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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 infiltration
b. phlebitis
c. circulatory overload
d. bleeding at the venipuncture site
e. blockage of the infusion flow
PROCEDURE RATIONALE1. From the physician’s order determine he
type and sequence of solutions to be used.
IV infusion should only be performed with
support of a physician’s order.
2. Determine the rate of flow and infusion
schedule.
3. Ensure that the correct solution is being
infused. 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.
PROCEDURE RATIONALE5. Observe the rate of flow every hour.
Compare the rate of flow regularly.
6. If the rate is too fast, slow it so that the
infusion 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 of
hypervolemia 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 and
needle.
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 solution
container. 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 than
half 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 a
rapid 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 or
obstructions 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.
PROCEDURE RATIONALE14. Lower the solution container below the
level 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. If
the leak is at the catheter connection,
tighten the tubing into the catheter.
16. If the leak cannot be stopped, slow the
infusion 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 fluid infiltration
a. Palpate the surrounding tissue for
edema.
b. Feel the surrounding skin for
changes in temperature
c. If the tubing does not have a
backcheck valve, lower the infusion
bottle below the venipuncture site.
d. Use a sterile syringe of saline to
withdraw 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 a
tourniquet 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. The
clinical 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.
PROCEDURE RATIONALE19. Be alert to signs of circulatory overload. circulatory overload means that the
circulatory system contains more fluid than
normal.
20. Inspect for bleeding at the IV site. Bleeding into the surrounding tissues can
occur while the infusion is freely flowing.
21. If the client is able, teach him or her when
to 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.
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 and
infection.
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 tape
3. Infusion rate and amount absorbed
4. 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 fluid
remains 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 the
site 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.
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 RATIONALEA. Changing IV Container
1. Review physician’s order for changes
in fluid administration.
2. Obtain the correct solution container
and make sure it is properly labeled.
Check for sterility and integrity.
to prevent medication error
3. Prepare to change solution when it
only 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 physician’s order. Prepare all
necessary materials for changing IV
solution and place it on an IV tray.
for faster, organized and smooth change
6. Identify the patient and explain what
you 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 flow
rate.
prevent solution remaining in drip chamber
from emptying while changing the solution.
8. Remove the protective cover from the
entry site of the new IVF bottle and
disinfect rubber port with cotton and
alcohol.
to maintain sterility of the solution.
PROCEDURE RATIONALE9. Remove old solution from IV pole. brings work to eye level.
10. Quickly remove spike from old IV
solution, 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 IV pole. 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 the
response of the client to the therapy.
provides ongoing evaluation of response to
therapy
B. Changing IV Tubing
1. Determine the need to change the IV
tubing.
a. tubing should be changed
48-96 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 prevents
movement of extremity, which could dislodge
needle or catheter.
4. Do hand washing. reduces transmission of microorganisms.
5. Open the administration set and attach
it to the container, using sterile
technique.
provides nurse with ready access to new
infusion set and maintains sterility of infusion
set.
PROCEDURE RATIONALE6. Tighten the clamp and hang the
container on the pole if it is not already
hung.
to avoid spillage of fluid as tubing is removed.
7. Remove the protective cap from the
end 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 the
dressing carefully from around the
needle. Take care not to dislodge the
needle from the vein.
9. Place a sterile swab under the hub of
the catheter to absorb any leakage
that might occur when the tubing is
disconnected. Clamp the old tubing.
10. While holding the hub of the needle
with 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 grasp
the 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 solution
flowing.
permits the solution to enter catheter or
tubing.
13. Clean the venipuncture site, working
from the insertion point outward in a
circular manner.
minimize spread of microorganisms.
PROCEDURE RATIONALE14. Apply a sterile dressing over the site
and 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 with
the date and time of the change and
your initials.
16. Regulate the flow of the solution
according to the order on the chart.
maintains infusion flow at prescribed rate.
17. Record the change of the tubing in the
appropriate place on the client’s chart.
EVALUATION FOCUS
1. Status of IV site.
2. Patency of IV system.
3. Accuracy of flow.
DISCONTINUING AN INTRAVENOUS INFUSION
Definition:
When an IV infusion is no longer necessary to maintain the client’s 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 the
client’s 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 client’s body secretions.
Equipment:
Clean glove
Waste receptacle tray
Dry or antiseptic-soaked swabs
Plaster
Sterile dressing
PROCEDURE RATIONALE1. Verify written doctor’s order to
discontinue 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 IV
administration set.
PROCEDURE RATIONALE5. Put on the clean glove. clamping the tubing prevents the fluid from
flowing out of the needle onto the client or
bed
6. Moisten adhesive tapes around the IV
catheter 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 catheter
by 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 the site,
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 client’s arm or leg above the
body if any bleeding persists.
pressure stops bleeding and prevents
hematoma formation.
10. Inspect the catheter for completeness. raising the limb decreases blood flow to the
area.
11. Report a broken catheter to the nurse
in charge immediately.
if a piece of tubing remains in the client’s 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 by
applying a sterile dressing.
application of tourniquet decreases the
possibility of a piece moving until a physician
is notified.
14. Discard the IV solution container, if
infusions are being discontinued, and
discard the used supplies
appropriately.
the dressing continues the pressure and
covers the open area in the skin, preventing
infection.
PROCEDURE RATIONALE15. Document all relevant information
a. the amount of fluid infused
b. type of solution
c. container number
d. time of discontinuance
e. the client’s response to the
procedure
EVALUATION FOCUS
1. Appearance of the venipuncture site.
2. The pulse
3. Respirations, skin color, edema, sputum, cough and urine output.
4. And how the client feels physically and psychologically.
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 by
mouth.
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 patient’s 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.
Special Considerations:
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.
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 Ringer’s (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 and
electrolytes 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 ringer’s), 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 client’s 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
6. Avoid using veins that are
a. In areas of flexion/joints ( e.g. the antecubital fossa)
b. Highly visible, because they tend to roll away from the needle
c. Damaged by previous use, phlebitis, infiltration, or sclerosis
d. Continually distended with blood, or knotted or tortuous
e. 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 chemotherapy
administration 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 through
toddler age-group.
GERIATRIC
1. Skin becomes paper-thin. Anchor catheters carefully to avoid tears and
infiltrations.
2. Insert catheter without a tourniquet if skin is fragile and veins are palpable and
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
PROCEDURE RATIONALE1. Verify the physician order for type and
amount of solution to use and the flow
rate.
Serious errors can be avoided by careful
checking.
2. Observe the 10 rights in preparing and
administering 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 client’s
anxiety.
4. Do hand washing. reduces transmission of microorganisms.
5. Prepare necessary materials for the
procedure.
to avoid delay
6. Check the sterility and integrity of the IV
solution, IV set and other devices.
Crack or leak would indicate contamination.
7. Place IV label on IVF bottle duly signed by
RN who prepared it.
a. patient’s name
b. room number
c. IV solution
d. drug incorporation (if any)
e. bottle sequence
f. drop rate
g. time started
h. 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 tubing
covered 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.
PROCEDURE RATIONALE9. Spike the solution container
a. 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 and
insert 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
client’s 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 protective
cap 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 tubing
cap, maintaining sterile technique.
To maintain system sterility.
14. Then prepare to assist the IV therapist in
IV insertion.
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.
Special Considerations:
1. Confirm that there is a physician’s 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 nurse’s 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. Don’t 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 client’s blood and donor’s blood.
2. Febrile reaction: sensitivity of the client’s 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.
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 anemias
surgery, disorders with slow bleeding. One unit raises hematocrit by approximately
4%.
3. Autologos red blood cells – Used for blood replacement following planned elective
surgery. 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 not
need to be typed and crossmatched (contains no RBC).
6. Albumin and plasma protein fraction – Blood volume expander; provides plasma
protein.
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 RATIONALE1. Verify doctor’s written order for blood
transfusion.
Serious errors can be avoided by careful
checking.
2. Obtain client’s consent before the
transfusion. Informed consent involves
explaining medical indications for
transfusion, benefits, risks, and
alternatives.
basis for legal purposes.
PROCEDURE RATIONALE3. Explain the procedure and its purpose to
the 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 solution
infusing, you will need to perform a
venipuncture on a suitable vein and start
an IV infusion of normal saline.
6. Request prescribed blood/blood
component 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 compatible
blood from the laboratory or blood bank.
8. With another nurse, compare the
laboratory blood record with
a. The client’s name and identification
number.
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 at
room 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.
PROCEDURE RATIONALE11. Verify the client’s identity by asking the
full 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 before
transfusion as prescribed.
prevents allergic reaction.
14. Do hand hygiene before ad after the
procedure.
prevents spread of microorganism.
15. Prepare equipment needed for the
procedure.
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 blood
bag gently several times to mix the cells
with the plasma.
Rough handling can damage the cells.
19. Expose the port on the blood bag by
pulling back the tabs.
20. Spike blood bag port carefully and hang
the unit. Be sure blood clamp is closed.
PROCEDURE RATIONALE21. Gently squeeze the flexible sides of the
drip 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 and
remove 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 the
blood transfusion.
allows passage of blood components into the
vein.
25. Run the blood slowly for the first 15
minutes 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 10
minutes of transfusion.
early identification of reaction facilitates
prompt intervention.
27. Remind the client to call a nurse
immediately if any unusual symptoms are
felt during the transfusion.
28. Document relevant data. Record time
blood 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 minutes
after 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 & ½ hours. Do not transfuse blood
more than 4 hours.
PROCEDURE RATIONALE31. Assess the client every 30 minutes or
more 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, close
the 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, serial
platelet count within specified time as
prescribed &/or per institution’s policy.
to check the effect of the blood transfusion.
35. Discard the administration set according
to agency 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, pertinent
observations and nursing intervention and
endorse accordingly.
documentation of relevant information and
serves as future reference for legal purposes.
38. Remind the doctor about the
administration 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.
