Blood

What are the reasons for infusing blood?

Massive blood loss

  Improve Oxygen carrying capacity

  Active bleeding

  Correction of coagulation defects

  Replace plasma proteins

Blood

Planning to Infuse Blood

What must be included in the order for blood products?

     Must include Type & Cross match,

Must include specific type of blood product

and number of units

Blood

Planning to Infuse Blood

Must consent be obtained from

the patient before administration?

Yes, the patient must sign

a consent form before

administration of

blood or blood products.

Blood

Planning to Infuse Blood

What size guage must

be in place at the IV site?

20 guage or larger.

It is OK to use 22 guage at SHMC

Internal diameters are now larger,

outside diameter is the same.

Blood

Planning to Infuse Blood

Should you select a larger or smaller

vein for administration?

Try to select a larger vein,

Stay away from the hand

Blood

Planning to Infuse

What supplies are needed?

 A pump

 Appropriate tubing/filter 

 Consent

Patent IV site

Blood

Receiving the blood product

Why is it so important to coordinate

care before you receive the

blood product?

  once the blood arrives on the floor, the clock is ticking, you must be ready to double check per protocol and hang the blood ASAP

At Riverbend it must be hung within 15 minutes.

Blood

Receiving the blood product

What 5 things must be checked

with another approved person?

1. Name & MRUN on transfusion record (TR) and chart match

2. Donor # on bag & TR match

3. Blood type & Rh on bag & TR match

4. If autologous, SS# match

5. Dr. order

Blood

Infusion of Blood Product

What equipment is

needed for hanging blood?

(besides the pump)

         Tubing/Filter

       0.9% Normal Saline (250cc bag)

Blood

Infusing of blood products

How many approved people are needed to

do the in patinet room check?

Two

Blood

Infusion of blood products

What must be checked in

the patient's room by both

approved staff members?

Patient’s armband for name & birth date

This must be checked by two

staff members.

Blood

Infusion of blood products

What must also be checked before

infusion of blood products?

A set of patient vital signs prior

to infusion.

Blood

Evaluating the Infusion of Blood

What must be routinely

monitored during infusion of blood.

  Vital Signs:  every 5 minutes for first 15 minutes.

  Volume in first 15 min. ~ 30ml, then adjust rate for appropriate time.

 After first 15 min., observe hourly.

 Change in VS,  increase in temp, Pt. unstable,

 then stop transfusion…

Blood

Evaluating the Infusion of Blood

What must be routinely

monitored after infusion of blood?

 Effectiveness of infusion:

 Activity level

 Color

 Lab values

Blood

Transfusion Reaction

What are acute

transfusion reactions?

  Acute Hemolytic Reaction

ABO incompatibility

Blood

Transfusion Reaction

What are acute

transfusion reactions?

Febrile Reactions

Blood

Transfusion Reaction

What are acute

transfusion reactions?

   Allergic reactions

Mild – urticaria, itching, flushing

Severe /Anaphylactic  - Anxiety, urticaria, wheezing, progressing to cyanosis, shock, possible cardiac arrest.

Blood

Transfusion Reaction

What are acute

transfusion reactions?

Circulatory Overload

and

Sepsis

Blood

Transfusion Reactions

What are Delayed blood

transfusion reactions?

Infections (Hep B, C, HIV, EBV, CMV

Blood

Transfusion Reactions

What are Delayed blood

transfusion reactions?

Iron Overload

Blood

Transfusion Reactions

What are Delayed blood

transfusion reactions?

Graft vs. Host Disease

Blood Transfusion Products

What are RBSs?

Whole blood minus plasma

Blood Transfusion Products

What are the indications that

RBCs will be prescribed?

Severe or symptomatic anemia;

Acute blood loss

Blood Transfusion Products

What is the Volume and Infusion Rate

of RBCs?

Volume: 330 ml

Rate: 1-3 hours (after 1st 15 minutes).

Slower if patient is fluid excessed.

Blood Transfusion Products

What are Nursing Considerations

When Administering RBCs?

ABO and Rh compatability

required

Blood Transfusion Products

What are Nursing Considerations

When Administering RBCs?

Handle gently;

cells break

Blood Transfusion Products

What are Nursing Considerations

When Administering RBCs?

Expected outcome post infusion:

HCT increased by 2-3%

HGB increased by 1g.

Blood Transfusion Products

What are Nursing Considerations

When Administering RBCs?

Use standard blood tubing

(Has inline filter)

Blood Transfusion Products

What are Leukocyte-Poor

RBCs?

RBCs with 99% of

leukocytes removed.

Blood Transfusion Products

What are the indications to

use Leukocyte-Poor RBCs?

Severe or asymptomatic anemia,

acute blood loss

The leukocyte-poor RBCs prevent febrile

reactions from leukocyte antibodies,

immunosuppressed patients

Blood Transfusion Products

What are the Volume and Infusion

rate for Leukocyte-Poor RBCs?

Volume: 330 ml

Rate: 1-2 hours (after 1st 15 minutes).

Slower if patient is fluid excessed.

Blood Transfusion Products

What are Nursing Considerations

for administration of Leukocyte-Poor

RBCs?

The same as for RBCs, except add a leukocyte

removal filter (PALL filter).

Blood Transfusion Products

What are Nursing Considerations

for administration of Leukocyte-Poor

RBCs?

Unit can be yellow tinged.

Blood Transfusion Products

What are Nursing Considerations

for administration of Leukocyte-Poor

RBCs?

Agitate bag more often;

Platelets will tend to aggregate.

Blood Transfusion Products

What is Plasma?

FFP (fresh frozen)

Clotting factors and serum

Blood Transfusion Products

What are the indicaitons that

Plasma (FFP) will be administered?

Clotting deficiencies

especially factors V and VII.

Blood Transfusion Products

What are the Volume and Rate of

Plasma (FFP)?

Volume: 200 - 250ml

Rate: Infuse rapidly;

as fast as patient tolerates.

Blood Transfusion Products

What are the Nursing Considerations

for administration of Plasma (FFP)?

ABO compatability required.

Blood Transfusion Products

What are the Nursing Considerations

for administration of Plasma (FFP)?

Use within 24 hours after thawing.

Blood Transfusion Products

What are the Nursing Considerations

for administration of Plasma (FFP)?

Contains no platelets or RBCs.

Blood Transfusion Products

What are the Nursing Considerations

for administration of Plasma (FFP)?

Use standard blood filter.

Blood Transfusion Products

What are Platelets (PLT)?

Platelet-rich plasma separated

from fresh blood

(Leukocyte-poor PLTs available)

Blood Transfusion Products

What are the indications that

Platelets (PLTs) will be prescribed?

Thrombocytopenia

Acute Leukemia

Replaces inadequate number of PLTs

or dysfunctional PLTs.

Blood Transfusion Products

What are the Volume and Rate

of Platelets (PLTs)?

Volume: 40ml/unit;

Several units per bag.

Rate: infuse rapidly

5 minutes/unit

Blood Transfusion Products

What are Nursing Considerations

for administering Platelets (PLTs)?

ABO compatability not necessary,

but highly recommended for repeated units.

Blood Transfusion Products

What are Nursing Considerations

for administering Platelets (PLTs)?

Each unit raises PLT count by 5000

Blood Transfusion Products

What are Nursing Considerations

for administering Platelets (PLTs)?

Patients with a history of platelet transfusion

reactions require premedication with

anithistamine and antipyretics,

or use leukocyte-poor platelets.

Blood Transfusion Products

What are Nursing Considerations

for administering Platelets (PLTs)?

Avoid giving to patients with a fever.

Blood Transfusion Products

What are Nursing Considerations

for administering Platelets (PLTs)?

Use PALL filter with leukocyte-poor

platelets

Blood Transfusion Products

What is Cryoprecipitate?

Coagulation Factors

VIII and XIII

Blood Transfusion Products

What are the indications that

Cryoprecipitate will be prescribed?

Hemophilia A

Fibrinogen defeciency

Von Willebrand's disease

Blood Transfusion Products

What are the Volume and Rate for

Cryoprecipitate?

Volume: 10 units per bag=

110 - 150 ml total.

Rate: Infuse within 20 minutes.

Blood Transfusion Products

What are Nursing Consideration

when administering Cryoprecipitate?

ABO compatability necessary,

not Rh

Blood Transfusion Products

What are Nursing Consideration

when administering Cryoprecipitate?

Use within 3 hours

Blood Transfusion Products

What are Nursing Consideration

when administering Cryoprecipitate?

Can be given thru 20-22 guage IV needle

Blood Transfusion Products

What are Nursing Consideration

when administering Cryoprecipitate?

Short half life - may need repeated doses.

Requires use of a blood filter.

Blood Transfusion Products

What are the features of Albumin?

25% (25g/100ml)

Hyperosmolar

(100ml osmotically =

500 ml of plasma)

Blood Transfusion Products

What are the indications that

Albumin will be prescribed?

Volume expansion,

Hypoproteinemia,

reduce 3rd space shift

(Increased colloidal osmotic pressure and causes

a significant ICF which leads to ECF shift)

Blood Transfusion Products

What are the Volume and Rate of

Albumin?

Volume: 50 or 100ml bottles

Rate: 1-2 ml/minute

Blood Transfusion Products

What are Nursing Considerations

when administering Albumin?

No ABO compatability issue,

pasteurized

Blood Transfusion Products

What are Nursing Considerations

when administering Albumin?

Watch for pulmonary edema or other

signs and symptoms of fluid overload

Blood Transfusion Products

What are Nursing Considerations

when administering Albumin?

Use vented tubing that comes with

the bottle; drip rate usually 20gtt/ml.

Need 15 micron filter

Blood Transfusion Products

What are Nursing Considerations

when administering Albumin?

For treatment of shock give rapidly

For normal plasma volume give 1-2 ml/minute

TPN

Total Parenteral Nutrition

Why would a patient get TPN?

The patient is nutritionally depleted,

administered via central line in SVC due

to the high percentage of Dextrose,

which is irritating to veins.

TPN

Peripheral Parenteral Nutrition (PPN)

When would a patient receive PPN?

When the patient is not nutritionally depleted.

PPN provides a complete source of nutrition

which may be given via a PIV,

percentage of 10% or less of Dextrose in solution

It is not used very often.

Assessment for Hanging TPN

When does a patient need TPN?

Inadequate nutrition

(decreased serum albumin esp. post-op

surgical patients)

Impaired intestinal absorption

Assessment for Hanging TPN

When does a patient need TPN?

Increased Nutritional need

-bowel surgery

-malnutrition (supplement at a slow rate)

-excessive Na+ loss (sepsis, burns, need a

balanced electrolyte solution

Hepatic/Renal Failure

(difficult to metabolize proteins)

Assessment for Hanging TPN

When does a patient need TPN?

Chronic weight loss that can't be controlled

-cancer

-surgery

-GI disease

-can't tolerate enteral tube

feedings

TPN

What are the basics of TPN

knowledge?

TPN custom made for patient each day

TPN orders based on daily needs and lab values

TPN order good for one day only

(requires and order q daily)

TPN prepared in 2-3 liter bags;

volume for 24 hours in one bag.

TUBING CHANGED EVERY 48 HOURS

TPN Ingredients

What is the base or standard

solution for TPN?

Electrolytes, Amino Acids and Dextrose

TPN Ingredients

What is the standard

percentage of Dextrose

and why?

Standard solution is 20% (gives 1 cal/ml)

increased dextrose = increased calories and

increased hypertonicity which leads to

irritated veins.

TPN Ingedients

What else does TPN

contain and why?

Crystalline Amino Acids, (they may be increased

if not healling well, breaking down more nitrogen

than taking in).

NaCl

Na Acetate (bicarb, can be increased for

acidotic patients).

TPN Ingedients

What else does TPN

contain and why?

KCL (can be increased or

decreased r/t condition)

K Phosphate (renal patients don't excrete well,

may be decreased)

Calcium gluconate

TPN Ingedients

What else does TPN

contain and why?

Magnesium Sulfate (same as K phosphate, also helps people heal, nerve transmissions)

Multi-vitamins

Trace elements (minerals)

TPN Ingedients

What else does TPN

contain and why?

Fat Emulsions

3 methods of administering Fat emulsion

-added to bag of TPN = TNA (total nutritional admixture)

-infused along with TPN solution (Lipids)

-administered without TPN as a fat/calorie supplement

a) 10% & 20% available

b) can be given PIV

c)infuse for 12 hours/every 24 hours

TPN Ingedients

What else does TPN

contain and why?

DO NOT GIVE IF LIPIDS IF ALLERGIC TO EGGS

Insulin  in solution and/or sub-Q per sliding scale

r/t high amount of glucose, even for non-diabetics

Check CBGs every 6 hours

PPN if glucose is < 10%

Planning to administer TPN

What are the necessary checks?

Is the CL correctly placed?

current MD order

room temperature

check label against order

date and time bag hung

sticker on bag goes on charting record

want to make sure if MD ordered lipids as well

Planning to administer TPN

What equipment is necessary to

administer TPN

TPN solution

IV pump

IV tubing

Micro filters

Saline flushes

If triple lumen CL, use median line

may need 2 pumps, one for lipids and one for TPN.

(lipids = fat emulsion in Sigma pump)

Planning to administer TPN

Is strict aseptic technique required?

Yes, scrub the hub well.

Implementing TPN

What do you check in the

patient's room?

Patient's name & birth date & armband

Implementing TPN

What is the rate for TPN?

It should be started slowly, 50-75 ml/hour

for the first 24 hours and then increase.

Can be 30 ml/hour to start

Never go cold turkey, always wean off slowly,

ie. no new order

Implementing TPN

Must TPN always be given

on a pump?

Yes

Implementing TPN

What patient teaching should be done?

Purpose/rationale

rationale for frequency of CBGs

UOP may increase initially r/t high glucose

Implementing Lipids

What should be assessed before giving lipids?

Assess for disturbance in fat metabolism,

egg allergy,

pancreatitis,

or risk of fat embolism

Evaluating TPN

What may need troubleshooting?

1. For example, if the VTBI is 200ml and there is no new bag and no order for TPN you should decrease the rate by 10% (10 or 15ccs)

Want to wean off to try to avoid hypoglycemia.

2. Continue assessment of IV site

Evaluating TPN

What labs are ordered for effectiveness

or ingredient adjustments?

Chem panel- Na+, K+, Cl (electrolytes), kidney/liver function

Triglycerides r/t lipids

CO2-acid base issues, indirect indication of base, bicarb

Evaluating TPN

What labs are ordered for effectiveness

or ingredient adjustments?

Pre-albumin

Serum osmolality- TPN can create an osmolatity imbalance, TPN has hyperosmolality

24 hr UUN (urine urea nitrogen) measures amount

of nitrogenous waste excreted through the kidney

Evaluating TPN

What assessments will you make after

while administering TPN?

I & O and weight, ex. fluid overload

Any S/S of infection (glucose medium for growth)

Is therapy promoting desired outcome?

TPN

In my notes about tubing

Standard tubing except for filter-extension

tubing. Separate, attaches to end of IV tubing.

Lipids takes another tubing.

Joins TPN tubing BELOW the filter.

TPN line attaches to lipid line at lipids

lowest attachment.

No drugs should go through

TPN.

It is not in our scope of practice to push or

run even compatible drugs through a TPN line.

Chest tubes

After looking at the Atrium University powerpoint

that Maggie posted under

Unit 3: Chest tube lab

I think that studying that is way better than

my flashcards could be unless I hear differently.

I will look at my Closed Chest Drainage Systems

handout tomorrow to see if I can make flashcards out of that but I have to get some shuteye.