Genius Definition Essay
MONITORING AN INTRAVENOUS INFUSION
Definition: __________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________
Assessment Focus 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ …show more content…
special consideration: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 1. _________________________________________ 2. _________________________________________ 3. _________________________________________ 4. _________________________________________ 5. _________________________________________
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|From the physician’s order determine he type and sequence of solutions to be used. | | | | | | |
|Determine the rate of flow and infusion schedule. | | | | | | |
|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. | | | | | | |
|Change the solution to correct one. Document and report the error according to agency protocol. | | | | | | |
|Observe the rate of flow every hour. Compare the rate of flow regularly. | | | | | | |
|If the rate is too fast, slow it so that the infusion will be completed at the planned time. | | | | | | |
|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. | | | | | | |
|Check if the rate is too slow. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Inspect the patency of the tubing and needle.
| | | | | | |
|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. | | | | | | |
|Observe the drip chamber. If it is less than half full, squeeze the chamber to correct amount of fluid | | | | | | |
|to flow in. | | | | | |
|
|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. | | | | | | |
|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. | | | | | | |
|Lower the solution container below the level of the infusion site and observe for a return flow of | | | | | | |
|blood from the vein. | | | | | | |
|Check for leakage. Locate the source. If the leak is at the catheter connection, tighten the tubing | | | | | | |
|into the catheter. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
|Inspect the infusion site for fluid infiltration | | | | | | |
|Palpate the surrounding tissue for edema. | | | | | | |
| | | | | | | |
|Feel the surrounding skin for changes in temperature | | | | | | |
| | | | | | | |
|If the tubing does not have a backcheck valve, lower the infusion bottle below the venipuncture site. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Try to stop the flow by applying a tourniquet 10-15 cm (4-6 in.) above the insertion site and opening | | | | | | |
|the roller clamp. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Be alert to signs of circulatory overload. | | | | | | |
| | | | | | | |
| | | | | | | |
|Inspect for bleeding at the IV site. | | | | | | |
| | | | | | | |
| | | | | | | |
|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. | | | | | | |
CHANGING AN INTRAVENOUS CONTAINER AND TUBING
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Assessment Focus: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________
Special Considerations: 1. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ 8. _______________________________________________________________________________________________________________________ 9. _______________________________________________________________________________________________________________________ 10. _______________________________________________________________________________________________________________________ 11. _______________________________________________________________________________________________________________________
Patient Education: Teach the client ways to maintain the infusion system, like: 1. ____________________________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________________________ 1. _______________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________
Equipments:
1. Container with the correct kind and amount of sterile solution 2. Administration set, including sterile tubing and drip chamber 3. Timing label 4. Sterile gauge square for positioning the needle 5. Alcohol swab 6. Clean glove 7. Tape
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Changing IV Container | | | | | | |
|Review physician’s order for changes in fluid administration. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Obtain the correct solution container and make sure it is properly labeled. Check for sterility and | | | | | | |
|integrity. | | | | | | |
|Prepare to change solution when it only remains in the neck of the bottle and make sure the drip | | | | | | |
|chamber is half full. | | | | | | |
|Wash hands. | | | | | | |
| | | | | | | |
|Verify the physician’s order. Prepare all necessary materials for changing IV solution and place it on | | | | | | |
|an IV tray. | | | | | | |
|Identify the patient and explain what you are going to do, why is it necessary, and how he can | | | | | | |
|cooperate. | | | | | | |
| | | | | | | |
|Move the roller clamp to reduce flow rate. | | | | | | |
| | | | | | | |
|Remove the protective cover from the entry site of the new IVF bottle and disinfect rubber port with | | | | | | |
|cotton and alcohol. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Remove old solution from IV pole. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
| | | | | | | |
|Invert the IV bottle and hang to IV pole. | | | | | | |
| | | | | | | |
|Check the tubing for air. If with air, remove air from the tubing. | | | | | | |
| | | | | | | |
| | | | | | | |
|Regulate IV to prescribed rate. | | | | | | |
| | | | | | | |
|Observe system for patency and the response of the client to the therapy. | | | | | | |
| | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Changing IV Tubing | | | | | | |
|Determine the need to change the IV tubing. | | | | | | |
|tubing should be changed 48-96 hours, depending on agency protocol. | | | | | | |
| | | | | | | |
|puncture of infusion tubing. | | | | | | |
| | | | | | | |
|Contamination of tubing. | | | | | | |
| | | | | | | |
|Occlusion of tubing. | | | | | | |
|Assemble the equipment. | | | | | | |
| | | | | | | |
|Explain the procedure to the patient. | | | | | | |
| | | | | | | |
|Do hand washing. | | | | | | |
| | | | | | | |
|Open the administration set and attach it to the container, using sterile technique. | | | | | | |
| | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Tighten the clamp and hang the container on the pole if it is not already hung. | | | | | | |
| | | | | | | |
| | | | | | | |
|Remove the protective cap from the end of the tubing, and prime the tubing. Clamp the tubing and | | | | | | |
|replace the cap. | | | | | | |
| | | | | | | |
|Don gloves. Remove the tape and the dressing carefully from around the needle. Take care not to | | | | | | |
|dislodge the needle from the vein. | | | | | | |
| | | | | | | |
|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 | | | | | | |
|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. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Open the clamp to start the solution flowing. | | | | | | |
|Clean the venipuncture site, working from the insertion point outward in a circular manner. | | | | | | |
|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. | | | | | | |
|Tape a label on the new tubing with the date and time of the change and your initials. | | | | | | |
|Regulate the flow of the solution according to the order on the chart. | | | | | | |
|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: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________
Assessment Focus: 1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 4. __________________________________________________________
SPECIAL CONSIDERATIONS: 1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 4. __________________________________________________________ 5. __________________________________________________________
Equipment: 1. Clean glove 2. Waste receptacle tray 3. Dry or antiseptic-soaked swabs 4. Plaster 5. Sterile dressing
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Verify written doctor’s order to discontinue IV infusion. | | | | | | |
|Wash hands. | | | | | | |
|Prepare all necessary equipments. | | | | | | |
|Close the roller clamp of the IV administration set. | | | | | | |
|Put on the clean glove. | | | | | | |
|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. | | | | | | |
|Gently remove the needle or catheter by pulling it out along the line of the vein. | | | | | | |
|Immediately apply pressure to the site, using the cotton swab, for 2 to 3 minutes. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Hold the client’s arm or leg above the body if any bleeding persists. | | | | | | |
|Inspect the catheter for completeness. | | | | | | |
|Report a broken catheter to the nurse in charge immediately. | | | | | | |
|If a broken piece can be palpated, apply a tourniquet above the insertion site. | | | | | | |
|Cover the venipuncture site by applying a sterile dressing. | | | | | | |
|Discard the IV solution container, if infusions are being discontinued, and discard the used supplies | | | | | | |
|appropriately. | | | | | | |
|Document all relevant information | | | | | | |
|the amount of fluid infused | | | | | | |
|type of solution | | | | | | |
|container number | | | | | | |
|time of discontinuance | | | | | | |
|the client’s response to the procedure | | | | | | |
STARTING AN INTRAVENOUS INFUSION
Definition: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ 4. ____________________________________________________________________ 5. ____________________________________________________________________ 6. ____________________________________________________________________ 7. ____________________________________________________________________ 8. ____________________________________________________________________ 9. ____________________________________________________________________
Patient Education: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Preparation Of Patient: 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. _________________________________________________________________________________________ 5. _________________________________________________________________________________________ 6. _________________________________________________________________________________________ 7. _________________________________________________________________________________________ 8. _________________________________________________________________________________________
Special Considerations: 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. _________________________________________________________________________________________ 5. _________________________________________________________________________________________
Types of Solutions: 1. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Kinds of Needles and Catheters 1. ______________________________________________________________ 1. _________________________________________ 2. _________________________________________ 2. ______________________________________________________________ 3. _________________________________________ 4. _________________________________________ 3. ______________________________________________________________ 5. _________________________________________ 6. _________________________________________
Site Selection Guidelines: (Take into account available vein condition, patient comfort, and type and duration of IV therapy) 1. ______________________________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________________ 3. ______________________________________________________________________________________________________________________ 4. ______________________________________________________________________________________________________________________ 5. ______________________________________________________________________________________________________________________ 7. ___________________________________________ 8. ___________________________________________ 9. ___________________________________________
6. ______________________________________________________________________________________________________________________ 1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 5. ____________________________________________________________________________________________________ 7. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Age-Related Considerations: PEDIATRIC 1. _________________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________________ 4. _________________________________________________________________________________________________________________ 5. _________________________________________________________________________________________________________________
GERIATRIC 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________
Equipments: 1. Infusion set as ordered 2. Intravenous solution as prescribed by physician 3. Intravenous catheter 4. IV pole 5. 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 |2 |3 |4 |5 |
|Verify the physician order for type and amount of solution to use and the flow rate. | | | | | | |
|Observe the 10 rights in preparing and administering medications. | | | | | | |
|Identify client and explain the procedure, secure consent if necessary. | | | | | | |
|Do hand washing. | | | | | | |
|Prepare necessary materials for the procedure. | | | | | | |
|Check the sterility and integrity of the IV solution, IV set and other devices. | | | | | | |
|Place IV label on IVF bottle duly signed by RN who prepared it. | | | | | | |
|patient’s name | | | | | | |
|room number | | | | | | |
|IV solution | | | | | | |
|drug incorporation (if any) | | | | | | |
|bottle sequence | | | | | | |
|drop rate | | | | | | |
|time started | | | | | | |
|date started | | | | | | |
|Open and prepare the infusion set. | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Move roller clamp to off position. | | | | | | |
| | | | | | | |
|Leave the ends of the tubing covered with the plastic caps until the infusion is started. | | | | | | |
|Spike the solution container | | | | | | |
|Remove the protective cover from the entry site of the IVF bottle and disinfect rubber port with cotton| | | | | | |
|and alcohol. | | | | | | |
| | | | | | | |
|Remove the cap from the spike and insert the spike into the insertion site of the IVF bottle. | | | | | | |
|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. | | | | | | |
|Fill the drip chamber with solution. Squeeze the chamber gently until it is half full of solution. | | | | | | |
|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. | | | | | | |
|Reclamp the tubing and replace the tubing cap, maintaining sterile technique. | | | | | | |
|Then prepare to assist the IV therapist in IV insertion. | | | | | | |
BLOOD TRANSFUSION
Definition: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Special Considerations: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ 8. _______________________________________________________________________________________________________________________ 9. _______________________________________________________________________________________________________________________ 10. _______________________________________________________________________________________________________________________ 11. _______________________________________________________________________________________________________________________ 12. _______________________________________________________________________________________________________________________ 13. _______________________________________________________________________________________________________________________ 14. _______________________________________________________________________________________________________________________
Types Of Transfusion Reactions: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________
Blood Products For Transfusion: 1. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________
Assessment Focus: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Equipments: 1. Unit of blood that has been correctly crossmatched 2. Blood administration set 3. 500 ml or 250 ml of normal saline solution for infusion 4. IV pole 5. # 18 or # 19-guage needle or catheter (if one is not already in place) 6. Alcohol swab 7. Plaster 8. Clean glove 9. Tourniquet
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Verify doctor’s written order for blood transfusion. | | | | | | |
| | | | | | | |
|Obtain client’s consent before the transfusion. Informed consent involves explaining medical | | | | | | |
|indications for transfusion, benefits, risks, and alternatives. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
|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. | | | | | | |
|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. | | | | | | |
|Using a clean tray, get the compatible blood from the laboratory or blood bank. | | | | | | |
|With another nurse, compare the laboratory blood record with | | | | | | |
|The client’s name and identification number. | | | | | | |
|The serial # on the blood bag label. | | | | | | |
|The ABO group and Rh type on the blood bag label or check crossmatching form. | | | | | | |
|Check blood bag for bubbles, cloudiness, dark color or sediments. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting| | | | | | |
|the transfusion. | | | | | | |
| | | | | | | |
|Verify the client’s identity by asking the full name and/or checking the arm band for name and ID | | | | | | |
|number. | | | | | | |
| | | | | | | |
|Get the baseline V/S: BP, RR, Temperature before transfusion and refer to M.D accordingly. | | | | | | |
| | | | | | | |
|Give pre-med 30 minutes before transfusion as prescribed. | | | | | | |
| | | | | | | |
|Do hand hygiene before ad after the procedure. | | | | | | |
| | | | | | | |
|Prepare equipment needed for the procedure. | | | | | | |
| | | | | | | |
|Set up the transfusion equipment. | | | | | | |
|Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood | | | | | | |
|components to be transfused. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
| | | | | | | |
|Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma. | | | | | | |
| | | | | | | |
|Expose the port on the blood bag by pulling back the tabs. | | | | | | |
| | | | | | | |
|Spike blood bag port carefully and hang the unit. Be sure blood clamp is closed. | | | | | | |
| | | | | | | |
|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. | | | | | | |
|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). | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and | | | | | | |
|secure with adhesive tape. | | | | | | |
|Shut off the primary IV and begin the blood transfusion. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Observe the client for the first 5 to 10 minutes of transfusion. | | | | | | |
| | | | | | | |
|Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion. | | | | | | |
|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. | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Swirl the bag hourly. | | | | | | |
| | | | | | | |
|Check the V/S of the client 15 minutes after initiating transfusion. If there are no signs of reaction,| | | | | | |
|establish the required flow rate. | | | | | | |
| | | | | | | |
|Assess the client every 30 minutes or more often, depending on the health status, until 1 hour | | | | | | |
|post-transfusion. | | | | | | |
| | | | | | | |
|If any untoward reaction or signs occur, stop the transfusion immediately and notify the physician | | | | | | |
|ASAP. | | | | | | |
| | | | | | | |
|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. | | | | | | |
|Re-check Hgb, Hct, bleeding time, serial platelet count within specified time as prescribed &/or per | | | | | | |
|institution’s policy. | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
| | | | | | | |
|Remove glove. | | | | | | |
|Document the procedure, pertinent observations and nursing intervention and endorse accordingly. | | | | | | |
|Remind the doctor about the administration of Calcium Gluconate if patient had several units of blood |to maintain cardiac function and prevent hypocalcaemia that may lead to citrate | | | | | |
|transfusion 93-6 or more units of blood). |toxicity. | | | | | |
Definition: __________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________
Assessment Focus 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ …show more content…
special consideration: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 1. _________________________________________ 2. _________________________________________ 3. _________________________________________ 4. _________________________________________ 5. _________________________________________
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|From the physician’s order determine he type and sequence of solutions to be used. | | | | | | |
|Determine the rate of flow and infusion schedule. | | | | | | |
|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. | | | | | | |
|Change the solution to correct one. Document and report the error according to agency protocol. | | | | | | |
|Observe the rate of flow every hour. Compare the rate of flow regularly. | | | | | | |
|If the rate is too fast, slow it so that the infusion will be completed at the planned time. | | | | | | |
|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. | | | | | | |
|Check if the rate is too slow. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Inspect the patency of the tubing and needle.
| | | | | | |
|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. | | | | | | |
|Observe the drip chamber. If it is less than half full, squeeze the chamber to correct amount of fluid | | | | | | |
|to flow in. | | | | | |
|
|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. | | | | | | |
|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. | | | | | | |
|Lower the solution container below the level of the infusion site and observe for a return flow of | | | | | | |
|blood from the vein. | | | | | | |
|Check for leakage. Locate the source. If the leak is at the catheter connection, tighten the tubing | | | | | | |
|into the catheter. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
|Inspect the infusion site for fluid infiltration | | | | | | |
|Palpate the surrounding tissue for edema. | | | | | | |
| | | | | | | |
|Feel the surrounding skin for changes in temperature | | | | | | |
| | | | | | | |
|If the tubing does not have a backcheck valve, lower the infusion bottle below the venipuncture site. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Try to stop the flow by applying a tourniquet 10-15 cm (4-6 in.) above the insertion site and opening | | | | | | |
|the roller clamp. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Be alert to signs of circulatory overload. | | | | | | |
| | | | | | | |
| | | | | | | |
|Inspect for bleeding at the IV site. | | | | | | |
| | | | | | | |
| | | | | | | |
|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. | | | | | | |
CHANGING AN INTRAVENOUS CONTAINER AND TUBING
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Assessment Focus: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________
Special Considerations: 1. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ 8. _______________________________________________________________________________________________________________________ 9. _______________________________________________________________________________________________________________________ 10. _______________________________________________________________________________________________________________________ 11. _______________________________________________________________________________________________________________________
Patient Education: Teach the client ways to maintain the infusion system, like: 1. ____________________________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________________________ 1. _______________________________________________________ 2. _______________________________________________________ 3. _______________________________________________________ 4. _______________________________________________________
Equipments:
1. Container with the correct kind and amount of sterile solution 2. Administration set, including sterile tubing and drip chamber 3. Timing label 4. Sterile gauge square for positioning the needle 5. Alcohol swab 6. Clean glove 7. Tape
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Changing IV Container | | | | | | |
|Review physician’s order for changes in fluid administration. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Obtain the correct solution container and make sure it is properly labeled. Check for sterility and | | | | | | |
|integrity. | | | | | | |
|Prepare to change solution when it only remains in the neck of the bottle and make sure the drip | | | | | | |
|chamber is half full. | | | | | | |
|Wash hands. | | | | | | |
| | | | | | | |
|Verify the physician’s order. Prepare all necessary materials for changing IV solution and place it on | | | | | | |
|an IV tray. | | | | | | |
|Identify the patient and explain what you are going to do, why is it necessary, and how he can | | | | | | |
|cooperate. | | | | | | |
| | | | | | | |
|Move the roller clamp to reduce flow rate. | | | | | | |
| | | | | | | |
|Remove the protective cover from the entry site of the new IVF bottle and disinfect rubber port with | | | | | | |
|cotton and alcohol. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Remove old solution from IV pole. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
| | | | | | | |
|Invert the IV bottle and hang to IV pole. | | | | | | |
| | | | | | | |
|Check the tubing for air. If with air, remove air from the tubing. | | | | | | |
| | | | | | | |
| | | | | | | |
|Regulate IV to prescribed rate. | | | | | | |
| | | | | | | |
|Observe system for patency and the response of the client to the therapy. | | | | | | |
| | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Changing IV Tubing | | | | | | |
|Determine the need to change the IV tubing. | | | | | | |
|tubing should be changed 48-96 hours, depending on agency protocol. | | | | | | |
| | | | | | | |
|puncture of infusion tubing. | | | | | | |
| | | | | | | |
|Contamination of tubing. | | | | | | |
| | | | | | | |
|Occlusion of tubing. | | | | | | |
|Assemble the equipment. | | | | | | |
| | | | | | | |
|Explain the procedure to the patient. | | | | | | |
| | | | | | | |
|Do hand washing. | | | | | | |
| | | | | | | |
|Open the administration set and attach it to the container, using sterile technique. | | | | | | |
| | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Tighten the clamp and hang the container on the pole if it is not already hung. | | | | | | |
| | | | | | | |
| | | | | | | |
|Remove the protective cap from the end of the tubing, and prime the tubing. Clamp the tubing and | | | | | | |
|replace the cap. | | | | | | |
| | | | | | | |
|Don gloves. Remove the tape and the dressing carefully from around the needle. Take care not to | | | | | | |
|dislodge the needle from the vein. | | | | | | |
| | | | | | | |
|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 | | | | | | |
|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. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Open the clamp to start the solution flowing. | | | | | | |
|Clean the venipuncture site, working from the insertion point outward in a circular manner. | | | | | | |
|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. | | | | | | |
|Tape a label on the new tubing with the date and time of the change and your initials. | | | | | | |
|Regulate the flow of the solution according to the order on the chart. | | | | | | |
|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: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________
Assessment Focus: 1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 4. __________________________________________________________
SPECIAL CONSIDERATIONS: 1. __________________________________________________________ 2. __________________________________________________________ 3. __________________________________________________________ 4. __________________________________________________________ 5. __________________________________________________________
Equipment: 1. Clean glove 2. Waste receptacle tray 3. Dry or antiseptic-soaked swabs 4. Plaster 5. Sterile dressing
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Verify written doctor’s order to discontinue IV infusion. | | | | | | |
|Wash hands. | | | | | | |
|Prepare all necessary equipments. | | | | | | |
|Close the roller clamp of the IV administration set. | | | | | | |
|Put on the clean glove. | | | | | | |
|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. | | | | | | |
|Gently remove the needle or catheter by pulling it out along the line of the vein. | | | | | | |
|Immediately apply pressure to the site, using the cotton swab, for 2 to 3 minutes. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Hold the client’s arm or leg above the body if any bleeding persists. | | | | | | |
|Inspect the catheter for completeness. | | | | | | |
|Report a broken catheter to the nurse in charge immediately. | | | | | | |
|If a broken piece can be palpated, apply a tourniquet above the insertion site. | | | | | | |
|Cover the venipuncture site by applying a sterile dressing. | | | | | | |
|Discard the IV solution container, if infusions are being discontinued, and discard the used supplies | | | | | | |
|appropriately. | | | | | | |
|Document all relevant information | | | | | | |
|the amount of fluid infused | | | | | | |
|type of solution | | | | | | |
|container number | | | | | | |
|time of discontinuance | | | | | | |
|the client’s response to the procedure | | | | | | |
STARTING AN INTRAVENOUS INFUSION
Definition: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. ____________________________________________________________________ 2. ____________________________________________________________________ 3. ____________________________________________________________________ 4. ____________________________________________________________________ 5. ____________________________________________________________________ 6. ____________________________________________________________________ 7. ____________________________________________________________________ 8. ____________________________________________________________________ 9. ____________________________________________________________________
Patient Education: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Preparation Of Patient: 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. _________________________________________________________________________________________ 5. _________________________________________________________________________________________ 6. _________________________________________________________________________________________ 7. _________________________________________________________________________________________ 8. _________________________________________________________________________________________
Special Considerations: 1. _________________________________________________________________________________________ 2. _________________________________________________________________________________________ 3. _________________________________________________________________________________________ 4. _________________________________________________________________________________________ 5. _________________________________________________________________________________________
Types of Solutions: 1. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Kinds of Needles and Catheters 1. ______________________________________________________________ 1. _________________________________________ 2. _________________________________________ 2. ______________________________________________________________ 3. _________________________________________ 4. _________________________________________ 3. ______________________________________________________________ 5. _________________________________________ 6. _________________________________________
Site Selection Guidelines: (Take into account available vein condition, patient comfort, and type and duration of IV therapy) 1. ______________________________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________________________ 3. ______________________________________________________________________________________________________________________ 4. ______________________________________________________________________________________________________________________ 5. ______________________________________________________________________________________________________________________ 7. ___________________________________________ 8. ___________________________________________ 9. ___________________________________________
6. ______________________________________________________________________________________________________________________ 1. ____________________________________________________________________________________________________ 2. ____________________________________________________________________________________________________ 3. ____________________________________________________________________________________________________ 4. ____________________________________________________________________________________________________ 5. ____________________________________________________________________________________________________ 7. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Age-Related Considerations: PEDIATRIC 1. _________________________________________________________________________________________________________________ 2. _________________________________________________________________________________________________________________ 3. _________________________________________________________________________________________________________________ 4. _________________________________________________________________________________________________________________ 5. _________________________________________________________________________________________________________________
GERIATRIC 1. _______________________________________________________________________________________ 2. _______________________________________________________________________________________ 3. _______________________________________________________________________________________
Equipments: 1. Infusion set as ordered 2. Intravenous solution as prescribed by physician 3. Intravenous catheter 4. IV pole 5. 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 |2 |3 |4 |5 |
|Verify the physician order for type and amount of solution to use and the flow rate. | | | | | | |
|Observe the 10 rights in preparing and administering medications. | | | | | | |
|Identify client and explain the procedure, secure consent if necessary. | | | | | | |
|Do hand washing. | | | | | | |
|Prepare necessary materials for the procedure. | | | | | | |
|Check the sterility and integrity of the IV solution, IV set and other devices. | | | | | | |
|Place IV label on IVF bottle duly signed by RN who prepared it. | | | | | | |
|patient’s name | | | | | | |
|room number | | | | | | |
|IV solution | | | | | | |
|drug incorporation (if any) | | | | | | |
|bottle sequence | | | | | | |
|drop rate | | | | | | |
|time started | | | | | | |
|date started | | | | | | |
|Open and prepare the infusion set. | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Move roller clamp to off position. | | | | | | |
| | | | | | | |
|Leave the ends of the tubing covered with the plastic caps until the infusion is started. | | | | | | |
|Spike the solution container | | | | | | |
|Remove the protective cover from the entry site of the IVF bottle and disinfect rubber port with cotton| | | | | | |
|and alcohol. | | | | | | |
| | | | | | | |
|Remove the cap from the spike and insert the spike into the insertion site of the IVF bottle. | | | | | | |
|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. | | | | | | |
|Fill the drip chamber with solution. Squeeze the chamber gently until it is half full of solution. | | | | | | |
|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. | | | | | | |
|Reclamp the tubing and replace the tubing cap, maintaining sterile technique. | | | | | | |
|Then prepare to assist the IV therapist in IV insertion. | | | | | | |
BLOOD TRANSFUSION
Definition: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indications: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Special Considerations: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ 8. _______________________________________________________________________________________________________________________ 9. _______________________________________________________________________________________________________________________ 10. _______________________________________________________________________________________________________________________ 11. _______________________________________________________________________________________________________________________ 12. _______________________________________________________________________________________________________________________ 13. _______________________________________________________________________________________________________________________ 14. _______________________________________________________________________________________________________________________
Types Of Transfusion Reactions: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________
Blood Products For Transfusion: 1. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 6. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ 7. _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________
Assessment Focus: 1. _______________________________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________________________
Equipments: 1. Unit of blood that has been correctly crossmatched 2. Blood administration set 3. 500 ml or 250 ml of normal saline solution for infusion 4. IV pole 5. # 18 or # 19-guage needle or catheter (if one is not already in place) 6. Alcohol swab 7. Plaster 8. Clean glove 9. Tourniquet
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Verify doctor’s written order for blood transfusion. | | | | | | |
| | | | | | | |
|Obtain client’s consent before the transfusion. Informed consent involves explaining medical | | | | | | |
|indications for transfusion, benefits, risks, and alternatives. | | | | | | |
|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. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
|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. | | | | | | |
|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. | | | | | | |
|Using a clean tray, get the compatible blood from the laboratory or blood bank. | | | | | | |
|With another nurse, compare the laboratory blood record with | | | | | | |
|The client’s name and identification number. | | | | | | |
|The serial # on the blood bag label. | | | | | | |
|The ABO group and Rh type on the blood bag label or check crossmatching form. | | | | | | |
|Check blood bag for bubbles, cloudiness, dark color or sediments. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting| | | | | | |
|the transfusion. | | | | | | |
| | | | | | | |
|Verify the client’s identity by asking the full name and/or checking the arm band for name and ID | | | | | | |
|number. | | | | | | |
| | | | | | | |
|Get the baseline V/S: BP, RR, Temperature before transfusion and refer to M.D accordingly. | | | | | | |
| | | | | | | |
|Give pre-med 30 minutes before transfusion as prescribed. | | | | | | |
| | | | | | | |
|Do hand hygiene before ad after the procedure. | | | | | | |
| | | | | | | |
|Prepare equipment needed for the procedure. | | | | | | |
| | | | | | | |
|Set up the transfusion equipment. | | | | | | |
|Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood | | | | | | |
|components to be transfused. | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
| | | | | | | |
|Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma. | | | | | | |
| | | | | | | |
|Expose the port on the blood bag by pulling back the tabs. | | | | | | |
| | | | | | | |
|Spike blood bag port carefully and hang the unit. Be sure blood clamp is closed. | | | | | | |
| | | | | | | |
|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. | | | | | | |
|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). | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and | | | | | | |
|secure with adhesive tape. | | | | | | |
|Shut off the primary IV and begin the blood transfusion. | | | | | | |
| | | | | | | |
|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. | | | | | | |
| | | | | | | |
|Observe the client for the first 5 to 10 minutes of transfusion. | | | | | | |
| | | | | | | |
|Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion. | | | | | | |
|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. | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|Swirl the bag hourly. | | | | | | |
| | | | | | | |
|Check the V/S of the client 15 minutes after initiating transfusion. If there are no signs of reaction,| | | | | | |
|establish the required flow rate. | | | | | | |
| | | | | | | |
|Assess the client every 30 minutes or more often, depending on the health status, until 1 hour | | | | | | |
|post-transfusion. | | | | | | |
| | | | | | | |
|If any untoward reaction or signs occur, stop the transfusion immediately and notify the physician | | | | | | |
|ASAP. | | | | | | |
| | | | | | | |
|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. | | | | | | |
|Re-check Hgb, Hct, bleeding time, serial platelet count within specified time as prescribed &/or per | | | | | | |
|institution’s policy. | | | | | | |
| | | | | | | |
|PROCEDURE |RATIONALE |1 |2 |3 |4 |5 |
|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. | | | | | | |
| | | | | | | |
|Remove glove. | | | | | | |
|Document the procedure, pertinent observations and nursing intervention and endorse accordingly. | | | | | | |
|Remind the doctor about the administration of Calcium Gluconate if patient had several units of blood |to maintain cardiac function and prevent hypocalcaemia that may lead to citrate | | | | | |
|transfusion 93-6 or more units of blood). |toxicity. | | | | | |