Chapter 3
Case Study #1
1. Indications for a blood transfusion for Helen:
- Anemia (Hgb of 6.5 g/dL)
- Fatigue and exhaustion
- Pale appearance
2) Considerations for starting an IV for the blood transfusion:
- Client assessment: Check Helen’s vital signs, hydration status, and any underlying medical conditions.
- Site selection: Choose the best IV site, taking into consideration the age of the client, access, and current skin condition. Consider the size of catheter, optimally a 20-gauge catheter or larger for blood administration.
- Equipment and supplies: Ensure you have all necessary equipment, such as an IV catheter, blood tubing, sterile dressing, and saline.
- Safety measures: Follow standard infection control procedures to prevent transmission of infectious diseases.
- Client comfort: Explain the procedure to Helen.
3) Steps to prepare for the administration of blood for Helen:
- Ensure Helen has signed the consent for blood transfusion
- Verify the correct patient with 2 identifiers, blood type, and cross-match
- Check the compatibility of the blood with the client’s blood type and cross-match
- Check for any allergies or sensitivities to components of the blood
- Ensure that the blood is labeled
4) Precautions or nursing considerations:
- Monitor for adverse reactions, such as fever, chills, itching, or hives
- Observe for signs of anaphylaxis
- Check the IV site regularly for any signs of infiltration or infection
- Monitor vital signs and fluid status
- Monitor for signs of fluid volume overload; administer transfusion at an appropriate rate to not overload the client
5) Assessments to be completed prior to the blood transfusion:
- Vital signs
- Lung sounds
- Allergies or sensitivities to components of the blood
- Blood type and cross-match
Assessments to be completed during the blood transfusion:
- Vital signs
- Lung sounds
- Fluid status
- IV site
- Any adverse reactions
6) Blood type O- is compatible with O- and O+ blood types.
7) Steps to ensure safety for the client during blood transfusion:
- Verify the correct client and blood type
- Check the compatibility of the blood with the clent
- Check for any allergies or sensitivities to components of the blood
- Monitor vital signs, lung sounds, and fluid status
- Observe for signs of adverse reactions
8) Steps for the procedure of administering the blood transfusion:
- Administer furosemide 20 mg IV as ordered
- Complete checks with a second RN
- Attach the transfusion set to the IV tubing
- Begin the transfusion at a slow rate and monitor vital signs
- Observe the client for adverse reactions and adjust the rate as needed
- Document the transfusion, including the amount and rate of transfusion, any adverse reactions, and any changes in the client’s condition
- Administer furosemide 20 mg IV between units
- Administer second unit of PRBCs
- Discontinue the transfusion and remove the IV catheter once the transfusion is complete
All of the answers to the interactive element are found within the element.