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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 RATIONALE
1. From the physician’s order determine he IV infusion should only be performed with
type and sequence of solutions to be used. support of a physician’s order.

2. Determine the rate of flow and infusion


schedule.

3. Ensure that the correct solution is being Stopping the infusion may allow a thrombus
infused. If the solution is incorrect, slow to form in the IV catheter. If this occurs, the
the rate of flow to a minimum to maintain catheter must be removed and another
the patency of the catheter. 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 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 the Infusions that are off schedule can be harmful
infusion will be completed at the planned to a client.
time.

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 solution administered to quickly may cause a
needle. 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 if the container is too low, the solution may
half full, squeeze the chamber to correct not flow into the vein because there is
amount of fluid to flow in. 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 Rapid flow of fluid into the drip chamber
obstructions to flow. Arrange the tubing so indicates patency of the IV line. Closing the
that it is lightly coiled and under no drip regulator to the prescribed rate of flow
pressure. If it is dangling below the prevents fluid overload.
venipuncture, coil it carefully on the
surface of the bed.
PROCEDURE RATIONALE
14. Lower the solution container below the The solution may not flow upward into the
level of the infusion site and observe for a vein against the force of gravity.
return flow of blood from the vein.

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 Absence of blood return may indicate that the
infusion as much as possible without needle is no longer in the vein or the tip of
stopping it, and replace the tubing with a the catheter is partially obstructed.
new sterile set.

17. Inspect the infusion site for fluid To ascertain the presence of infiltration
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 to see if blood returns. Blood may indicate
backcheck valve, lower the infusion that the IV needle is still in the vein.
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.

18. Inspect for the presence of phlebitis. The a new venipuncture site is usually selected,
clinical signs are redness, warmth, and and he injured vein is not used for further
swelling at the IV site and burning pain infusions.
along the course of a vein.
PROCEDURE RATIONALE
19. 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 RATIONALE
A. Changing IV Container
1. Review physician’s order for changes in
fluid administration.

2. Obtain the correct solution container to prevent medication error


and make sure it is properly labeled.
Check for sterility and integrity.

3. Prepare to change solution when it prevents air from entering tubing


only remains in the neck of the bottle
and make sure the drip chamber is half
full.

4. Wash hands.

-reduces transmission of microorganisms

5. Verify the physician’s order. Prepare all for faster, organized and smooth change
necessary materials for changing IV
solution and place it on an IV tray.

6. Identify the patient and explain what ensures correct client undergoes procedure.
you are going to do, why is it
necessary, and how he can cooperate.

7. Move the roller clamp to reduce flow prevent solution remaining in drip chamber
rate. from emptying while changing the solution.

8. Remove the protective cover from the to maintain sterility of the solution.
entry site of the new IVF bottle and
disinfect rubber port with cotton and
alcohol.
PROCEDURE RATIONALE
9. Remove old solution from IV pole. brings work to eye level.

10. Quickly remove spike from old IV prevent solution inside the drip from running
solution, and without touching tip, dry and maintain sterility.
spike it to the new solution bottle while
kinking the tubing below the drip
chamber.

11. Invert the IV bottle and hang to IV allows gravity to assist with the delivery of
pole. fluid into the drip chamber then to the tubing.

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

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

14. Observe system for patency and the provides ongoing evaluation of response to
response of the client to the therapy. therapy

B. Changing IV Tubing
1. Determine the need to change the IV tubing should be changed according to agency

tubing. protocol.

a. tubing should be changed


48-96 hours, depending on
agency protocol.

b. puncture of infusion tubing. results in leakage of fluid.

c. Contamination of tubing.
can allow entry of bacteria into bloodstream.

d. Occlusion of tubing.

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 provides nurse with ready access to new
it to the container, using sterile infusion set and maintains sterility of infusion
technique. set.
PROCEDURE RATIONALE
6. Tighten the clamp and hang the to avoid spillage of fluid as tubing is removed.
container on the pole if it is not
already hung.

7. Remove the protective cap from the replacing the cap maintains the sterility of the
end of the tubing, and prime the end of the tubing.
tubing. Clamp the tubing and replace
the cap.

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 holding the needle firmly but gently maintains
with the fingers of one hand, remove its position in the vein.
the tubing with the other hand, using a
twisting, pulling motion. Place the end
of the tubing in the kidney basin or
other receptacle.

11. Continue to hold the needle, and grasp attaches new, primed infusion tubing to hub
the new tubing with the other hand. of angiocatheter.
Remove the protective cap, and
maintain sterility, insert the tubing end
tightly into the needle hub.

12. Open the clamp to start the solution permits the solution to enter catheter or
flowing. tubing.

13. Clean the venipuncture site, working minimize spread of microorganisms.


from the insertion point outward in a
circular manner.
PROCEDURE RATIONALE
14. 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 maintains infusion flow at prescribed rate.
according to the order on the chart.

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 RATIONALE
1. 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 RATIONALE
5. 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 prevents direct contact with patient’ blood
catheter using cotton balls with
alcohol; remove plaster gently while
holding the needle firmly and applying
counteraction to the skin.

7. Gently remove the needle or catheter movement of the needle can injure the vein
by pulling it out along the line of the and cause discomfort to the client.
vein. Counteraction prevents pulling the skin and
causing discomfort

8. Immediately apply pressure to the pulling it out in line with the vein avoids injury
site, using the cotton swab, for 2 to 3 to the vein
minutes.

9. Hold the client’s arm or leg above the pressure stops bleeding and prevents
body if any bleeding persists. 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 if a piece of tubing remains in the client’s vein
in charge immediately. 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 application of tourniquet decreases the


applying a sterile dressing. possibility of a piece moving until a physician
is notified.

14. Discard the IV solution container, if the dressing continues the pressure and
infusions are being discontinued, and covers the open area in the skin, preventing
discard the used supplies infection.
appropriately.
PROCEDURE RATIONALE
15. 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 RATIONALE
1. Verify the physician order for type and Serious errors can be avoided by careful
amount of solution to use and the flow checking.
rate.

2. Observe the 10 rights in preparing and IV solutions are medications and should be
administering medications. doubled checked to reduce risk of error.

3. Identify client and explain the procedure, to facilitate cooperation and alleviate client’s
secure consent if necessary. anxiety.

4. Do hand washing. reduces transmission of microorganisms.

5. Prepare necessary materials for the to avoid delay


procedure.

6. Check the sterility and integrity of the IV Crack or leak would indicate contamination.
solution, IV set and other devices.

7. Place IV label on IVF bottle duly signed by For proper documentation.


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

8. Open and prepare the infusion set.


a. Remove the tubing from the Close proximity of roller clamp to drip
container and straighten it out. chamber allows more accurate regulation of
Slide the roller clamp along the flow rate.
tubing until it is just below the drip
chamber.

b. Move roller clamp to off position. To prevent spillage of fluid.

c. Leave the ends of the tubing This will maintain sterility of the ends of the
covered with the plastic caps until tubing.
the infusion is started.
PROCEDURE RATIONALE
9. Spike the solution container To maintain sterility of the solution.
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.

10. Invert the IV bottle and hang to IV pole. Height is needed to enable gravity to
Adjust the pole so that the container is overcome venous pressure and facilitate flow
suspended about 1 m (3 ft.) above the of the solution to the vein.
client’s head.

11. Fill the drip chamber with solution. creates suction effect; fluid enters drip
Squeeze the chamber gently until it is half chamber.
full of solution.

12. Prime the tubing. Remove the protective Tubing is primed to prevent the introduction
cap and release the roller clamp to allow of air into the client which can act as emboli.
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.

13. Reclamp the tubing and replace the tubing To maintain system sterility.
cap, maintaining sterile technique.

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 RATIONALE
1. Verify doctor’s written order for blood Serious errors can be avoided by careful
transfusion. checking.

2. Obtain client’s consent before the basis for legal purposes.


transfusion. Informed consent involves
explaining medical indications for
transfusion, benefits, risks, and
alternatives.
PROCEDURE RATIONALE
3. Explain the procedure and its purpose to reduces anxiety and promotes cooperation.
the patient. Instruct the client to re[port
promptly any sudden chills, nausea,
itching, rash, dyspnea, backpain, or other
unusual symptoms.

4. If the client has an IV solution infusing, to achieve maximal flow rate. Normal saline is
check whether the needle and solution are isotonic and reduces hemolysis.
appropriate to administer blood. The
needle should be gauge # 18 or # 19, and
the solution must be normal saline.

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 safe storage of the blood is only limited to 35


component from the blood bank to include days after extraction from he donor since the
blood typing and X-matching result, the BC deteriorates after this time causing in
expiration of he blood and blood result of allergic reaction when given.
transmissible disease.

7. Using a clean tray, get the compatible


blood from the laboratory or blood bank.

8. With another nurse, compare the to check for correct blood to infuse.
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.

9. Check blood bag for bubbles, cloudiness, these signs indicate bacterial contamination.
dark color or sediments.

10. Wrap blood with clean towel and keep it at RBCs deteriorate and lose their effectiveness
room temperature for no more than 30 after 2 hours at room temperature. Lysis of
minutes before starting the transfusion. RBCs releases potassium into the
bloodstream, causing hyperkalemia.
PROCEDURE RATIONALE
11. Verify the client’s identity by asking the to make sure you are doing the procedure to
full name and/or checking the arm band the correct patient.
for name and ID number.

12. Get the baseline V/S: BP, RR, to establish baseline data. V/S beyond normal
Temperature before transfusion and refer may result to the postponement of the
to M.D accordingly. transfusion.

13. Give pre-med 30 minutes before prevents allergic reaction.


transfusion as prescribed.

14. Do hand hygiene before ad after the prevents spread of microorganism.


procedure.

15. Prepare equipment needed for the for efficiency of work and accessibility of
procedure. needed materials.

16. Set up the transfusion equipment.


a. Ensure that the blood filter inside Blood filters have a surface area large enough
the drip chamber is suitable for to allow the blood components through easily
whole blood or the blood but are designed to trap clots.
components to be transfused.

17. If the main line is with dextrose 5% Infusing a normal saline before initiating the
initiate an IV line with appropriate IV transfusion also clears the IV catheter of
catheter with plain NSS on another site, incompatible solutions or medications.
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.

18. Prepare the blood bag. Invert the blood Rough handling can damage the cells.
bag gently several times to mix the cells
with the plasma.

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 RATIONALE
21. 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 tubing is primed to prevent the introduction of
remove air bubbles if any. Use needle G air into the client which can act as emboli.
18 or G 19 for side drip (for adults) or G
22 (for pediatrics).

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 allows passage of blood components into the
blood transfusion. vein.

25. Run the blood slowly for the first 15 the earlier the transfusion occurs, the more
minutes at 20 gtts/min. Note adverse severe it tends to be. Identifying such
reactions, such as chilling, nausea, reactions promptly helps to minimize the
vomiting, skin rash, or tachycardia. consequences.

26. Observe the client for the first 5 to 10 early identification of reaction facilitates
minutes of transfusion. 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 for documentation of relevant information and
blood was started, V/S, type of blood, future reference for legal purposes.
blood serial #, sequence # (e.g. #1 of
three ordered units), site of the
venipuncture, size of the needle, and drip
rate.

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

30. Check the V/S of the client 15 minutes Most adults can tolerate receiving one unit of
after initiating transfusion. If there are no blood in 1 & ½ hours. Do not transfuse blood
signs of reaction, establish the required more than 4 hours.
flow rate.
PROCEDURE RATIONALE
31. 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 to check the effect of the blood transfusion.
platelet count within specified time as
prescribed &/or per institution’s policy.

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 documentation of relevant information and


observations and nursing intervention and serves as future reference for legal purposes.
endorse accordingly.

38. Remind the doctor about the to maintain cardiac function and prevent
administration of Calcium Gluconate if hypocalcaemia that may lead to citrate
patient had several units of blood toxicity.
transfusion 93-6 or more units of blood).

EVALUATION FOCUS

1. Changes in vital signs or health status.


2. Presence of chills, nausea, vomiting, or skin rash.