Intravenous Transfusion
Assessment
1. First, I am going to check the chart of mypatient to review the accuracy and thecompleteness of the doctor's orders. So Ihave here Plain NSS 1000ml to run for 8hours.
2. "Hi Sir, How are you today? So Sir Smithcan you state your First Name? When isyour Date of Birth sir? (You also have tocheck the wristband of the patient)
3. I am going to collect all the equipmentthat I am going to use with this procedure.Leaving them in a clean, cluttered, andbedside stand.
Planning
4. "Sir I am going to do the IntravenousTransfusion. This will help you to restore thefluid that you've lost because subjectivelyyou said that you have been vomitingseveral times and objectively I can see thatyou have a sunken eyeball, pale skin anddry lips."
5. "Sir, I will going to place you in acomfortable position that is reclining positionand leaving your arm in a dependentposition"
Implementation
6. I am now going to perform my handhygiene. Leaving the equipment on clean,clutter – free bedside stands. I am nowgoing to wear my gloves and provideprivacy.
7. "Sir since i provided privacy already I amnow going to change your suit into a moreeasily removable gown"
8-9 I am going to open the sterile packageusing the sterile technique and I am going toprepare the IV Tubing and the IV Solution. Iwill check the IV Solution with the color of itit should have plain white and the expirationdate of it.
10-11. I am now going to open the Infusionset and maintain the sterility by holding atboth ends. And after that I am going toplace the roller clamp 2-5sm or 1-2 inchesbelow the drip chamber and close it.
12. I will now remove the rubber stopper ofthe IV Solution while maintaining the sterility
13. I will now Insert the infusion set into theIV Solution by inserting the tubing spike,using a twisting motion.Compress drip chamber and release,allowing it to fill one – half full with infusionfluid.
14. After that I will do the prime tubing.Slowly open the roller clamp to allow fluidto travel from the drip chamber throughtubing to the distal end and always Maintainsterility. There are no bubbles.
15. "Sir, what is your dominant hand? Whichside do you want me to venipuncture so thatit cannot interfere in your daily living?"I am now going to apply a tourniquet aroundthe arm 4-6 inches around the arm of theproposed insertion site.
16-18. I am going to select a vein that isstraight and well dilated. And using myindex and middle finger I am going topalpate the vein by pressing downward andI am going to note for a soft, resilient, andbouncy feel like when releasing pressure.And note that the insertion site does notinterfere with the activities of the daily livingof my patient.
19-20. If the insertion site needs a thoroughdrying, I am going to wash it with soap andwater first and dry it. I am now going to getthe cotton balls with alcohol to clean theinsertion site in vertical, horizontal, and incircular motion- from inner to outer.
21-27. I am now going to perform thevenipuncture.I will slowly open the roller clamp to regulatethe rate.I will now remove my gloves and performhand hygiene.28. I will observe the insertion site forswelling.
29-30. I will now secure the catheter byputting in the micropore tape. And put a curlloop to also secure it.
31-32. And after that I am going to recheckthe flow rate and correct the drops perminute. 31-32 drops per minute.
33. I am now going to dispose of the styletand put it in a sharp container.
34. Sir you have to be careful with yourmovement for you to do not dislodge thecatheter.
34-38. Just memorize all of it.F- DehydrationD- Subjective- Vomit for several timesObjectice- Sunken eyeballs, pale skin anddry lips.A- Intravenous InfusionR- Restore the fluid
Blood Transfusion
1. First, I am going to check the chart toverify the type of blood that I am going totransfuse with my patient. And after that Iam going to check for the consent form.
2. Now, I am going to review the client'smedical history, including the fluid balance,heart and lungs that may hinder the therapy."So maam, have you experienced bloodtransfusion before?"- (Yes)- "Is it successful ma'am or isthere any blood reaction with thatexperience of yours?"
3. Next, I am going to check for the patencyand the status of the cannula. So first, I amgoing to check the fluid- the compatible fluidwith the blood transfusion is Plain NSS andthe gauge number that we are going to useis gauge 18 because the blood is thick.Next, I am going to check for the cannula,so objectively I can't see any infiltration andthere is no plebitis. "Maam, do you feel anypain with your cannula?". And there is no pain.
4. And now, I am going to prepare andname all the equipment that I am going touse with this procedure.
5. I am going to plan the blood transfusionas soon as the blood component is ready. Iwill give diphenhydramine to my patient- thisis an antihistamine or anti allergy. I will alsoget the vital sign of my patients to get thebasal line of it so that I can easily see ifthere is a blood reaction happening duringthe transfusion.
6. "So maam, I am going to do the bloodtransfusion. This will help you to restore allthe blood that you've lost because of theaccident that you've been faced with. Sowhen there is a blood reaction like highfever, allergy and dyspnea we are going tostop the transfusion."
7. I am now going to provide privacy.
8. I will perform hand hygiene and wearclean gloves.
9. After that, I am going to verify and checkwith another nurse the signed consent formand the information needed if the obtainedblood bag at hand is for the correct clientusing the requisition form. I am going tocheck the clients name, identificationnumber, blood type and Rh group, and theblood donor number. I will observe the bloodfor abnormal color, RBC clumping, gasbubbles, any extraneous material, andpresence of any irregularities. Returnoutdated or abnormal blood to the bloodbank and If any one of the information doesnot exactly match, DO NOT administer.
10. I am now going to prepare the blood bagby mixing the blood bag gently severaltimes to mix the cell components with theplasma.And after that I am now going to remove theblood bag's port by pulling the taps.I will now insert the BT set into the bloodbag by spiking it and slowly twisting it andmake sure that the roller clamp of the BTset is close and I have to hang the bloodbag.After that I am going to do the prime tubing.I am going to disinfect the y port and insertthe needle of the bt set to y port and put aplaster.
11. I will now start the blood transfusion.First, I will close the IV roller clamp andopen the Blood bag roller clamp to allow theblood to flow into the saline-filled dripchamber. Squeeze the drip chamber toreestablish the liquid level one third full ifneeded and tap the filter to expel anyresidual air within the filter.I am going to readjust the flow rate with themain clamp to finish the transfusion within 4hours.Remove and discard gloves. Perform handhygiene.
12. And after that I am going to observe andcheck the client closely for the first 15minutes upon starting the transfusion. Andcheck for the vital signs in the first 15 mins,30 mins, and in an hour.
13. "Maam report to me for any signs ofdiscomfort because that could be a bloodreaction, ma'am. If there is a blood reaction,I am going to terminate the terminationimmediately and get your vital signs andrefer to the physician."
14. I am going to terminate the transfusionin two ways. First, if all the blood hastransfused already or second, if there is ablood reaction (fever, allergy, and dyspnea)
15. I am now going to discard all thesupplies appropriately and I am going toadjust the IV fluid to the ordered rate.
16. I am going to perform hand hygiene.
17. Basahin mo na lang yung nasa checklistsa may evaluation at recording andreporting.
