Intravenous Administration by pengxuebo

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									             Chapter 13 Intravenous Infusion
                 and Blood Transfusion

PHYSIOLOGY
     The body’s internal environment is made up of fluids ( primarily water ) and electrolytes

( dissolved substances ), which are constantly adjusting to maintain an environment that supports

life-sustaining physiologic processes.Fifty to 70 percent of an average person’s body weight is

water.The obese and elderly have less body water, and infants, although they have the greatest

percentage of body water, are unable to compensate readily for water losses.Physiologic factors

place these patients at greater risk for fluid balance problems.

     Most of our body water ( 66 percent ) is located inside our cells.The remaining 34 percent is

outside the cells:75 percent of this extracellular fluid is interstitial ( surrounding our cells ), and

the remaining 25 percent circulates as intravascular plasma within the vascular system.The

intravascular fluid space is the smallest, yet the most critical for life support.Normally, the

extracellular and intracellular spaces have equal osmotic pressure, so fluid does not move between

these two major compartments.In contrast, constant exchange of fluids occurs between the two

extracellular ( interstitial and intravascular ) fluid compartments.The movement of fluid between

extracellular fluid compartments is controlled by two opposing forces:osmotic pressure of plasma

proteins holding fluid within the vessels, and hydrostatic pressure in the arterioles forcing fluid

into the tissue spaces. An increase in venous hydrostatic pressure, or a decrease in plasma proteins,

will result in the retention of fluid in the interstitial space (edema ).

     Body water balance is dependant upon homeostatic physiologic responses to fluid gains

( intake ) and fluid losses (output ). To balance a typical amount of fluid intake, the kidneys will

produce 1 to 2L of urine per day. An increased fluid intake, however, will result in an increased

urine output.

     Body fluids contain dissolved electrolytes that influence not only fluid balance, but also vital

cellular processes. The major intracellular electrolytes are potassium, magnesium, phosphate, and

sulfate.                                                                       As
        Major extracellular electrolytes are sodium, chloride, and bicarbonate. with body fluids,



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it is essential to maintain a balance of these important electrolytes by replacing what is lost on a

daily basis.Stress, illness, and even medical management can influence gains and losses of these

important elements.

      Major Electrolyte
       Cations (+)                         Anion (-)

     Na+      Sodium                 Cl¯         Chloride

     K+       Potassium              HCO3¯        Bicarbonate

     Ca2+    Calcium                 HPO42¯ Phosphate

     Mg2+     Magnesium

     Fluid and electrolyte balance can be threatened by any disruption of health.Therapeutic

measures frequently necessitate peripheral or central intravenous infusion of fluids and

electrolytes to cover daily insensible ( nonmeasurable ) losses and to dilute the end products of

metabolism excreted by the kidneys.IV fluids are also administered to correct deficits (e.g.,

hemorrhage) or to compensate for ongoing abnormal fluid losses ( e.g., gastric suction ) .In

addition, when illness products an intense requirement for nutrients ( e.g., burn patients ) or when

the gastrointestinal tract is nonfunctioning ( e.g., pancreatitis ), infusion of parenteral nutrition is

indicated.




                           SECTION ONE
                        Intravenous Infusion

      Intravenous (IV) infusion is a method that a large volume of solution is infused into
body to handle fluid and electrolyte disturbances.

      Intravenous(IV) infusion is a serious and complex responsibility that requires not only
proficiency in performance, but also familiarity with the anatomy involved, ever mindful use of

principles of asepsis, and expertise in prevention, and management of complications that may

occur with treatment.

     IV fluids are medications and require a physician’s order. They are ordered to meet daily fluid




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and electrolyte requirements for the patient, to correct a fluid and electrolyte or blood deficit, or to

replace abnormal ongoing losses due to gastric suction or draining wounds. The type and amount

of fluid administered will be based on these types of need as well as the patient’s age and general

health status and the results of laboratory tests. Most patients receive crystalloid saline and/or

glucose infusion, frequently with the addition of potassium, to cover electrolyte losses due to

illness and stress.

     Patients receiving IV fluid require physical assessment of fluid status, regular monitoring of

response to IV therapy, and documentation of fluid intake and output from all sources. Shift and

24hour intake or output totals are evaluated and the physician is notified of any unanticipated

imbalance ( e.g., urine output<30 ml/hr ), as more intensive monitoring may be indicated.




Types of solutions
     The decision to use a specific type of IV solution is based on the individual’s condition or the

type of fluid and electrolyte imbalance to be corrected . There are many methods of

classification.

       ★IV fluids can be classified according to their osmolality in

relation to normal blood plasma.

       • Hypotonic fluids           have lower osmolality than plasma. They are administered to

correct dehydration as they move from blood vessels into the cells.

     Examples are 0.45 percent sodium chloride, 0.2 percent sodium chloride, or 5 percent

dextrose in water or combined with hypotonic saline.

     Excessive infusion can cause water intoxication.

       • Isotonic fluids have the same effective osmolality as plasma. They are administered
to expand the intravascular space to correct hypovolemia as in shock..

     Examples are lactated Ringer’s, 0.9 percent ( normal ) saline, and 5 percent dextrose in

normal saline.

     Excessive infusion can cause circulatory overload and pulmonary edema.




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      • Hypertonic fluids have greater osmolality than plasma, and are used primarily to
pull fluid from cells and the interstitial space into the intravascular space to relieve edema.

     Examples are >5 percent dextrose solutions, colloidal products such as dextran,

and 3 percent saline ( rarely used ).

     Excessive infusion can cause cellular dehydration and circulatory overload or

diuresis.

     ★IV fluids can also be categorized as nutrient fluids and

electrolytes fluids according to their purpose.

      • Nutrient solutions contain some form of glucose and water. calories and fluids
                                                                  For

replacement.Common nutrient solutions are 5% or 10%dextrose in water and 5% dextrose in

0.45% sodium chloride.Hypertonic ( >10 percent dextrose ) parenteral nutrition solutions are

irritating to peripheral veins and so must be infused into central veins, where blood flow is greater.

     • Electrolytes solutions contain varied amounts of cations and               anions.Commonly

used solutions are normal saline,Ringer’s solution, and lactated Ringer’s solution. Normal saline

and balanced electrolytes solutions commonly are used to restore vascular vo1ume,particularly

after trauma or surgery.They also may be used to replace fluid and electrolytes for patients with

continuing losses,for example,gastric suction or wound drainage.

     • Volume expanders are another types of solutions.They are used to increase the
blood volume following severe loss of blood or loss of plasma.Common volume expanders are

dextran,plasma,and human serum albumin.

       ★Clinically prepared fluids fall into the following three

categories:

      ▲Crystalloid Solution                Crystalloid solutions have small molecular weights and

stay in blood vessel for a short time,and can maintain the balance of fluids in intracellular and

extracellular, can correct the fluids and electrolytes disturbance.Commonly used crystalloid

solutions are:



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     • Dextrose in Water Solutions Dextrose in water solutions are used for fluids and
calories replacement,decreasing the consumption of albumen,and preventing the production of

ketone.After transported into body,glucose is decomposed quickly.So usually it doesn’t cause

hypertonic and diuretic effects.Clinically there are usually 5% and 10% dextrose in water

solutions.

     • Isotonic Electrolytes Solutions They are used in electrolytes replacement.Loss of
body fluids usually is accompanied with disturbance of electrolytes.So, the balance of fluids and

electrolytes must be maintained during fluids replacement.Commonly used isotonic electrolytes

solutions are o.9% sodium chloride,Ringer’s isotonic solution and 5% dextrose in water

solution.

     • Alkaline solutions
     NaHC03 in Water Solutions They are alkaline solutions,used in correcting acidosis,
and regulating of acid-base balance.After being transported into human body, NaHC03 is
                             -         -
decomposed to Na+ and HCO3 .HCO3 combines with H+ in human body, and then becomes

H2CO3,which is excreted out of body in form of C02 and H2 O.Clinically,the usually used

solutions are NaHC03 4% and 1.4% in water solutions.

     Sodium Lactate in Water Solutions They are also alkaline solutions,used to correct

acidosis.Sodium lactate is broken down to ion of Na+ and lactate in human body. + combines
                                                                               Na
            -
with HCO3 ,and then becomes NaHC03.The ion of lactate combines with H+, and then becomes

lactic acid,which can be excreted out of body in form of C02 and H2 O.The concentrations of the

solution usually used in clinic are 11.2% and 1.84%.

     • Hypertonic Solutions They are used for diuretic and dehydration purposes. They can
increase osmolality of blood plasm by pulling fluids into plasma,which can reduce the edema of

tissues.They can also decrease intracerebral pressure and improve the function of central nervous

system.Clinically,mannitol 20%,sorbitol 25% and dextrose 25%-50% in water solutions are

often used.

      ▲Colloidal Solution            Colloidal solutions have large molecular weight,and also

stay in blood for a long time.It can maintain plasma colloidal osmotic pressure effectively,

expand the blood volume,improve microcirculation,and elevate the blood pressure.Commonly


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used colloidal solutions are as follows:

     • Dextran It is water-soluble polysaccharide of high molecular polymer.In clinical
settings,the commonly used are moderate molecular and small molecular dextran.The moderate

molecular dextran can elevate plasma colloidal osmotic pressure,expand blood volume,and the

small molecular dextran can reduce the viscosity of blood,decrease the accumulation of

erythrocytes,                                                     and
             improve microcirculation and tissue perfusion volume, prevent the formation of

thrombosis.

     • Plasma Substitutes With the similar function as small molecular dextran,they can
expand vascular volume and cardiac output greatly,which can be used with whole blood in acute

massive hemorrhage . In clinical settings , the usually used plasma substitutes are

hydroxyethylamylum,povidone and oxypolygelation.

     • Blood Products         They can elevate colloidal osmotic pressure,expand vascular

volume,and provide protein and antibody.It also can help with tissue repair and enhance

immunity of body.

      ▲Parenteral Nutrition Solutions                   They are intravenously given to the

patients who are unable to get nutrition via gastrointestinal tract or have inadequate intake of

nutrients.                                          proteins,
          This form of solution can provide calories,                              and
                                                             vitamins and minerals, maintain

the balance of nitrogen.The main compositions include amino acids,fatty acids,vitamins,

minerals,                                          and
         high concentration of glucose or dextrose, water.The commonly used solutions are

multiple amino acids solutions and fat emulsions.



    Types and amounts of solutions that are transfused should be chosen according to the type

and degree of fluids,electrolytes and acid-base imbalance.The sequence of solution transfusion

should follow the principle of“colloidal solutions after crystalloid solutions,dextrose in water

solutions after sodium chloride solutions,rather acid solutions than alkaline solutions”.




Sites of venipuncture
    The nurses chose the site of venipuncture based on the patient’s age,consciousness,position,




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the length of time the infusion is to run,the type of solution used,and the condition of veins.

The common sites include:

Peripheral Superficial Vein                 That means the vein in the extremity of limbs within

hypodermic tissue.For adults,veins in hands and arms are commonly used.The veins in dorsal

hands are the first choice for adult patient when initiating infusion line.The median cubital,

        and
basilic, cephalic veins are commonly used for drawing blood,bolus injections of medication,

and as

insertion sites for a peripherally inserted central catheter (PICC) line.The saphena magna vein,

saphena parva vein in legs and veins in dorsal feet are common sites of injection too.But,they are

not the first choice,because of the danger of thrombosis caused by the vein valve.Veins in dorsal

foot are commonly used for children,but are avoided in adults because of the danger of

thrombophlebitis.

Veins in the Scalp             It is common used for infants because of their rich distribution,

accessibility,rare movement,easy securing the needle and relative ease of preventing dislocation

of the needle.Larger veins include temporal superficial vein,frontal vein,occipital vein,and

posterior ear vein.

Subclavian , External Jugular                     They are commonly used for central venous

access.Central venous catheters usually are inserted into the subclavian or external jugular vein,

with the distal tip of the catheter resting in the superior vena cava just above the right atrium.

     The nurse assessing the patient for potential venipuncture sites for IV infusion should

consider conditions and contraindications that exclude certain sites.First, because the very young

and older adults have fragile veins,the nurse should avoid using sites easily moved or bumped

such as the dorsal surface of the hand.Second,venipuncture is contraindicated in a site that has

signs of infection,             or          An
                   infiltration, thrombosis. infected site is not used because of the danger of

introducing bacteria from the skin surface into the bloodstream.Avoid using an extremity with a

vascular (dialysis) fistula on the operating side.Place IVs at the most distal point when

possible.Using a distal site first allows for the use of proximal sites 1ater if the patient would need

a venipuncture site change for long--term infusion.The nurses are responsible for ensuring all



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central lines and venous access ports aseptic and catheter unobstructed.



Peripheral Intravenous Infusion
Purposes
     1. To correct or prevent fluid and electrolyte disturbances resulted from illnesses, altered fluid

intake, or prolonged episodes of vomiting or diarrhea.

     2. To increase the blood volume, maintain blood pressure following severe loss of blood,

severe burns, or shock.

     3. To supply medication to cure diseases for rapid effectiveness.

     4. To supply nutrient substances to promote wound healing, weight gain and positive nitrogen

balance for patients with chronic consuming illness, inability to intake, digest or absorb a diet.

     5. To establish a lifeline for rapidly needed medications.

Preparation

Nurse:
     1. Review the physician’s order in patient’s record.

     2. Evaluate patient’s age and medical status. Evaluate patient’s renal status and other

pertinent lab data (e.g., electrolyte, serum glucose ).

     3. Wash hands and wear mask.

     1. Verify patient’s identity.

     2. Explain the procedure and purpose.Ask the patient to void.

     3. Position patient for comfort and optimal visibility for skill performance.

Environment:
     The environment must be cleaning, commodious and bright

Equipment:
     The nurse must become familiar with the equipment used in each particular agency because

correct selection and preparation of IV equipment assist in safe and quick placement of an IV

line.Sterile technique is necessary in the procedure of using the equipment.The equipment



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includes:

Medical tray:

·Disinfectant                         ·Sterile swab

·Tourniquet                                  ·Pad

·Adhesive tape                              ·File and opener

·IV solution and medication                ·Medical card

·Infusion set                               ·Bottle bag

·kidney-shaped tray ( Container for contaminated substances )



     It is essential that the solution must be sterile and in good condition.Before infusion,nurses

should check the quality of solution,for example, whether there is any deposition,cloudiness,

or foreign matter.Nurses should check whether the cap of bottle becomes 1oose,and whether

there is any cranny in the body of bottle.Nurses also should check the expiration date on the

label.Nurses should not use any questionable or contaminated solutions.

     Different types of tubing are used to administer medications or IV fluids.          the
                                                                               Currently, most

common tubes are plastic tube connected with single--or double--handle needle.They are

disposable.The drip chamber permits a predictable amount of fluid to be delivered.A commonly

used drip chamber is the microdrip,which delivers 10 to 20 drops per milliliter of solution.In

contrast , microdrip tubing provides a standard drop size of 60 drops per milliliter of

solution.Microdrip tubing is used to allow precise regulation of IV fluids even at slow rates.In

addition,patients may require IV extension tubing to increase mobility or to facilitate changes in

position.Intravenous pumps or volume control devices are used for children,patients with renal or

cardiac failure,or critically ill patients to prevent sudden uncontrolled fluid administration.

     In addition,there are different types of catheters for central venous access (CVC) which

differ in length,internal diameter,number of channels (access ports),method of insertion, material

and means of fixation.Usually, catheters with a length of 20cm are used for subclavian and

internal jugular lines,and 60cm for femoral and basilic lines.

Procedures and Key Points



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                   Steps                                     Rationale and key points

1. Check and right

  Review the physician’s order,including the        ·whether there is any deposition,cloudiness,

  bed number, patient’s name,
             the             medication             or foreign matter, whether the cap of bottle

  name,dosage,concentration,and date,               becomes 1oose,and whether there is any

  and     prepare      the    solution        and   cranny in the body of bottle, check the

  medication.Check the quality of solution          expiration date on the label

2. Complete the medication label and stick it       ·The original label should not be covered by

  upside down to the solution container               the writing label

3. Add medications into solution                    ·Assess for compatibility of medications

(1) Take the solution container into a bottle

  bag.

(2) Open the center of the mental cap of the

  solution container,and sterilize it

(3) Add the medication according to the

  physician’s order

(4) Arrange the sequence of IV solutions

  based on the patient’s condition

4. Insert the infusion set                          ·If there is a air needle,the nurse should

  Check the quality of the infusion set.Open          insert the air needle into the bottle at the

  the infusion set package,and remove the             same time

  protective cover of spike and insert it into      · nurse should keep the infusion set sterile
                                                     The

  fluid bottle.Close the clamp

5. Prepare the equipment and take them to the       · ensure the medication administered to the
                                                     To

  bedside.Check again                                 right patient

6. Discharge air                                    ·A certain height is needed to enable the

(1) Hang the solution container on the pole           gravity to overcome the venous pressure

                                                      and facilitate the solution flowing into the

                                                      vein



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(2)Turn the chamber upside down and squeeze        ·The nurse should eject air in the infusion set

  it gently until it is 1/2 to 2/3 full of           thoroughly and connect every part of the

  solution,then turn over the chamber.               infusion set tightly to prevent leaking air

  Release the clamp,and let the fluid run            from producing embolism

  through the tubing until the tubing is full of

  solution

(3) Close the clamp.Place the tubing end into      ·Maintain sterility of the system

  the bag of the set and place them in the

  medical tray

7. Select the venipuncture site                    ·Selecting vein according to the selecting

(1) Place a pad under the extremity                  principles

(2) Apply a tourniquet firmly 10 to 15cm           ·The tourniquet must be tight enough to

  above the venipuncture site.                       obstruct venous flow but not so tight to

                                                     occlude the arterial flow

                                                   · If the vein is not sufficiently dilated,

                                                     suggestions are given as follows:

                                                     (a) massage or stroke the vein;

                                                     (b) encourage the patient to clench and

                                                     open the fist;

                                                     (c) tap the vein with fingertips lightly

8. Sterilize the venipuncture site.Prepare         ·To clean organisms on the local skin to

  adhesive tape.                                     prevent infection

9.Check again.

10. Intravenous injection

(1) Placed the nondominant hand 3 to 5cm           ·Taut skin can stabilize the vein, make the

below the entry site to pull the skin taut           insertion easy and reduce the patient’s pain

against the vein . Hold the needle with            ·Nurse should pay attention to the inserting

dominant hand, insert the needle through the         angle to avoid transpiercing the vein

skin and into the vein



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(2) Once blood appears in the lumen of the           · Placing needle parallel to the vein can

needle, reduce the angle of the needle until it      reduce the risk of vein injury

is almost parallel to the skin,and advance the

needle a little.Hold the needle shaft steady

11. Fixation

Ask the patient to release fist, release the         ·Allow venous flow recover

tourniquet,and open the clamp

Place a piece of adhesive tape over the hub to       ·    Fixation of the needle can prevent

anchor the needle until the infusion is              movement and tension on the device, reduce

smooth.Place another piece of tape covering a        mechanical irritation and possible phlebitis or

sterile   dressing    to   cover   the   site   of   infection

venipuncture , maintain            the   dressing    ·Looping and fixing the tubing can prevent

sterile.Loop the tubing near the site of entry, pull on the needle

and anchor with adhesive tape. Apply a

padded arm board to splint the joint if needed

12. Regulate the flow rate according to the          ·          the
                                                      Generally, flow rate is 40 to 60gtt/min

patient’s condition and medication . Hold            for normal adult,and 20 to 40gtt/min for

watch beside the drip chamber and count              children

drops per 15 seconds in drip chamber to

calculate the drops per minute

13. Check again.

14. Disposure after operation                        ·Nurses should tell the patients not to change

Take off the tourniquet and pad.Help the             the flow rate by themselves,tell them the

patient take a comfortable position.Place the        symptoms      and      signs     of   common

call bell beside the patient . Observe the           complications,in order for them to notice the

patient’s response.                                  physician or nurse on time

Remove all equipment and dispose in proper

  manner. Wash hands

Document relevant data including infusion



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                           and
 initiated time, flow rate, the patient’s local

 and systemic condition.

 15. Change bottles

 If there is more than one bottle of solutions,     ·The nurse should check if there is air in the

 nurse should check the physician’s orders,and      tubing below the chamber to reduce risk of

 prepare the second bottle at least 1 hour before   clot formation in vein caused by empty IV

 the first bottle is finished, and change the       tubing

 bottle on time

 16. Disposure after infusion

 (1)After the prescribed amount of fluid has

   been infused, close the roller clamp,

   remove the adhesive tape,place a sterile

   swab over the venipuncture site and, use the

   other hand to withdraw the needle by

   pulling straight back away from the

   insertion site . And then elevate the

   extremity and apply pressure to the site for

   1 to 2 minutes to control bleeding and

   prevent hematoma formation

 (2)Help the patient to have a comfortable

 position.Record the volume of fluid infused

 and the time of the discontinuation

 (3)Dispose of the equipment in proper manner

 (4) Wash hands. Document relevant data




Cautions:
1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.

2. Arrange the sequence of IV fluids rationally according to the patient’s need. Assign medications


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according to the therapeutic principles and the half life of medications.

3. Protect and use veins reasonably (usually from small veins) to patients who need long-term IV

infusion.

4. Prevent air embolism by ejecting air thoroughly in infusion set, changing fluid bottles and

withdrawing the needle in time.

5. Assess for compatibility of medications. Ensure the needle have been inserted into vein before

administration irritative or special medications.

6. Master the flow rate strictly.

7. Assess during infusion carefully in order to find the problems and settle the problems on time.

Document the result after assessment.




Education
1. Tell the patient don’t regulate the flow rate optionally.

2. Introduce the signs and symptoms of complications with IV reactions, ask patient call nurse in

time when he find the signs of IV reaction.

3. Intensify mental nursing to patient who need long-term IV infusion.




Regulating the Infusion Flow Rate
     After the IV infusion is secured and the line is patent,the nurse must calculate the correct

flow rate according to the physician’s orders,regulate the rate of infusion,and monitor the

patient’s

responses.

★Calculate the Flow Rate                      Two commonly used methods of indicating flow rates

are designating the number of milliliters to be administered in 1 hour (ml/h) and the number of

drops to be given in l minute (gtt/min).Calculating methods are as followed:

     Milliliters per Hour Hourly rates of infusion can be calculated by dividing the total
infusion volume by the total infusion time in hours.Standard formula is:

     Milliliters per hour (ml/h)=Total infusion volume (ml)/Total infusion time (h)



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     Drops per Minute           Drops per minute should be calculated according to drop

factor.Drop factor is the number of drops delivered per milliliter of solution.Drop factor varies

with different types of infusion sets.Generally,drop factor is printed on the package of the

infusion set.Infusion sets commonly used at present have drop factors of 10,15,20 or 60 drops

/m1.Standard formula is:

     Drops per minute=Total infusion vo1ume (m1)×drop factor (drops/m1) /Total time

of infusion (min)



    Generally,flow rate is 40 to 60 (gtt/min) for normal adult,and 20 to 40 (gtt/min) for

child.Slow flow rate is suitable for the elderly,infants and patients with diseases in heart, 1ungs,

or kidney.When hypertonic solutions,solutions containing potassium,or solutions containing

medications for raising blood pressure are infused,the flow rate also should be slow.When a

patient with normal heart and lung function has severe dehydration,the flow rate should be rapid.

★Common Infusion Control Device
     Clamp Unless an infusion control device is used,the nurse manually regulates the drops
per minute of flow using the roller clamp to ensure that the prescribed amount of solution will be

infused in the correct time span.The rate of infusion with an IV roller clamp depends on the

height of the IV fluid container,IV tubing size,and fluid viscosity.The advantage is easy

operation,but the IV roller clamp is less precise than the IV pump in delivering IV fluids with

precision.If the flow rate is incorrect,problems such as hypervolemia,hypovolemia,or

inadequate medication administration may occur.

     Infusion Pump An infusion pump is designed to deliver a measured amount of fluid
over a period of time.It delivers that fluids intravenously by exerting positive pressure on the

tubing or on the fluid to ensure measured amount of fluid is infused uniformly in a given time.The

pump has a drop sensor, and an alarm that will sound if drops are not detected at the appropriate

rate.There are also alarms to alert the nurse to increase system pressure that can occur with an

exudation.




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Common Problems during Infusion and Methods to Treat
★Slow Flow Rate or No Infusion
     Infiltration An infiltration may be present when the insertion site becomes pale, cool,
and swollen.An exudation occurs when the needle has been dislodged from the vein and is in the

subcutaneous space.                 the
                   When this occurs, IV line must be discontinued and a new line established

at a new location.

     occlusion of the IV Needle or Catheter Occlusion of the IV needle or catheter
means that there are clots at the tip of the needle or catheter or/and that the catheter or needle tip

is against the vein wall.In addition,several problems narrowing the tubing may exist, such as a

too-tight IV dressing and a kink in the tubing.The nurse can assess it by lowering the IV

container below the level of the IV insertion site, open the roller clamp thoroughly, and observing

                   If
for a blood return. no blood return occurs,that means the needle or the tubing is occluded.The

nurse should inspect the area around the insertion site for anything that could obstruct the flow of

IV fluids,loose the IV dressing,check the tubing,change the position of the needle handle

slightly.If the flow rate is normal,the nurse can secure the needle again.

      In addition, the position of the extremity,particularly at the wrist or elbow,can decrease
flow rate.The flexed joint may alter the position of the needle tip, such as sliding out of the vein,

or occluded against the vein wall,which can decrease the flow rate.                   the
                                                                   Methods to inspect: flow

rate changes with the altering of the extremity, or there is infiltration in insertion site after the joint

is moved.                     if                                      ask
         Methods to deal with: the insertion site is close to a joint, the patient not to move

the limb and keep the limb extended.Occasionally using an arm board can help to keep the joint

extended and reduce its movement.If there is exudation in the infusion site,the nurse should

restart infusion at a new location.

      Hyperkinesia of Vein The hyperkinesia of the vein may be present when the
extremity is exposed in cold environment for a long time or the temperature of the fluid is too low.

The extremity will feel painful and the flow rate will become slow. Apply warm compresses can

relieve the hyperkinesia of the vein.

      Too Low Hydrostatic Pressure The height of the IV container can also affect flow



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      If                                 the
rates. the solution container is too low, flow rate slows down because hydrostatic pressure is

decreased.Raising the solution container usually can increase the flow rate because of increased

hydrostatic pressure.

★Too Large Volume of Solution in Chamber                                When removing air from

tubing,the nurse compresses the drip chamber too many times or too hard.To deal with this

problem,the nurse should remove the container from the IV pole,keep it in appropriate height,

and make the spike out of the liquid.If necessary,compress the tube above the chamber,and

allow the air within container entering tube until the volume of solution in chamber is

appropriate.Hang the container on the IV pole.

★Too Small Volume of Solution in Chamber                            This problem may result from

compressing chamber with less force or fewer times,or too slow when changing the IV solution

during continuous infusion.To solve it,the nurse should fold the tube below the chamber,and

compress the chamber or the tube above the chamber until the volume of solution in chamber is

appropriate.

★The Surface of Liquid Fall down Automatically                               It is because that the

tubing and chamber is not airtight.The nurse should check the whole infusion set system carefully

to see if there is untight connection of every part or cranny in infusion set.If necessary,the tube

system should be changed.

    These problems may occur with any patient at any time.When caring for a patient with an

infusion,the nurse should assess the site and the infusion rate at least once an hour.




Complications of Intravenous Therapy and Intervention
    The nurse must be aware of the potential hazards of IV therapy,the causes,symptoms and

signs, the prevention and intervention in order to prevent these complications or minimize their

effects as soon as possible.Common complications are fever,circulatory overload,phlebitis,

thrombosis,thrombophlebitis,air embolism,exudation,allergic reactions,and infection or

inflammation at the insertion site.




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★Fever
    Causes Fever can be caused by allergic reactions to a medication or IV fluid,impureness
of the solution,incomplete sterilization of the equipment, or no strict application of aseptic

techniques during starting an intravenous infusion.

    Symptoms and signs After starting intravenous therapy for some minutes or hours,the
patient feels cold,trembling and with increased body temperature to 38℃ to 40℃ or higher.

Systematic reactions may be present,such as nausea,vomiting,headache,and tachycardia.

    Preventions and Interventions To prevent fever reaction, nurse should inspect the
                                                            the

quality of solutions,the package of intravenous set and date of sterilization carefully.Once fever

reaction occurs,the nurse should reduce the flow rate or stop infusion and notice the physician

            For
immediately. the patient with high fever,                                      If
                                         physical cold therapy should be given. necessary,

administer the antiallergic medication according to physician’s order.Keep the residual solution,

medication,and equipment for the laboratory test.



★Phlebitis,Thrombosis,and Thrombophlebitis
    Causes These complications are caused by irritation to the lining of blood vessels.Factors

for these complications include chemical irritation to tissues by IV solutions or medications,

mechanical irritation to tissues by the needle or catheter during venipuncture or cannulation,

                                                                 and
localized allergic reaction to the indwelling catheter or needle, local infection by undemanding

sterile performance during initiating infusion.

    Symptoms and Signs             The patient feels pain in local site , with increased skin

temperature

and swelling over the vein,and in some cases,redness traveling along the path of the vein.

Occasionally systemic reactions may be present,such as fever,chill and so on.

    Preventions and Interventions To prevent phlebitis,the nurse should follow sterile
principles strictly,and protect the 1ocal site from contamination.When irritating medication is

infused, the medication should be diluted thoroughly and infused slowly.The needle should be

secured firmly to prevent the needle sliding out of the vein.Phlebitis is prevented by the routine




                                                  108
removal and rotation of IV sites for the continuing infusion patient.When phlebitis appears, the IV

line must be discontinued and a new line inserted in another vein.Apply warm compresses on the

site of phlebitis with 50% magnesium sulphate.Use physical therapy of ultrashort wave on local

site.If there is infection,use antibiotics according to physician’s order.



★Fluid Volume Excess
     Causes Fluid volume excess occurs when the patient has received a too large volume and
a

too rapid administration of IV solutions,which causes a sudden increase of circulating blood

volume and too heavy cardiac load.

     Symptoms and Signs The patient may have chest depressed,shortness of breath,cough,

frothy or pinkish sputum,facial paleness,diaphoresis,neck vein distention,rales in the lungs,

rapid heart rate,arrhythmia,rapid weight gain,pitting edema,and tachycardia.

     Preventions and Interventions The nurse should maintain the flow rate during the
infusion, especially for the patient with heart failure,the elderly and children.Do not change

infusion rate without physician’s approval. Avoid rapid flow rate at night because of nocturnal

decrease in renal function.                                       the
                           Once the symptoms and signs be present, nurse should slow the rate

of infusion or stop the infusion immediately,notify the physician,raise the head of the bed,and

monitor vital signs.The patient can assume a Folower’s position with the feet dangling at the

bedside if the patient’s condition is allowed,which can decrease venous return and work load of

the heart . The patient can receive the oxygen administration with greater flow rate if

necessary.Put 20% to 30% alcoho1 solution into humidified bottle,which can reduce the

surface tension in the pulmonary alveolus,disperse foam,improve air exchange in pulmonary

alveolus and reduce symptoms of hypoxia.According to the physician’s order,administer the

sedative,vasodilators,antiasthma,          and                       The
                                 digitalis, diuretics to the patient. nurse also can apply

tourniquet to limbs of the patient in alternation in order to reduce the venous return.The

tourniquet must be tight enough to obstruct venous flow but not so tight to occlude arterial

flow.Nurses can feel the pulse to assess the condition of arterial flow.Remove tourniquet from

one limb every 5 to 10 minutes until the symptoms are alleviated.


                                               109
★Air Embolism
     Causes When air in the infusion system enters the circulatory system,air embolism
occurs.The main reasons are:(a) When initiating a infusion line,nurses did not eject air in

                           or                             or
infusion system thoroughly, infusion set is not air tight, after changing the solution container,

nurses did not eject air in the tubing below the chamber on time.(b) After one bottle of fluid has

been infused, nurses do not alter the bottle or withdraw the needle because of negligent

supervision when the patient receives pressure infusion or pressure blood infusion . The

mechanism is that the air entering the vein becomes air embolus;then it enters the right atrium and

then enters the right ventricle through blood flow.When the air embolus is small,the right

ventricle can eject it into pulmonary artery and then into pulmonary small artery,where the air can

be absorbed by alveolocapillary in pulmonary alveolus,so the patient does not have obvious

discomfort without minor harm.When the air embolus is large,it enters the right ventricle and

blocks the entrance of pulmonary artery.This can stop the blood flow into pulmonary artery,so

the air exchange is affected with the result of hypoxia and immediate death.

     Symptoms and Signs The patient feels discomfort in chest or pain under the sternum,
with the presence of decreased blood pressure,cyanosis,tachycardia,increased venous pressure,

and unconsciousness.Clear and continuous bubble sound can be auscultated.

     Preventions and Interventions The nurse should perform preventions according to
the causes,such as inspecting the quality of infusion set,connecting every part tightly,ejecting air

in tubing thoroughly,checking the tubing below the chamber to make sure no air after changing

the bottle of solution,                                                          and
                       watching the patient with press infusion by special nurse, having patient

place head below heart level or perform Valsalva maneuver while changing tubing on central

venous lines.                         the
             Once air embolism occurs, nurse should help the patient to turn on left side with

head down immediately,because this position can increase the thoracic cavity pressure when the

patient inhales air,and reduce the air emboli entering vein.In addition,this position makes the

entrance of pulmonary artery below the right ventricle,which can cause the air embolus to float to

apex of the right ventricle and keep air emboli away from entrance of pulmonary artery.Thus the

                                              At
blood can flow into pulmonary artery smoothly. the same time, air emboli are vibrated to foams


                                                110
with the heart contraction and enter pulmonary artery in a small volume in divided times and

break up gradually.The nurse may administer oxygen therapy with high flow rate for the patient,

monitor vital signs and notify the physician.



★Infiltration
     Infiltration occurs when a catheter or needle penetrates the vessel wall during venipuncture or

later slips out of the vein and allows IV solution to flow into surrounding tissues.Infusion of

fluids into the circulation is hampered or interrupted as fluid enters the interstitial spaces.Local

tissues edema can occur.In addition,irritating medications or toxic medications can cause severe

tissue necrosis.Main symptoms and signs are edema,pale and pain in local tissue and interrupted

infusion.The prevention methods include:securely taping IV site;avoiding movement at site;

confirming placement by checking for IV patency , especially before administering IV

medications.When infiltration occurs,the infusion must be discontinued,the needle must be

changed to reinsert into another extremity.The extremity with infiltration can be raised to reduce

the edema,and can be wrapped by a warm towel for 20 minutes.This promotes venous blood

return,improves absorption of infiltrated fluid, and reduces pain and edema.



★Local Allergic Reactions                 Allergic reactions may occur at the IV site.Individuals

may demonstrate sensitivity to antiseptic solutions,                                        or
                                                    preparations applied to reduce bacteria, tape

used to secure the catheter.Indwelling catheters and needles may also cause allergic reaction.

Nurses should assess allergic history of the patient very carefully,change some supplies which can

cause allergic reactions,and administer antianaphylaxis medication based on the physician's

order if necessary.




★Infection or Inflammation at the Insertion Site                          Infection or inflammation

at the insertion site is most often related to performance of initiating infusion line.Microorganisms

gain access to the tissue and circulatory system through the tip of needle or cannula device



                                                111
inserted during venipuncture or enter later by migration along the interface between the catheter

and tissue.The local tissue may have redness,edema,heat,pain,and perhaps a discharge.The

patient may have systemic reactions,such as fever.Using aseptic technique for all IV-related care,

keeping dressing dry,and changing dressing on time according to agency policy can prevent

                            If                                        the
infection at insertion site. infection at the insertion site happened, nurse should remove IV to

another site if necessary,apply cool compress to site as ordered by the physician,elevate limb,

and observe for signs of sepsis.




INTRAVENOUS INDWELLING NEEDLE INFUSION
     Apply to the patients that have difficult to puncture and need long-term IV infusion.

Intravenous indwelling needles infusion can reduce the discomfort and damage of repeated

venipuncture and is advantageous to salvage and therapy.

PURPOSES
1. Provide an easy access for intermittent infusions or IV administration.

2. Protect patient’s veins from damnification of repeateded venipuncture.

Preparation

Nurse:
     1. Review the physician’s order in patient’s record.

     2. Evaluate patient’s age and medical status. Evaluate patient’s renal status and other

pertinent lab data (e.g., electrolyte, serum glucose ).

     3. Wash hands and wear mask.



     1. Verify patient’s identity.

     2. Explain the procedure and purpose.Ask the patient to void.

     3. Position patient for comfort and optimal visibility for skill performance.

Environment:
     The environment must be cleaning, commodious and bright




                                                  112
Equipment: Medical tray:
·Antiseptic solution                           ·Sterile swab

·Tourniquet                                   ·Pad

·Adhesive tape                                ·File and opener

·IV solution and medication                   ·Medical card

·Infusion set                                 ·Bottle bag

·Kidney-shaped tray

·Intravenous indwelling needle                ·Sterile gloves



Procedures
1. Check and right

  Review the physician’s order,including the bed number,the patient’s name,medication’s

  name,dosage,concentration,and date,and prepare the solution and medication.Check the

  quality of solution

2. Complete the medication label and stick it upside down to the solution container

3. Add medications into solution

(1) Take the solution container into a bottle bag.

(2) Open the center of the mental cap of the solution container,and sterilize it

(3) Add the medication according to the physician’s order

(4) Arrange the sequence of IV solutions based on the patient’s condition

4. Insert the infusion set

  Check the quality of the infusion set.Open the infusion set package, remove the protective

  cover of spike and insert it into fluid bottle.Close the clamp

5. Prepare the equipment and take them to the bedside.Check again

6. Discharge air

(1) Hang the solution container on the pole

(2)Turn the chamber upside down and squeeze it gently until it is 1/2 to 2/3 full of solution,then

  turn over the chamber.Release the clamp,and let the fluid run through the tubing until the




                                                 113
  tubing is full of solution

(3) Close the clamp.Place the tubing end into the bag of the set and place them in the medical tray

7. Wear gloves, prepare IV indwelling needle

Check the quality of the IV indwelling needle.Open the set package,take out the indwelling

needle and sterile the heparin cap, remove the protective cover of spike and insert it into the

heparin cap and discharge again. Close the clamp.Place the indwelling needle into the bag of the

set and place them in the medical tray.

8. Select the venipuncture site

(1) Place a pad under the extremity

(2) Apply a tourniquet firmly 10 to 15cm above the venipuncture site.

9. Sterilize the venipuncture site.

10.Check again.

11. Intravenous injection

(1) Place the nondominant hand 3 to 5cm below the entry site to pull the skin taut against the

vein.Hold the needle with dominant hand, insert the needle and catheter through the skin and into

the vein

(2) Once blood appears in the lumen of the catheter, reduce the angle of the needle until it is

almost parallel to the skin,advance the needle 0.2cm, then withdraw the needle 0.5cm, advance

the catheter and needle until the whole catheter is in vein.Hold the catheter shaft steady, withdraw

the needle.

12. Fixation

Ask the patient to release fist, release the tourniquet,and open the clamp.

Open the sterile adhesive tape bag, take out the crystal adhesive tape, and secure the injection site

hermetically. Loop the tubing near the site of entry,fix with adhesive tape, and write down the

date of installation on the tape.

13. Regulate the flow rate according to the patient’s condition and medication.Hold watch

beside the drip chamber and count drops per 15 seconds in drip chamber to calculate the drops per

minute

14. Check again.



                                                114
15. Disposure after operation

Take off the tourniquet and pad.Help the patient to take a comfortable position.Place the call bell

beside the patient.Observe the patient’s response.

Remove all equipment and dispose in proper manner. Wash hands

Document relevant data including infusion initiated time, flow rate,and the patient’s local and

systemic condition.

16. Change bottles

If there are more than one bottle of solution,nurses should check the physician’s orders,and

prepare the second bottle at least 1 hour before the first bottle is finished, and change the bottle on

time

17. Disposure after infusion

(1)After the prescribed amount of fluid has been infused,close the roller clamp,withdraw the

  needle from the heparin cap, sterile the heparin cap and seal the catheter with 0.9%NS in

  positive pressure.Close the Luer Lock of primed IV catheter set to peripheral cannula.

(2)Help the patient to have a comfortable position.Record the volume of fluid infused and the

time of the discontinuation

(3)Dispose of the equipment in proper manner

(4) Wash hands. Document relevant data




Cautions:
1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.

2. Keep the injection site cleaning. Observe the injection site carefully in order to find the

complications and settle them on time.

3. Seal the catheter with positive pressure after infusion to prevent occlusion of the catheter or

thrombophlebitis.
4. The catheter’s indwelling time is commonly about 3 to 5 days

5. Instruct the patient to take self-care. Avoid to energize and press excessive. Avoid the catheter to

be pulled out when change clothes.




                                                 115
EXTERNAL JUGULAR VENOUS CATHETER INFUSION
Purposes
1. Measurement of central venous pressure (CVP);

2. Apply a venous access when no peripheral veins are available;

3. Administration of vasoactive medications which cannot be given peripherally;

4. Administration of hypertonic solutions including total parenteral nutrition.

Preparation

Nurse:
     1. Review the physician’s order in patient’s record.

     2. Evaluate patient’s age and medical status. Evaluate patient’s renal status and other

pertinent lab data (e.g., electrolyte, serum glucose ).

     3. Evaluate patient’s mental status and cooperation status.

     4. Evaluate the site of venipuncture.

     5. Wash hands and wear mask.

     1. Verify patient’s identity.

     2. Explain the procedure and purpose to reduce the patient’s anxiety and tension.

     3. Position patient for optimal visibility for skill performance.

Environment:
     The environment must be cleaning, commodious and bright

Equipment: Medical tray:
·Antiseptic solution                           ·Sterile swab

·Adhesive tape                                ·File and opener

·IV solution and medication                   ·Medical card

·Infusion set                                 ·Bottle bag

·Kidney-shaped tray                            ·local anaesthetic

·Sterile venipuncture package                 ·Sterile gloves



                                                  116
Procedures
Steps 1 to 6 are the same as described in Peripheral Intravenous Infusion

7. Select the position

8. Select insertion site and sterile the skin

9. Open the sterile venipuncture package, wear sterile gloves, and drap the area

10. Infiltrate the skin and deeper tissues with local anaesthetic

11. Insert the catheter and cover with a sterile dressing

12. Connect with infusion set

13. Regulate the flow rate

14. Check again.

15. Disposure after operation

16. Change bottles

17. Disposure after infusion

     Patency of an unused central venous catheter is maintained by the regular instillation of a

small volume of dilute heparin ( 100 U/ml ) into the lumen. Clamp catheter lumen using online

slide clamp. Stuff the needle hub hole with a sterile resealable injection cap. Catheter insertion site

protection and stabilization are accomplished by regular antimicrobial cleaning and sterile

dressing changes every day.

18. Infusion again

     Remove the sterile resealable injection cap, sterile the needle hub hole, connect with infusion

set, unclamp lumen, then initiate IV infusion. It is necessary to check patency of the catheter and

the position of the catheter tip before using the 1ine every time.

19. Withdraw the catheter

     The lumen of the catheter connect with a syringe, withdraw the catheter while pump the

syringe, press the insertion site for several minutes. Sterile the local skin with 75% ethanol

solution, and cover it with sterile dressing.




                                                 117
Cautions
1. Follow the principles of asepsis and check system strictly to prevent infection and mistakes.

2. Select the insertion site carefully.

3. Intensify evaluation during infusion. Flush the catheter with dilute heparin ( 100 U/ml ) if return

blood appears in the catheter to prevent occlusion.

4. Seal the catheter with positive pressure after infusion to prevent occlusion of the catheter.

Clot appears in the catheter should be sucked use a syringe to avoid to be pushed into
blood circulation.
5. To stabilize and protect catheter site to prevent contamination or dislodgement. Observe the

injection site carefully in order to find the complications and settle them on time.




SUBCLAVIAN VENOUS CATHETER INFUSION
INFUSION PARTICLE CONTAMINATION


                                          Section Two
                                   Blood Transfusion
     Blood transfusion is the IV administration of whole blood or a blood component such as
plasma, packed red cells, white blood cells, or platelets. Administration of blood or blood products
requires the nurse to follow a specific procedure to match the blood accurately, identify the blood
for the individual and recipient correctly, and monitor the patient throughout the procedure for
transfusion reactions. The nurse is responsible for assessment before, during, and after transfusion
and for regulation of transfusion.


                                     Physiology of Blood

Blood Groups and Types
     Blood groups are named by types of the proteins as antigens on the surface of an individual’s
red blood cells. Because antigens promote agglutination or clumping of blood cells, they are also




                                                 118
known as agglutinogens. Based on the types of antigens or agglutinogens, human blood can be
classified into several groups.
★ABO Blood Groups System
     The most important grouping for transfusion purposes is the ABO system, which includes A,
B, O, and AB blood types. The determination of blood groups is based on the presence or absence
of A and B red cell antigens or agglutinogens.
          Individuals with A antigens on the red blood cells belong to groups A. Individuals with
     B antigens on the red blood cells belong to groups B. The person with A and B antigens has
     AB blood. Neither A nor B antigens are present on red blood cells belong to groups O.

     Individuals with type A blood naturally produce anti –B antibodies in their plasma. Similarly,
type B individuals naturally produce anti-A antibodies. A type O individual possesses neither A
nor B antigen, which is why a person with type O blood is considered a universal blood donor. An
AB type individual produces neither antibody, which is why type AB individuals can be universal
recipients. If blood that is mismatched with the patient’s blood is transfused, a transfusion reaction
occurs. The transfusion reaction is an antigen-antibody reaction and can range from a mild
response to severe anaphylactic shock.



                                  ABO Blood Groups System

     Blood types        Red Blood cells Antigens           Plasma Antibodies

                           ( Agglutinogens )                 ( Agglutinin )
         A                           A                             B
         B                           B                             A
         AB                       A and B                          --
         O                           --                         A and B



                              Rhesus ( Rh ) Blood Group
     The Rh factor is an inherited antigen in the erythrocytes of most people. There are six
antigens such as C, c, D, d, E, e antigens in the Rh system. The one designated D is of first
concern. Blood that contains the D antigen is known as Rh-positive. An Rh-negative individual
lacks D antigen. If Rh-positive blood is transfused into an Rh-negative person, the recipient will
form antibodies to the Rh factor and a second exposure to RH-positive blood will result in
hemolysis, or red blood cell destruction, in the recipient. The Rh factor is of special importance
during pregnancy because Rh incompatibility between mother and fetus is often the problem,



                                                 119
which makes the infant has hemolytic disease. A Rh negative mother who gives birth to a Rh
positive infant is given Rh Gama ( an ani-Rh γ globulin ) within 72 hours after delivery to
prevent the permanent active immunity to Rh antigen.


                    Blood Typing and Cross-matching Test
     In order to avoid transfusing incompatible red blood cells, both blood donor and recipient
must be typed and their blood cross-matched prior to transfusion. Blood typing is done to
determine the ABO blood group and Rh factor status.
     Cross-matched test is also necessary to identify possible interactions of minor antigens
with their corresponding antibodies.
     Type A blood reacts with anti-A reagent, and has anti-B antibodies present in the serum. On
the other hand, type b blood reacts with anti-B reagent, and has anti-A anti-bodies present in the
serum. Type AB blood reacts with anti-A and anti-B reagent, and has no antibodies present in the
serum. Type O reacts with neither reagent and has both A and b antibodies in the serum. As a rule
blood selected for transfusion must be of the same type as that of the recipient. Blood transfusion
must be matched to the patient’s blood in terms of the compatibility of agglutinogens. Mismatched
blood causes hemolytic reactions. In the urgent situations, type O blood may be used for patients
with other blood types. The person with Rh negatives blood should always receive Rh negative
blood. The person with Rh positive blood may receive either Rh positive or Rh negative blood.
     ★Direct     Cross-matching Test
     Red blood cells from the donor blood are mixed with serum from the recipient to examine
whether the antibodies to the donated red blood cells are present in the recipient’s serum.
     ★Indirect      Cross-matching Test
     Red blood cells from the recipient blood are mixed with serum from the donor to examine
whether the antibodies to the recipient’s red blood cells are present in the donated serum.
     The mixture is examined for visible agglutination. The results should be no agglutination or
hemolysis of red blood cells. The risk of transfusion reaction is small.


Categories of Blood Products
     ★Whole       Blood
     Whole blood is referred to the collected blood that is preserved without any change. There
are two kinds of whole blood, fresh whole blood and stored whole blood.
     Fresh Blood The blood can be preserved in 4℃ within 1 week. It contains all kinds of
component, and can replace blood volume and all blood components such as blood cells, plasma,



                                                 120
platelets, and other clotting factors. The fresh whole blood is often suitable for the patients with
hematopathy.
      Stored Blood The stored blood can be preserved in temperature 4℃ for 2 to 3 weeks. It
contains many kinds of components, but some components such as white blood cells, platelets and
thrombogen are damaged. Lysis of red blood cells release potassium into the bloodstream, and the
levels of potassium and acid in serum are increased. Therefore, the large infusion of stored blood
can result in hyperkalemia and acidosis. It is applicable for the massive hemorrhage or surgery.
       ★Blood Components
      Red Blood cells it is transfused to increase the oxygen carrying capacity of blood in the
patients with anemia, less surgical bleeding or disorders with less bleeding and replenishes red
blood cells in cardiovascular failure for avoiding cardiovascular overload. One unit is 100ml of
red blood cells, and can raise hematocrit by approximately 4%.
      Plasma Plasma, which contains plasma protein without blood cells and antigens, is the
important component of whole blood. It is not necessary to be tested blood typing and
cross-matching when plasma is transfused to replenish blood volume, proteins and clotting factors.
     Fresh plasma contains all clotting factors, and is suitable for the patients who lack of
clotting factors.
     Stored plasma is suitable for the patients with low blood volume and protein.
     Frozen plasma should be preserved in -30℃ and is valid for 1 year. The nurse should leave
Frozen plasma to thaw in 37℃ of warm water, then transfuse it into the patient within 6 hours.
Frozen plasma is dried and made into dry plasma in vacuum set. Period of validity is 5 years for
Dry plasma. Dry plasma should should be dissolved in normal saline before transfused.
     White Blood cells Concentrates White blood cells concentrates are made from
centrifugal fresh blood. They are preserved in temperature 4℃ and are valid for 48 hours. It is
suitable for the patients who have leuokocytopenia and severe infection. One unit is 25ml of white
blood cells concentrates.
     Albumin It is transfused to increase blood volume and provide plasma proteins for the
patients with low blood proteins.
     Platelet concentrates Platelet concentrates are made from centrifugal whole blood,
and should be preserved in temperature 22℃ and is valid for 24 hours. Platelets infusion is
indicated for treatment or prevention of bleeding related to deficiencies in number or function of a
patient’s platelets. It may not only reduce the risk of complications but also improve the patient’s
response to platelet therapy. One unit is 25ml of platelet concentrates.
     Coagulants Coagulants include clotting factors and cryoprecipitate, and is suitable for


                                                 121
the patients with deficiencies of variety of clotting factors. Cryoprecipitate contains clotting factor
Ⅷ, which is missing from the blood of hemophiliacs. It is abstracted from frozen plasma and
administered in small quantities. One unit is 50ml of coagulants.


                      The Purposes of Blood Transfusion

     1. To supply and restore the blood volume.
     2. To maintain hemoglobin levels and the oxygen carrying capacity of red blood cells.
     3. To increase the plasma protein and maintain the colloid osmotic pressure.
     4. To supply clotting factors and platelets to prevent or treat hemorrhagic disease.
     5. To supply antibody and alexin to resist the infection.
     6. To remove deleterious substances from blood.


     The Indications of Blood Transfusion
     1. Hemorrhage
     2. Anemia or hypoproteinemia
     3. serious infection
     4. Disturbances of blood coagulation
     The Contraindications of Blood Transfusion
     1. Acute pulmonary edema
     2. Congestive heart failure
     3. Pulmonary embolism
     4. Malignant hypertension
     5. Hypercythemia
     6. Serious renal failure
     7.Serious allergy to blood transfusion


                            Methods of Blood Transfusion

     The ways to blood transfusion include venous and arterial infusion. There are two methods of
venous blood transfusion, direct and indirect venous blood transfusion.
                            Direct Venous Blood Transfusion
     The blood which is collected from the donors is infusion into the patients immediately. When
there is no blood in bank, but the patient is in dire need of blood transfusion, or infants need a little


                                                  122
blood transfusion, the direct venous blood transfusion is more appropriate.
                       Indirect Venous Blood Transfusion
     The collected blood is infused into the patient as well as the method of intravenous infusion.
                             Arterial Blood Transfusion
     The blood is infused and pumped from the artery to the aortic arch, coronary artery, and
carotid to improve the blood in the brain and heart. Arterial blood transfusion is more
appropriate for the patients with serious hemorrhagic shock or first-aid resuscitation.


                 Blood Transfusion and Nursing process

Assessment
     The nurse should understand the importance of blood transfusion. By gathering assessment
data through the patient’s history and physical and psychological examination, the nurse will
describe the potential and actual problems and identify the nursing diagnoses.


                                                History
     The clinical condition, treatment and transfusion history should be assessed. The assessment
should include gender of the patient, diagnosis, place and reason for the blood transfusion, the
amount and type of the blood or blood components required, the history of the transfusion
reactions, and certain conditions of blood transfusion.


                                      Physical Examination
     The baseline of vital signs, which include the patient’s temperature, pulse, respiration and
blood pressure, should be measured and recorded before blood transfusion. The skin and blood
vessels for the puncture also be assessed. Based on the patient’s condition, amount of transfusion
and the patient’s age, the vein of puncture is chosen. Normally the vein in upper limbs is suitable
for blood transfusion. The vena in elbow area is suitable for dire need of blood transfusion. Blood
transfusion is performed through external jugular vein and subclavian vein in circulatory failure. If
the patient has an IV line in place, the nurse should assess the venipuncture was performed with
number 9 or large gauge catheter.


                                    Psychological Examination
     The nurse should assess the patient’s psychological status, the extent if willingness to receive
blood transfusion, and being afraid of it. The patients who first receive the blood or blood



                                                 123
components may know less about the transfusion and feel nervous. The patients who have the
experience of the transfusion reactions may be afraid of transfusion again.


Nursing diagnosis
     When caring for the patients with blood transfusion, it is particularly important that the nurse
should be skilled in using critical thinking to formulate nursing diagnoses. The nurse should
identify the relevant factors, and provide the interventions to treat or modify the related factors for
the diagnoses to be resolved. The following diagnoses are related to the blood transfusion:


      Alerted         Tissue       Perfusion           (   Renal,   Cerebral,     Cardiopulmonary,
Gastrointestinal, Peripheral )
     Alerted tissue perfusion is related to circulatory deficit. For an adult, there is no need for
blood transfusion if the bleeding is not more than 500ml. If the bleeding is more than 1000ml,
blood should be infused to the patients to restore blood volume in time.
      Activity Intolerance
     Activity intolerance is related to anemia. The blood transfusion is appropriate for the male
patients with less than 12.5g/dl hemoglobin in blood, and female patients with less than 11.0g/dl.
These patients may look too weak; have pale skin, mucosa and nail. They may breathe rapidly and
feel palpitation after movements. They also have crura edema in the lower extremities. The blood
is transfused to increase the number of red blood cells, and maintain hemoglobin levels and the
oxygen carrying capacity of blood.
      Serious Infection
     For the patients with serious burn or infective shock, blood transfusion supplies antibody and
complement to resist the infection.
      Fear and/or Impaired Tissue Integrity
     Fear and/or impaired tissue integrity is related to bleeding caused by disturbances of blood
coagulation. The patients are provided clotting factors, such as antihemophilic factor (AHF) or
factor Ⅷ, or platelet concentrates to prevent or treat bleeding disease through blood transfusion.
      Other Nursing Diagnosis
     ·knowledge deficit regarding blood transfusion
     ·anxiety related to knowledge deficit
     ·hyperthermia related to blood transfusion reaction
     ·cardiac output decreased related to blood transfusion reaction




                                                 124
Planning
     The nursing plans should include:
     ·The selections of blood donors are performed carefully.
     ·The nurse prepares everything for the blood transfusion correctly.
     ·According to the principles, the blood transfusion is performed.
     ·The nurse administrates the procedures of blood transfusion. The patient’s temperature,
pulse, respiration, blood pressure, and the volume and color of any urine passed should be
measured and reported. The reaction of blood transfusion should be observed continuously and be
managed if any reaction occurs.
     After blood transfusion, the following objectives can be achieved:
     ·The patient can tell the knowledge related to the blood transfusion, and identify the
reactions related to blood transfusion.
     ·The blood volume or hemoglobin or clotting function can be maintained in normal level.
     ·The patient can restore the activity tolerance.
     ·The patient can eliminate the anxiety and fear.
     ·The patient can maintain the tissue integrity.


Implementation

                            Preparations for Blood Transfusion
     Prepare the Blood When a transfusion is ordered, the specimen of blood is collected
from the patient. The nurse should fill in the blank of the appropriate form and send it to the bank.
Blood typing and cross-matching are tested in the blood bank.
     Obtaining the Blood According to the physician’s order, the blood is obtained from the
blood bank. The nurse should check the application form and the blood bag label with a laboratory
technician.
     Three checks include:
     ·The expiry date of the blood is not beyond.
     ·The pack is intact and without any leaking.
     ·The quality of the blood. Stored blood should have two layers. The plasma is primrose
yellow in higher layer and red blood cells is dark red in lower layer. The interface between red
blood cells and plasma is clear. There is no evidence of haemolysis. The blood should have no
cloudiness, bubbles, dark color, or sediment.
     Eight rights include: the patient’s name, the bed number, inpatient number, the number of



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the blood bag label, the ABO groups and Rh type on the blood bag label, the results of
cross-matching, the category and the amount of the blood.
     Then the nurse signs the appropriate form and carries the blood.
     After Obtaining the Blood The obtained blood should not be shaken to avoid red
blood cells being damaged. The nurse should make sure that the stored blood is kept in room
temperature for 15 to 20 minutes before transfusion. The blood must not be warmed to avoid the
reactions caused by solidified and denatured plasma albumin.
     Recheck the Blood The nurse should check the blood and the laboratory report with
another nurse, validate the collect blood, and inspect blood for clots before starting blood
transfusion.
     Check Consent Form The patients should understand and agree to receive the blood
transfusion, and be asked to sign consent forms before blood transfusion.


                                       Administering Blood
★Indirect Venous Transfusion
                    Equipment
           Medical tray:

           ·transfusion sheet                       ·transfusion set

           ·Disinfectant                               ·Sterile swab

           ·Tourniquet                                 ·Pad

           ·Adhesive tape                              ·250 ml bag of normal saline

           ·Blood unit ( packed blood )                ·Kidney-shaped tray

                                    Procedures and key points
1. Wash hands, wear a mask, and carry the equipment to bedside
2. Recheck the physician’s order for number and type of transfusion unit and the patient’s name
  and bed number.
3. Explain procedures to the patient, instruct the patient to identify blood transfusion reactions
  ----the special education is provided before transfusion
  ----the patient know any unusual symptoms related to blood transfusion, such as sudden chill,
nausea, itching, rash, dyspnea, back pain, and call a nurse immediately if any unusual symptoms
are found during the transfusion
  ----timely report of any blood transfusion reaction can make nurse discontinue it and minimize
reaction



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4. Perform venipuncture on a suitable vein use transfusion set connecting with 0.9% normal saline.
  ----large gauge needle is necessary to infuse the red blood cells and avoid damage of red blood
cells and hemolysis. Filter removes debris and particulate material from the blood
5. Gently agitate blood bag, and suspend. Spike blood bag port carefully with the transfusion
needle and start the blood transfusion. Observe the patient closely for first 5-15minutes with flow
rate of 20 drops per minute because most blood transfusion reactions occur during this time. Then
regulate the required flow rate according to the patient’s condition if no adverse reaction occurs
  ----using the main clamp to regulate flow rate with 40 to 60 drops per minute for adults, and
decreases for children
6. Complete the transfusion, infuse NS to clear the tubing, then remove the needle.
  ----the normal saline infusion is necessary between two blood units for more than two blood
units’ transfusion
7.Wash hands
8. Record administration of blood transfusion
  ----recording the time, blood components, amount, blood type, blood bag number, flow rate,
vital signs and reactions


Clinical alert
     ·The nurse should comply with the principles of surgical asepsis and blood transfusion
procedure. The nurse should check the blood with another registered nurse and make sure it
correct before transfusion.
     ·The nurse should perform the intravenous infusion before blood transfusion, and choose the
sterile blood administration set with in-line filter, and prime it with 0.9% normal saline ( use of
any other solution may result in hemolysis ). Some 0.9% normal saline should be infused between
two blood units to prevent transfusion reaction. When the blood transfusion is completed, the
nurse should flush the blood administration set with saline solution. New blood administration set
should be used after the transfusion has run for more than 12 hours in order to prevent bacterial
growth. If the primary intravenous infusion should be continued, the nurse should use new
infusion set, and regulate the flow rate to the desired rate.
     ·The drug such as ( hyperosmolar or hypoosmolar solutions, medications or other additives )
must not be added to blood under any circumstances.
     ·During blood transfusion the patient is at risk for a reaction, particularly during the first 15
minutes. Therefore, the nurse should observe the vital signs and skin color, detect the early
warning symptom and signs of reactions, and provide the intervention. If the patient has serious



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reaction, the nurse should stop the blood transfusion immediately, replace it with normal saline
infusion, and send the residual blood and blood administration set to laboratory to analyze the
reason for reactions. The nurse should also notify the physician.
     ·Most adults can tolerate receiving one unit of blood in 1.5 to 2 hours. Transfusion rate
should be slowered properly for elders, serious anemia patients, and heart function failure patients.
     ·The empty blood bag should be preserved for 12 hours after transfusion in order to analyse
the transfusion reaction reasons when it occurs.


★Direct Venous Blood Transfusion:
Equipment
·50ml syringe
·Blood pressure cuff
·Disinfectant
·Sterile swabs
·Adhesive tape, Dressing
1. Explain the procedures to the donor and recipient
  ----making the patient and the donor understand the procedure and cooperate with it
2. Wash hands and wear mark, put anticoagulant in the syringe
  ----adding 5ml of 3.8% sodium citrate into 50ml of blood
3. The donor and patient lie on the bed and show the arm
4. Check the name, the result of blood typing and cross-matching between the donor and the
recipient
  ----preventing the mistake
5. The blood pressure cuff is tangled on the arm and pressured by air. The nurse should choose the
large vena, clear the skin over insertion site with antiseptic swabs, perform venipuncture to collect
the blood, and infuse blood to the recipient by intravenous injection
  ----the pressure is maintained 100mmHg
6. Cooperate with three nurses, the first nurse is responsible for collecting the blood, the second
nurse is for transferring and the third nurse is for infusion
  ----if the blood should be collected continually, the nurse should change the syringe ( don’t
remove the needle ), meanwhile make the cuff loosen, and press the venipuncture site to reduce
the bleeding
7. When infusion is completed, remove the needle and press the venipuncture site
8. Disinfect and clean the equipment, and record administration of blood transfusion



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  ----record the time and amount of blood transfusion and reaction


Evaluation
1. The methods and procedure of blood transfusion are correct and skilled.
2. The patient gains the knowledge related to blood transfusion, and cooperate with the nurse.
3. The blood transfusion is safety without any reaction.
4. The patient has normal T, P, R, BP, and the volume and color of urine passed during the blood
transfusion.
5. The patient has restored normal blood volume, has normal hemoglobin and blood coagulation
function in blood. The infection has been controlled.



                                         Autologous Transfusion


     Autologous transfusion also be called autotransfusion, is the collection and reinfusion of
a patient’s own blood. The blood for an autologous transfusion can be obtained by preoperative
donation when the surgery can be planned in advance (e.g., open heart, orthopedic, plastic, or
gynecological ). There are three approaches of autologous blood:
       ★Preoperative autologous Blood Storage
          The patient donates 1 to 5 units of her/his own blood depending on the type of surgery
     and the ability of the patient to maintain an acceptable hematocrit. Units of blood are asked to
     draw from a patient usually starting 3 to 5 weeks before an elective surgical procedure, and
     then the blood are stored for transfusion at the time of the surgery. The blood should be
     collected once a week or two weeks until 3 days before surgery. It is helpful for the patient to
     withstand the blood loss that occurs with the collection, and return to normal level of plasma
     albumin.

       ★Perioperative Hemodilution
     Blood is collected at the date of surgery ( most often prior to surgery ). The fluid volume lost
is replaced with intravenous crystal solution or colloid solution. Blood loss in surgery thus occurs
at a lower hemotocrit ( each drop of blood lost has fewer red cells in it ), therefore, the amount of
red blood cells and other blood components lost during the entire procedure may be reduced.
Finally, collected blood is returned to the patient after the surgical procedure.
       ★Intraoperative Lost Blood
     The lost blood is salvaged from the surgical field for reinfusion during or after the surgical
procedure. For the patients with rupture of spleen or fallopian-tube, if the bleeding in abdominal



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cavity is not contaminated and coagulated within 16 hours, the blood can usually be collected.
Then, the filtered blood is returned to the patient after anticoagulation is added in.
     Autologous transfusions are safer for the patient because they decrease the risk of
complications such as mismatched blood and exposure to blood-borne infectious agents. It is not
necessary to take the time to type and cross-match the patient’s blood.


                       Componential Transfusion

     Componential transfusion is called transfusion of a special component. Because patients
seldom require all of the components of whole blood, it makes sense to transfuse only that portion
needed by the patient for a specific condition or disease. This treatment, referred to as “blood
component therapy”, allows several patients to benefit from one unit of donated whole blood, and
it is helpful to reduce the blood transfusion reaction. With current development of theory and
technology, whole blood can be easily separated into several components. According to patient’s
condition, providing transfusion of a particular blood component, which is separated from the
whole blood and purified, is more appropriate. The special component, such as red blood cells,
platelets, white blood cells, albumin, and coagulants, is usually transfused for the patients who are
lack of the components in blood.
     The transfusion of blood components should be performed in continual nursing observation
to ensure the safety. The principles of administration include the following.
     · During the transfusion of blood components, the patients may receive the blood
components from several donors, so it is necessary to administer medication ( antihistamines ) as
ordered to prevent the anaphylactic reactions.
     ·It is necessary for the patient to be tested blood typing and cross-matching before red blood
cells is transfused.
     ·Some of blood components, such as white blood cells, platelet concentrates, are living for
short time, so it is necessary to transfuse blood components completely within term of validity by
special blood administration set.
     ·Blood components should be first transfused to provide the fresh components if the patients
need both whole blood and blood components.


          Transfusion Reactions and Nursing Interventions

     A transfusion reactions is a systemic response by the body to blood incompatible with that



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of the recipient. Causes include red cell incompatibility or allergic sensitivity to the leukocytes,
platelets, or plasma protein components of the transfused blood or to the potassium or citrate
preservative in the blood. Blood transfusion can also result in the transmission of infectious
disease. Transfusion of ABO or Rh incompatible blood can result in a hemolytic transfusion
reaction with destruction of the transfused red blood cells and subsequent risk of kidney damage
or failure. Other forms of transfusion reaction also may occur, including febrile, allergic,
circulatory overload, and bacterial reaction. Because the risk of an adverse reaction is high when
blood is transfused, the nurse should take every precaution to prevent the occurrence of
transfusion reactions through scrupulous technique. The nurse should know more about blood
transfusion reaction. The patients must be assessed frequently and observed carefully during the
transfusion. The transfusion should be stopped immediately if serious reaction occurs.
Febrile Reaction            Febrile reaction is the most common reaction of blood transfusion.
      a. Causes        factors causing febrile reaction are included.
     ·The blood, blood bag or blood administration set is contaminated by bacteria.
     ·The principles of surgical asepsis are violated during blood transfusion.
     ·Antibodies in recipient react to antigens on donor’s white blood cells, platelets, or plasma
proteins, especially with multiple transfusions or previous pregnancy.
      b. Clinical Manifestations               After first 30 minutes to 6 hours after the transfusion,
the patient may have sudden chills and fever ( the temperature can range from 38℃ to 40℃ ),
flushing, headache, anxiety, nausea, vomit, muscle pain. The mild reaction may be relieved within
1 to 2 hours, and the temperature drops to the normal level.
     C. Nursing Intervention:
     Preventing Intervention To prevent the febrile reaction, the nurse should remove the
factors causing fever, follow the principles of surgical asepsis during blood transfusion.
Disposable blood administration set should be chosen.
     Nursing Intervention If the febrile reaction occurs, the nurse interventions are the
following:
     ·Transfusion should be administered slowly if mild reaction occurs.
     ·Stop transfusion immediately and send the blood bag and blood administration set to the
laboratory if severe reaction occurs.
     ·Monitor the vital signs.
     ·Provide cold therapy if the patient has hyperthermia.
     ·Administer antipyretics as ordered.




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Anaphylactic Transfusion Reactions
     a. Causes        The factors causing anaphylactic transfusion reactions include:
     ·The patient has anaphylactic predisposition. The whole antigen is produced to cause the
anaphylaxis when the variant proteins in donated blood combine with the proteins of the patient.
     ·There are substances causing anaphylaxis in donated blood.
     ·After the patient received several blood transfusion, the allergic antibody is produced in
patient’s plasma. When blood transfusion is performed again, the antibody-antigen reaction cause
anaphylaxis.
     ·The allergic antibody in donated blood is infused into the patient. The anaphylaxis may
occur if the antibody reacts to antigen.
     b. Clinical Manifestations
     In mild anaphylaxis After blood transfusion, the patient may feel skin itching, and
covered with urticaria.
     In medium anaphylaxis The patient may have vascular and neuropathic edema,
normally appear in face. The patient may have palpebra, or lip edema. The laryngeal edema also
may occur. The patient may have dyspnea, bronchial spasm, or chest pain. The wheezing sounds
are found when lungs auscultated.
     In serious anaphylaxis The patient may suffer from anaphylaxis shock.
     C. Nursing Intervention                      Although anaphylactic transfusion reactions are
relatively rare, they can occur in any patient.
     Preventing Intervention
     ·Administer blood or blood products correctly.
     ·Choose blood donor without history allergy.
     ·Blood donor should be fasting for 4 hours before being drawn blood.
     ·The patient having history of allergy should be given antihistamines as ordered before
transfusion.
     Nursing Intervention           When a patient has a transfusion reaction, prompt nursing
actions can decrease the severity of the response. The management of anaphylactic transfusion
includes the following:

In mild anaphylaxis
     ·Slow down the transfusion.
     ·Administer antihistamines as ordered.
     ·Monitor vital signs.
     In medium or serious anaphylaxis



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     ·Stop transfusion immediately. Notify physician and blood bank.
     ·Administer 0.5 to 1ml of 1/1000 adrenaline by hypodermic injection as ordered. The
antihistamines should be given as ordered.
     ·Maintain IV access with normal saline.
     ·Give oxygen therapy to patient with dyspnea. Give tracheotomy for patient with severe
laryngeal edema.
     ·Manage shock. Initiate cardiopulmonary resuscitation if necessary.
     ·Monitor the patient’s vital signs.


Hemolytic Reaction
     Hemolytic reaction belongs to the clinical signs caused by the destruction or hemolysis of red
blood cells in recipient’s blood or donated blood. It is the most serious blood transfusion reaction.
It is classified into intravascular hemolytic reaction and extravascular hemolytic reaction.
★Intravascular Hemolytic reaction
     a. Causes The factors causing intravascular hemolytic reaction include the following:
     ·Incompatibility blood infusion: 10ml or more of ABO incompatible whole blood or red
blood cells are infused.
     ·Degenerated blood transfusion: The red blood cells are destructive and hemolytic in infused
blood. For example, the blood is stored for a long time, preserved in high temperature, shaken
violently, or infected by bacteria.
     ·Hyperosmolar, hypoosmolar solution or medicines that influence the blood pH may have
been added into the donated blood, then resulting in damage of red blood cells.
     b. Clinical Manifestations The clinical signs include three stages.
     In the first stage The agglutinative reaction occurs between antibodies in recipient’s
blood plasma and antigens in red blood cells in donated blood. The red blood cells are clumping,
and block some small blood vessels. The patient may have headache, nausea, vomit, chest pain,
numbness, and increased pain in kidney region.
     In the second stage The agglutinative red blood cells are hemolytic. Large amount of
hemoglobin are present in plasma. The patient may suffer from hemoglobinuria, jaundice, chills,
fever, dyspnea, cyanosis, and hypotension.
     In the third stage Large amount of hemoglobin is flowing from plasma to renal tubule,
and become crystallization while they are meeting the acid substances and block the renal tubule.
Endothelial cells within renal tubule are ischemia and necrotic because of the interaction between
antigens and antibodies. The obstruction of renal tubule is more serious. It may cause oliguria,



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anuria, even acute renal failure or death.
     c. Nursing intervention
     Preventing Intervention The nurse should meticulously verify and document patient
identification from sample collection to component infusion to prevent the hemolytic reaction, and
make sure the compatibility of blood typing and cross-matching.
     Nursing Intervention if the reaction occurs, the nursing interventions are the following;
     ·Stop transfusion immediately, remove blood and any blood-filled tubing, and replace with
saline bag and new tubing to keep line open, notify the physician and blood bank immediately.
     ·Provide oxygen therapy, maintain IV access, administer medicines as ordered.
     · Return blood bag and tubing to blood bank. Obtain blood and urine samples of the patient
to the laboratory.
     ·Local block in both areas of lumbar regions and heat therapy on the back should be
provided to reduce the spasm of renal vascular.
     ·Infuse sodium bicarbonate by intravenous injection to make urine alkaline to promote
hemoglobin dissolved to reduce the obstruction of renal tubule.
     ·Monitor vital signs every 15 minutes; monitor and record urine output hourly by inserting
indwelling catheter. Peritoneal dialysis or haemodialysis may be required if renal failure occurs.
     ·Treating shock as prescribed, if present.
     ·Give mental support.
★Extravascular Hemolytic Reaction
      Extravascular hemolytic reaction is caused by D, C, and E antibodies in Rh system.
The red blood cells are destructive and hemolytic. The hemoglobin is changed into bilirubin. The
bilirubin are broken down in liver and eliminated through digestive system. Extravascular
hemolytic reaction is present after one week or more of blood transfusion. The signs of reaction
are mild. The patients have mild fever, anemia and feel tired. The bilirubin in blood is increasing.
These kinds of patients should be explored about the factors causing the reaction, identified the
diagnosis and avoid the blood transfusion as possible.


The reaction Related to Large Volume of Blood Transfusion
     ★Circulatory Overload
     Circulatory overload is a risk when a patient receives massive whole blood or packed red
blood cells transfusions for massive hemorrhagic shock or when a patient with normal blood
volume receives blood. Patients particularly at risk for circulatory overload are older adults and
those with cardiopulmonary diseases.



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     a. Causes Too rapid infusion expands the vascular volume more than patient’s heart can
tolerate; result in pulmonary edema.
     b. Clinical Manifestations            It can occur at anytime during or immediately after
completion of the transfusion. The patient may have cough, dyspnea, anxiety, headache,
tachycardia, tachypnea, orthopnea, increased venous pressure. The neck veins are distended. Moist
rale is found in lungs auscultated.
     c. Nursing Intervention The amount and flow rate should be regulated according to
patient’s clinical status to prevent the circulatory overload. The management includes:
     ·Assist the patient in upright position with feet down.
     ·Notify physician.
     ·Stop or slow transfusion as ordered.
     ·Monitor the patient’s vital signs.
     ·Administer morphine, diuretics, oxygen as ordered.
     ★Hemorrhage
     a. Causes Platelets and thrombogen are damaged in stored blood. Too much sodium
citrate is infused, and may cause the disturbances of blood coagulation.
     b. Clinical Manifestations The patient may have wound bleeding, skin bleeding,
     gingival bleeding, bleeding in venipuncture site, or hematuria.

     c. Nursing Intervention
     ·Monitor the symptoms and signs of hemorrhage .
     ·One unit of fresh blood is infused after 3 unit of stored blood.
     ·The patients are provided the blood components according to lack of coagulants.
     ★Sodium Citrate Poisoning Reaction
     a. Causes Too much sodium citrate is infused. Sodium citrate and calcemia are combined
in patient’s blood, and hypocalcemia is present.
     b. Clinical Manifestations The patient may suffer from tetany and hypotension. It may
be found that the Q—T interval is prolonged in EKG. Cardiac arrest may occur if the condition is
serious.
     c. Nursing Intervention After 1000ml of blood is infused, it is possible for the patient
to be injected with 10ml of 10% calcium gluconate as prescribed by intravenous injection in order
to prevent hypocalcemia.
Other Reactions
     There are several other blood transfusion reactions, such as air embolism, sepsis,
hypothermia, and blood transmitted disease (such as hepatitis, malaria, and AIDS ). Stored blood



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may cause hyperkalemia because blood cells break down during storage and potassium is released
into the vascular space. The potassium level should be checked frequently for a patient who
receives several units of blood. If the potassium is elevated, the patient may be given an ion
exchange resin such as polystyrene sulfate.


                              Selection of Blood Donors
     The selection of blood donors must be done more carefully to protect the donor from possible
ill effects of donation and to recipient from exposure to diseases transmitted through the blood.
The following population should be contraindicated for blood donors.
     ·The person who have the history of allergies, hepatitis and malaria, HIV infection
     ·The person with risk factors for HIV infection, heart disease, cancers, severe asthma,
bleeding disorders, convulsions, hypertensions or hypotensions
     ·The patient who undergo the operation, pregnancy women, or the persons who take certain
medicines
     ·The person who have high-risk behaviors such as having unsafe sex relationships, IV drug
abuse
     The persons who are allowed to donate blood should have blood cell count, temperature,
pulse, respiration, and blood pressure measurement.



                               The Principles of Blood Transfusion

     When the nurses perform the blood transfusion, they should comply with the principles
described in the following:
     ·Blood transfusion is usually specified in the physician’s order. It is necessary for the patient
to be tested blood typing and cross-matching before blood transfusion.
     ·In general, whole blood is administered ABO identical. In emergency situations, when time
does not allow ABO determination, group O blood may be given. In addition, group AB blood can
accept group A and B blood with direct cross-matching test negative, transfusion rate must be
slowly, and the amount of blood should not overrun 400 ml.
     ·Cross-matching test should be do again if the patient need another blood transfusion to
examine antibodies produced in the blood serum




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