Blood Transfusion Nursing Care Plans Diagnosis and InterventionsBlood Transfusion NCLEX Review and Nursing Care Plans Show
Blood Transfusion (BT) is a medical procedure that involves the transfer of whole blood or blood components/products from one person to another. If the body is deficient in one or more of the components that make up healthy blood, a transfusion can help supply what the body is missing. Understand the basics behind this potentially life-saving procedure, as well as how nurses should manage and intervene before, during, and after the procedure. Indications of Blood TransfusionBlood Transfusions are generally given to people for several reasons, including anemia, complications during pregnancy and childbirth, severe trauma due to accidents, and surgical procedures. The following are the key goals of this procedure:
Blood is frequently needed in circumstances such as blood loss secondary to bleeding and trauma, inadequate blood production brought about by chronic blood disorders such as thalassemia and leukemia, and excessive cell destruction. Blood transfusions should only be used to treat a condition that would cause considerable morbidity or mortality that could not be avoided or controlled adequately with alternative methods. Blood ComponentsA blood component is a part of the blood that has been separated from whole blood. It is made up of several parts, including the ones listed below:
Prevention of Blood Transfusion ReactionsBlood transfusions are generally regarded to be safe, however there are some risks involved. Complications may appear right away, or they may take some time to appear. The following are some of the most common blood transfusion adverse reactions or complications.
Assessment on Blood Transfusion Adverse Reactions and Complications
Although it is very tough to prevent the above-mentioned adverse reactions and complications of blood transfusion, nurses should carefully undertake the following recommended nursing interventions to minimize their occurrence. Transfusion reactions can be avoided by:
Recognizing any reaction signs or symptom or adverse reactions:
Respond as necessary to manage the adverse reaction’s symptoms:
Blood Transfusion Reaction Nursing Interventions
Blood Transfusion Nursing Care Plan 1Ineffective Breathing Pattern Nursing Diagnosis: Ineffective Breathing Pattern related to blood transfusion as evidenced by increased respiratory rate, labored breathing, nasal flaring and cough. Desired Outcome: The patient will maintain an effective breathing pattern, as evidenced by normal respiratory rate, relaxed breathing, and absence of cough.
Blood Transfusion Nursing Care Plan 2Fluid Volume Excess Nursing Diagnosis: Fluid Volume Excess related to blood transfusion reactions as evidenced by crackles breath sounds, jugular vein distention, changes in blood pressure, and oliguria. Desired Outcome: The patient will be normovolemic as evidenced by urine output greater than or equal to 30 mL/hr, clear lung sounds, blood pressure with established limits, and absence of jugular distention.
Blood Transfusion Nursing Care Plan 3Altered Tissue Perfusion Nursing Diagnosis: Altered Tissue Perfusion related to complications from blood transfusion Desired Outcome: The patient will show no further deterioration and maintain maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, normal Arterial Blood Gas (ABG), adequate urine production and absence of swelling.
Blood Transfusion Nursing Care Plan 4Hyperthermia Nursing Diagnosis: Hyperthermia related to adverse reactions from blood transfusion as evidenced by increase in body temperature, warm skin and chills. Desired Outcome: The patient will maintain normal body temperature as evidenced by an acceptable range of vital signs, dry skin and absence of chills.
Blood Transfusion Nursing Care Plan 5Hypothermia Nursing Diagnosis: Hypothermia related to adverse reactions from blood transfusion procedure as evidenced by 33.5 degrees Celsius body temperature, cold clammy skin, shivering and slow weak pulse. Desired Outcome: The patient will re-establish a normal body temperature between 36 degrees Celsius and 37.4 degrees Celsius.
Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What is an important nursing responsibility when administering blood?Nursing care of the patient undergoing a blood transfusion is of utmost importance. Nurses are responsible not only for the actual administration of the blood product and monitoring of the patient during its administration but also efficiently identifying and managing any potential transfusion reactions.
What nursing actions are needed prior to administering the blood?Before the Transfusion. Find current type and crossmatch. Take a blood sample, which will last up to 72 hours. ... . Obtain informed consent and health history. Discuss the procedure with your patient. ... . Obtain large bore IV access. ... . Assemble supplies. ... . Obtain baseline vital signs. ... . Obtain blood from blood bank.. What must you check about the patient before administering a blood product?Patients should be under regular visual observation and, for every unit transfused, minimum monitoring should include: Pre-transfusion pulse (P), blood pressure (BP), temperature (T) and respiratory rate (RR).
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