Bt complications

1. Nelia B. Perez RN, MSN

2. Complications, Nursing Complications, Nursing
Interventions and Preventive Interventions and Preventive
Measures of Blood TransfusionMeasures of Blood Transfusion
Infiltration
Thrombophlebitis
Circulatory Overload
Air Embolism
Catheter embolism infection
Transfusion Reaction

3. InfiltrationInfiltration
–A substance (blood) that passes into the
tissues and forms an accumulation of the
blood to the skin
Manifestations:
–Blanching of skin
–Swelling, pain at site
–Cool to touch
–Decreased infusion rate

4. Nursing Interventions:
–Discontinue IV
–Restart in a new site
–Apply warm compress to increase fluid
absorption
Preventive Measures:
–Check the IV site before starting the transfusion
–Monitor the site during the transfusion
–Inspect the site thoroughly.
–Make sure that a main line is set before starting
the transfusion.

5. ThrombophlebitisThrombophlebitis
–Inflammation of a vein with formation of a
thrombus / clot
Manifestations:Manifestations:
–Redness, heat & swelling at site
–Possible pain
–Red line along course of vein

6. Nursing Interventions:Nursing Interventions:
–Discontinue IV
–Restart in a new site
–Apply warm compress to site
Preventive MeasuresPreventive Measures:
–Check the site before transfusion
–Monitor and inspect the site during and after
the transfusion
–Inquire and tell the patient to notify you if any
sudden awkward feeling is felt
–Check the integrity of the IV line and patency

7. Circulatory OverloadCirculatory Overload
–Too rapid infusion of the blood causing
fluid volume overload to the patient
Manifestations:Manifestations:
–Apprehension, shortness of breath
–Coughing, frothy sputum, crackles
–Engorged neck veins
–Increased central venous pressure and
jugular vein pressure
–Increased blood pressure and pulse

8. Nursing Interventions:Nursing Interventions:
–Stop the infusion / Slow down IV rate
–Inform the doctor at once.
–Monitor CVP through a separate line
–Maintain the I.V. infusion with normal saline solution
–Administer oxygen.
–Elevate the patient’s head.
Preventive Measures:Preventive Measures:
–Always monitor the patient’s vital signs before, during
and after blood transfusion
–Transfuse blood slowly.
–Don’t transfuse more than 2 units of blood in 4 hours.
–Have oxygen readily available at the bedside of the
patient.

9. Air EmbolismAir Embolism
–Obstruction of the circulation by air that has
gained entrance to veins usually caused by
empty IV lines and sets
–Blood given under air pressure following
severe blood loss
Manifestations:Manifestations:
–Dyspnea, cyanosis, hypotension, tachycardia
–Loss of consciousness
–Wheezing, chest pain

10. Nursing Interventions:Nursing Interventions:
–Stop infusion immediately
–Clamp tubing
–Turn client to the left with his left down
–Administer oxygen
–Inform the doctor
Preventive Measures:Preventive Measures:
–Have a clamp accessible at the bedside
–Check the patient and site and line every now
and then
–Monitor the time of the transfusion.

11. Catheter Embolism InfectionCatheter Embolism Infection
Clogging of the catheter set causing
obstruction of a blood vessel by a clot or
particle that leads to development of
infection
Manifestations:Manifestations:
–Fever, shills, flushing, tachycardia

12. Nursing Interventions:Nursing Interventions:
–Stop the transfusion at once.
–Replace the whole set.
–Inform the doctor.
–Open the main line

13. Preventive Measures:Preventive Measures:
–Monitor patient’s vital signs.
–Use a blood set with filter and check the patency of
the whole set before transfusion.
–Assess patient for occurrence of signs and symptoms
of fever.
–Inspect the blood before the transfusion.
–Change the blood tubing and filter every 4 hours.
–Infuse each unit of blood over 2 to 4 hours; terminate
the infusion if the time period exceeds 4 hours.
–Maintain sterile technique when administering blood
products.

14. Transfusion ReactionTransfusion Reaction
Includes Hemolytic, Allergic, Pyrogenic,
Anaphylactic
–Caused by ABO & Rh incompatibility,
allergic antigen
Manifestations:Manifestations:
–Fever, chills, headache, lumbar or sternal
pain, palpitations, tachycardia, urticaria,
laryngeal edema, bronchospasm,
–Flushing, heat along vein

15. Nursing Interventions:Nursing Interventions:
–Stop the IV at once.
–Continue main IV
–Inform the doctor
–Give medicines as prescribed
–Send blood and urine specimen for work-up
Preventive Measures:Preventive Measures:
–Have a thorough assessment of the patient
before hand. Take note of the occurrence of any
allergies.
–Monitor patient’s vital signs.
–Always check the line, site, and set for the
validity and availability of the company…

16. Citrate IntoxicationCitrate Intoxication
–Large amounts of citrated blood in
patients with decreased liver function.
Manifestations:Manifestations:
–Neuromascular irritability
–Bleeding due to decreased calcium
–Cardiac arrhythmias
–Hypotension
–Muscle cramps
–Nausea and vomiting
–Seizures
–Tingling in the fingers

17. Nursing Interventions:Nursing Interventions:
–Monitor and treat hypocalcemia
–Encourage patient to eat foods rich in calcium
–Monitor how many blood bags already infused to
the patient.
–Monitor calcium and citrate level if with multiple
transfusions
Preventive Measures:Preventive Measures:
–Remind the doctor about how many blood bags
already infused to the patient
–Avoid using citrated blood
–Monitor liver function
–Have calcium gluconate available in your unit.

18. WHAT TO DO IF TRANSFUSION WHAT TO DO IF TRANSFUSION
REACTION OCCURS…REACTION OCCURS…
When they do occur, it is usually
because of ABO incompatibility
between patient and donor during
transfusion of red cells.
Ensure that the intended recipient is
getting the intended unit at the time of
transfusion.

19. Acute Transfusion Reactions Acute Transfusion Reactions signs and
symptoms will usually appear within the first 5-
15 minutes after the transfusion is started, but
can happen anytime during the transfusion.
Types of Acute Transfusion Reactions:Types of Acute Transfusion Reactions:
–Acute hemolytic Transfusion Reaction
–Febrile nonhemolytic Transfusion Reaction
–Mild allergic (Urticarial)
–Anapylactic
–Transfusion Associated Circulatory Overload
–Transfusion – Related Acute Lung Injury
–Septic Transfusion Reaction

20. Symptoms you might see during an acute acute
transfusion reactiontransfusion reaction include:
–Temperature increase of more than 1°C or 2°F
–Bloody urine
–Chills
–Hypotension
–Severe low back, flank, or chest pain
–Low or absent urine output
–Nausea and vomiting
–Dyspnea, wheezing
–Anxiety, "sense of impending doom"
–Diaphoresis
–Generalized bleeding, especially from punctures
and surgical wounds.

21. Should any of these symptoms occur, discontinue the
unit immediately, hang normal saline (on a new
tubing) to maintain vascular access, and call for
assistance.
Closely monitor the patient’s vital signs and
symptoms.
Notify the physician and obtain further orders to
address the patient’s symptoms.
Recheck the patient’s identifying information against
the transfusion record and blood bag.
All bags, tubings, filters, and paperwork should be
retained and forwarded per hospital policy.

22. Importance of Giving Health Importance of Giving Health
Education to Patients and FamilyEducation to Patients and Family
It can establish rapport to you and the
patient and family.
Tension will be lessen on their part and
anxiety will be alleviated.
To enlighten them the real concept of blood
transfusion therapy.
It serves as a channel and communication
between you and your patient.

23. The client’s major concern is likely to be
the safety of the transfusion, specifically the
risk of contracting AIDS.
Provide accurate information for the client,
and begin efforts to ensure a safe and
effective transfusion before the blood or
component is collected.

25. Date and time the transfusion was started and
completed
Name of the health care professional who
verified the information of the patient and the
blood
Catheter type and gauge
Total amount of the transfusion
Patient’s vital signs before and after the
transfusion
DOCUMENTING BLOOD DOCUMENTING BLOOD
TRANSFUSIONSTRANSFUSIONS

26. Infusion device used
Flow rate and if blood warming was used
Vital signs obtain prior to, during, and after
the transfusion
Name of the component, unit number
Evidence of possible transfusion reaction.
–Document interventions done and to whom you
notified.
Patient’s outcome.

27. Date Time
12/12/0
8
2:00
pm
D = Patient reports nausea and chills
= Cyanosis of the lips noted at 1:50 pm, with PRBCs transfusing
A = Infusion stopped. Approximately 100 mL infused.
= Tubing changed of 1,000 mL of D5NSS infusing at KVO rate in right arm.
= Notified Dr. X.
= BP:170/90, Pulse Rate: 104, Respiratory Rate: 25, Temperature: 36.0°C.
= Blood sample taken from PRBCs. Urine specimen also sent out to lab for
urinalysis.
= Gave patient diphenhydramine 50mg via IV as prescribed by the doctor.
= Two blankets placed on patient.
R = Patient reports he’s getting warmer and less nauseated.
= BP: 148/80; Pulse Rate: 80; Respiratory Rate: 20; Temperature: 36.8°C.
= Patient no longer complaining of nausea or chills.
---------------------------------------------------------------- Ram M. Mar, R.N.

28. TWELVE SIMPLE STEPS NECESSARY IN TWELVE SIMPLE STEPS NECESSARY IN
CARING FOR A PATIENT RECEIVING BLOOD CARING FOR A PATIENT RECEIVING BLOOD
TRANSFUSIONTRANSFUSION
STEP 1: OBTAIN PATIENT’S TRANSFUSION HISTORY
STEP 2: SELECT A LARGE GAUGE NEEDLE OR
CATHETER
STEP 3: CONSIDER THE TUBING & FILTER’S PORE SIZE
STEP 4: FOLLOW PROTOCOL TO OBTAIN THE BLOOD
PRODUCT ACCORDING TO HOSPITAL POLICY
STEP 5: IDENTIFY THE BLOOD PRODUCT & THE
PATIENT
STEP 6: OBTAIN BASELINE VITAL SIGNS & RECORD

29. STEP 7: USE 0.9% NORMAL SALINE FOR
THE STARTER SOLUTION
STEP 8: START THE TRANSFUSION
SLOWLY
STEP 9: MAINTAIN THE PRESCRIBED
TRANSFUSION RATE
STEP 10: MONITOR PATIENT’S V/S &
DOCUMENT
STEP 11: OBSERVE FOR ANY ADVERSE
REACTION
STEP 12: COMPLETE THE NECESSARY
PAPERWORK

30. Calculation of IV Flow RatesCalculation of IV Flow Rates
Calculation of cc/hr is essential in most IV therapy.
Volume
# of hrs
E.g.1 L over 8 hrs = 125 cc/hr
50 cc over 20 minutes = 150 cc/hr
= cc/hr
Computations of flow and Computations of flow and
drip ratesdrip rates

31. Calculation of gtt/min (Long Method)Calculation of gtt/min (Long Method)
STEPS :
1. Need to know cc/hr to calculate
2. Gtt factor = gtt / ml
gtt factors : macrodrip 10, 15, 20 gtts/ml
microdrip 60 gtt/ml
EXAMPLE : LONG METHOD
Doctors Order : Run 1L D5W over 8 hours
Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr
125 cc x 60 gtt/ml = 125 gtt/ml
60 min 1
10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min
60 min 1
15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min
60 min 1
20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min
60 min 1

32. SHORT METHOD
cc / hr ÷ 6for 10 gtt / min
cc / hr ÷ 4for 15 gtt / min
cc / hr ÷ 3for 20 gtt / min
cc / hr = gtt / min for microdrip set

33. 10 Rights in Safe Drug Administration10 Rights in Safe Drug Administration
•Right DRUG
•Right PATIENT
•Right DOSE
•Right ROUTE
•Right TIME
•Right DOCUMENTATION
•Right PATIENT’S HISTORY
•Right DRUG ALLERGIES
•Right DRUG-DRUG, DRUG-FOOD INTERACTION
•Right HEALTH EDUCATION