16 Initiating Blood Therapy
Assessment
- Reviewed physician’s order.
- Inspected integrity and intactness of present intravenous (IV) line.
- Obtained client’s transfusion history.
- Verified consent forms were signed. Identified indication for blood product.
- Obtained vital signs before initiating transfusion.
- Assessed client’s need for intravenous (IV) fluids or medication before transfusion.
- Assessed client understanding of procedure.
Nursing Diagnosis
- Developed appropriate nursing diagnosis based on assessment data.
Planning
- Identified expected outcomes.
- Explained procedure and its purpose to client.
Evaluation
- Monitored intravenous (IV) site and status of infusion.
- Assessed client for any changes in vital signs or other signs of transfusion reaction.
- Reassessed client and assessed laboratory values to determine response to administration of blood component. Identified unexpected outcomes.
- Recorded on appropriate form type and amount of blood comment administered, vital signs before, during, and after transfusion and client’s response to blood therapy.
- Reported immediately signs and symptoms of a transfusion reaction or deterioration in cardiac, respiratory and/or renal status.
Initiating Blood Therapy – Implementation
- Pre administration:
- Obtained blood product from blood bank per agency protocol.
- Checked appearance of blood product.
- Correctly verified right blood product and right client.
- Reviewed purpose of treatment and asked client to report any changes felt during transfusion.
- Had client void or emptied urine collection container.
- Administration:
- Performed hand hygiene and applied clean gloves.
- Opened Y tubing blood administration set.
- Set roller clamp(s) to “off” position.
- Spiked normal saline IV bag with Y tubing spike. Primed both sides of Y tubing, filled half of drip chamber and closed clamps.
- Hung on IV pole and finished priming the tubing.
- Prepared blood component for administration. Opened clamp of Y tubing and primed with blood.
- Attached primed tubing to client’s venous access device and opened common tubing clamp.
- Initiated infusion of blood product.
- Remained with client during the first 15 minutes of transfusion.
- Appropriately monitor client’s vital signs.
- Regulated infusion according to health care provider’s orders.
- Cleared infusion tubing with 0.9% normal saline after blood completely infused.
- Disposed of supplies. Removed gloves and performed hand hygiene.
Faculty Comments
| Assessment | Nursing Diagnosis | Planning | Implementation | Evaluation |
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| Attempt Number & Outcome Number |
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| Student Signature
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| The student was unable to perform the skill competently and will be retested. |
Faculty Signature |
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