Chapter 8: IV Therapy

8.11 Transfusion of Blood and Blood Products

Critical Thinking Exercises: Questions, Answers, and Sources / References

  1. How long can blood or blood products be at room air temperature before being considered at risk for infusion?

Answer: 4 hours

 

2. 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?

Answer: it is important to  discuss general potential  S&S and ask the patient to report any changes to how they feel. General S&S with potential concern include:

  • Fever
  • Light headedness
  • Shivering
  • anxiety
  • Back or chest pain
  • Nausea/vomiting
  • Shortness of breath (dyspnea)
  • Bleeding/pain at IV site
  • Rash ≥ 25% of body
  • Urticaria (itching)

The following chart represents different types of transfusion reactions and their accompanying signs & symptoms. For more information about what the nurse should do in response to an actual or potential reaction including prevention refer to your agency guidelines. A summary is also included in Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 8.11 Transfusion of Blood and Blood Products. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/8-11-transfusion-of-blood-and-blood-products/

Type of Reaction S&S
Allergic

Mild: antibodies against donor plasma proteins. Flushing, itching, urticaria (hives)

Anaphylactic: antibodies to donor plasma. anxiety, urticarial, dyspnea, wheezing, severe hypotension, shock, cardiac arrest

Febrile Non Hemolytic Greater than (>) 1 degree above the temp when the transfusion was initiated

Chills, headache, flushing, anxiety, muscle pain

Acute hemolytic Chills, fever, low back pain, tachycardia, tachypnea, hypotension, hemoglobinemia / uria, circulatory shock, cardiac arrest, death
Circulatory overload Dyspnea, cough, crackles, distended neck veins, hypertension
Sepsis Rapid onset chills, fever, severe hypotension, circulatory shock

Sources: Canadian Blood Services. (2017c). Clinical guide to transfusions. Blood componentshttps://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-components

Potter, P., Perry, A., Stockert, P. , Hall, A. (2019). Canadian Fundamentals of Nursing. Sixth Edition. B. Astle & W. Duggleby (Eds). Milton, Ont: ELSEVIER

Sample Quiz Questions
  1. When preparing to administer a blood product the nurse notes a discrepancy between the spelling of the patient’s name on the prescriber’s order and the transfusion medical services (TMS) documents. The nurse should first:
Distractor Answer More information
Get a 2nd health care provider to confirm it is the correct patient Incorrect The nurse must stop and investigate. Another health care provider won’t be able to provide guidance about a misspelled name
Stop and investigate Correct At any time if there is a discrepancy, the nurse must stop and investigate to prevent an error with blood administration
Proceed cautiously with the transfusion Incorrect The nurse cannot proceed until all discrepancies are sorted out
Call the prescriber Incorrect It is not likely that the prescriber can resolve a misspelled name. The nurse should call transfusion medical services (TMS) / blood bank

Sources:

Alberta Health Services. (2015a). Transfusion of blood and blood components. Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-59.pdf.

Alberta Health Services. (2015b) (2017) . Transfusion of blood and blood components—Acute adult. Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-adult-acute-procedure-ps-59-01.pdf.

Canadian Blood Services (2017a). Blood administration. Retrieved from https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.

Interior Health. (2018). Transfusion practices manual. Retrieved from http://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.

Vancouver Coastal Health. (2008). Administration of blood components and blood products. Vancouver, BC: Vancouver Health Authority.

 

2. The nurse is administering a transfusion of packed red blood cells. Which of the following are appropriate nursing actions? (Select all that apply)

Distractor Answer More information
Preassessment should include vital signs Correct A baseline set of vitals serves as a reference point in the event of a potential reaction
Preassessment should include observing for rash Correct Rash is one symptom of an allergic reaction. If present before the transfusion, it might be difficult to assess for this potential reaction
The nurse should remain with the patient for the first 20 minutes of the transfusion Incorrect While not a bad thing, protocols suggest to remain with the patient for the first 5 minutes of the transfusion. Before leaving the patient, teach about what signs to report immediately
The nurse should aim to have the transfusion done quickly Incorrect Transfusions of packed RBCs are initiated at 50-100 cc/hr (check agency policy) with the goal of completion within 2 hours or according to the prescribers’ order
The nurse should call for delivery of the blood product as soon as the order is received Incorrect The nurse should call for delivery of the product when it can be infused. Blood products that can’t be infused within 30 minutes of arrival should be returned to the TMS
The nurse can use a regular IV administration set if Blood tubing is not available Incorrect Blood tubing must have a filter to filter out clots, debris, and coagulated protein
The nurse can continue to give scheduled IV meds through the same site as the transfusion Incorrect Meds are not compatible with blood. If necessary, a separate site should be used for medications needed during a transfusion

Sources:

Alberta Health Services. (2015a). Transfusion of blood and blood components. https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-59.pdf.

Alberta Health Services. (2015b) (2017) . Transfusion of blood and blood components—Acute adulthttps://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-adult-acute-procedure-ps-59-01.pdf.

Canadian Blood Services (2017a). Blood administrationhttps://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.

Interior Health. (2018). Transfusion practices manualhttp://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.

Vancouver Coastal Health. (2008). Administration of blood components and blood products. Vancouver, BC: Vancouver Health Authority.

 

3. An infusion of packed red blood cells is indicated for:

a. Hypotension (incorrect: hypotension requires volume and not necessarily RBCs)

b. Anemia  (Correct)

c. Hypertension (incorrect)

d. hives (incorrect)

 

Sources:

Canadian Blood Services (2017a). Blood administrationhttps://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.

Interior Health. (2018). Transfusion practices manualhttp://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.