{"id":985,"date":"2015-06-22T23:05:01","date_gmt":"2015-06-23T03:05:01","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/blood-and-blood-product-administration\/"},"modified":"2022-06-08T11:34:01","modified_gmt":"2022-06-08T15:34:01","slug":"8-11-transfusion-of-blood-and-blood-products","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/8-11-transfusion-of-blood-and-blood-products\/","title":{"raw":"8.11 Transfusion of Blood and Blood Products","rendered":"8.11 Transfusion of Blood and Blood Products"},"content":{"raw":"All healthcare practitioners who administer blood or blood products must complete specific training for safe transfusion practices and be competent in the transfusion administration process. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. These guidelines apply to adult patients only.\r\n\r\nThe transfusion of blood or blood products (see Figure 8.31) is the administration of whole blood, its components, or plasma-derived products. The primary indication for a red blood cell (RBC) transfusion is to improve the oxygen-carrying capacity of the blood (Canadian Blood Services, 2017a). An order from a healthcare provider is required for the transfusion of blood or blood products. RBC transfusions are indicated in patients with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with bone marrow suppression may be candidates for RBC transfusion. In patients with acute blood loss, volume replacement is often more critical than the composition of the replacing fluids (Canadian Blood Services, 2017a). Transfusions can restore blood volume, restore oxygen-carrying capacity of blood with red blood cells, and provide platelets and clotting factors. The most common type of blood transfusion is blood that is donated by another person (allogeneic). Autologous transfusion is the transfusion of one's own blood (Perry et al., 2018).\r\n\r\n[caption id=\"attachment_5795\" align=\"aligncenter\" width=\"199\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1204-e1443928446983.jpg\"><img class=\"wp-image-5795 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1204-e1443928446983-199x300.jpg\" alt=\"Red Blood Cells and Blood IV tubing\" width=\"199\" height=\"300\" \/><\/a> Figure 8.31 Red blood cells and blood IV tubing. Note the filter is the bottom half of the drip chamber[\/caption]\r\n\r\nTransfusion therapy is considered safe, and stringent precautions are followed in the collection, processing, and administration of blood and blood components. However, transfusions still carry risks such as incompatibility, human error, and disease transmission, and\u00a0blood transfusion must be taken seriously at all times. Incompatibility can be decreased by using irradiated red blood cells or leukocyte-reduced blood. The majority of blood transfusion complications are a result of human error (Perry et al., 2018).\r\n\r\nCompatibility testing is vital for all recipients of blood or blood products. Recipients must be transfused with an ABO group specific to their own blood type or ABO group-compatible. There are three types of blood typing systems:\u00a0ABO, Rh, and human leukocyte antigen (HLA). For more information on these, refer to the online resources at the end of this chapter. It is vital to understand what types of blood groups are compatible for transfusions (Canadian Blood Services, 2017b).\r\n\r\nWhen administering blood and blood products, it is important to know the patient's values and beliefs regarding blood products. Some groups of individuals, mainly Jehovah's Witnesses, may refuse blood transfusions or blood products based on religious beliefs. These individuals sometimes refuse transfusion of whole blood and primary blood components but may accept transfusion of derivatives of primary blood components such as albumin solutions, clotting factors, and immunoglobulins. Always assess each individual's preference to establish if a blood component is an acceptable treatment to manage their illness or condition (Canadian Blood Services, 2017a).\r\n\r\nWhen managing blood transfusions, it is important to identify issues promptly to manage reactions effectively. Transfusion reactions (mild to life-threatening) may occur despite all safety measures taken. All transfusion reactions and transfusion errors must be reported to the agency's transfusion medical services (TMS, a.k.a. the \"blood bank\"). It is imperative to know what signs and symptoms to look for, and to educate your patient on what to report and when to report potential transfusion reactions. Mild to severe reactions may include the following (Canadian Blood Services, 2017b):\r\n<ul>\r\n \t<li>Temperature \u2265 38.0\u00b0C or change of 1\u00b0C from pre-transfusion value<\/li>\r\n \t<li>Acute or delayed hemolytic transfusion reaction<\/li>\r\n \t<li>Hypotension\/shock<\/li>\r\n \t<li>Rigors<\/li>\r\n \t<li>Anxiety<\/li>\r\n \t<li>Back or chest pain<\/li>\r\n \t<li>Nausea\/vomiting<\/li>\r\n \t<li>Shortness of breath (dyspnea)<\/li>\r\n \t<li>Hemoglobinuria<\/li>\r\n \t<li>Bleeding\/pain at IV site<\/li>\r\n \t<li>Tachycardia\/arrhythmia<\/li>\r\n \t<li>Generalized flushing<\/li>\r\n \t<li>Rash \u2265 25% of body<\/li>\r\n \t<li>Urticaria and other anaphylaxis reactions<\/li>\r\n \t<li>Hemolysis after transfusion<\/li>\r\n \t<li>Cytopenias after transfusion<\/li>\r\n \t<li>Virus, parasite, and prion infections<\/li>\r\n \t<li>Non-immunological reactions including infection<\/li>\r\n \t<li>Circulatory overload<\/li>\r\n \t<li>Hypothermia<\/li>\r\n<\/ul>\r\nIt is important to note that some reactions can occur one or more days after a transfusion (Canadian Blood Services, 2017b). As such, patients going home after a transfusion require education about what to watch for and what do do in the event of a reaction. For more information on types of reactions, signs and symptoms, and treatments, review the article <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4260299\/\" target=\"_blank\" rel=\"noopener\">adverse events related to blood transfusions<\/a>, or see the online resources at the end of this chapter.\u00a0If patient has a blood transfusion reaction, always follow agency policy to manage mild to severe blood reactions. This text will cover pre transfusion preparation (Checklist 75), transfusion of blood\r\n\r\nand blood products (Checklist 76) and then managing a blood transfusion \/ blood product reaction (Checklist 77).\r\n\r\nThe steps\u00a0in Checklist 75 must be completed <em>before<\/em> obtaining the blood or blood product from the blood bank (Alberta Health Services, 2015a, 2015b; Perry et al., 2018; Vancouver Coastal Health, 2008).\r\n<table style=\"border-color: #000000; height: 3653px; width: 100%;\" border=\"1px solid rgb(0, 0, 0)\">\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 204px; width: 977.4px;\" colspan=\"5\">\r\n<h3 style=\"text-align: center;\"><a id=\"checklist75\"><\/a>Checklist 75: Pre transfusion Preparation<\/h3>\r\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 333px; width: 977.4px;\" colspan=\"5\">\r\n<h5><span style=\"color: #333333;\">S<\/span><span style=\"color: #333333;\">afety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Some blood products require refrigeration. Complete the preparation BEFORE calling for delivery of the blood \/ blood product.<\/li>\r\n \t<li>If the product does require refrigeration and cannot be administered immediately, return it to TMS (transfusion medical services) for safe storage.<\/li>\r\n \t<li>If there is any discrepancy between patient information, group and screen, product ordered, etc., do not proceed. Stop and verify any discrepancies.<\/li>\r\n \t<li>Be diligent when preparing to infuse blood. Distractions may lead to errors when verifying information.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; width: 479.8px; height: 121px;\" colspan=\"3\">\r\n<h4 style=\"text-align: center;\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center; height: 121px; width: 480.6px;\" colspan=\"2\">\r\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 346px; width: 479.8px;\" colspan=\"3\">1. Verify prescribers\u2019 order for the specific blood or blood product order<\/td>\r\n<td style=\"border: 1px solid #000000; height: 346px; width: 480.6px;\" colspan=\"2\">Order must verify the type of product; amount; date, time, rate or duration of the infusion; any modifications to the blood component; specific transfusion requirements; and sequence in which multiple components are to be transfused (if multiple components are ordered).\r\n\r\n[caption id=\"attachment_6804\" align=\"aligncenter\" width=\"197\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Sept-22-2015-033.jpg\"><img class=\" wp-image-975\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-300x199.jpg\" alt=\"Physician orders for a blood transfusion\" width=\"197\" height=\"130\" \/><\/a> Physician orders for a blood transfusion[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 234px; width: 479.8px;\" colspan=\"3\">2.\u00a0Verify the prescriber's orders for any pre- or post-transfusion medications to be administered.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 234px; width: 480.6px;\" colspan=\"2\">Medications given prior to transfusion are only considered for persons with documented moderate to severe reactions. Typically medications are administered 30 minutes prior to the transfusion. Examples of meds might include diphenhydramine, acetaminophen, and furosemide.\r\n\r\n<strong>Remember<\/strong>: These medications can also mask a potential reaction.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 57px; width: 479.8px;\" colspan=\"3\">3.\u00a0Obtain the patient\u2019s transfusion history, and note any known allergies and previous transfusion reactions.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 57px; width: 480.6px;\" colspan=\"2\">Past complications may require patient to have pre- and post-transfusion medications to prevent further transfusion reactions.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 190px; width: 479.8px;\" colspan=\"3\">4. Check that the correct patient facility identification and TMS identification band are on the person.\r\n\r\nIf no facility identification band, apply one.\r\n\r\nIf no TMS (a.k.a. blood band) present, STOP. Notify TMS.\r\n\r\nIf any discrepancies STOP. Do not proceed until the discrepancy is resolved.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 190px; width: 480.6px;\" colspan=\"2\">Group, screen, and cross match must be completed within 96 hours of the transfusion to establish any new antibody formation and to ensure current compatibility.\r\n\r\nIf group and screen are outdated, initiate processes for new testing.\r\n\r\nOnly TMS can apply blood product related bands.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 475px; width: 479.8px;\" colspan=\"3\">5. Establish IV site or verify patency of current site.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 475px; width: 480.6px;\" colspan=\"2\">IV sites must be patent and without complications.\r\n\r\nBlood and blood products cannot be mixed with IV medications. If necessary, establish a site specifically for the blood product.\r\n\r\nThe IV cannula must be large enough to allow flow of\u00a0 product at the correct rate. Generally for adults 20 to 22 gauge.\u00a0Large cannulas are necessary for rapid infusion (i.e., 16 or larger).\r\n\r\n[caption id=\"attachment_6167\" align=\"aligncenter\" width=\"179\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0908.jpg\"><img class=\" wp-image-6167\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_0908-300x199.jpg\" alt=\"Assess patency of IV site\" width=\"179\" height=\"119\" \/><\/a> Assess patency of IV site[\/caption]\r\n\r\nCVCs with multiple lumens may allow blood or blood products to be given simultaneously when medications and other solutions infuse through separate lumens.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 395px; width: 479.8px;\" colspan=\"3\">6.\u00a0Verify correct infusion equipment. Prime an IV line following <a href=\"http:\/\/opentextbc.ca\/clinicalskills\/chapter\/8-4-iv-assessment-maintenance-troubleshooting-and-discontinuation\/#checklist66\">Checklist\u00a066<\/a>.\r\n\r\nInitiate primary IV @ 30 cc\/hr.\r\n\r\nEnsure a back up line of 0.9% NS with a standard IV administration set is available at the bedside in the event of emergency.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 395px; width: 480.6px;\" colspan=\"2\">Blood components require filter tubing to remove clots, debris, and coagulated protein. <span style=\"font-size: 1.125rem; font-family: inherit;\">A straight blood administration set is used for all transfusions (we no longer use Y'd blood tubing).<\/span>\r\n\r\nGlass bottles containing albumin and IVIG\u00a0 require vented tubing.\r\n\r\nIf using a pressure infusion device, ensure it is safe to use with transfusions. Some infusion devices can cause mechanical hemolysis.\r\n<ul>\r\n \t<li>0.9% NS for RBC<\/li>\r\n \t<li>D5W for IVIG<\/li>\r\n<\/ul>\r\nRefer to blood product fact sheets for all other products.\r\n\r\nIf this is an elective transfusion, an alternate approach is to prime the IV administration set with the blood product just prior to administration.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 57px; width: 479.8px;\" colspan=\"3\">7.\u00a0Assess laboratory values to confirm rationale for transfusion.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 57px; width: 480.6px;\" colspan=\"2\">For example Hgb, hematocrit, coagulation values, platelent count. This ensures the transfusion is appropriate.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 253px; width: 479.8px;\" colspan=\"3\">8.\u00a0Check that the prescriber has obtained the necessary consent.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; height: 253px; width: 480.6px;\" colspan=\"2\">It is the prescriber's responsibility to obtain consent for blood or blood products.\r\n\r\n<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-019.jpg\"><img class=\"wp-image-977 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-201x300.jpg\" alt=\"Consent\" width=\"115\" height=\"172\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 154px; width: 479.8px;\" colspan=\"3\">9.\u00a0 The nurse confirms consent by ensuring the patient understands the procedure, rationale and by providing an opportunity for the patient's concerns \/ questions to be answered.\r\n\r\nRN to document confirmation of consent.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 154px; width: 480.6px;\" colspan=\"2\">Blood products require consent prior to administration.\r\n\r\nNotify the prescriber if patient is unable to provide indication of understanding the proposed blood or blood product transfusions.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 396px; width: 479.8px;\" colspan=\"3\">10. Obtain and record the pre-transfusion baseline vitals including temperature, pulse, respirations, blood pressure, and SpO<sub>2<\/sub>.\r\n\r\nIn addition, assess for other symptoms that may be confused with transfusion reaction.<\/td>\r\n<td style=\"border: 1px solid #000000; height: 396px; width: 480.6px;\" colspan=\"2\">Fever, rashes, flank pain, or shortness of breath may be preexisting and thus difficult to differentiate from a transfusion reaction.\r\n\r\nThis assessment should be done within 30 minutes of initiating the transfusion. These serve as a baseline in which to compare any changes that may suggest transfusion reaction.\r\n\r\n<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-107.jpg\"><img class=\"wp-image-6464 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/Sept-22-2015-107-209x300.jpg\" alt=\"Pre-assessment of vital signs\" width=\"124\" height=\"178\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 246px; width: 479.8px;\" colspan=\"3\">11.\u00a0Have emergency equipment available at the bedside (oxygen, suction, etc.).<\/td>\r\n<td style=\"border: 1px solid #000000; height: 246px; width: 480.6px;\" colspan=\"2\">Be prepared for potential complications, as prompt intervention may be required to prevent serious complications.\r\n\r\n[caption id=\"attachment_6428\" align=\"aligncenter\" width=\"165\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2294.jpg\"><img class=\"wp-image-6428\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_2294-300x199.jpg\" alt=\"Emergency equipment at bedside\" width=\"165\" height=\"109\" \/><\/a> Emergency equipment check at bedside[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 154px; width: 479.8px;\" colspan=\"3\">12. Complete all documentation as required per agency policy.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; height: 154px; width: 480.6px;\" colspan=\"2\">Proper documentation provides evidence that all required procedures have been followed to prepare for a transfusion.\r\n\r\nYou have completed bedside check #1. You are now ready to call for the blood product.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; height: 38px; width: 977.4px;\" colspan=\"5\">Data sources: Alberta Health Services, 2015b; Canadian Blood Services, 2017c; Interior Health, 2018; Perry et al., 2018; Vancouver Coastal Health, 2008<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n&nbsp;\r\n<table style=\"border-color: #000000; width: 100%; height: 3564px;\" border=\"1px solid rgb(0, 0, 0)\">\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; width: 985.4px; height: 204px;\" colspan=\"5\">\r\n<h3 style=\"text-align: center;\"><a id=\"checklist76\"><\/a>Checklist 76: Transfusion of Blood and Blood Products<\/h3>\r\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 985.4px; height: 390px;\" colspan=\"5\">\r\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\r\n<ul>\r\n \t<li>Blood\u00a0 and blood products cannot be mixed with any IV medications<\/li>\r\n \t<li>Specific blood administration tubing is required for all blood transfusions. New tubing \/ filter is required after 4 hours.<\/li>\r\n \t<li>See agency policy for using EID for the administration of blood products. EIDs should have a sticker on them to indicate their safe use with blood products.<\/li>\r\n \t<li>Intravenous immunoglobulin (IVIG) is only compatible with D5W.<\/li>\r\n \t<li>All blood products taken from the blood bank must be hung within 30 minutes and administered (infused) within 4 hours due to the risk of bacterial proliferation in the blood component at room temperature. If the product cannot be infused within 4 hours, stop the transfusion and return the remaining blood component to the TMS.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; width: 479px; height: 121px;\" colspan=\"3\">\r\n<h4 style=\"text-align: center;\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center; width: 489.4px; height: 121px;\" colspan=\"2\">\r\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">1. Verify prescribers\u2019 order and pre-transfusion preparation.\u00a0Checklist 75 is complete.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Reduces risk to patient. Promotes safety.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 57px;\" colspan=\"3\">2. Obtain blood product from TMS within 30 minutes of planned transfusion.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 57px;\" colspan=\"2\">Plan for pickup or delivery of blood and blood products. Do not request blood or blood products if pre-transfusion preparation is not complete.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 252px;\" colspan=\"3\">3. Complete visual inspection of product. Assess blood bag for\u00a0any signs of leaks or contamination, such as clumping, clots, gas bubbles, or a purplish discoloration.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 252px;\" colspan=\"2\">Ensures integrity of the product. If any concerns, return product to TMS.\r\n\r\n[caption id=\"attachment_2489\" align=\"aligncenter\" width=\"254\"]<img class=\"wp-image-2489 \" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products-300x191.jpg\" alt=\"\" width=\"254\" height=\"162\" \/> Figure 8.32 Blood product example[\/caption]<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">4.\u00a0Document any clinical sign or symptom that may be confused with a transfusion reaction (e.g., existing fever).<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Serves as baseline to which further assessments can be compared.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 653px;\" colspan=\"3\">5. Complete bedside check with two healthcare providers:\r\n\r\n<strong>Transfusionist<\/strong>: Leads and verbalizes all of the necessary elements.\r\n\r\n<strong>2nd person verifier<\/strong>: Verbally confirms after each element is checked.\r\n\r\n&nbsp;\r\n<ul>\r\n \t<li>Confirm prescriber's order.<\/li>\r\n \t<li>Patient identification: Patient to state full name and DOB. Must be an exact match on patient facility ID and TMS documents<\/li>\r\n \t<li>TMS ID band number (a.k.a. blood band)<\/li>\r\n \t<li>Blood component: Read out the name of the component on the TMS document and the blood component container label.<\/li>\r\n \t<li>Patient ABO group: From the TMS documents<\/li>\r\n \t<li>Blood component ABO group: From the TMS document and blood component container label<\/li>\r\n \t<li>Blood component serial number: From the TMS document and blood component label<\/li>\r\n \t<li>Blood component expiry date<\/li>\r\n<\/ul>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 653px;\" colspan=\"2\">All verification numbers\/information must match exactly. Must be completed by two trained staff members competent in blood transfusion administration process as set out by the agency.\r\n\r\n&nbsp;\r\n\r\n[caption id=\"attachment_982\" align=\"aligncenter\" width=\"184\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-032.jpg\"><img class=\"wp-image-982\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-300x208.jpg\" alt=\"Identify patient\" width=\"184\" height=\"128\" \/><\/a> Confirm patient identity[\/caption]\r\n\r\n&nbsp;\r\n\r\n[caption id=\"attachment_6516\" align=\"aligncenter\" width=\"178\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-033.jpg\"><img class=\" wp-image-6516\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-1.jpg\" alt=\"TMS record\" width=\"178\" height=\"118\" \/><\/a> TMS record[\/caption]\r\n\r\nIf there are any discrepancies, STOP the process and contact the TMS for resolution and direction. Do not proceed.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 155px;\" colspan=\"3\">6. Perform hand hygiene.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 155px;\" colspan=\"2\">Decreases risk of transmitting microorganisms.\r\n\r\nDo not remove the product from the presence of the patient; prime at bedside. If product is removed from bedside, the final verification process must be completed again.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 242px;\" colspan=\"3\">7. Invert product 5 to 10 times and insert spike of the blood administration set into the blood product container.\r\n\r\nSqueeze the drip chamber.\r\n\r\nCompletely cover the filter with product. Fill the top of the drip chamber 1\/2 to 1\/3 full.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 242px;\" colspan=\"2\">&nbsp;\r\n\r\n<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1178-e1442761410159.jpg\"><img class=\"wp-image-5773 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1178-e1442761410159-199x300.jpg\" alt=\"Prime blood tubing\" width=\"107\" height=\"162\" \/><\/a>\r\n\r\nPriming blood tubing is very similar to priming IV tubing.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 587px;\" colspan=\"3\">8. Initiate transfusion.\r\n\r\nStay at the patient\u2019s bedside for the first 5 minutes ensuring the blood enters the patient\u2019s circulation.\r\n\r\nObtain vitals after 15 minutes. Assess for other signs of reaction. If stable, increase transfusion rate as per orders or as per the nurse's judgment of patient risk.\r\n\r\nAdvise patient on the signs and symptoms of transfusion reaction and what and when to report.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 587px;\" colspan=\"2\">Adults: Initiate infusion as per agency guidelines. Infusions always start out slowly because most transfusion reactions occur within first 15 minutes of a transfusion.\u00a0Infusing small amounts of blood component initially minimizes volume of blood to which patient is exposed, thereby minimizing severity of reaction.\r\n\r\n&nbsp;\r\n\r\nFor example: Packed RBCs: 50 ml\/hour for 15 minutes. Platelets \/ plasma: 50 to 100 ml\/hour for 15 minutes\r\n\r\n[caption id=\"attachment_57732\" align=\"aligncenter\" width=\"190\"]<a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1200-e1442761865948.jpg\"><img class=\"wp-image-5792 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1200-e1442761865948-300x199.jpg\" alt=\"Infusion of packed RBC\" width=\"190\" height=\"126\" \/><\/a> Infusion of packed RBC[\/caption]\r\n\r\nFor all units to be infused, r<span style=\"font-family: inherit; font-size: inherit;\">emain with the patient for the first 5 minutes and assess for clinical signs of transfusion reaction.<\/span>\r\n\r\nRecommended best practice is to transfuse each unit of packed RBCs over 2 hours as long as no medical contraindications are evident OR as per prescribers\u2019 orders.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 192px;\" colspan=\"3\">9. Continue to monitor vitals signs q1h up to and including 1 hour post transfusion or until patient is stable.\r\nOngoing patient assessment and monitoring is necessary.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 192px;\" colspan=\"2\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-107.jpg\"><img class=\"wp-image-6464 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/Sept-22-2015-107-209x300.jpg\" alt=\"vital signs\" width=\"120\" height=\"173\" \/><\/a><\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 166px;\" colspan=\"3\">10. In the event of a transfusion reaction, stop the infusion.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 166px;\" colspan=\"2\">\r\n<ul>\r\n \t<li>Manage transfusion reactions as per agency protocol.<\/li>\r\n \t<li>Complete required transfusion reaction form.<\/li>\r\n \t<li>Return remaining blood to blood bank for further investigation.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">11. For additional units, repeat steps 2 to 9.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Follow the same process to ensure patient safety.\r\n\r\nBlood tubing must be discarded after 2 units or 4 hours, whichever comes first.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 101px;\" colspan=\"3\">12. At the end of the transfusion, flush lines according to agency flushing protocol.\r\n\r\n&nbsp;<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 101px;\" colspan=\"2\">CVCs often require 20 saline turbulent flush after a transfusion to maintain lumen patency. See agency flushing and locking protocols.\r\n\r\n&nbsp;<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 19px;\" colspan=\"3\">13. Discard waste in biohazard waste container.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 19px;\" colspan=\"2\">This prevents the spread of biohazard waste.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 479px; height: 273px;\" colspan=\"3\">14. Complete all documentation as required by agency.<\/td>\r\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 273px;\" colspan=\"2\">Documentation may include:\r\n<ul>\r\n \t<li>Transfusion record form<\/li>\r\n \t<li>All vital signs and reactions<\/li>\r\n \t<li>Any significant findings, initiation and termination of transfusion<\/li>\r\n \t<li>Record of transfusion on the in-and-out sheet<\/li>\r\n \t<li>Blood component tags filled out and returned to TMS<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; width: 985.4px; height: 38px;\" colspan=\"5\">Data sources: Alberta Health Services, 2015a, 2015b; Canadian Blood Services, 2017; Interior Health, 2018; Perry et al., 2018; Vancouver Coastal Health, 2008<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-color: #000000;\">\r\n<tbody>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"5\">\r\n<h3 style=\"text-align: center;\"><a id=\"checklist77\"><\/a>Checklist 77: Managing a Blood or Blood Product Transfusion Reaction<\/h3>\r\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">\r\n<h5><span style=\"color: #333333;\">Safety considerations:<\/span><em><span style=\"color: #333333;\">\u00a0<\/span><\/em><\/h5>\r\n<ul>\r\n \t<li>Always review your agency's algorithm for managing mild to severe reactions. For example, if a reaction is mild (e.g., fever), and without any other complications, a patient may continue the transfusion if monitored closely. Most other transfusion reactions require the transfusion to be stopped immediately.<\/li>\r\n \t<li>A blood transfusion reaction may occur 24 to 48 hours post-transfusion.<\/li>\r\n \t<li>Each separate unit presents a potential for an adverse reaction.<\/li>\r\n \t<li>Follow emergency transfusion guidelines when dealing with an emergency blood or blood product transfusion.<\/li>\r\n \t<li>Be aware of which types of blood or blood products cause the most types of transfusion reactions.<\/li>\r\n \t<li>Be aware of the types of patients at high risk for blood or blood product transfusion reactions.<\/li>\r\n \t<li>Always have emergency equipment and medications available during a transfusion. For example, epinephrine IV should always be readily available.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000; text-align: center; width: 50%;\" colspan=\"3\">\r\n<h4 style=\"text-align: center;\">Steps<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"2\">\r\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">1.\u00a0Stop transfusion immediately.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The severity of a blood transfusion reaction is related to the amount of product infused and the amount of time it has been infusing.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">2. Disconnect blood administration set from the extension set. Turbulent flush the VAD as per agency protocol. Attached new IV administratoin set (primed with 0.9% NS) and keep IV line open with 0.9% saline.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Do not allow blood in tubing to be transfused.\r\n\r\nIV access is necessary in the event\u00a0 emergency medications are needed.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">3.\u00a0Complete assessment including vitals signs, respiratory assessment, and which parts of the body are affected (i.e., hives or rash).<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Assessment findings may inform the type and severity of reaction.\r\n\r\nProvide supportive measures as required (oxygen, etc.).<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">4. Report symptoms to prescriber for medical assessment, identification of type of reaction, and instructions for treatment.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The prescriber responsible for the patient must be informed of all transfusion reactions. Treat signs and symptoms as ordered.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">5. Frequent monitoring. Check vital signs every 15 minutes until stable.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Frequent assessment helps to determine improved or worsening condition.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">6. Check all labels, tags, forms, blood order, and patient\u2019s identification band to determine if there is a clerical discrepancy.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Clerical errors account for the majority of blood transfusion reactions.\r\n\r\n&nbsp;<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7.\u00a0Notify the TMS \/ lab to report the reaction and steps taken. Document as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Notify TMS when any adverse reaction occurs, even if transfusion is continued.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7a. Allergic transfusion reactions (except anaphylaxis): TMS will determine need for further bloodwork.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Transfusion may be resumed if:\r\n<ul>\r\n \t<li>Physician order to do so; AND<\/li>\r\n \t<li>Transfusionist confirms ID with blood product tag and label as correct; AND<\/li>\r\n \t<li>Vigilant monitoring by transfusionist is possible; AND<\/li>\r\n \t<li>Product can be reasonably infused within 4 hours of issuance from TMS.<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7b. All other transfusion reactions including anaphylaxis: monitor renal function \/ fluid balance, vital signs. Document as per agency policy. Anticipate need for blood work. Collect urinalysis and microscopic urinalysis on first voided sample. Send to lab. If sepsis suspected: obtain blood cultures. Return blood bag with sterile capped tubing attached with completed reaction report form in a biohazard bag.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Blood and urine samples can help identify the type of blood transfusion reaction.\r\n\r\nAll blood products and IV tubing are investigated by the transfusion services and reported to Canadian Blood Services and Public Health Agency of Canada. These professional bodies are responsible for reporting and recording incidents of reactions.<\/td>\r\n<\/tr>\r\n<tr style=\"border-color: #000000;\">\r\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">8.\u00a0Document as per agency policy.<\/td>\r\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Document time, date, signs and symptoms, type of product, notification to the physician and management of reaction, and patient response to management of reaction. Documentation includes, but is not limited to:\r\n<ul>\r\n \t<li>Transfusion reaction form<\/li>\r\n \t<li>Patient chart<\/li>\r\n \t<li>Report for transfusion services (blood bank)<\/li>\r\n \t<li>Patient Safety Learning System (PSLS) report<\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<table style=\"border-collapse: collapse; width: 100%;\" border=\"0\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 100%;\">Data Sources:\u00a0Alberta Health Services, 2015a, 2015b; Canadian Blood Services, 2017; Interior Health, 2018;<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center;\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>How long can blood or blood products be at room air temperature before being considered at risk for infusion?<\/li>\r\n \t<li>You are about to initiate an infusion of packed red blood cells. What patient teaching is important to include about possible signs and symptoms of reaction?<\/li>\r\n<\/ol>\r\n<h2>Attributions<\/h2>\r\nFigure 8.31. <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/blood-and-blood-product-administration\/\">Red Blood Cells<\/a> from BCIT\u00a0is\u00a0used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.\r\n\r\nFigure 8.32 Blood Product Example by author\u00a0is licensed under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 4.0<\/span><\/a>\u00a0international license.\r\n\r\n<\/div>","rendered":"<p>All healthcare practitioners who administer blood or blood products must complete specific training for safe transfusion practices and be competent in the transfusion administration process. Always refer to your agency policy for guidelines for preparing, initiating, and monitoring blood and blood product transfusions. These guidelines apply to adult patients only.<\/p>\n<p>The transfusion of blood or blood products (see Figure 8.31) is the administration of whole blood, its components, or plasma-derived products. The primary indication for a red blood cell (RBC) transfusion is to improve the oxygen-carrying capacity of the blood (Canadian Blood Services, 2017a). An order from a healthcare provider is required for the transfusion of blood or blood products. RBC transfusions are indicated in patients with anemia who have evidence of impaired oxygen delivery. For example, individuals with acute blood loss, chronic anemia and cardiopulmonary compromise, or disease or medication effects associated with bone marrow suppression may be candidates for RBC transfusion. In patients with acute blood loss, volume replacement is often more critical than the composition of the replacing fluids (Canadian Blood Services, 2017a). Transfusions can restore blood volume, restore oxygen-carrying capacity of blood with red blood cells, and provide platelets and clotting factors. The most common type of blood transfusion is blood that is donated by another person (allogeneic). Autologous transfusion is the transfusion of one&#8217;s own blood (Perry et al., 2018).<\/p>\n<figure id=\"attachment_5795\" aria-describedby=\"caption-attachment-5795\" style=\"width: 199px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1204-e1443928446983.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5795 size-medium\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1204-e1443928446983-199x300.jpg\" alt=\"Red Blood Cells and Blood IV tubing\" width=\"199\" height=\"300\" \/><\/a><figcaption id=\"caption-attachment-5795\" class=\"wp-caption-text\">Figure 8.31 Red blood cells and blood IV tubing. Note the filter is the bottom half of the drip chamber<\/figcaption><\/figure>\n<p>Transfusion therapy is considered safe, and stringent precautions are followed in the collection, processing, and administration of blood and blood components. However, transfusions still carry risks such as incompatibility, human error, and disease transmission, and\u00a0blood transfusion must be taken seriously at all times. Incompatibility can be decreased by using irradiated red blood cells or leukocyte-reduced blood. The majority of blood transfusion complications are a result of human error (Perry et al., 2018).<\/p>\n<p>Compatibility testing is vital for all recipients of blood or blood products. Recipients must be transfused with an ABO group specific to their own blood type or ABO group-compatible. There are three types of blood typing systems:\u00a0ABO, Rh, and human leukocyte antigen (HLA). For more information on these, refer to the online resources at the end of this chapter. It is vital to understand what types of blood groups are compatible for transfusions (Canadian Blood Services, 2017b).<\/p>\n<p>When administering blood and blood products, it is important to know the patient&#8217;s values and beliefs regarding blood products. Some groups of individuals, mainly Jehovah&#8217;s Witnesses, may refuse blood transfusions or blood products based on religious beliefs. These individuals sometimes refuse transfusion of whole blood and primary blood components but may accept transfusion of derivatives of primary blood components such as albumin solutions, clotting factors, and immunoglobulins. Always assess each individual&#8217;s preference to establish if a blood component is an acceptable treatment to manage their illness or condition (Canadian Blood Services, 2017a).<\/p>\n<p>When managing blood transfusions, it is important to identify issues promptly to manage reactions effectively. Transfusion reactions (mild to life-threatening) may occur despite all safety measures taken. All transfusion reactions and transfusion errors must be reported to the agency&#8217;s transfusion medical services (TMS, a.k.a. the &#8220;blood bank&#8221;). It is imperative to know what signs and symptoms to look for, and to educate your patient on what to report and when to report potential transfusion reactions. Mild to severe reactions may include the following (Canadian Blood Services, 2017b):<\/p>\n<ul>\n<li>Temperature \u2265 38.0\u00b0C or change of 1\u00b0C from pre-transfusion value<\/li>\n<li>Acute or delayed hemolytic transfusion reaction<\/li>\n<li>Hypotension\/shock<\/li>\n<li>Rigors<\/li>\n<li>Anxiety<\/li>\n<li>Back or chest pain<\/li>\n<li>Nausea\/vomiting<\/li>\n<li>Shortness of breath (dyspnea)<\/li>\n<li>Hemoglobinuria<\/li>\n<li>Bleeding\/pain at IV site<\/li>\n<li>Tachycardia\/arrhythmia<\/li>\n<li>Generalized flushing<\/li>\n<li>Rash \u2265 25% of body<\/li>\n<li>Urticaria and other anaphylaxis reactions<\/li>\n<li>Hemolysis after transfusion<\/li>\n<li>Cytopenias after transfusion<\/li>\n<li>Virus, parasite, and prion infections<\/li>\n<li>Non-immunological reactions including infection<\/li>\n<li>Circulatory overload<\/li>\n<li>Hypothermia<\/li>\n<\/ul>\n<p>It is important to note that some reactions can occur one or more days after a transfusion (Canadian Blood Services, 2017b). As such, patients going home after a transfusion require education about what to watch for and what do do in the event of a reaction. For more information on types of reactions, signs and symptoms, and treatments, review the article <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4260299\/\" target=\"_blank\" rel=\"noopener\">adverse events related to blood transfusions<\/a>, or see the online resources at the end of this chapter.\u00a0If patient has a blood transfusion reaction, always follow agency policy to manage mild to severe blood reactions. This text will cover pre transfusion preparation (Checklist 75), transfusion of blood<\/p>\n<p>and blood products (Checklist 76) and then managing a blood transfusion \/ blood product reaction (Checklist 77).<\/p>\n<p>The steps\u00a0in Checklist 75 must be completed <em>before<\/em> obtaining the blood or blood product from the blood bank (Alberta Health Services, 2015a, 2015b; Perry et al., 2018; Vancouver Coastal Health, 2008).<\/p>\n<table style=\"border-color: #000000; height: 3653px; width: 100%;\">\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; height: 204px; width: 977.4px;\" colspan=\"5\">\n<h3 style=\"text-align: center;\"><a id=\"checklist75\"><\/a>Checklist 75: Pre transfusion Preparation<\/h3>\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 333px; width: 977.4px;\" colspan=\"5\">\n<h5><span style=\"color: #333333;\">S<\/span><span style=\"color: #333333;\">afety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Some blood products require refrigeration. Complete the preparation BEFORE calling for delivery of the blood \/ blood product.<\/li>\n<li>If the product does require refrigeration and cannot be administered immediately, return it to TMS (transfusion medical services) for safe storage.<\/li>\n<li>If there is any discrepancy between patient information, group and screen, product ordered, etc., do not proceed. Stop and verify any discrepancies.<\/li>\n<li>Be diligent when preparing to infuse blood. Distractions may lead to errors when verifying information.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; width: 479.8px; height: 121px;\" colspan=\"3\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; text-align: center; height: 121px; width: 480.6px;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 346px; width: 479.8px;\" colspan=\"3\">1. Verify prescribers\u2019 order for the specific blood or blood product order<\/td>\n<td style=\"border: 1px solid #000000; height: 346px; width: 480.6px;\" colspan=\"2\">Order must verify the type of product; amount; date, time, rate or duration of the infusion; any modifications to the blood component; specific transfusion requirements; and sequence in which multiple components are to be transfused (if multiple components are ordered).<\/p>\n<figure id=\"attachment_6804\" aria-describedby=\"caption-attachment-6804\" style=\"width: 197px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/10\/Sept-22-2015-033.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-975\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-300x199.jpg\" alt=\"Physician orders for a blood transfusion\" width=\"197\" height=\"130\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-300x199.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-768x509.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-1024x678.jpg 1024w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-65x43.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-225x149.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-350x232.jpg 350w\" sizes=\"auto, (max-width: 197px) 100vw, 197px\" \/><\/a><figcaption id=\"caption-attachment-6804\" class=\"wp-caption-text\">Physician orders for a blood transfusion<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 234px; width: 479.8px;\" colspan=\"3\">2.\u00a0Verify the prescriber&#8217;s orders for any pre- or post-transfusion medications to be administered.<\/td>\n<td style=\"border: 1px solid #000000; height: 234px; width: 480.6px;\" colspan=\"2\">Medications given prior to transfusion are only considered for persons with documented moderate to severe reactions. Typically medications are administered 30 minutes prior to the transfusion. Examples of meds might include diphenhydramine, acetaminophen, and furosemide.<\/p>\n<p><strong>Remember<\/strong>: These medications can also mask a potential reaction.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 57px; width: 479.8px;\" colspan=\"3\">3.\u00a0Obtain the patient\u2019s transfusion history, and note any known allergies and previous transfusion reactions.<\/td>\n<td style=\"border: 1px solid #000000; height: 57px; width: 480.6px;\" colspan=\"2\">Past complications may require patient to have pre- and post-transfusion medications to prevent further transfusion reactions.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 190px; width: 479.8px;\" colspan=\"3\">4. Check that the correct patient facility identification and TMS identification band are on the person.<\/p>\n<p>If no facility identification band, apply one.<\/p>\n<p>If no TMS (a.k.a. blood band) present, STOP. Notify TMS.<\/p>\n<p>If any discrepancies STOP. Do not proceed until the discrepancy is resolved.<\/td>\n<td style=\"border: 1px solid #000000; height: 190px; width: 480.6px;\" colspan=\"2\">Group, screen, and cross match must be completed within 96 hours of the transfusion to establish any new antibody formation and to ensure current compatibility.<\/p>\n<p>If group and screen are outdated, initiate processes for new testing.<\/p>\n<p>Only TMS can apply blood product related bands.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 475px; width: 479.8px;\" colspan=\"3\">5. Establish IV site or verify patency of current site.<\/td>\n<td style=\"border: 1px solid #000000; height: 475px; width: 480.6px;\" colspan=\"2\">IV sites must be patent and without complications.<\/p>\n<p>Blood and blood products cannot be mixed with IV medications. If necessary, establish a site specifically for the blood product.<\/p>\n<p>The IV cannula must be large enough to allow flow of\u00a0 product at the correct rate. Generally for adults 20 to 22 gauge.\u00a0Large cannulas are necessary for rapid infusion (i.e., 16 or larger).<\/p>\n<figure id=\"attachment_6167\" aria-describedby=\"caption-attachment-6167\" style=\"width: 179px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_0908.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6167\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_0908-300x199.jpg\" alt=\"Assess patency of IV site\" width=\"179\" height=\"119\" \/><\/a><figcaption id=\"caption-attachment-6167\" class=\"wp-caption-text\">Assess patency of IV site<\/figcaption><\/figure>\n<p>CVCs with multiple lumens may allow blood or blood products to be given simultaneously when medications and other solutions infuse through separate lumens.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 395px; width: 479.8px;\" colspan=\"3\">6.\u00a0Verify correct infusion equipment. Prime an IV line following <a href=\"http:\/\/opentextbc.ca\/clinicalskills\/chapter\/8-4-iv-assessment-maintenance-troubleshooting-and-discontinuation\/#checklist66\">Checklist\u00a066<\/a>.<\/p>\n<p>Initiate primary IV @ 30 cc\/hr.<\/p>\n<p>Ensure a back up line of 0.9% NS with a standard IV administration set is available at the bedside in the event of emergency.<\/td>\n<td style=\"border: 1px solid #000000; height: 395px; width: 480.6px;\" colspan=\"2\">Blood components require filter tubing to remove clots, debris, and coagulated protein. <span style=\"font-size: 1.125rem; font-family: inherit;\">A straight blood administration set is used for all transfusions (we no longer use Y&#8217;d blood tubing).<\/span><\/p>\n<p>Glass bottles containing albumin and IVIG\u00a0 require vented tubing.<\/p>\n<p>If using a pressure infusion device, ensure it is safe to use with transfusions. Some infusion devices can cause mechanical hemolysis.<\/p>\n<ul>\n<li>0.9% NS for RBC<\/li>\n<li>D5W for IVIG<\/li>\n<\/ul>\n<p>Refer to blood product fact sheets for all other products.<\/p>\n<p>If this is an elective transfusion, an alternate approach is to prime the IV administration set with the blood product just prior to administration.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 57px; width: 479.8px;\" colspan=\"3\">7.\u00a0Assess laboratory values to confirm rationale for transfusion.<\/td>\n<td style=\"border: 1px solid #000000; height: 57px; width: 480.6px;\" colspan=\"2\">For example Hgb, hematocrit, coagulation values, platelent count. This ensures the transfusion is appropriate.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 253px; width: 479.8px;\" colspan=\"3\">8.\u00a0Check that the prescriber has obtained the necessary consent.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; height: 253px; width: 480.6px;\" colspan=\"2\">It is the prescriber&#8217;s responsibility to obtain consent for blood or blood products.<\/p>\n<p><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-019.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-977 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-201x300.jpg\" alt=\"Consent\" width=\"115\" height=\"172\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-201x300.jpg 201w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019.jpg 685w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-65x97.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-225x336.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-019-350x523.jpg 350w\" sizes=\"auto, (max-width: 115px) 100vw, 115px\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 154px; width: 479.8px;\" colspan=\"3\">9.\u00a0 The nurse confirms consent by ensuring the patient understands the procedure, rationale and by providing an opportunity for the patient&#8217;s concerns \/ questions to be answered.<\/p>\n<p>RN to document confirmation of consent.<\/td>\n<td style=\"border: 1px solid #000000; height: 154px; width: 480.6px;\" colspan=\"2\">Blood products require consent prior to administration.<\/p>\n<p>Notify the prescriber if patient is unable to provide indication of understanding the proposed blood or blood product transfusions.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 396px; width: 479.8px;\" colspan=\"3\">10. Obtain and record the pre-transfusion baseline vitals including temperature, pulse, respirations, blood pressure, and SpO<sub>2<\/sub>.<\/p>\n<p>In addition, assess for other symptoms that may be confused with transfusion reaction.<\/td>\n<td style=\"border: 1px solid #000000; height: 396px; width: 480.6px;\" colspan=\"2\">Fever, rashes, flank pain, or shortness of breath may be preexisting and thus difficult to differentiate from a transfusion reaction.<\/p>\n<p>This assessment should be done within 30 minutes of initiating the transfusion. These serve as a baseline in which to compare any changes that may suggest transfusion reaction.<\/p>\n<p><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-107.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6464 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/Sept-22-2015-107-209x300.jpg\" alt=\"Pre-assessment of vital signs\" width=\"124\" height=\"178\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 246px; width: 479.8px;\" colspan=\"3\">11.\u00a0Have emergency equipment available at the bedside (oxygen, suction, etc.).<\/td>\n<td style=\"border: 1px solid #000000; height: 246px; width: 480.6px;\" colspan=\"2\">Be prepared for potential complications, as prompt intervention may be required to prevent serious complications.<\/p>\n<figure id=\"attachment_6428\" aria-describedby=\"caption-attachment-6428\" style=\"width: 165px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_2294.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6428\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_2294-300x199.jpg\" alt=\"Emergency equipment at bedside\" width=\"165\" height=\"109\" \/><\/a><figcaption id=\"caption-attachment-6428\" class=\"wp-caption-text\">Emergency equipment check at bedside<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 154px; width: 479.8px;\" colspan=\"3\">12. Complete all documentation as required per agency policy.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; height: 154px; width: 480.6px;\" colspan=\"2\">Proper documentation provides evidence that all required procedures have been followed to prepare for a transfusion.<\/p>\n<p>You have completed bedside check #1. You are now ready to call for the blood product.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; height: 38px; width: 977.4px;\" colspan=\"5\">Data sources: Alberta Health Services, 2015b; Canadian Blood Services, 2017c; Interior Health, 2018; Perry et al., 2018; Vancouver Coastal Health, 2008<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<table style=\"border-color: #000000; width: 100%; height: 3564px;\">\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; width: 985.4px; height: 204px;\" colspan=\"5\">\n<h3 style=\"text-align: center;\"><a id=\"checklist76\"><\/a>Checklist 76: Transfusion of Blood and Blood Products<\/h3>\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 985.4px; height: 390px;\" colspan=\"5\">\n<h5><span style=\"color: #333333;\">Safety considerations:\u00a0<\/span><\/h5>\n<ul>\n<li>Blood\u00a0 and blood products cannot be mixed with any IV medications<\/li>\n<li>Specific blood administration tubing is required for all blood transfusions. New tubing \/ filter is required after 4 hours.<\/li>\n<li>See agency policy for using EID for the administration of blood products. EIDs should have a sticker on them to indicate their safe use with blood products.<\/li>\n<li>Intravenous immunoglobulin (IVIG) is only compatible with D5W.<\/li>\n<li>All blood products taken from the blood bank must be hung within 30 minutes and administered (infused) within 4 hours due to the risk of bacterial proliferation in the blood component at room temperature. If the product cannot be infused within 4 hours, stop the transfusion and return the remaining blood component to the TMS.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; width: 479px; height: 121px;\" colspan=\"3\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; text-align: center; width: 489.4px; height: 121px;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">1. Verify prescribers\u2019 order and pre-transfusion preparation.\u00a0Checklist 75 is complete.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Reduces risk to patient. Promotes safety.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 57px;\" colspan=\"3\">2. Obtain blood product from TMS within 30 minutes of planned transfusion.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 57px;\" colspan=\"2\">Plan for pickup or delivery of blood and blood products. Do not request blood or blood products if pre-transfusion preparation is not complete.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 252px;\" colspan=\"3\">3. Complete visual inspection of product. Assess blood bag for\u00a0any signs of leaks or contamination, such as clumping, clots, gas bubbles, or a purplish discoloration.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 252px;\" colspan=\"2\">Ensures integrity of the product. If any concerns, return product to TMS.<\/p>\n<figure id=\"attachment_2489\" aria-describedby=\"caption-attachment-2489\" style=\"width: 254px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-2489\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products-300x191.jpg\" alt=\"\" width=\"254\" height=\"162\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products-300x191.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products-65x41.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products-225x143.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2018\/08\/blood-products.jpg 343w\" sizes=\"auto, (max-width: 254px) 100vw, 254px\" \/><figcaption id=\"caption-attachment-2489\" class=\"wp-caption-text\">Figure 8.32 Blood product example<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">4.\u00a0Document any clinical sign or symptom that may be confused with a transfusion reaction (e.g., existing fever).<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Serves as baseline to which further assessments can be compared.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 653px;\" colspan=\"3\">5. Complete bedside check with two healthcare providers:<\/p>\n<p><strong>Transfusionist<\/strong>: Leads and verbalizes all of the necessary elements.<\/p>\n<p><strong>2nd person verifier<\/strong>: Verbally confirms after each element is checked.<\/p>\n<p>&nbsp;<\/p>\n<ul>\n<li>Confirm prescriber&#8217;s order.<\/li>\n<li>Patient identification: Patient to state full name and DOB. Must be an exact match on patient facility ID and TMS documents<\/li>\n<li>TMS ID band number (a.k.a. blood band)<\/li>\n<li>Blood component: Read out the name of the component on the TMS document and the blood component container label.<\/li>\n<li>Patient ABO group: From the TMS documents<\/li>\n<li>Blood component ABO group: From the TMS document and blood component container label<\/li>\n<li>Blood component serial number: From the TMS document and blood component label<\/li>\n<li>Blood component expiry date<\/li>\n<\/ul>\n<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 653px;\" colspan=\"2\">All verification numbers\/information must match exactly. Must be completed by two trained staff members competent in blood transfusion administration process as set out by the agency.<\/p>\n<p>&nbsp;<\/p>\n<figure id=\"attachment_982\" aria-describedby=\"caption-attachment-982\" style=\"width: 184px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-032.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-982\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-300x208.jpg\" alt=\"Identify patient\" width=\"184\" height=\"128\" srcset=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-300x208.jpg 300w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-768x531.jpg 768w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-65x45.jpg 65w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-225x156.jpg 225w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032-350x242.jpg 350w, https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-032.jpg 974w\" sizes=\"auto, (max-width: 184px) 100vw, 184px\" \/><\/a><figcaption id=\"caption-attachment-982\" class=\"wp-caption-text\">Confirm patient identity<\/figcaption><\/figure>\n<p>&nbsp;<\/p>\n<figure id=\"attachment_6516\" aria-describedby=\"caption-attachment-6516\" style=\"width: 178px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-033.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6516\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/Sept-22-2015-033-1.jpg\" alt=\"TMS record\" width=\"178\" height=\"118\" \/><\/a><figcaption id=\"caption-attachment-6516\" class=\"wp-caption-text\">TMS record<\/figcaption><\/figure>\n<p>If there are any discrepancies, STOP the process and contact the TMS for resolution and direction. Do not proceed.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 155px;\" colspan=\"3\">6. Perform hand hygiene.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 155px;\" colspan=\"2\">Decreases risk of transmitting microorganisms.<\/p>\n<p>Do not remove the product from the presence of the patient; prime at bedside. If product is removed from bedside, the final verification process must be completed again.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 242px;\" colspan=\"3\">7. Invert product 5 to 10 times and insert spike of the blood administration set into the blood product container.<\/p>\n<p>Squeeze the drip chamber.<\/p>\n<p>Completely cover the filter with product. Fill the top of the drip chamber 1\/2 to 1\/3 full.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 242px;\" colspan=\"2\">&nbsp;<\/p>\n<p><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1178-e1442761410159.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5773 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1178-e1442761410159-199x300.jpg\" alt=\"Prime blood tubing\" width=\"107\" height=\"162\" \/><\/a><\/p>\n<p>Priming blood tubing is very similar to priming IV tubing.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 587px;\" colspan=\"3\">8. Initiate transfusion.<\/p>\n<p>Stay at the patient\u2019s bedside for the first 5 minutes ensuring the blood enters the patient\u2019s circulation.<\/p>\n<p>Obtain vitals after 15 minutes. Assess for other signs of reaction. If stable, increase transfusion rate as per orders or as per the nurse&#8217;s judgment of patient risk.<\/p>\n<p>Advise patient on the signs and symptoms of transfusion reaction and what and when to report.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 587px;\" colspan=\"2\">Adults: Initiate infusion as per agency guidelines. Infusions always start out slowly because most transfusion reactions occur within first 15 minutes of a transfusion.\u00a0Infusing small amounts of blood component initially minimizes volume of blood to which patient is exposed, thereby minimizing severity of reaction.<\/p>\n<p>&nbsp;<\/p>\n<p>For example: Packed RBCs: 50 ml\/hour for 15 minutes. Platelets \/ plasma: 50 to 100 ml\/hour for 15 minutes<\/p>\n<figure id=\"attachment_57732\" aria-describedby=\"caption-attachment-57732\" style=\"width: 190px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/DSC_1200-e1442761865948.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-5792 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/06\/DSC_1200-e1442761865948-300x199.jpg\" alt=\"Infusion of packed RBC\" width=\"190\" height=\"126\" \/><\/a><figcaption id=\"caption-attachment-57732\" class=\"wp-caption-text\">Infusion of packed RBC<\/figcaption><\/figure>\n<p>For all units to be infused, r<span style=\"font-family: inherit; font-size: inherit;\">emain with the patient for the first 5 minutes and assess for clinical signs of transfusion reaction.<\/span><\/p>\n<p>Recommended best practice is to transfuse each unit of packed RBCs over 2 hours as long as no medical contraindications are evident OR as per prescribers\u2019 orders.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 192px;\" colspan=\"3\">9. Continue to monitor vitals signs q1h up to and including 1 hour post transfusion or until patient is stable.<br \/>\nOngoing patient assessment and monitoring is necessary.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 192px;\" colspan=\"2\"><a href=\"http:\/\/opentextbc.ca\/clinicalskills\/wp-content\/uploads\/sites\/82\/2015\/09\/Sept-22-2015-107.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-6464 aligncenter\" src=\"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-content\/uploads\/sites\/472\/2015\/05\/Sept-22-2015-107-209x300.jpg\" alt=\"vital signs\" width=\"120\" height=\"173\" \/><\/a><\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 166px;\" colspan=\"3\">10. In the event of a transfusion reaction, stop the infusion.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 166px;\" colspan=\"2\">\n<ul>\n<li>Manage transfusion reactions as per agency protocol.<\/li>\n<li>Complete required transfusion reaction form.<\/li>\n<li>Return remaining blood to blood bank for further investigation.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 38px;\" colspan=\"3\">11. For additional units, repeat steps 2 to 9.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 38px;\" colspan=\"2\">Follow the same process to ensure patient safety.<\/p>\n<p>Blood tubing must be discarded after 2 units or 4 hours, whichever comes first.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 101px;\" colspan=\"3\">12. At the end of the transfusion, flush lines according to agency flushing protocol.<\/p>\n<p>&nbsp;<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 101px;\" colspan=\"2\">CVCs often require 20 saline turbulent flush after a transfusion to maintain lumen patency. See agency flushing and locking protocols.<\/p>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 19px;\" colspan=\"3\">13. Discard waste in biohazard waste container.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 19px;\" colspan=\"2\">This prevents the spread of biohazard waste.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 479px; height: 273px;\" colspan=\"3\">14. Complete all documentation as required by agency.<\/td>\n<td style=\"border: 1px solid #000000; width: 489.4px; height: 273px;\" colspan=\"2\">Documentation may include:<\/p>\n<ul>\n<li>Transfusion record form<\/li>\n<li>All vital signs and reactions<\/li>\n<li>Any significant findings, initiation and termination of transfusion<\/li>\n<li>Record of transfusion on the in-and-out sheet<\/li>\n<li>Blood component tags filled out and returned to TMS<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; width: 985.4px; height: 38px;\" colspan=\"5\">Data sources: Alberta Health Services, 2015a, 2015b; Canadian Blood Services, 2017; Interior Health, 2018; Perry et al., 2018; Vancouver Coastal Health, 2008<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-color: #000000;\">\n<tbody>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"5\">\n<h3 style=\"text-align: center;\"><a id=\"checklist77\"><\/a>Checklist 77: Managing a Blood or Blood Product Transfusion Reaction<\/h3>\n<h5 style=\"text-align: center;\"><em><span style=\"color: #000000;\">Disclaimer:\u00a0Always review and follow your agency policy regarding this specific skill.<\/span><\/em><\/h5>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"5\">\n<h5><span style=\"color: #333333;\">Safety considerations:<\/span><em><span style=\"color: #333333;\">\u00a0<\/span><\/em><\/h5>\n<ul>\n<li>Always review your agency&#8217;s algorithm for managing mild to severe reactions. For example, if a reaction is mild (e.g., fever), and without any other complications, a patient may continue the transfusion if monitored closely. Most other transfusion reactions require the transfusion to be stopped immediately.<\/li>\n<li>A blood transfusion reaction may occur 24 to 48 hours post-transfusion.<\/li>\n<li>Each separate unit presents a potential for an adverse reaction.<\/li>\n<li>Follow emergency transfusion guidelines when dealing with an emergency blood or blood product transfusion.<\/li>\n<li>Be aware of which types of blood or blood products cause the most types of transfusion reactions.<\/li>\n<li>Be aware of the types of patients at high risk for blood or blood product transfusion reactions.<\/li>\n<li>Always have emergency equipment and medications available during a transfusion. For example, epinephrine IV should always be readily available.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000; text-align: center; width: 50%;\" colspan=\"3\">\n<h4 style=\"text-align: center;\">Steps<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000; text-align: center;\" colspan=\"2\">\n<h4 style=\"text-align: center;\">\u00a0Additional Information<\/h4>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">1.\u00a0Stop transfusion immediately.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The severity of a blood transfusion reaction is related to the amount of product infused and the amount of time it has been infusing.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">2. Disconnect blood administration set from the extension set. Turbulent flush the VAD as per agency protocol. Attached new IV administratoin set (primed with 0.9% NS) and keep IV line open with 0.9% saline.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Do not allow blood in tubing to be transfused.<\/p>\n<p>IV access is necessary in the event\u00a0 emergency medications are needed.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">3.\u00a0Complete assessment including vitals signs, respiratory assessment, and which parts of the body are affected (i.e., hives or rash).<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Assessment findings may inform the type and severity of reaction.<\/p>\n<p>Provide supportive measures as required (oxygen, etc.).<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">4. Report symptoms to prescriber for medical assessment, identification of type of reaction, and instructions for treatment.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">The prescriber responsible for the patient must be informed of all transfusion reactions. Treat signs and symptoms as ordered.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">5. Frequent monitoring. Check vital signs every 15 minutes until stable.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Frequent assessment helps to determine improved or worsening condition.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">6. Check all labels, tags, forms, blood order, and patient\u2019s identification band to determine if there is a clerical discrepancy.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Clerical errors account for the majority of blood transfusion reactions.<\/p>\n<p>&nbsp;<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7.\u00a0Notify the TMS \/ lab to report the reaction and steps taken. Document as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Notify TMS when any adverse reaction occurs, even if transfusion is continued.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7a. Allergic transfusion reactions (except anaphylaxis): TMS will determine need for further bloodwork.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Transfusion may be resumed if:<\/p>\n<ul>\n<li>Physician order to do so; AND<\/li>\n<li>Transfusionist confirms ID with blood product tag and label as correct; AND<\/li>\n<li>Vigilant monitoring by transfusionist is possible; AND<\/li>\n<li>Product can be reasonably infused within 4 hours of issuance from TMS.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">7b. All other transfusion reactions including anaphylaxis: monitor renal function \/ fluid balance, vital signs. Document as per agency policy. Anticipate need for blood work. Collect urinalysis and microscopic urinalysis on first voided sample. Send to lab. If sepsis suspected: obtain blood cultures. Return blood bag with sterile capped tubing attached with completed reaction report form in a biohazard bag.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Blood and urine samples can help identify the type of blood transfusion reaction.<\/p>\n<p>All blood products and IV tubing are investigated by the transfusion services and reported to Canadian Blood Services and Public Health Agency of Canada. These professional bodies are responsible for reporting and recording incidents of reactions.<\/td>\n<\/tr>\n<tr style=\"border-color: #000000;\">\n<td style=\"border: 1px solid #000000;\" colspan=\"3\">8.\u00a0Document as per agency policy.<\/td>\n<td style=\"border: 1px solid #000000;\" colspan=\"2\">Document time, date, signs and symptoms, type of product, notification to the physician and management of reaction, and patient response to management of reaction. Documentation includes, but is not limited to:<\/p>\n<ul>\n<li>Transfusion reaction form<\/li>\n<li>Patient chart<\/li>\n<li>Report for transfusion services (blood bank)<\/li>\n<li>Patient Safety Learning System (PSLS) report<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-collapse: collapse; width: 100%;\">\n<tbody>\n<tr>\n<td style=\"width: 100%;\">Data Sources:\u00a0Alberta Health Services, 2015a, 2015b; Canadian Blood Services, 2017; Interior Health, 2018;<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center;\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>How long can blood or blood products be at room air temperature before being considered at risk for infusion?<\/li>\n<li>You are about to initiate an infusion of packed red blood cells. What patient teaching is important to include about possible signs and symptoms of reaction?<\/li>\n<\/ol>\n<h2>Attributions<\/h2>\n<p>Figure 8.31. <a href=\"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/blood-and-blood-product-administration\/\">Red Blood Cells<\/a> from BCIT\u00a0is\u00a0used under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\">CC BY-SA 4.0<\/a>\u00a0international license.<\/p>\n<p>Figure 8.32 Blood Product Example by author\u00a0is licensed under a\u00a0<a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\"><span class=\"cc-license-identifier\">CC BY-SA 4.0<\/span><\/a>\u00a0international license.<\/p>\n<\/div>\n","protected":false},"author":397,"menu_order":11,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by"},"chapter-type":[],"contributor":[],"license":[50],"class_list":["post-985","chapter","type-chapter","status-publish","hentry","license-cc-by"],"part":912,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/985","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":25,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/985\/revisions"}],"predecessor-version":[{"id":5212,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/985\/revisions\/5212"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/912"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/985\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=985"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=985"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=985"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=985"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}