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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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Insulin

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What is Insulin?

Insulin is a natural hormone secreted by the cells of the pancreas whenever glucose levels in the blood are increased. Insulin attaches to cells that use glucose for energy and stimulates it to uptake glucose from the blood.

Whenever insulin secretion or insulin-cell receptor sensitivity is impaired, synthetic insulin is needed to continue the function of natural insulin and maintain life.

Unfortunately, synthetic insulin cannot reverse abnormal insulin conditions and is thus needed by patients throughout his or her lifetime.

Indication

Synthetic insulin is required in patients suffering from:

  • Type 1 Diabetes
  • Type 2 Diabetes if other measures such as lifestyle change and oral drug therapy can’t anymore adequately maintain the blood glucose levels

Types of Insulin

Type Insulin Onset Peak (h) Duration Color Nursing Considerations
Rapid-Acting Lispro, Aspart, Glulisine <15 min 1-2 3-5 Clear Clients must eat a meal within 10-15 minutes of injection
Short-Acting Regular 0.5-1 h 2-4 3-8 Clear

Only insulin that can be administered through IV

Should be given 30 – 45 minutes prior to meals

Intermediate Acting NPH 2-4 h 5-8 12-18 Cloudy Pre-filled syringes should be stored in the refrigerator with needle tips up
Long Acting Determir, Glargine 2-4 h Peakless 20-24 Clear Don’t mix with any other insulin or solution
Premixed 2-4 h Peakless 20-24 Cloudy

Rapid-acting Mixture: client must eat within 15 minutes of injection

Short-acting mixture: client should eat within 30 minutes of injection

Don’t mix with any other insulin

What does the peak hour mean?

The peak hour of each type of insulin is the time when hypoglycemia symptoms usually occur.

For instance, if you give a rapid acting insulin at 0800h, then you must look for hypoglycemia symptoms between 0900h-1000h since its peak hour is 1-2 hrs from the time of administration.

Hypoglycemia symptoms to note for include:

  • hunger
  • decreased levels of consciousness
  • hunger
  • diaphoresis
  • weakness
  • dizziness
  • tachycardia

Insulin Administration: Mixing Insulin

Let’s take this scenario as an example:

Doctor orders to give a mixture of 3 units of regular insulin (clear) and 2 units of NPH (cloudy).

Method 1

  1. Add a total of 5 units of air to the syringe
  2. Withdraw 3 units of clear insulin
  3. Change the needle
  4. Withdraw 2 units of cloudy insulin

Method 2

  • If the needle cannot be changed, add a total of 5 units of air to the syringe
  • Withdraw 3 units of clear insulin
  • Withdraw 2 units of cloudy insulin

These methods will prevent the clear solution being contaminated by the cloudy one. If the short-acting medication was contaminated by the intermediate-acting one, masking effect could occur which could be fatal for the client.

Mixing Insulin Clear Before Cloudy
Mixing Insulin Clear Before Cloudy

When mixing insulin just remember: a clear day is preferable to a cloudy day.

Key Points

  • Blood glucose must always be tested prior to administration.
  • Insulin is never to be administered to an already hypoglycemic client.
  • CLEAR insulin must be withdrawn first prior to CLOUDY insulin when mixing insulin.
  • The peak hour of each type of insulin is the time when hypoglycemia symptoms usually occur.
  • Regular insulin is the only insulin that can be given through IV.  All other insulin types are given through subcutaneous injection.