ACTIVE LEARNING TEMPLATE: Nursing Skill
STUDENT NAME
REVIEW MODULE CHAPTER
Description of Skill Client can receive transfusions of whole blood or components of whole blood for replacement due to blood loss or blood disease
Indications
CONSIDERATIONS
Excessive blood loss, anemia, kidney failure, coagulation factor deficiencies, thrombocytopenia/platelet dysfunction, hemophilia A, Burns, hypoproteinemia
Nursing Interventions (pre, intra, post) Explain the procedure to the client, assessed vital signs in the clients temperature prior to transfusion, remain with the client during the initial 15 to 30 minutes of the transfusion, verify the prescription for a specific blood product, obtain consent, obtain blood samples for a type and cross match. Obtain final signs upon completion.
Outcomes/Evaluation
Client Education
Increased blood volume, increased blood pressure, increased hemoglobin levels, improved clotting
Educate on the specific reason why the client is receiving the blood, educate on the risks and benefits
Potential Complications Acute hemolytic transfusion reaction febrile transfusion reaction Allergic transfusion reaction Circulatory overload Bacterial transfusion reaction
Nursing Interventions
Stop the transfusion, remove the blood tubing from the IV access. Avoid infusing further blood products into the circulatory system, initiate an infusion of 0.9% sodium chloride using new tubing, monitor vital signs, send blood bag and administration sent to the lab for testing
ACTIVE LEARNING TEMPLATES
THERAPEUTIC PROCEDURE A