9 intravenous therapy (1) rationale

8/22/2019 9 Intravenous Therapy (1) Rationale

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MONITORING AN INTRAVENOUS INFUSION

Definition:

An important nursing responsibility is to monitor an IV infusion so that the flow of the

correct solution is maintained at the correct rate.

Indications:

1. To maintain prescribed flow rate.2. To prevent complications associated with IV therapy.

Assessment Focus

1. Appearance of infusion site; patency of system.2. Type of fluid being infused and rate of flow.3. Response of the client.

special consideration:

1. Assess the whole infusion system at least every hour to ascertain problems.2. Maintain asepsis.3. Ensure that the correct type and amount of fluid is infused within the specified time

period.

4. Prevent or identify early:a. fluid infiltrationb. phlebitisc. circulatory overloadd. bleeding at the venipuncture sitee. blockage of the infusion flow

PROCEDURE RATIONALE

1. From the physicians order determine hetype and sequence of solutions to be used.

IV infusion should only be performed with

support of a physicians order.

2. Determine the rate of flow and infusionschedule.

3. Ensure that the correct solution is beinginfused. If the solution is incorrect, slow

the rate of flow to a minimum to maintain

the patency of the catheter.

Stopping the infusion may allow a thrombus

to form in the IV catheter. If this occurs, the

catheter must be removed and another

venipuncture should be performed before the

infusion can be resumed

4. Change the solution to correct one.Document and report the error according

to agency protocol.


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PROCEDURE RATIONALE

5. Observe the rate of flow every hour.Compare the rate of flow regularly.

6. If the rate is too fast, slow it so that theinfusion will be completed at the planned

time.

Infusions that are off schedule can be harmful

to a client.

7. Assess the client for the manifestations ofhypervolemia and its complications,

including dyspnea; rapid, labored

breathing; cough; crackles in the lungs

bases; tachycardia; and bounding pulses.

8. Check if the rate is too slow.

9. Inspect the patency of the tubing andneedle.

solution administered to quickly may cause a

significant increase in circulating blood

volume. Hypervolemia may result in

pulmonary edema and cardiac failure.

10.Observe the position of the solutioncontainer. If it is less than 1 m (3ft) above

the IV site, readjust it to the correct

height of the pole.

11.Observe the drip chamber. If it is less thanhalf full, squeeze the chamber to correct

amount of fluid to flow in.

if the container is too low, the solution may

not flow into the vein because there is

insufficient gravitational pressure to overcome

the pressure of the blood within the vein.

12.Open the drip regulator and observe for arapid flow of fluid from the solution

container into the drip chamber. Then

partially close the drip regulator to

reestablish the prescribed rate of flow.

13.Inspect tubing for pinches or kinks orobstructions to flow. Arrange the tubing so

that it is lightly coiled and under no

pressure. If it is dangling below the

venipuncture, coil it carefully on the

surface of the bed.

Rapid flow of fluid into the drip chamber

indicates patency of the IV line. Closing the

drip regulator to the prescribed rate of flow

prevents fluid overload.


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PROCEDURE RATIONALE

14.Lower the solution container below thelevel of the infusion site and observe for a

return flow of blood from the vein.

The solution may not flow upward into the

vein against the force of gravity.

15.Check for leakage. Locate the source. Ifthe leak is at the catheter connection,

tighten the tubing into the catheter.

16.If the leak cannot be stopped, slow theinfusion as much as possible without

stopping it, and replace the tubing with a

new sterile set.

Absence of blood return may indicate that the

needle is no longer in the vein or the tip of

the catheter is partially obstructed.

17.Inspect the infusion site for fluidinfiltration

a. Palpate the surrounding tissue foredema.

b. Feel the surrounding skin forchanges in temperature

c. If the tubing does not have abackcheck valve, lower the infusion

bottle below the venipuncture site.

d. Use a sterile syringe of saline towithdraw fluid from the rubber at

the end of the tubing near the

venipuncture site. Discontinue the

IV infusion if blood does not return.

e. Try to stop the flow by applying atourniquet 10-15 cm (4-6 in.)

above the insertion site and

opening the roller clamp.

To ascertain the presence of infiltration

to see if blood returns. Blood may indicate

that the IV needle is still in the vein.

18.Inspect for the presence of phlebitis. Theclinical signs are redness, warmth, and

swelling at the IV site and burning pain

along the course of a vein.

a new venipuncture site is usually selected,

and he injured vein is not used for further

infusions.


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PROCEDURE RATIONALE

19.Be alert to signs of circulatory overload. circulatory overload means that thecirculatory system contains more fluid than

normal.

20.Inspect for bleeding at the IV site. Bleeding into the surrounding tissues canoccur while the infusion is freely flowing.

21.If the client is able, teach him or her whento call for assistance, e.g., if the solution

stops dripping or the venipuncture site

becomes swollen.

EVALUATION FOCUS

1. Amount of fluid infused according to the schedule.2. Intactness of IV system.3. Appearance of IV site.4. Urinary output compared to urinary intake.5. Tissue turgor; specific gravity of urine.6. Vital signs and lung sounds compared to baseline data.


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CHANGING AN INTRAVENOUS CONTAINER AND TUBING

Indications:

1. To maintain the flow of required fluids.

2. To maintain sterility of the IV system and decrease the incidence of phlebitis andinfection.

3. To maintain patency of the IV tubing.4. To prevent infection at the IV site and the introduction of microorganisms into the

bloodstream.

Assessment Focus:

1. Presence of fluid infiltration, bleeding, or phlebitis at IV site.2. Allergy to tape3. Infusion rate and amount absorbed4. Appearance of the dressing for integrity, moisture, and need for change.5. The date and time of the previous dressing change.

Special Considerations:

1. Intravenous solution container are changed when only a small solution of the fluidremains in the neck of the container and fluid still remains in the drip chamber.

However, all IV bags should be changed every 24 hours, regardless of how much

solution remains, to minimize the risk of contamination.

2. IV tubing is changed every 48 to 96 hours, depending on agency protocol, as is thesite dressing.

3. Determine allergies to tape or iodine.4. Select the correct solution.5. Prime the tubing before attaching it to the IV needle.6. Wear gloves when there is possibility of contact with the body secretions.7. Prevent needle dislodgement when disconnecting and connecting the IV tubing and

when cleaning the venipuncture site.8. Make sure the IV system is intact and the correct flow rate is established.9. Inspect and clean the venipuncture site appropriately.10.Secure the needle appropriately with the tape and apply an appropriate dressing.11.Label the container, tubing, and dressing appropriately.

Patient Education:

Teach the client ways to maintain the infusion system, like:

1. Avoid sudden twisting or turning movements of the arm with the needle.2. Avoid stretching or placing tension on the tubing.3. Try to keep the tubing from dangling below the level of the needle.4. Notify a nurse if

a. The flow rate suddenly changes or the solution stops dripping.b. The solution container is nearly empty.c. There is blood in the IV tubing.d. Discomfort or swelling is experienced at the IV site.


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Equipments:

Container with the correct kind and amount of sterile solution Administration set, including sterile tubing and drip chamber Timing label Sterile gauge square for positioning the needle Alcohol swab Clean glove Tape

PROCEDURE RATIONALE

A. Changing IV Container1. Review physicians order for changes in

fluid administration.

2. Obtain the correct solution containerand make sure it is properly labeled.

Check for sterility and integrity.

to prevent medication error

3. Prepare to change solution when itonly remains in the neck of the bottle

and make sure the drip chamber is half

full.

prevents air from entering tubing

4. Wash hands.

-reduces transmission of microorganisms

5. Verify the physicians order. Prepare allnecessary materials for changing IV

solution and place it on an IV tray.

for faster, organized and smooth change

6. Identify the patient and explain whatyou are going to do, why is it

necessary, and how he can cooperate.

ensures correct client undergoes procedure.

7. Move the roller clamp to reduce flowrate.

prevent solution remaining in drip chamber

from emptying while changing the solution.

8. Remove the protective cover from theentry site of the new IVF bottle and

disinfect rubber port with cotton and

alcohol.

to maintain sterility of the solution.


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PROCEDURE RATIONALE

9. Remove old solution from IV pole. brings work to eye level.

10.Quickly remove spike from old IVsolution, and without touching tip,

spike it to the new solution bottle while

kinking the tubing below the drip

chamber.

prevent solution inside the drip from running

dry and maintain sterility.

11.Invert the IV bottle and hang to IVpole.

allows gravity to assist with the delivery of

fluid into the drip chamber then to the tubing.

12.Check the tubing for air. If with air,remove air from the tubing.

prevent air embolism

13.Regulate IV to prescribed rate. maintain measures to restore fluid balance

14.Observe system for patency and theresponse of the client to the therapy.

provides ongoing evaluation of response to

therapy

B. Changing IV Tubing1. Determine the need to change the IV

tubing.

a. tubing should be changed48-96 hours, depending on

agency protocol.

b. puncture of infusion tubing.

c. Contamination of tubing.

d. Occlusion of tubing.

tubing should be changed according to agency

protocol.

results in leakage of fluid.

can allow entry of bacteria into bloodstream.

2. Assemble the equipment. ensures efficient and safe procedure.

3. Explain the procedure to the patient. promotes cooperation and preventsmovement of extremity, which could dislodge

needle or catheter.

4. Do hand washing. reduces transmission of microorganisms.

5. Open the administration set and attachit to the container, using sterile

technique.

provides nurse with ready access to new

infusion set and maintains sterility of infusion

set.


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PROCEDURE RATIONALE

6. Tighten the clamp and hang thecontainer on the pole if it is not

already hung.

to avoid spillage of fluid as tubing is removed.

7. Remove the protective cap from theend of the tubing, and prime the

tubing. Clamp the tubing and replace

the cap.

replacing the cap maintains the sterility of the

end of the tubing.

8. Don gloves. Remove the tape and thedressing carefully from around the

needle. Take care not to dislodge the

needle from the vein.

9. Place a sterile swab under the hub ofthe catheter to absorb any leakage

that might occur when the tubing is

disconnected. Clamp the old tubing.

10.While holding the hub of the needlewith the fingers of one hand, remove

the tubing with the other hand, using a

twisting, pulling motion. Place the end

of the tubing in the kidney basin or

other receptacle.

holding the needle firmly but gently maintains

its position in the vein.

11.Continue to hold the needle, and graspthe new tubing with the other hand.

Remove the protective cap, and

maintain sterility, insert the tubing end

tightly into the needle hub.

attaches new, primed infusion tubing to hub

of angiocatheter.

12.Open the clamp to start the solutionflowing.

permits the solution to enter catheter or

tubing.

13.Clean the venipuncture site, workingfrom the insertion point outward in a

circular manner.

minimize spread of microorganisms.


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PROCEDURE RATIONALE

14.Apply a sterile dressing over the siteand tape the needle in place. Apply a

labeled tape over the dressing. The

label should include the date and time

the dressing is applied; the original

date and time of the venipuncture; the

size of the catheter or needle; and

your initials, as the nurse who changed

the dressing.

15.Tape a label on the new tubing withthe date and time of the change and

your initials.

16.Regulate the flow of the solutionaccording to the order on the chart.

maintains infusion flow at prescribed rate.

17.Record the change of the tubing in theappropriate place on the clients chart.

EVALUATION FOCUS

1. Status of IV site.2. Patency of IV system.3. Accuracy of flow.


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DISCONTINUING AN INTRAVENOUS INFUSION

Definition:

When an IV infusion is no longer necessary to maintain the clients fluid intake or to

provide a route for medication administration, the infusion is discontinued.

Indications:

1. To discontinue an intravenous infusion when the therapy is complete or when theclients oral fluid intake and hydration status are satisfactory.

2. The medications administered via IV route are no longer necessary.3. There is a problem with the infusion that cannot be fixed (e.g. thrombophlebitis,

etc.).

Assessment Focus:

1. Appearance of IV catheter.2. Amount of fluid infused.3. Any bleeding from infusion site.4. Appearance of the venipuncture site.

SPECIAL CONSIDERATIONS:

1. Maintain asepsis.2. Prevent discomfort to the client.3. Prevent bleeding and hematoma formation.4. Make sure a catheter is removed intact.5. Wear gloves to prevent contamination by the clients body secretions.

Equipment:

Clean glove

Waste receptacle tray Dry or antiseptic-soaked swabs Plaster Sterile dressing

PROCEDURE RATIONALE

1. Verify written doctors order todiscontinue IV infusion.

2. Wash hands. reduces anxiety and promotes cooperation

3. Prepare all necessary equipments. reduces transmission of microorganisms

4. Close the roller clamp of the IVadministration set.


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PROCEDURE RATIONALE

5. Put on the clean glove. clamping the tubing prevents the fluid fromflowing out of the needle onto the client or

bed

6. Moisten adhesive tapes around the IVcatheter using cotton balls with

alcohol; remove plaster gently while

holding the needle firmly and applying

counteraction to the skin.

prevents direct contact with patient blood

7. Gently remove the needle or catheterby pulling it out along the line of the

vein.

movement of the needle can injure the vein

and cause discomfort to the client.

Counteraction prevents pulling the skin and

causing discomfort

8. Immediately apply pressure to thesite, using the cotton swab, for 2 to 3

minutes.

pulling it out in line with the vein avoids injury

to the vein

9. Hold the clients arm or leg above thebody if any bleeding persists.

pressure stops bleeding and prevents

hematoma formation.

10.Inspect the catheter for completeness. raising the limb decreases blood flow to thearea.

11.Report a broken catheter to the nursein charge immediately.

if a piece of tubing remains in the clients vein

it could move centrally (toward the heart or

lungs) and cause serious problems.

12.If a broken piece can be palpated,apply a tourniquet above the insertion

site.

13.Cover the venipuncture site byapplying a sterile dressing.

application of tourniquet decreases the

possibility of a piece moving until a physician

is notified.

14.Discard the IV solution container, ifinfusions are being discontinued, and

discard the used supplies

appropriately.

the dressing continues the pressure and

covers the open area in the skin, preventing

infection.


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PROCEDURE RATIONALE

15.Document all relevant informationa. the amount of fluid infusedb. type of solutionc. container numberd. time of discontinuancee. the clients response to the

procedure

EVALUATION FOCUS

1. Appearance of the venipuncture site.2. The pulse3. Respirations, skin color, edema, sputum, cough and urine output.4. And how the client feels physically and psychologically.


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STARTING AN INTRAVENOUS INFUSION

Definition:

It is one of the commonest invasive procedure in hospitals and is administered either by

the peripheral or central route.

It is the aseptic instillation of fluids, electrolytes, nutrients, or medications through a

needle into a vein.

Indications:

1. To supply fluid when clients are unable to take in an adequate volume of fluids bymouth.

2. To provide salts needed to maintain electrolyte balance.3. To provide glucose (dextrose), the main fuel for metabolism.4. To provide water-soluble vitamins and medications.5. To establish a lifeline for rapidly needed medications.6. To provide nutrition while resting the gastrointestinal tract.7. To monitor central venous pressure.8. To restore acid-base balance.9. To restore volume of blood components.

Patient Education:

Educating the patient is one of the best complication prevention measures that can be

done!!!

All procedures should be explained to the patient with regard to why, what,

complications, and signs and symptoms about which to call a nurse.

Preparation Of Patient:

1. Explain procedure and answer all questions to decrease anxiety.2. Describe the patients participation and the importance of holding still during the

procedure.3. Assist in positioning the patient in a comfortable position that allows easy access to

the desired site.

4. Show the patient the equipment.5. Touch the patient to assess the skin.6. Anxiety can cause vasoconstriction.7. If site selected is hairy, clip or shave.8. Ensure patient is not allergic to skin prep agent.


1. Maintain asepsis.2. Select the correct solution.3. Prime the tubing.4. Label the container appropriately.5. Label the IV tubing with the date and time of attachment.


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Types of Solutions:

1. Isotonic solution- A solution that exert the same osmotic pressure as that found in plasma.

- It has no effect on the cell/expand intravascular compartments only.- Ex. 0.9% NaCl (normal saline), Lactated Ringers (a balanced electrolyte

solution), D5W (5% dextrose in water), Blood components.

2. Hypotonic solution- A solution that exert less osmotic pressure than that of blood plasma.

- Cell size increases and extracellular fluid (ECF) volume decreases; fluid andelectrolytes shift out of intravascular compartment, hydrating intracellular and

interstitial compartment.

- Ex. 0.45% NaCl, 0.2% NaCl, 0.33 NaCl, 2.5% Dextrose.3. Hypertonic solution

- A solution that exert higher osmotic pressure than that of blood plasma.- Cell size decreases and ECF volume increases; fluid and electrolytes are drawn

into intravascular compartment, dehydrating intracellular and interstitial

compartments.

- Ex. D5NS (5% dextrose in normal saline), D5 1/2NS (5% dextrose in 0.45%NaCl), D5LR (5% dextrose in lactated ringers), D10W, D20W.

Kinds of Needles and Catheters

Butterfly Needles (Wing-tipped needle)- Used in short-term IV therapy- Easy to insert, infiltrate easily

Over-the-needle Cannula (Angiocatheter)- Most common- Cannula is over needle: allows ease of insertion

Inside-the-needle Catheter- Catheter of 14- to 19-gauge inside the needle-

Rarely used because of advances in midline and central catheters- Shearing of catheter is a major risk

Site Selection Guidelines:

(Take into account available vein condition, patient comfort, and type and duration of IV

therapy)

1. Start distally and move proximally. Use lower extremities as a last resort.2. Use the clients non dominant arm whenever possible to increase patient mobility.3. Use smallest catheter that accomplishes the purpose.4. Dorsal metacarpal veins of the hand provide the most comfortable insertion site (skin

on back of the hand is less sensitive).

5. Select a vein that is- Easily palpated and feels soft and full- Naturally splinted by bones- Large enough to allow adequate circulation around the catheter


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6. Avoid using veins that area. In areas of flexion/joints ( e.g. the antecubital fossa)b. Highly visible, because they tend to roll away from the needlec. Damaged by previous use, phlebitis, infiltration, or sclerosisd. Continually distended with blood, or knotted or tortuouse. In a surgically compromised or injured extremity, because of possible impaired

circulation and discomfort for the client.

7. The median basilica and cephalic veins are not recommended for chemotherapyadministration due to potential for extravasation and poor healing resulting in

impaired joint movement.

Age-Related Considerations:

PEDIATRIC

1. Dorsal surfaces of hands and feet are most frequently used.2. Dorsal vein of hand allows child the greatest mobility.3. Always select site that will require the least restraint.4. Scalp veins are very fragile and require protection so they are not infiltrated

easily (used for neonates and infants)

5. Foot, scalp and antecubital sites are most commonly used in infant throughtoddler age-group.

GERIATRIC

1. Skin becomes paper-thin. Anchor catheters carefully to avoid tears andinfiltrations.

2. Insert catheter without a tourniquet if skin is fragile and veins are palpableand visible.

3. Vascular disease, obesity, and dehydration may limit venous access.

Equipments:

Infusion set as ordered

Intravenous solution as prescribed by physician Intravenous catheter IV pole IV tray containing

- Adhesive or nonallergic tape

- Clean glove

- Tourniquet

- Antiseptic swab

- Sterile gauge dressing or transparent occlusive dressing

- Arm splint, if required

- Towel or pad


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PROCEDURE RATIONALE

1. Verify the physician order for type andamount of solution to use and the flow

rate.

Serious errors can be avoided by careful

checking.

2. Observe the 10 rights in preparing andadministering medications.

IV solutions are medications and should be

doubled checked to reduce risk of error.

3. Identify client and explain the procedure,secure consent if necessary.

to facilitate cooperation and alleviate clients

anxiety.

4. Do hand washing. reduces transmission of microorganisms.

5. Prepare necessary materials for theprocedure.

to avoid delay

6. Check the sterility and integrity of the IVsolution, IV set and other devices.

Crack or leak would indicate contamination.

7. Place IV label on IVF bottle duly signed byRN who prepared it.

a. patients nameb. room numberc. IV solutiond. drug incorporation (if any)e. bottle sequencef. drop rateg. time startedh. date started

For proper documentation.

8. Open and prepare the infusion set.a. Remove the tubing from the

container and straighten it out.

Slide the roller clamp along the

tubing until it is just below the drip

chamber.

b. Move roller clamp to off position.

c. Leave the ends of the tubingcovered with the plastic caps until

the infusion is started.

Close proximity of roller clamp to drip

chamber allows more accurate regulation of

flow rate.

To prevent spillage of fluid.

This will maintain sterility of the ends of the

tubing.


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PROCEDURE RATIONALE

9. Spike the solution containera. Remove the protective cover from

the entry site of the IVF bottle and

disinfect rubber port with cotton

and alcohol.

b. Remove the cap from the spike andinsert the spike into the insertion

site of the IVF bottle.

To maintain sterility of the solution.

10.Invert the IV bottle and hang to IV pole.Adjust the pole so that the container is

suspended about 1 m (3 ft.) above the

clients head.

Height is needed to enable gravity to

overcome venous pressure and facilitate flow

of the solution to the vein.

11.Fill the drip chamber with solution.Squeeze the chamber gently until it is half

full of solution.

creates suction effect; fluid enters drip

chamber.

12.Prime the tubing. Remove the protectivecap and release the roller clamp to allow

the fluid to travel from drip chamber

through the tubing until all the bubbles

are removed. Tap the tubing if necessary

with your fingers to help the bubbles

move.

Tubing is primed to prevent the introduction

of air into the client which can act as emboli.

13.Reclamp the tubing and replace the tubingcap, maintaining sterile technique.

To maintain system sterility.

14.Then prepare to assist the IV therapist inIV insertion.


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BLOOD TRANSFUSION

Definition:

Blood transfusion is the introduction of whole blood or blood components (such as serum,

plasma, platelets, or erythrocytes) into the venous circulation.

Indications:

1. To restore blood volume after severe hemorrhage.2. To combat infection due to decreased or defective white cells or antibodies.3. To restore the capacity of the blood to carry oxygen.4. To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or

platelet concentrates, which prevents or treat bleeding.


1. Confirm that there is a physicians order and assigned consent from the client.2. Have two health care professionals confirm that the client name and ID #, and

crossmatching result are correct.

3. Maintain asepsis.4. Keep blood cold until ready for use.5. Blood should be stored in the blood bank and not in the nurses station.6. Do not use blood if released from blood bank for more than 30 minutes.7. Give pre-med 30 minutes before transfusion as prescribed.8. Dont use blood with bubbles and has been discolored.9. Wear gloves before performing venipuncture, transfusing the blood, and when

terminating blood and disposing of equipment.

10.Administer all blood products through the correct filter for prevention of emboli.11.Monitor patient carefully throughout blood transfusion.12.Crystalloid solutions other than 0.9% saline and all medications are incompatible with

blood products. They may cause agglutination and or hemolysis.

13.Do not transfuse a unit of blood more than 4 hours.

14.Assess the client closely for transfusion reactions.

Types Of Transfusion Reactions:

1. Hemolytic reaction: incompatibility between clients blood and donors blood.2. Febrile reaction: sensitivity of the clients blood to white blood cells, platelets or

plasma proteins.

3. Allergic reactions (mild): sensitivity to infused plasma proteins.4. Allergic reaction (severe): antibody-antigen reaction.5. Circulatory overload: blood administered faster than the circulation can

accommodate.

6. Sepsis: contaminated blood administered.


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Blood Products For Transfusion:

1. Whole blood - Not commonly used except for extreme cases of acute hemorrhage.Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh

platelets, and other clotting factors.

2. Red blood cells Used to increase the oxygen-carrying capacity of blood in anemiassurgery, disorders with slow bleeding. One unit raises hematocrit by approximately

4%.

3. Autologos red blood cells Used for blood replacement following planned electivesurgery. Client donates blood for autologos transfusion 4-5 weeks prior to surgery.

4. Platelets replaces platelets in clients with bleeding disorders or platelet deficiency.Fresh platelets most effective.

5. Fresh frozen plasma Expands blood volume and provides clotting factors. Does notneed to be typed and crossmatched (contains no RBC).

6. Albumin and plasma protein fraction Blood volume expander; provides plasmaprotein.

7. Clotting factors and cryoprecipitate Used for clients with clotting factor deficiencies.Each provides different factors involved in the clotting pathway; cryoprecipitate also

contain fibrinogen.

Assessment Focus:

1. Clinical signs of reaction (sudden chills, fever, nausea, itchiness, low back pain,dyspnea).

2. Manifestations of hypervolemia.3. Status of infusion site.4. Any unusual symptoms.

Equipments:

Unit of blood that has been correctly crossmatched Blood administration set

500 ml or 250 ml of normal saline solution for infusion IV pole # 18 or # 19-guage needle or catheter (if one is not already in place) Alcohol swab Plaster Clean glove Tourniquet

PROCEDURE RATIONALE

1. Verify doctors written order for bloodtransfusion.

Serious errors can be avoided by careful

checking.

2. Obtain clients consent before thetransfusion. Informed consent involves

explaining medical indications for

transfusion, benefits, risks, and

alternatives.

basis for legal purposes.


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PROCEDURE RATIONALE

3. Explain the procedure and its purpose tothe patient. Instruct the client to re[port

promptly any sudden chills, nausea,

itching, rash, dyspnea, backpain, or other

unusual symptoms.

reduces anxiety and promotes cooperation.

4. If the client has an IV solution infusing,check whether the needle and solution are

appropriate to administer blood. The

needle should be gauge # 18 or # 19, and

the solution must be normal saline.

to achieve maximal flow rate. Normal saline is

isotonic and reduces hemolysis.

5. If the client does not have an IV solutioninfusing, you will need to perform a

venipuncture on a suitable vein and start

an IV infusion of normal saline.

6. Request prescribed blood/bloodcomponent from the blood bank to include

blood typing and X-matching result, the

expiration of he blood and blood result of

transmissible disease.

safe storage of the blood is only limited to 35

days after extraction from he donor since the

BC deteriorates after this time causing in

allergic reaction when given.

7. Using a clean tray, get the compatibleblood from the laboratory or blood bank.

8. With another nurse, compare thelaboratory blood record with

a. The clients name and identificationnumber.

b. The serial # on the blood bag label.c. The ABO group and Rh type on the

blood bag label or check

crossmatching form.

to check for correct blood to infuse.

9. Check blood bag for bubbles, cloudiness,dark color or sediments.

these signs indicate bacterial contamination.

10.Wrap blood with clean towel and keep it atroom temperature for no more than 30

minutes before starting the transfusion.

RBCs deteriorate and lose their effectiveness

after 2 hours at room temperature. Lysis of

RBCs releases potassium into the

bloodstream, causing hyperkalemia.


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PROCEDURE RATIONALE

11.Verify the clients identity by asking thefull name and/or checking the arm band

for name and ID number.

to make sure you are doing the procedure to

the correct patient.

12.Get the baseline V/S: BP, RR,Temperature before transfusion and refer

to M.D accordingly.

to establish baseline data. V/S beyond normal

may result to the postponement of the

transfusion.

13.Give pre-med 30 minutes beforetransfusion as prescribed.

prevents allergic reaction.

14.Do hand hygiene before ad after theprocedure.

prevents spread of microorganism.

15.Prepare equipment needed for theprocedure.

for efficiency of work and accessibility of

needed materials.

16.Set up the transfusion equipment.a. Ensure that the blood filter inside

the drip chamber is suitable for

whole blood or the blood

components to be transfused.

Blood filters have a surface area large enough

to allow the blood components through easily

but are designed to trap clots.

17.If the main line is with dextrose 5%initiate an IV line with appropriate IV

catheter with plain NSS on another site,

anchor catheter properly and allow a small

amount of solution to infuse to make sure

there are no problems with the flow or the

venipuncture site.

Infusing a normal saline before initiating the

transfusion also clears the IV catheter of

incompatible solutions or medications.

18.Prepare the blood bag. Invert the bloodbag gently several times to mix the cells

with the plasma.

Rough handling can damage the cells.

19.Expose the port on the blood bag bypulling back the tabs.

20.Spike blood bag port carefully and hangthe unit. Be sure blood clamp is closed.


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PROCEDURE RATIONALE

21.Gently squeeze the flexible sides of thedrip chamber to reestablish the liquid level

with drip chamber one-third full. Make

sure filter is submerged in the blood.

22.Open the clamp and prime tubing andremove air bubbles if any. Use needle G

18 or G 19 for side drip (for adults) or G

22 (for pediatrics).

tubing is primed to prevent the introduction of

air into the client which can act as emboli.

23.Disinfect the Y-injection port of IV tubing(PNSS) and insert the needle from BT

administration and secure with adhesive

tape.

24.Shut off the primary IV and begin theblood transfusion.

allows passage of blood components into the

vein.

25.Run the blood slowly for the first 15minutes at 20 gtts/min. Note adverse

reactions, such as chilling, nausea,

vomiting, skin rash, or tachycardia.

the earlier the transfusion occurs, the more

severe it tends to be. Identifying such

reactions promptly helps to minimize the

consequences.

26.Observe the client for the first 5 to 10minutes of transfusion.

early identification of reaction facilitates

prompt intervention.

27.Remind the client to call a nurseimmediately if any unusual symptoms are

felt during the transfusion.

28.Document relevant data. Record timeblood was started, V/S, type of blood,

blood serial #, sequence # (e.g. #1 of

three ordered units), site of the

venipuncture, size of the needle, and drip

rate.

for documentation of relevant information and

future reference for legal purposes.

29.Swirl the bag hourly. to mix the solid with the plasma.

30.Check the V/S of the client 15 minutesafter initiating transfusion. If there are no

signs of reaction, establish the required

flow rate.

Most adults can tolerate receiving one unit of

blood in 1 & hours. Do not transfuse blood

more than 4 hours.


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31.Assess the client every 30 minutes ormore often, depending on the health

status, until 1 hour post-transfusion.

32.If any untoward reaction or signs occur,stop the transfusion immediately and

notify the physician ASAP.

33.When blood is consumed, don glove, closethe roller clamp of BT set and disconnect

from IV line. Flush the line with saline

solution by opening the mainline and

adjust the drip to desired rate.

34.Re-check Hgb, Hct, bleeding time, serialplatelet count within specified time as

prescribed &/or per institutions policy.

to check the effect of the blood transfusion.

35.Discard the administration set according toagency practice. Needles should be placed

in a labeled puncture-resistant container

designed for such disposal. Blood bags

and administration sets should be bagged

and labeled before being sent for

decontamination and processing.

36.Remove glove.

37.Document the procedure, pertinentobservations and nursing intervention and

endorse accordingly.

documentation of relevant information and

serves as future reference for legal purposes.

38.Remind the doctor about theadministration of Calcium Gluconate if

patient had several units of blood

transfusion 93-6 or more units of blood).

to maintain cardiac function and prevent

hypocalcaemia that may lead to citrate

toxicity.

EVALUATION FOCUS

1. Changes in vital signs or health status.2. Presence of chills, nausea, vomiting, or skin rash.

9 intravenous therapy (1) rationale

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