HHC Health & Home Care Clinical Policy And

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HHC HEALTH & HOME CARE Section: 9-31 Infusion Therapy: Management of Blood Transfusion Reactions __RN PURPOSE: To provide prompt attention to any suspected transfusion reaction. CONSIDERATIONS: 1. Transfusion therapy entails a number of calculated risks. Some of the potential complications cannot be prevented with absolute certainty. 2. Transfusion reactions may occur due to incompatibilities of red blood cells, leukocytes, platelets, and plasma proteins. 3. Immediate reactions occur within 48 hours after the initiation of a transfusion. Most reactions occur within this time frame. 4. Delayed reactions occur two or more days after transfusion and usually are the result of alloimmunization or transmitted disease. 5. Yellowing of the skin can occur from 1-6 months after receiving blood. 6. All transfusion reactions must be reported to the physician and transfusion product supplier. 7. See Attachment A, Report of Transfusion Reaction. EQUIPMENT: Gloves Alcohol applicator (wipe/swab/disk/ampule) Normal saline 500cc Standard mini-drip or maxi-drip IV administration sets Straight catheter set Airway Tourniquet Vacutainer with needle Lab studies supplies: red top tube (chemistries) lavender top tube (CBC) blood culture tubes urine specimen container Blood bank transfusion request Patient's blood sample for type and cross-match and type and cross-match lab slips Transfusion reaction form Emergency medication (per physician orders): Tylenol Lasix Benadryl Solu-Cortef Epinephrine hydrochloride 1:1000 Puncture-proof container Impervious trash bag PROCEDURE: 1. Adhere to Universal Precautions. 2. Stop transfusion immediately and maintain IV at KVO with normal saline. Consequences are in direct proportion to amount of incompatible blood administered. In minor reactions, blood transfusion may be resumed. 3. Notify physician at once. 4. Administer emergency medications, as ordered by physician. 5. Anticipate and be prepared for possible emergency backup, i.e., 911, CPR, hospital admission. 6. Support patient emotionally and physically. 7. Obtain VS, urine specimen, and any lab specimens per physician orders. 8. Notify transfusion product supplier. 9. After patient is stabilized, transport to transfusion product supplier: remainder of unit of blood tubing, copies of the transfusion reaction form and copies of blood bank transfusion request. 10. Discard soiled supplies in appropriate containers. 11. Remove gloves. AFTER CARE: 1. Document in patient's record: a. Date, time, procedure and observations, including all vital signs. b. Type and appearance of venous access site. c. Patient's response to procedure. d. Instructions given to patient/caregiver. e. Copy of transfusion reaction form. 222
HHC HEALTH & HOME CARE Infusion Therapy: References REFERENCES Alexander, M., and A. Corrigan. 2004. Core curriculum for infusion nursing. 3 rd ed. Philadelphia: Lippincott, Williams, and Wilkins. Camp-Sorrel, D. 2004. Access device guidelines: Recommendations for nursing practice and education. Oncology Nurses Society. Ernst, D., and C. Ernst. 2003. Phlebotomy for nurses and nursing personnel. Center for Phlebotomy Education, Hankins, J., R. Lonsawy, C. Hedrick, and M. Perdue, eds. 2001. Infusion therapy in clinical practice. 2 nd ed. St. Louis: W. B. Saunders Company. Infusion Nurses Society. 2000. Infusion nursing standards practice, Journal of Intravenous Nursing 23:6S. Infusion Nurses Society. 2002. Policies and procedures for infusion nursing. 2 nd ed. Cambridge, MA: Infusion Nurses Society. Masoorli, S. 1995. Home infusion therapy: Shielding yourself from lawsuit. Nursing 95. Springhouse, PA: Springhouse Corporation. Nettina, Sandra M., and L. S. Brunner. 2001. The Lippincott manual of nursing practice. 8 th ed. Philadelphia: J. B. Lippincott. Phillips, L. 1997. Manual of IV therapeutics. 2 nd ed. Philadelphia: F. A. Davis Company Terry, Judy. 1995. Intravenous therapy: Clinical principles and practices. 1 st ed. St. Louis: W. B. Saunders Company. Weinstein, S. M, and A. L. Plumer. 1997. Principles and practices of intravenous therapy. Philadelphia: Lippincott-Raven Company. 223
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