoproteinemia in burns and hypoalbuminemia in shock and coagulation factors and complement; used in control of bleeding when replacement of coagulation factors is needed.ARDs; used to support blood pressure in dialysis and acute liver failure.
  • Factor VIII concentrate (hemophilic factor): used to treat patients with hemophilia and von Willebrand’s disease
  • Cryoprecipitate: used to treat patients with factors VIII and XIII deficiencies, von Willebrand’s factor, and fibrinogen.

Who Needs Blood Transfusions?

A patient may require a transfusion for the following:

  • To increase blood volume after surgery, trauma, or hemorrhage;
  • To increase the number of red blood cells in a patient with severe anemia;
  • To provide platelets to patients with low platelet counts caused by treatment with chemotherapy;
  • To provide clotting factors in plasma for patients with hemophilia, von Willebrand’s disease, or disseminated intravascular coagulopathy (DIC); or
  • To replace plasma proteins such as albumin.

Before Transfusing Blood

  1. Assess why the patient needs to be transfused so that he/she can evaluate specific response to the procedure.
  2. Verify the health care provider’s order for the type of blood product to be given.
  3. Review the patient’s transfusion history. Watch out for any reactions or pretransfusion medications to be given. If prior reaction has occurred, pre-medications can be given to prevent a subsequent reaction.
  4. Review the patient’s baseline vital signs to compare with vital signs during the transfusion. Changes in baseline such as increased body temperature, heart rate, and respiration rate may indicate a transfusion reaction.
  5. Assess the type, integrity, and patency of the venous access in place so the transfusion will be completed without infiltration of the IV.
  6. Verify that a large-bore catheter (18- or 19- gauge) is to be used. Small-bore needles may cause hemolysis as red blood cells are large and will not flow through a small-bore needle.
  7. Review institution policy and procedure for the administration of blood components. Each institution has its own guidelines to ensure safe administration of blood products.
  8. Make sure that the client has signed an informed consent that includes potential risks and benefits of the procedure.

Unexpected Outcomes

REACTION SIGNS AND SYMPTOMS NURSING ACTIVITY
Allergic reaction: allergy to blood transfused Anaphylaxis, itching, urticaria, local erythema, hives, coughing, nausea, vomiting, respiratory distress, wheezing, hypotension, loss of consciousness, and possible cardiac arrest.
  • Discontinue transfusion immediately.
  • Notify health care provider immediately.
  • Give antihistamine parenterally, as necessary.
Febrile reaction: fever develops during infusion Fever and chills, headache, flushing, and malaise
  • Discontinue transfusion immediately.
  • Notify health care provider immediately.
  • Treat symptoms.
Hemolytic transfusion reaction: incompatibility of blood product

Immediate onset;

Facial flushing, fever, chills, headache, nausea, low back pain, chest pain, tachycardia, sensation of heat and pain along vein receiving blood, bronchospasm, anxiety, hypotension, vascular collapse, shock and possibly

Death.

  • Discontinue transfusion immediately.
  • Notify health care provider immediately.
  • Obtain blood samples from site and send to laboratory.
  • Obtain first voided urine and send to laboratory.
  • Treat shock if present.
  • Send unit, tubing, and filter to laboratory.
Circulatory overload: too much blood administered or transfused too fast Difficulty breathing, Dry cough, crackles at the base of the lungs, tachypnea, distended neck veins, headache, hypertension, tachycardia, and Pulmonary edema
  • Slow or discontinue transfusion.
  • Notify health care provider immediately.
  • Monitor vital signs.
  • Place in upright position with feet dependent or in high Fowler’s position.
  • Give diuretics as ordered.
Bacterial reaction: bacteria present in blood Fever, hypertension, abdominal pain, vomiting, diarrhea, back pain, profound hypotension and dry, flushed skin
  • Discontinue transfusion immediately.
  • Notify health care provider immediately.
  • Monitor vital signs.
  • Obtain culture of patient’s blood and return bag to laboratory.
  • Administer antibiotics stat.

 

Sources:

Fundamental & Advanced Nursing Skills, 3rd Edition, 1-4180-5233-7, P1062-1070

Visual Nursing: A guide to Diseases, Skills and Treatments, 2nd Edition, 978-1-60913-650-5, P330-331

Clinical Nursing Skills, 4th Edition, 978-1-4511-9271-1, P888

Clinical Nursing Skills and Techniques, 8th Edition, 978-0-323-08383-6, P737-750

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Positioning Clients

Adapted from DepositPhotos.com
Adapted from DepositPhotos.com

 

Not all clients can independently move nor position themselves in bed. Immobility may be due to factors like growth development, health status, nutrition, personal values and attitudes, and excessive humidity.

Positioning a client in good body alignment and changing position regularly are essential aspects of nursing practice. It is essential to provide meticulous care to a client who must remain in bed. Healthcare givers’ measures should ensure to preserve the joints, bones and skeletal muscles and must be carried out for all clients who require bed rest. Positions in which clients are placed, methods of moving and turning should all be based on the principles of maintaining the musculoskeletal system in proper alignment. The health care provider must also use good body mechanics when moving and turning clients to preserve his or her own musculoskeletal system from injury.

Why is it important?

  • Promote comfort
  • Restore body function
  • Prevent deformities and muscle strain
  • Stimulate proper respiration and circulation
  • Administer treatments or perform examinations
  • Provide hygiene, bed bath or sponge bath
  • Assess skin conditions
  • Assess wounds/dressings
  • Change linens
  • Obtain specimen

Considerations before positioning a client    

  • Follow/carry out Physician’s orders meticulously
  • Perform hand hygiene
  • Identity client and introduce yourself
  • Explain to the client the need for moving or positioning him/her
  • Explain to the client the need for employing equipment/devices
  • Provide privacy; properly drape the client
  • Assess skin condition of  the client
  • Gerontologic considerations (Muscle atrophy, limited mobility level, kyphosis, bone changes, osteoporosis, osteoarthritis)

 

Body Mechanics

The process of using alignment, posture and balance in a synchronized manner to perform tasks such as moving, bending and lifting.

  • Assume a proper stance before moving or positioning clients.
  • Establish a comfortable height. Keep the client as close as possible to your body.
  • Push and pull objects when moving them to conserve energy. Avoid leaning and stretching.
  • Use the large muscles for lifting and moving, not the back muscles. Maintain low back in neutral position. Move the hip and shoulders as one unit. Avoid twisting your body.
  • To avoid strain, request assistance from other members of the health care team when handling equipment/devices while working with heavy clients.

Client Teaching

  • Teach the importance of passive or assistive range of motion (ROM) exercises to maintain joint mobility
  • Incorporated ADLs into exercise program if appropriate
  • Explain the need for schedule, frequency or duration of turning and moving him in bed
  • Offer an ambulation schedule
  • Discuss pain control measures required before positioning or moving the client
  • Teach the use of proper body mechanics especially for those times when assistive equipment is not used
  • Teach ways to prevent postural hypotension

Expected Outcomes

  • Client comfort is increased
  • Proper body mechanics are used when preparing for and providing client care. Center of gravity is maintained when lifting objects/equipment
  • Injuries are prevented to both the nurse and the client
  • Clients and nurses are not injured when nursing care is provided
  • Breathing is adequate
  • Joint movement is maintained
  • Skin remains intact without evidence of breakdown

Documentation

  1. Injury to client resulting from poor body mechanics
  2. Client’s acceptance and feelings about the procedure
  3. Time when client was moved, and the duration of administering the procedure
  4. Devices needed for positioning client
  5. Number of health care personnel required for turning and moving client
  6. Ways in which client assists in moving (Identify whether patient was Independent or dependent, or if Partial Assist was necessary)
  7. Special requirements of client for proper body alignment (e.g. support pillows)

Assistive Equipment/Devices useful when positioning clients

  • Pillows
  • Friction-reducing sheet (Lateral Assist)
  • Drawsheet (Trochanter roll)
  • Trapeze
  • Transfer board (polyethylene board) and gurney covered with sheets
  • Bath blanket
  • Gurney, bed or CT table
  • Gait belt
  • Electric beds
  • Powered stand-assist device
  • Powered full-body lift
  • Chair
  • Hoyer lift base
  • Canvas straps

Positions for Client Care

 

POSITIONS PLACEMENT RATIONALE
High-Fowler’s Head of bed 60° angle Thoracic surgery, severe respiratory conditions
Fowler’s Head of bed 45°-60° angle; hips may or may not be flexed Postoperative, gastrointestinal conditions, promote lung expansion
Semi-Fowler’s Head of bed 30° angle Cardiac, respiratory, neurosurgical conditions
Low-Fowler’s Head of bed 15° angle For ease of breathing, promote skin integrity, provide comfort
Knee-Gatch Lower section of bed (under knees) slightly bent Provide comfort
Trendelenburg Head of bed lowered and foot raised Percussion, vibration and drainage (PVD) procedure, promote venous return
Reverse Trendelenburg Bed frame is tilted up with foot of bed down Gastric conditions, prevent esophageal reflux
Orthopneic Client sits either in bed or on the side of the bed with an overbed table across the lap Facilitate respiration
Dorsal recumbent position Client’s head and shoulders are slightly elevated on a small pillow Provide comfort and facilitate healing following certain surgeries  or anesthetics
Prone position Client lies on the abdomen with the head turned to one side; hips not flexed. Prevent flexion contractures of the hips and knees; promote drainage from the mouth especially from unconscious clients recovering from surgery of the mouth or throat.
Lateral Client lies on one side of the body; top hip and knee flexed Provide comfort for clients with sensory or motor deficits on one side  the body.
Sim’s (Semi-prone) Client assumes a posture halfway between the lateral and prone positions; lower arm is positioned behind the client, upper arm is flexed at the shoulder and elbow. Facilitate drainage from the mouth and prevent aspiration of fluids, especially for unconscious or paralyzed clients.

Sources:

Adapted from Altman 3rd Ed. – Fundamentals and Advanced Nursing Skills

Adapted from Craven 7th Edition – Fundamentals of Nursing

Adapted from Perry & Potter 8th Ed.

Adapted from Berman 10th Edition – Kozier & Erb’s Fundamentals of Nursing

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Intravenous Therapy: Discontinuing the IV and Changing To A Heparin Lock

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What is a heparin lock?

A heparin lock, also known as a saline lock, is a plastic device with a covered rubber entry screwed into the hub of an existing IV catheter.

It allows access to the vein without having to run IV fluids into the body.

When is an IV line changed into a heparin lock?

These are the two occasions when heparin lock is placed:

  1. when IV line has been discontinued but the access to the vein is needed for continuous infusion of fluid or medication changes
  2. when client requires IV medications but does not necessarily need continuous fluid infusions

What are the advantages of having a heparin lock?

Changing to a heparin lock allows:

  • an improved client mobility
  • quick medication administration during emergency cases
  • access to vein without necessarily having an IV line

What is the main disadvantage of a heparin lock?

The main disadvantage of a heparin lock is blood clotting.

This can be prevented through a Saline Flush wherein a normal saline is regularly flushed into the heparin lock.

Materials Needed:

  • Gloves
  • Syringe with saline flush solution
  • Sterile needles
  • Alcohol swab

Discontinuing the IV And Changing To A Heparin Lock

Steps

Rationale

1. Check health care provider’s order to discontinue IV and to insert a saline lock. Ensures accurate placement of saline lock.
2. Wash hands and put on clean gloves. Reduces number of microorganisms.
3. Check client’s identification bracelet. Ensures correct procedure is performed for the client.
4. Explain procedure and reason for discontinuing IV to client. Decreases anxiety.
5. Prepare supplies at bedside. Ensures smooth procedure.
6. If inserting a new heparin lock: Prime the extension tubing with saline and place the saline lock on it. Follow the procedures for starting an IV, including assessing and preparing the site, inserting the IV catheter. Do not attach the IV catheter to the IV tubing. Instead, attach it the to the extension tubing. Dress the site per protocol. Priming the extension tubing prevents air from being forced into the vein.
7. If discontinuing an IV and converting to a heparin lock: Stop IV infusion.

  • For IV tubing,roll clamp to close IV tubing.
  • For infusion pump,turn switch to off.
Stops the flow of fluid in the IV tubing.
8. Place heparin lock:

  • Open sterile package with needleless adapter heparin lock.
  • For existing IV, loosen IV tubing and remove.
  • Screw heparin lock into hub of tubing
  • To check for patency remove cap from one-way valve following vigorous scrubbing with alcohol at the connection site. Connect needleless Leur-locking syringe to the valve. Inject solution into IV site per protocol, using gentle pulsating motions to create turbulence. Remove syringe and replace sterile cap at end of tubing.
Secures the heparin lock.
9. Check for patency of IV:

  • Clean heparin lock with antiseptic solution (usually alcohol wipe).
  • Insert saline syringe with 25-gauge needle into center of diaphragm. (Needleless system will not require needle.)
  • Pull back gently on syringe and watch for blood return.
  • Inject saline slowly into lock.
  • Assess client’s pain at site.
Ensures the IV is patent so that the heparin lock will function. Flushing with saline clears the lock.

  • Flushing should be done slowly.
  • Assess for pain to ensure site is patent.
10. Keep lock patent with heparin or normal saline. Every 8 hours:

  • Clean the rubber diaphragm with an antiseptic swab (not applicable if needleless system).
  • Insert the syringe or needleless adapter with heparin or saline into the diaphragm.
  • Inject heparin or saline slowly into lock.
Ensures patency of saline lock.
Only use heparin if prescribed as “flush with heparin” or if institutional policy requires it. Needleless system reduces risk of needle sticks.
11. Remove the syringe or needleless adapter from the diaphragm and swab it with an antiseptic swab. Discard needle or adapter in sharps container. Reduces transmission of microorganisms. Reduces risk of needle sticks.
12. Assess the site for any signs of leakage, irritation, or infiltration. Detects problems with the site that need additional assessment and intervention.
13. Remove gloves and dispose with all used materials. Wash hands. Reduces transmission of microorganisms.

Note. Adapted from Fundamental and Advanced Nursing Skills. Third Edition, p. 1056-1059, by G. B. Altman, 2010,
Delmar: Cengage Learning.

What to document?

Document:

  • date and time the IV line was discontinued and heparin lock was placed
  • abnormal findings at the IV insertion site
  • type of solutions infused in lock – whether it’s heparin or saline

Key Considerations:

  • Discontinuing the IV line and changing to a heparin lock is a responsibility of a nurse that cannot be delegated to an unlicensed or untrained personnel.
  • Many institutions, adapting recent studies, flush heparin locks with normal saline solution rather than heparin before and after a medication is administered to maintain patency of a heparin lock.
  • If swelling is noted at IV site, stop pushing the heparin lock. Pull back the plunger and check for blood return. If there is no blood, remove and start a new heparin lock in another site and flush with saline.