NCP Blood Component Therapy

Blood Component Therapy

Whole Blood; Packed Red Blood Cells (RBCs); Random Donor; Platelet Pheresis Packs; Platelets; Fresh Frozen Plasma; Albumin; Coagulation Factors; Autotransfusion

Blood component therapy is used in the management of a variety of hematological disorders. Intravenous (IV) administration of blood and blood products is used to restore circulating volume and to replace the cellular components of the blood. Advances in medical technology have significantly improved the safety of blood transfusion therapy. Blood is commonly typed by the ABO system, the Rh system, and human leukocyte antigen found on tissue cells, blood leukocytes, and platelets. Today specific blood component therapy has essentially replaced the practice of whole blood transfusions. Specific components may consist of RBCs, fresh frozen plasma, platelets, granulocytes (white blood cells [WBCs]), specific coagulation factors (e.g., factors VIII and IX), and volume expanders such as albumin and plasma protein fraction. This use of blood components has expanded the availability of replacement therapy to more patients with reduced risk of side effects.

Several types of transfusion options exist: (1) homologous (traditional method using random donors); (2) autologous (method using blood products donated by the patient for own use, either by planned preprocedure donations that store blood until needed or by blood salvage, which consists of collecting, filtering, and then returning the patient’s own blood that is lost during a surgical procedure or an acute trauma by use of an automatic “cell saver device”); and (3) directed transfusions (blood donations by one person are directed to a specific recipient). Blood component therapy can be safely administered by qualified nurses in the hospital, ambulatory care, and home setting.

Nursing Diagnosis

Deficient Knowledge

Common Related Factors	Defining Characteristics
Unfamiliarity with transfusion process Misinformation about risks of transfusion	Questioning Verbalized misconceptions Refusal to permit transfusion
Common Expected Outcome Patient or family verbalizes understanding of the need for a transfusion and the screening process performed before the transfusion begins.	NOC Outcomes Knowledge: Treatment Procedures; Anxiety Self-Control NIC Intervention Teaching: Procedure/Treatment

Ongoing Assessment

Actions/Interventions

Rationale

Assess knowledge of the transfusion process.

Adults learn best when teaching builds on knowledge or experience.

Assess the patient’s moral, ethical, and religious background as it relates to administration of blood.

Some religions prohibit the transfusion of blood products. If a critical need for blood products arises in a patient with such prohibitions, there is a need for sensitive discussion, decision making, and possible legal action, depending on individual clinical circumstances. Research and clinical trials of oxygen-carrying hemoglobin substitutes may offer alternatives to patients whose religious beliefs prevent the use of donor blood transfusions. Recombinant human erythropoietin (e.g., epoetin alfa) may reduce the effects of blood loss without transfusion.

Therapeutic Interventions

Actions/Interventions	Rationale
Offer explanation of precautionary measures used by the blood bank.	Many patients are concerned about the safety of blood transfusions and the risk of disease caused by blood-borne pathogens. Blood typing, cross-matching, and testing for hepatitis, syphilis, human immunodeficiency virus (HIV), and cytomegalovirus is done routinely on all donated blood.
Explain the specific type of blood product to be transfused and the reason for infusion.	Patients should understand the specific clinical conditions that are being treated and the results or improvements that are anticipated. They should also understand that transfusion administration time frames differ for individual blood components.
Acknowledge concerns. Provide factual information.	Blood transfusion is not without risk. Risks and benefits need to be addressed. Also, patients may have many misconceptions regarding the likelihood of disease transmission, especially that of HIV.
Explain the procedure for administering blood.	Knowledge of routine procedures related to blood component therapy helps ensure that the patient is not concerned when vital signs are taken frequently.

Nursing Diagnosis

Risk for Injury

Common Risk Factor
Blood component transfusion therapy: ·     Hemolytic reaction ·     Allergic reaction ·     Febrile transfusion reaction ·     Circulatory overload
Common Expected Outcome Patient receives blood without reaction.	NOC Outcomes Blood Coagulation; Circulatory Status; Blood Transfusion Reaction NIC Interventions Blood Product Administration; Allergy Management; Shock Management; Emergency Care

Ongoing Assessment

Actions/Interventions	Rationale
Assess for previous transfusions or reactions.	Potential for reaction increases in patients who have been previously sensitized to an antigen through transfusion. Patient may require premedication, such as Benadryl and acetaminophen.
Check for signed consent for blood transfusion.	A signed consent ensures that the patient has received information about the benefits and risks associated with blood component therapy.
Check that the component order is appropriate, that the volume order is within safe range, and that the rate of infusion is appropriate.	The patient's cardiopulmonary status must be considered when determining the rate of infusion. This is especially important in older patients.
Assess the adequacy and patency of venous access.	An 18-gauge needle is required for most blood components, especially if rapid infusion is indicated.
Confirm blood product, ABO and Rh compatibility, patient identification, and expiration date.	Discrepancies must be resolved before the product is administered. Mismatches account for the majority of transfusion reactions.
Take vital signs before therapy begins, then every 15 minutes for the next hour, and every hour thereafter. Blood should be infused slowly during the first 15 minutes.	Preexisting fever causes delay in the transfusion procedure. Most reactions occur early during administration.
Assess for signs and symptoms of a reaction to blood product:	Transfusion therapy is not without hazard.
·     Hemolytic reaction: chills, fever, low back pain, tachycardia, tachypnea, hypotension, bleeding (especially hematuria), oppressive feeling, and acute renal failure	Hemolytic reaction is the most serious reaction and potentially life threatening. It is caused by infusion of incompatible blood products. Some are due to naturally occurring antibodies in the ABO antigen system. Reaction may be immediate or delayed. Delayed reactions usually occur in patients who have been previously sensitized to an antigen through transfusion or pregnancy.
·     Allergic reaction: flushing, itching, hives, wheezing, laryngeal edema, and anaphylaxis	These reactions are caused by sensitivity to plasma protein or donor antibody that reacts with recipient antigen.
·     Febrile nonhemolytic reaction: sudden chills and fever, headache, flushing, and anxiety.	Common transfusion reaction is caused by hypersensitivity to donor white blood cells (WBCs), platelets, or plasma proteins. Use of a leukocyte-poor filter when transfusing blood products to a person requiring frequent transfusions or who is immunosuppressed may reduce or prevent febrile nonhemolytic reactions.
·     Circulatory overload: dyspnea, cough, distended neck veins, increased blood pressure (BP), and crackles heard on pulmonary auscultation	This occurs when fluid is administered at a rate or volume greater than the circulatory system can manage. This is especially common in older patients.

Therapeutic Interventions

Actions/Interventions	Rationale
Follow institutional policy for obtaining blood product from blood bank.	Patient safety is a priority. Infusion of the blood product should begin within 30 minutes of receipt of blood from the blood bank. If there is a delay, blood must be returned to the blood bank for adequate refrigeration (check institutional policy for any restrictions on returning products). However, blood unrefrigerated for more than 30 minutes cannot be returned.
Prime blood tubing with normal saline solution and connect to patient’s IV access.	This is used as a standby for infusion when blood transfusion is completed or if a reaction occurs. Lactated Ringer’s or dextrose solution may induce RBC hemolysis.
Premedicate with prescribed antipyretics, antihistamines, and/or steroids those patients who have received frequent previous transfusions or who are immunocompromised.	These patients have been sensitized to donor WBC antigens and may experience febrile transfusion reactions if not premedicated. Ensure that an emergency drug kit is available when in the home setting.
Maintain appropriate infusion rate. Increase rate as condition warrants.	Start slowly for first 15 to 20 minutes to monitor for possible reaction. One unit of packed red blood cells (RBCs) can usually be infused over 2 hours, unless the patient is at risk for fluid overload, has cardiopulmonary disease, or is elderly. Blood not infused within 4 hours should be discontinued.
If any type of reaction occurs, stop the transfusion immediately. Keep the IV access open with 0.9% normal saline solution and notify the physician and blood bank.	Early assessment facilitates prompt treatment.
For acute hemolytic reaction:	This is usually caused by ABO incompatible blood that is mistakenly given to the wrong patient.
·     Be prepared to treat shock.	This is a potentially life-threatening reaction.
·     Maintain BP with IV colloids.	Fluid resuscitation is needed to maintain circulatory volume.
·     Insert Foley catheter and monitor urine output.	A decreased urine volume indicates hypovolemia.
·     Draw testing blood samples and collect urine sample.	Blood sampling permits repeat typing and cross-match to examine compatibility. Hemolysis of RBCs causes free hemoglobin (Hgb) to be released into the plasma, which is later filtered by the kidneys and released into the urine. Urine is tested for presence of RBCs.
·     Anticipate possible transfer to critical care and initiation of dialysis if renal failure develops.	Specialized care is needed to support the patient’s recovery and prevent more serious complications.
·     Return blood product to blood bank.	Testing will be done to reexamine compatibility of the product and the recipient.
For allergic reaction:	This is common in patients with history of allergies.
·     Give antihistamines as prescribed.	These drugs decrease the patient’s hypersensitivity response.
·     Anticipate the need for epinephrine, corticosteroids, and pressor medications.	Emergency treatment may be needed if severe respiratory distress, hypotension, or shock is present.
·     Anticipate the need for intubation.	Aggressive respiratory measures may be required to maintain an airway.
For febrile, nonhemolytic reaction:	This occurs because of the recipient’s sensitization to the donor’s WBCs, platelets, or plasma.
·     Give antihistamines as prescribed.	These drugs suppress the inflammatory response in this type of reaction.
·     Give antipyretics as prescribed.	These drugs reduce fever.
·     Send blood sample, blood bag, and urine sample to the laboratory.	Follow-up testing will be done.
For circulatory overload:	Overload is seen in elderly patients and in those with cardiac and renal dysfunction.
·     Keep patient in high Fowler’s (upright) position.	This position promotes effective breathing and gas exchange by pooling excess fluid in dependent parts of the body.
·     Administer diuretics, oxygen, and morphine, as prescribed.	These measures promote fluid balance and effective gas exchange.
·     Insert Foley catheter.	This measure allows for frequent monitoring of urine output.
·     Anticipate transfer to critical care if pulmonary edema is severe.	Specialized care is required to support the patient’s recovery and reduce complications.