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Blood Management, Past & Present

Deborah Tolich, RN; Alysha Fuller, BSN; India Carter RN

Learning Objectives:

• Describe the evolution of transfusion use through the ages


• Explain the progression from bloodless medicine to blood management
• Summarize transfusion options available through formal BMS programs
• Discuss the role of the BMS coordinator and the healthcare team in blood management

Self-study module:
• Read and review self-study packet
• Complete and submit registration form, post-test and evaluation. (Required to obtain
continuing education)
• For questions or further information regarding this module, please contact Deborah
Tolich at 216-363-3353 or by email deborah.tolich@csauh.com

History of Transfusion (Past)


Back to the beginning of recorded history, man has been fascinated with blood. There is evidence that primitive
man was aware of the importance of blood. In all cultures there is a record relating to blood use. A popular
treatment through the ages was bloodletting or the act of deliberately causing someone to bleed. This practice
was also used as a form of punishment most likely to weaken the individual by causing them to become anemic.
The ancient Chinese believed that blood contained the soul, which also appears in The Old Testament of Holy
Scriptures that life resides in the blood (Lev. 17:11). The Israelites were commanded not to eat it, if blood was
spilled, it was to be covered over with dust (Lev. 17:13). In Greek mythology, exchange transfusions were used
to prevent aging. The blood of a young person would be given to an older person. The ancient Romans
believed blood had medicinal properties and were known to drink the blood of fallen gladiators. Pharaohs
bathed in blood to cure ills. The Norse believed that ingesting the blood of whales would cure certain diseases.
This demonstrates the wide range of beliefs regarding the benefits and uses for blood (Zauder 2000)21.

Science evolved in the use of blood and in the 17th century breakthroughs occurred in its use as a medical
treatment. Physiological approaches to transfusion did not occur until 1665 when William Harvey (1928)9
described circulation. Around this same time, Sir Christopher Wren (1665)18, of London, England, used a
hollow quill as an intravenous device. Colle12 first introduced the concept that blood transfusion was a life-
sustaining treatment. Medical advances of blood transfusion therapy have continued to occur over the past 350
years (Spence 2000)16.

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Blood Transfusion Therapy
In the mid 1600s, several individuals claimed to be the first to transfuse blood. Richard Lower7,8 of London,
England, joined the artery of one dog to the jugular vein of another in 1665. This direct transfusion introduced
the idea that volume repletion could restore an animal that had been exsanguinated to a near death state. A year
later he transfused sheep’s blood into a human with no apparent effect. He was not the first though; a physician
by the name of Jean Baptiste Denis had performed the first animal to human transfusion several months earlier.
Before long it became apparent that animal to human transfusions were not successful. This produced a high
mortality rate and eventually the scientific arena came to the conclusion that blood was not universal between
species. These transfusions were described as incompatible and European governments were prompted to ban
this procedure (Spence 2000)16.

Revisiting Transfusion
Zauder (2000)21 describes blood transfusion attempts as being abandoned for 150 years until 1785 when it was
reported that Phillip Physic15 transfused a post-partum patient that had hemorrhaged. Dr. James Blundell
renewed the interest in transfusions during the first quarter of the nineteenth century. He was also disturbed by
post-partum hemorrhage, which was a common problem. Due to the lack of infusion equipment and
anticoagulant, he invented several tools to facilitate transfusion. A thought occurred to him that only blood of
the same species could be used, but it was difficult to give up the notion of bi-species transfusions. He
determined that blood kept its properties as it passed through an instrument and that the injection of 20 ml of air
had a fatal effect. Dr. Blundell also learned that it was desirable to transfuse the same amount as was lost and
that a slow transfusion rate was best. Apparently he tried several different approaches in order to reach his
conclusions. Ten patients were transfused with a 50% survival rate. We can certainly appreciate much better
statistics in our day. All of the data that were published in 1849 documented 48 patients with 30 surviving.
Wars have, and continue to bring focus to the needs of trauma patients. It is believed that Union army
physicians administered four transfusions during the American Civil War. These transfusions most likely
occurred under terrible conditions with makeshift equipment.

The second half of the nineteenth century was centered on improving direct and indirect transfusions as well as
developing methods to prevent coagulation. This proved frustrating which caused the use of animal blood and
even human milk to be revisited as a substitute for blood. The results were reconfirmed that animal blood and
human milk cannot serve as a substitute for human blood. By the end of the nineteenth century, W.T. Bull3
pioneered the concept of fluid replacement with crystalloid solutions. At this time, blood transfusion continued
to carry a high mortality rate. Transfusion therapy was again abandoned until further technology could be
developed, but did not make a distinctive impact until the Twentieth Century.

The Age of Transfusion


The birth of immunology in the 1880s discussed by Zauder (2000)21 helped researchers determine that red blood
cells had a tendency to clump in certain species. Dr. Karl Landsteiner6 in 1901 published a paper discussing the
agglutination of human red cells. It was the first step in identifying blood types, which followed a year later.
Soon T. J. Greenwalt (1997)5 wrote that 64.4% of transfusions would be compatible without knowing the blood
group of either the donor or the recipient. ABO typing was developed and became a common practice prior to
transfusion. The next challenge was developing an anticoagulant and a convenient method of transferring blood
between donor and recipient.

Dr. Landsteiner (1901)6 helped things along by developing the ability to anticoagulate and store blood. This
made direct donor-recipient transfusions obsolete. In 1915, it was determined that sodium citrate inhibited

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coagulation and it was possible to keep blood viable for several days in refrigerated storage. Later dextrose was
added which allowed blood to be stored for 21 days.

Issues regarding anticoagulation and storage were resolved just in time for blood to be used in WW I.
However, this created a whole new set of problems such as the need for a donor pool and questions of storage.
These problems led to the creation of blood banks. The first blood bank was founded in Leningrad in 1932. The
onset of WW II pushed for the modernization of blood transfusion therapy. Wartime presented the need for a
blood supply that was readily available in addition to presenting the option for viable substitutes for transfusion.
It spearheaded efforts focused on component therapy and ways of minimizing and managing excessive blood
loss. Through wartime experience the assumption was made that blood and blood products were safe for
general use. Therefore, physicians returning home after the war had developed a reliance on blood products and
began insisting on their availability. This marked an era where transfusion was considered vital to medicine
despite the risks.

Blood Transfusion
The Twentieth Century continued to reinforce the business of blood banking. Zauder (2000)21 again recounts
how relatives or volunteers made up the first blood donors. Eventually another class of donor surfaced and was
known as the professional donor or paid donor. In the 1940s, it was recognized that there were several risks to
transfusion. During this time, reports surfaced of jaundice occurring after transfusion therapy and to the
determination that the jaundice was related to the transfusions.

By the 1960s, the problem of volunteer versus paid donors came to light in the United States and raised the
question about quality. It was noted that nearly 50% of the blood supply came from paid donors. These donors
were considered to be suboptimal and were referred to as “ooze for booze.” Obtaining a blood supply was
uncoordinated chaos. Paid donors received as little as $5 a unit. Their blood was typed and tested for syphilis.
At the same time, hospitals were billing patients anywhere from nothing to $60 a unit. The American Red
Cross and the American Association of Blood Banks were in a turf war over money. Blood was now
recognized as a commodity.

Prior to 1972, blood was tested only for syphilis. In 1972, testing to identify hepatitis B was begun but proved
ineffective. It was at this time that the incidence of hepatitis was much higher in paid donors than in volunteers.
Even though the FDA had mandated testing bureaucracy debated on how to handle the testing. In 1978, the
FDA stepped in and began requiring blood and blood products to be labeled as originating from a paid or
volunteer donor. Hospitals in turn did not want to be accused of using inferior products, and therefore, refused
to purchase paid donor blood products. This essentially closed the chapter on volunteer donors versus paid
donors.

Testing of blood and screening of donors continued to make important safety upgrades. More sensitive tests
were developed. In 1982 the first reports of HIV infecting individuals through blood transfusion appeared.
Donor screening was expanded to include steps to exclude individuals considered high risk for HIV. A year
after HIV was identified, the first commercial test kit surfaced. Many criticized the blood banking industry for
a slow response to mandatory testing for HIV. Today nine tests for infectious diseases are completed on donor
blood (see figure 1.1). The burden of testing though continues to lie in that of unknown diseases. What has yet
to be detected as a blood borne disease cannot be identified through a test that does not yet exist. (See figure
1.2 and 1.3.)

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The immune response of blood transfusion is currently unknown. However, it has been stated that the decrease
in immune function post transfusion is estimated as costly to both patients and the healthcare system. This is
referred to as transfusion-associated immunomodulation or TRIM. Experts contend that TRIM causes the body
to become more vulnerable to infections and cancer recurrence. Dr. Paul Tartter in 1992 made the observation
that immune function can be affected from hours up to years after a transfusion. He noted lymphocyte
inhibition for up to 30 years in women who were transfused as newborns for RH incompatibility. Immune
suppression can be a life-threatening outcome of transfusion therapy. It delays the healing process and
increases the use of antibiotic treatment. A patient who has received a blood transfusion is more likely to have
an increased length of stay in the hospital. Blumberg (1997)2 determined that as the number of blood
transfusion increases so does the number of days spent in the hospital. Therefore immunomodulation has a
negative effect on patient recovery and an economic effect on the healthcare system as well. (See figure 1.4.)

Tests Performed on Donated Blood


• Hepatitis B surface antigen
• Hepatitis B core antibody Figure 1.1
• Hepatitis C virus antibody
• HIV-1 and HIV-2 antibody
• HTLV-1 and HTLV-II antibody
• Serologic test for syphilis
• Nucleic acid testing (NAT) for HIV-1 and HIV-2
• NAT for West Nile Virus

www.aabb.org/all_about_blood/FAQs/aabb_faqs.htm1

Risk of RBC Transfusion in United States

z Febrile non-hemolytic RXN: 1/100 tx


z Minor allergic reactions: 1/100-1000 tx
z Bacterial contamination: 1/ 2,500,000
z Viral Hepatitis 1/10,000 Figure 1.2
z Hemolytic transfusion Rxn Fatal: 1/500,000
z Immunosuppression: Unknown
z HIV infection 1/500,000

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Blood Borne Diseases
• Hepatitis Figure 1.3
• Cytomegalovirus
• Hepatitis A Virus (HAV)
• Hepatitis C Virus (HCV)
• HIV
• Human T Lymphotropic Virus
• West Nile Virus
• Babesiosis
• Chaga’s Disease
• Lyme Disease
• Malaria

Principle Risks and Side Effects of Blood Transfusion

1. Transmission of infectious disease 11. Iron overload


2. Acute hemolytic reaction 12. Multi-organ failure
3. Febrile reaction 13. Metabolic complications
4. Allergic reaction 14. Depression of erythropoiesis
5. Immunomodulation
6. Delayed hemolytic reactions
7. Post transfusion purpura
8. Bacterial contamination
9. Circulatory overload
10. Hemolysis
Shannon Farmer (2000) Your Body Your Choice3

Figure 1.4

Blood Transfusion Alternatives


Richard Spence, MD (2000)16 describes major forces that have driven forward the development of transfusion
alternatives in his history of Bloodless Medicine and Surgery. These forces included increased knowledge of
the risks of blood, exploding advancement in medical technology, and the pressure from Jehovah’s Witnesses to
receive healthcare without transfusions. As the medical community became more aware of disease transmission
risk and other risks of blood transfusion, alternatives were sought. Thus the age of autotransfusion was born.
Fantus recommended that patients pre-donate their own blood. During the 1960s, the combination of pre-
donation and autotransfusion began to be used. However, these procedures were not used very much. The
focus was more on advanced surgical procedures including open-heart surgery that relied heavily on blood
transfusions. The first heart-lung bypass machines used blood as a priming agent. It was not unusual for a
patient to be cross-matched for 25 units of blood for a single-vessel bypass surgery in the early 1970s. Even
though the collection and reinfusion of shed blood or autotransfusion has been available since around 1914, and
technology has addressed cell separation and the removal of contamination and impurities, it has only been in
the past 25 years that these methods have progressed to more widespread use.

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Jehovah’s Witnesses were unable to take advantage of many of the surgical advances that were being made due
to a reliance on transfusion. Their decision to seek good medical care without the use of blood was met with
disdain by many in the medical community. Many physicians did not understand the Witnesses position and
classified them as a religious sect that refused all medical treatment for themselves and their children. Few
would perform major surgery on a Jehovah’s Witness patient. Dr. Denton Cooley was one of the first pioneers
of bloodless surgery. In 1977, he published 20 years of experience in performing open-heart surgery without
blood. His work inspired others to provide surgical treatment to the Witnesses. A surgeon in California, Dr.
Ron Lapin, operated on several thousand patients during his career and was one of the first to recognize the
need for bloodless surgery. In the late 1970s, he started the first bloodless medicine and surgery center in
Bellflower Hospital in California. Dr. Lapin created and published the first journal in this field and also began
training and credentialing physicians. In the late 1980s and early 1990s, the first bloodless medicine and
surgery programs in New Jersey, Chicago, Cleveland and in Europe were established.

Today there is still much scrutiny regarding blood transfusion. Little data exists to support the clinical use of
blood transfusion. The last several years has brought debates in identifying an appropriate transfusion trigger
and what is considered to be the appropriate use of blood transfusions. Most physicians are aware of the risks
of transfusion however, more education is needed in the area of alternatives. Much has been learned about
anemia management with the Jehovah’s Witness population, but this knowledge has been slow in being applied
to all patients. In the past 5-7 years, a shift in healthcare from a religious based approach to a universal
approach has been noted.

A Paradigm Shift (Present & Future)


The term “bloodless medicine and surgery” (BMS) became the popular term referring to healthcare without
blood transfusions. Some physicians felt that this was a misnomer by stating that when there is surgery blood is
lost. Many physicians became comfortable performing “bloodless medicine and surgery” to treat Jehovah’s
Witnesses, but remained unsure as how to apply these strategies universally. In 1997, the first organization
dedicated to BMS was established. The National Association of Bloodless Medicine and Surgery (NABMS)
was co-founded by Sharon Vernon, RN, who at that time was the Director of the Center for Bloodless Medicine
and Surgery at St. Vincent Charity Hospital in Cleveland, Ohio. The organization established standards for
BMS programs and initiated an accreditation process and sponsored national and international conferences
focused on BMS. In 2001, NABMS changed its name to the Association for Blood Conservation (ABC).

One of the most significant medical advances of the Twentieth Century is Homologous (donor) blood
transfusion. As more physicians adopted transfusion reduction strategies, the terminology also began shifting.
Programs determined to standardize this approach to healthcare adopted the term “blood conservation”. This
change in terminology was more acceptable to healthcare providers. “Blood conservation” included those who
refuse transfusions, but also attracted those who wanted to avoid transfusion for reasons other than religious
beliefs. Eventually hospitals began applying basic blood conservation principles to all patients. The bloodless
program at St. Vincent Charity (SVCH) in Cleveland, Ohio became the Regional Center for Blood
Conservation (RCBC) in the fall of 2002. SVCH was the first hospital in Ohio to make blood conservation the
standard of care. During this shift to widespread application of blood conservation two additional organizations
were formed: the Network for the Advancement of Transfusion Alternatives (NATA), which is an European
based organization, and the Society for the Advancement of Blood Management (SABM) in the United States.
These two organizations, SABM and NATA, are firmly established in scientific rationale, evidence-based
practices and strongly endorse positive patient outcomes through blood management. SABM’s goal is to

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incorporate blood management strategies into clinical practice while assisting the public and medical
community to embrace the benefits of successful blood management practices.

However, many clinicians continue to view transfusion medicine as excessively focused on the supply of blood
components rather than from a patient/demand perspective. This perception prompted another terminology
change to “blood management.” This term is evolving into an umbrella term that includes care without
transfusions, care that minimizes transfusions, and necessary transfusions. According to the leaders of blood
management, the clinical focus should be on what is best for the patient as opposed to what is best for the blood
supply. Throughout the practice of medicine there has been little evidence that transfusions lead to improved
patient outcomes in several clinical settings. The evidence also has suggested that many transfusions are
unnecessary and may have caused more problems than benefits. This evidence is leading to a re-analysis of
transfusion practices that focus more on the clinical problem and alternatives to transfusion.

The Need for a Paradigm Shift


A paradigm shift to blood management will focus more on the patient’s blood management rather than
management of the blood supply. Blood management is directed at what is medically appropriate for a patient
and should be based on scientific evidence, impartiality, and cost-effectiveness without altering what is best for
the patient.

Dr. James Isbister (2005)11 has identified the following as indicators for this needed adjustment:
• Patients perceive blood as something special and beneficial but have difficulty accepting small risks
over which they have no control.
• Blood donors believe their donation is a gift and will be used appropriately and safely to benefit
individuals on an equitable and not for profit basis.
• Clinicians think blood is ordinary and take blood transfusions for granted. Benefit is assumed and the
risks are considered minimal.
• Bureaucrats view blood as a commodity and transfusion medicine as an expensive support service that
should be regulated and funded as a franchise.
These mal-aligned perspectives should be of concern to all health care professionals. We currently have an
armament of techniques and strategies available to avoid or minimize transfusions. However what is needed
now is a broad clinical commitment to patient blood conservation techniques combined with realistic cost and
accountability of homologous products. Limitations of the blood supply coupled with patients seeking greater
input and choice in their medical management may force a partial paradigm shift. This would be complete if
the obsession with cost and safety would shift to patient driven outcomes. How will you respond in supporting
this shift to patient centered blood management?

Blood Management Communication


Some physicians and nurses may not personally agree with the aspect of blood management dealing with
absolute refusal. It may become difficult for healthcare professionals to refrain from projecting their personal
views to patients and their families. Caregivers may also express their personal views to others members of the
healthcare team, however, caution must be used to determine if the patient, family members or visitors may
overhear these conversations. Please consider how you would feel if someone verbally disrespects a strongly
held belief of yours or a dear loved one. Would you feel confident in the care that person is providing? As
professionals, we are not responsible to take on the choices or outcomes from decisions patients make. Our role
is to provide information for informed decision-making. In order to provide very good care, we need to keep
the lines of communication open with our patients and families. We will not be able to do this if patients and/or

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families perceive a lack of autonomous respect on our part. Knowledge and information can promote
respectful cooperation by caregivers. Figure 3.4 gives examples of ineffective and effective communication.

Figure 3.4
Effective Communication Ineffective Communication
• I need to verify you refuse blood • You refuse blood, so you want to die.
transfusion in your care. • If you don’t take blood, you’ll die.
• Does your refusal of blood transfusion • Jehovah’s Witnesses have a suicide wish.
include a life-threatening situation? • All you people are crazy.
• Your blood counts are __, normally we • I can’t believe you would rather die than
would transfuse at this level however, take a blood transfusion and save your life.
we are doing XYZ to treat your anemia

Role of Blood Management Nurses/Coordinator


The role of the nurse coordinator in a blood management program is comprehensive. Coordinator job
descriptions vary from program to program to fit the needs of the population they are serving. In areas of the
country where nurses are in extreme demand, non-nursing personnel may be used to fill this position. A main
attribute of a formalized program is it consists of policies, procedures, and guidelines to prevent, treat, and
proactively manage anemia. The preferred standard for a Coordinator is a registered nurse. Many programs rely
on the skills of one coordinator to manage the needs of the program 24/7. Other programs have added staff
based on volume and program activities. The nurse coordinator is responsible for managing the daily functions
of the program. For facilities that do not have a formalized blood management program, staff nurses can assume
the responsibilities applicable to their position. He/she is accountable for all of the following:

Formalized Program Coordinator: General Staff Nurse:


• Patient rounds • Identify blood management
• Education (patients, families, healthcare team) patients
• General office duties • Patient education of blood
• Assists in program marketing management strategies
• Recruiting and organizing program volunteers • Keeping current with research
• Organizing educational programs and presentations • Promoting/advocating blood
• Keeping current with research management treatment
• Outpatient treatment and education • Documentation
• Data collection and input
The participation of the coordinator or staff nurse varies depending on the level of blood management that the
patient elects. In the case of patients refusing blood transfusion, the coordinator/nurse will ensure that all
appropriate forms are completed. A release of liability (ROL) or legal hospital form for blood refusal (Figure
2.1) should be read, understood, signed and placed under the appropriate tab in the chart if available. The
document protects the hospital, doctors, nurses and all other healthcare personnel from being held liable in the
event that a negative outcome occurs due to the refusal of blood (Vernon, Pfeifer 1997)20. Advance directives
also fall under this umbrella. For the majority of no blood patients, a durable power of attorney for healthcare is
the document of choice. It should be completed prior to admission to the hospital. If it is not completed, the
program coordinator can assist in providing information, explaining all of the medical terms and how his/her

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decisions will impact the medical care he/she will receive. For a staff nurse, empowering patients to complete
this document and obtaining assistance in understanding the form is recommended. For Jehovah’s Witness
patients, the nurse can offer to contact someone from their community to assist them with the form. The
coordinator is available to explain and discuss blood management options with patients and their families. The
objective is for the coordinator to facilitate informed decision-making on the part of the patient (Wolfe 2000)19.
In facilities that do not have a coordinator, the staff nurse should assume this role.
There may be certain procedures or medications that are not acceptable for some Jehovah’s Witnesses, but may
be acceptable to others (Wolfe 2000)19. The coordinator, nurse, and physician are responsible for ascertaining
which medications, such as minor blood fractions and procedures (which may include cell saver and
hemodilution) are acceptable for each individual person. The coordinator is responsible for explaining blood
management methods to ensure that the patient feels comfortable in making healthcare decisions. The following
is a brief list of blood management modalities that may need to be explained:
• Advanced cell saver system (This system re-circulates blood that could have been lost during
surgery.)
• Surgical instruments to minimize bleeding
• Anesthesia techniques
• Special glues and adhesives to minimize bleeding
• Meticulous surgical techniques
• Non-invasive oxygen monitor
• Medications
(Vernon, Pfeifer 2003)20

Nurse/Coordinator-Patient Refusing Blood


An important part of a coordinator’s daily routine is hospital patient rounds. For the staff nurse establishing a
rapport with the patients in your care is a key element. Patients are assessed prior to going on rounds to identify
areas that may need more attention. For example, is it really necessary to draw a daily CBC if a patient is not
actively bleeding and is refusing to accept blood transfusions? Patients are also assessed to determine their
commitment to avoid blood, to ascertain if family members are aware of their healthcare wishes and to
determine the support structure for the patient. Ascertaining where family members stand in regard to a
patient’s blood refusal allows caregivers to be alert for potential problem. Educational needs are evaluated.
Each patient has a different need, and it rests with the coordinator or nurse to confirm that patients are or have
been educated regarding how their medical directives will affect their healthcare (Vernon, Pfeifer 1997)20. All
barriers need to be handled efficiently.

The program coordinator is available 24 hours a day, 7 days a week to hospital staff, patients, and family
members for emergency questions, concerns or situations. In a blood management program, coordinators need
to be visible to healthcare personnel. This is also accomplished while on patient rounds. Usually several
members of the healthcare team are directly involved in a patient’s care and every member needs to be aware of
who the coordinators are and how to access the services available (Vernon, Pfeifer 2003)20. Patient rounds
provide a forum to communicate with members of the team, but it is also a good time for questions, concerns or
problems to be related either to or from the coordinator. In this instance the coordinator is a liaison between the
patient and the healthcare team. The coordinator has an established rapport with the patient and their family
that enables them to relate family dynamics, which may help or impede the recovery process. After patient
rounds, a treatment plan is devised focusing on blood management needs, education, advance directives and
informed consent. This is done as a guide to make sure the patient receives all the appropriate blood

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conservation techniques. This plan is discussed with the patient, if medically appropriate. The coordinator
documents in the nurses notes of the medical record. Rounds are an important component in discharge planning
as well.

For the staff nurse, maintaining open communication with the patient and the healthcare team is important.
The nurse acts as a conduit in advocating and ensuring the patient’s wishes are upheld. Therefore, it is essential
to investigate acceptable blood management strategies for each patient refusing blood transfusion. It is also the
staff nurse’s responsibility to proactively recommend blood management treatment to physicians in order to
prevent a moderate to severe anemia. Close assessment for bleeding or risk of anemia is a valuable skill.
Monitoring lab values aids in managing the blood management needs of patients.

Bloodless, level I or category I, no blood- refusal of blood transfusions in all situations, including life or death
or has a strong desire to avoid blood transfusion.

This is the most aggressive option of blood management. If a patient wants to avoid blood transfusion, but
would accept it in a life-threatening situation, some programs may classify them in this category. By permitting
individuals not adamant in blood refusal, the program is providing the most aggressive of blood management
treatments. The coordinator or staff nurse will explain the options to such a patient and ascertain their consent
in listing them in this level. The patient’s wishes regarding blood transfusion must be documented in the
medical record and communicated to the healthcare team. A release of liability (ROL) may or may not be
signed if the patient is not adamant in their refusal. Formalized programs may have a safe guard in place that
will prevent blood bank orders from being processed. In this case, the healthcare team must be aware of the
safeguard measures in place for “no blood” patients. If a situation occurs where a bloodless patient has
accepted a transfusion, the safety measures would need to be disengaged according to hospital policy. If the
patient has signed an ROL, they will need to rebuke their refusal at the bottom of the ROL form or as
established by the facility (See figure 2.1.)

Traditionally the majority of bloodless patients have been Jehovah’s Witnesses. However, this trend is
changing as many programs are servicing more individuals that are not Jehovah’s Witnesses. Today healthcare
consumers are concerned with the health risks of blood transfusion. Some chronically ill patients refuse blood
transfusion as a measure not to sustain life. Due to their adamant stand, we will give attention to Jehovah’s
Witnesses:

• Jehovah’s Witness- refuse for bible-based reasons. Leviticus 7:26, 27; 17:10-14; Acts 15: 28, 29.
• All adult baptized Jehovah’s Witnesses have the opportunity to complete an advanced directive
stating that they refuse blood transfusions provided by their religious organization. Non –baptized
person’s can complete a generic living will that includes a section refusing blood.
• Once a year an Advanced Directive for Healthcare is reviewed from the Watchtower Bible & Tract
Society. Forms are available at a congregation of Jehovah’s Witnesses.
• They want good medical care without use of blood.
• They refuse whole blood and four primary components: packed red cells, plasma, platelets, and
white cells.
• They may be willing to accept procedures involving the use of own blood.
• They may be willing to accept minor blood fractions based on their personal decision such as
albumin, cryoprecipitate, interferons, and interleukins. (Figure 3.5)
• They will not accept pre-donated- (stored) blood of their own.

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• They are willing to accept alternatives.
• No blood bank orders.
• All staff should be made aware of patient’s refusal of blood.
• Followed by coordinators while in the hospital.
Referenced: http://www.watchtower.org

Nurse/Coordinator-Blood Avoidance
The coordinator’s role for patient’s wishing to avoid blood is different. The coordinator or staff nurse evaluates
patients in order to incorporate blood management techniques and therapies. This is achieved by screening all
anemic patients with a hemoglobin at or below a predetermine level for example 10 gm/dl. Recommendations
can be made in the chart and/or to the physician of anemic patients that may benefit from blood management.
While on patient rounds or during patient assessments, education is given to patients that are placed on a blood
management protocol to keep him/her informed of what is being done to avoid unnecessary blood transfusions.
Patients are closely monitored to assess how they respond to the treatment and if any adjustments need to be
made (Wolfe 2000)19.

The coordinator is also responsible for patients that are referred to an outpatient clinic for anemia treatment.
Nurses working in this type of area can assume the role of coordinator. Patients may be referred for treatment
prior to elective surgery to increase red cell mass. This is done so the patient will have a higher hemoglobin
level prior to surgery. The desired result is to avoid a blood transfusion because the patient will not become so
anemic that a transfusion is necessary. The doctor must be kept informed of the patient’s progress, and
recommendations are made if extra treatments are needed to prepare the patient for surgery or to treat existing
anemia.

Conservation, level II or category II, blood avoidance- blood transfusion is permissible in their treatment.
Some programs present this as a voluntary option for patients. Others may classify all patients not electing the
previous option into this category.

• Not used at most healthcare facilities


• Avoidance usually because of risk of disease transmission or factors that affect immune system
• Low blood supply, high demand
• Low volume laboratory tubes used universally
• May include formalized program screening

Nurse/Coordinator- Blood Management Facility:


The process is started when the patient is admitted or has pre-admission testing for surgery. The patient is
asked if they will accept blood as part of their treatment. If the patient says “no”, they will be listed as
bloodless, level I or category I. If the patient answers “yes”, they will be listed as conservation, level II or
category II. For the “no blood” patient, many programs have a safeguard in place through computer order entry
that prevents blood-banking orders from being processed. Patients are also asked if he or she has an advanced
directive. For a “no blood” patient this form is very important because it allows everyone involved in his or her
care to know the patient’s belief to refuse blood. Therefore, if the patient becomes unconscious or unable to
speak, this legal document speaks for them. In the case of a Jehovah’s Witness patient, the advance directive
will give information if minor blood fractions and reinfusion techniques are acceptable (Figure 3.1.)
Once a “no blood” patient is admitted, the patient’s transfusion status is made known to all staff, using a “no
blood” wristband, “no blood” placards over bed, and a “no blood” label on the chart. Identification materials

11
are supplied to the admitting offices and to each nursing unit. If the patient has not already done so, the nurse or
coordinator ensures a release of liability (ROL) is signed and included in the patient’s chart. A question may
appear on the nurses’ health history regarding acceptance or denial of blood transfusions. This provides an
opportunity for the nurse to validate the patients’ transfusion status. The nurse should ask the patient or next of
kin if blood transfusion is a permissible treatment option. The admitting nurse also needs to assess the patient
for signs of anemia (see nursing care plan for the anemic patient supplementary material). In most formal
programs a referral can be made to the blood management department. Patients coming in for surgery may
have already received anemia management pre-operatively. Pre-op blood management begins at least three
weeks prior to surgery (Figure 3.3.)

Pre-op Blood Management

At least 3 weeks prior to surgery:


• Hemoglobin < 13 gm/dl
Figure 3.3
• Iron sat <30%
• Procrit and IV iron, folic, vitamin C
• Response monitored and faxed to physician

St. Vincent Charity Hospital, Cleveland, OH

Universal Blood Management Strategies13,17:


• Avoid unnecessary lab draws; use add-on-testing when appropriate (This means using blood
that may be available from previous blood draws.)
• Limit blood draws to once or twice a day; minimize testing to treatable values
• Screen for anemia before major surgical procedures
• Pre-treat surgical patients with hemoglobin <13 with Procrit, IV iron as indicated
• Use intra-operative conservation techniques
• Proactively treat post-operative anemia
• Lower or eliminate numerical transfusion triggers

According to Proehlman & Pearl (2002)14, iatrogenic blood loss can add up to be significant. Every drop of
blood is precious to a moderately anemic patient. Therefore, the physician should order only necessary lab
draws for treatable conditions. A CBC drawn every day or Q 8 hours when active bleeding is not occurring
would be considered unnecessary. Utilizing point of care testing also conserves blood lost for laboratory testing
(Wolfe 2002)19.
There are several strategies that can be used to minimize blood loss in the operating room. Anesthesia can use
hypothermic conditions to slow down blood loss. The surgeon should be meticulous in technique used during
surgery. Perfusion should be used when indicated. The basic perfusion methods would be:
• Intraoperative cell savage
• Hemodilution
• Platelet sequestration

A CBC and/or H&H can be drawn after surgery if there has been a significant blood loss. This will allow the
physician to assess for anemia and to have treatment started immediately. The usual treatment includes IV iron

12
sucrose, Procrit injections, Vitamin C and Folic acid. For patients who will accept a blood transfusion, the
physician could consider lowering the transfusion trigger or basing transfusion on specific clinical criteria.
Transfusion triggers can vary between 7.0 g/dl and 10.0g/dl. Paul Hebert, MD, (1999)10 demonstrated that a
conservative blood transfusion approach to anemia could be well tolerated. If the patient is not exhibiting
symptoms such as extreme fatigue, shortness of breath, or tachycardia, the physician may want to lower
transfusion trigger between 6.0 g/dl – 8.0g/dl depending on co-morbidities. The physician should assess each
patient’s objective and subjective data. Nurses can and do have an impact on blood management. Look for
opportunities to prevent or suggest proactive measures for anemia (Figure 3.6) (Wolfe 2000)19.

10 Steps to Blood Management

• Determine anemia risk (low, medium, high)


• Transfusion trigger- Hgb. 6-7 gm/dl
• Set a transfusion target if transfusion therapy is
initiated.
• Evaluate and treat iron deficiency- IV iron
preferred Figure 3.6
• Pre-op treatment 4 weeks prior to surgery
• Intra-op blood conservation
• Limit lab draws
• Use in-patient and outpatient anemia orders if
available
• Refer to hospital transfusion criteria
• Referral to formal program is available

Summary
The use of blood has developed over the ages. During the past 50 or more years, medical science has
discovered risks in blood use and has made significant advances in alternatives. Regardless of our individual
choice related to blood transfusion treatment, we need to exercise discernment when caring for others whose
belief system differs from our own. As professionals we need to maintain effective communication and become
knowledgeable regarding options to blood transfusion and anemia management. A formalized blood
management program is a valuable asset but is not available to many healthcare professionals. Program
coordinators must assist in case managing “no blood” patients and can be instrumental in diffusing difficult
situations. They provide information and education thus assisting the physician and nursing staff in ensuring
informed consent for blood management strategies. The role of the program coordinator does not diminish the
importance of bedside nurses who are an important part of the healthcare team and are instrumental in the
successful treatment of patients utilizing blood management. For the majority of nurses, becoming educated
and empowered to promote this approach at their healthcare facility will only benefit the patients in their care.
Staff nurses have a unique opportunity to positively impact patient care through anemia management. Are you
up to the challenge?

13
References

1. American Association for Blood Banking, Facts about Blood and Blood Products, retrieved 10/17/05,
http://www.aabb.org/Content/About_Blood/Facts_About_Blood_and_Blood_Banking/aabb_faqs.htm

2. Blumberg N., (July 1997), Allogeneic Transfusion & Infection: Economic & Clinical Implications,
Seminars in Hematology, 34(3) (Suppl 2): 34-40

3. Bull WT. (1884), On the Intravenous Injection of Saline as a Substitute for the Transfusion of Blood,
Medical Record; 25:6

4. Farmer S., Webb D., (2000), Your Body, Your Choice, Media Masters Pte Ltd., Singapore

5. Greenwalt TJ. (1997), A Short History of Transfusion Medicine, Transfusion; 37:5

6. Landsteiner K. (1901) Uber Agglutionationscheinungen Normal Menchen Bluts, Wein Klinische


Wochenschrift; 49:1040.

7. Lower R., (1666), The method observed in transfusing the blood out of one animal into another,
Philosophical Transactions Royal Society London; 1:353.

8. Lower R., (1667), An Account of the Experiment Practiced Upon a Man in London, Philosophical
Transactions Royal Society London; 2:557.

9. Harvey W., (1928), Exercitato Anatomica Demortu Cordis et Sanguinis in Anamalibus; Translated by
Leake, CD. Springfield, Illinois: CC Thomas.

9. Hebert P., Wells G., Blajchman M., Marshall J, Martin C., Pagliarello G., Tweeddale M., Schweitzer I.,
Yetsir E., and the Transfusion Requirements in Critical Care Investigators for the Canadian Critical Care
Trials Group, (1999). A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements
Critical Care, New England Journal of Medicine, February 11, Vol 340 No 6 pp 409-417

11. Isbister J., What is Blood Management, SABM Symposium 2005, September 16-18, 2005

12. Malof MFR., (1954), History of Blood Transfusion, Journal of History Medicine; 9:59.

13. Pahlman A., Carven J., Lindsay K., (December 2001) Conserving Blood in the Intensive Care Unit,
Critical Care Nurse /Supplement

14. Pearl, Ronald G., Pohlman, A. (December 2002) Understanding and Managing Anemia in Critically Ill
Patients, Critical Care Nurse/ Supplement

15. Schmidt PJ. (1968), Transfusion in America in the eighteenth and nineteenth century. New England
Journal of Medicine, 279:1319

14
16. Spence R., (2000), A Brief History of Bloodless Medicine and Surgery, Network for Advancement of
Transfusion Alternatives, retrieved 10/1/05, http://www.nataonline.com/Art.php3?NumArticle=71

17. Trovarelli T., Kahn B., Vernon S., (November 1998), Transfusion Free Surgery is a Treatment Plan for
All Patients, AORN Journal

18. Wren C., (1665), An Account of the Rise and Attempts to a Way to Conveigh Liquors Immediately into the
Mass of Blood, Philosophical Transactions Royal Society London, 1:128

19. Wolfe S., (May 2000), Are You Ready For Bloodless Medicine, RN, www.Rnweb.com

20. Vernon, S., Pfiefer G., (December 2003), Blood Management Strategies for Critical Care Patients,
Critical Care Nurse

21. Zauder H., Stehling L., (2000) History and Development of Transfusion Medicine, Network for
Advancement of Transfusion Alternatives, retrieved 1/1/05,
http://www.nataonline.com/Art.php3?NumArticle=31

15
Blood Management, Past & Present
Registration Form

Name (please print):_________________________________________________

Mailing Address:___________________________________________________
(street)

___________________________________________________
(City, State, Zip Code)

Telephone: _(______)______________________________________________

Email address: _____________________________________________________

Please complete the checklist below and return all forms to:

St. Vincent Charity Hospital


Karen Komondor, RN
Nursing Education Department
2351 East 22nd Street 301C
Cleveland, OH 44115.
or by fax to 216-694-4664

o Post activity evaluation


o Post test

16
Post-Test

Instructions: Please answer the following questions after reading the study material. In order to
receive CEU credits, return this post-test along with the Program Evaluation form.

1. The first human transfusions included which of the following:

a. Animal to human
b. Direct human to human
c. Milk as a transfusion fluid
d. All of the above

2. The most recent update in terminology for eliminating or reducing transfusion is;

a. Bloodless Medicine and Surgery (BMS)


b. Transfusion-free Medicine
c. Blood Management
d. Blood Conservation

3. The role of a program coordinator does not include:

a. Arranging for nursing home placement or home health care


b. Assessment and planning of anemia interventions
c. Ensuring all legal documents and patient identification are in place
d. Crisis intervention

4. What differences in services do program coordinators provide to “Bloodless” versus “Conservation”


patients?

a. All bloodless patients are assessed opposed to conservation, which is triggered, by hemoglobin
or referral.
b. Both groups receive the same services.
c. The program nurses more closely monitor conservation patients.
d. Nurse coordinator’s provide services only to Jehovah’s Witnesses

5. What is the responsibility of a staff nurse regarding the admission of a bloodless patient?

a. Call the program coordinators to determine transfusion status.


b. Assess transfusion status and indicate on nursing admission,; place no blood identification,;
signed ROL on chart.
c. Monitor patient for anemia, initiate anemia care plan, advocate for blood management strategies.
d. B & C

17
6. The following are a matter of individual choice for Jehovah’s Witnesses:

a. Plasma
b. Red cells
c. Albumin and albumin containing medications
d. Four primary components

7. Below are all the steps to blood management except:

a. Minimize lab draws


b. Pre-op treatment
c. Transfusion trigger of 9.0 gm/dl
d. Treat iron deficiency

8. What is the impact of Transfusion Related ImmunoModulation (TRIM):

a. Has no impact on mortality


b. Increases infection risk and cancer reoccurrence
c. Costly to patients and the healthcare system
d. B&C

9. What is the goal of effective communication?

a. Avoid misunderstandings
b. Improve patient satisfaction
c. Keep the lines of communication open
d. Ensure informed decision-making
e. All of the above

10. What two organizations are dedicated to Blood Management?

a. AABB
b. ARC
c. SABM
d. NATA
e. C&D

18
ST. VINCENT CHARITY HOSPITAL
DIVISION OF NURSING † NURSING EDUCATION
EVALUATION
TITLE: Blood Management Past & Present

DATE: ___________________________________

Did the offering meet the following objectives? YES NO


Describe the evolution of transfusion use through the ages.
Explain the progression from bloodless to blood management.

Summarize the transfusion options available through BMS programs.


Discuss the role of BMS coordinators and the healthcare team in blood
management.
Were the program objectives related to the purpose and goals of the program?
Was the program content relevant to the program objectives?
Did the program meet your personal objectives?

***** Please evaluate the following using the rating scale provided below. *****
1=Excellent 2=Good 3=Average 4= Poor 5= Not Applicable

1 2 3 4 5

Topic Selection

Practical Value

Program Administration

Handouts

19
**RATE THE OVERALL OFFERING USING THE RATING SCALE PROVIDED BELOW.**
EXCELLENT GOOD AVERAGE POOR

WHICH TOPIC WAS THE MOST VALUABLE TO YOU?


__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

WHICH TOPICS, IF ANY, DO YOU FEEL SHOULD BE:


ADDED:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________

DELETED:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

COMMENTS:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

20
Supplementary
Information

Blood Management Past & Present

21
TRANSFUSION STATUS:

OPTION 1: BLOODLESS OPTION 2: CONSERVATION:

Who should register for this option?


Who should register for this option?
• Persons who are not opposed to blood
• Strongly opposed to the use of blood
transfusion therapy
transfusion
• All patients who do not elect the bloodless
• Refuse transfusion under ALL circumstances
option
• Anyone who wants to avoid blood
transfusion
How do caregivers know I am “bloodless?

• Wristband indicating “no blood” status


What services will I receive?
• Sticker on your chart
• Sign over your bed space • The majority of your blood conservation
treatment will be dependent on your doctor.
• Blood Conservation nurses screen anemic
hospital patients for opportunities to include
What services will I receive?
blood conservation techniques and
treatments in their care.
• Aggressive blood conservation treatment
appropriate to your individual needs
• If requested by you or your family, you can
receive further information.
• Blood Conservation registered nurses will
assess your needs for blood conservation
treatment and coordinate your treatment in the
hospital and as an outpatient if needed. For more information:
• Blood Conservation registered nurses will Contact the Regional Center for Blood Conservation at
provide you and your family with information 216-363-3353.
regarding your treatment.

Additional information:
• A system safeguard is in place for Bloodless
patients that prevent ALL transfusion related
services from being processed.
• You can change options at any time during
your hospitalization.
• The choice of accepting or refusing blood
transfusion incurs risks and benefits. Please
discuss these with your doctor.

Figure 2.1

22
RELEASE OF LIABILITY

You are hereby notified and instructed that I absolutely, unequivocally and resolutely refuse homologous blood (another person’s
blood) and stored autologous blood (my own stored blood) under any and all circumstances, no matter what my medical condition.
This means no whole blood, no red cells, no white cells, no platelets, and no blood plasma no matter what the consequences, even if
my physician and other health-care providers involved in my care believe that only blood transfusion therapy will preserve my life or
health.

I accept and request alternative non-blood medical management to build up or conserve my own blood, to avoid or minimize blood
loss, to replace lost circulatory volume, or to stop bleeding.

I am and have been made aware of the risks and consequences that may result to my health or life from my refusal to receive blood. I
fully understand and appreciate these risks and consequences and have made my decision to refuse blood voluntarily of my own free
will, without influence or duress from any third party.

I hereby release (Hospital name), its successors, assigns, members, officers, directors, partners, affiliates, representatives,
agents, and employees from any and all damages, injuries, costs, losses, claims, expenses, liabilities, and demands of any kind
or description whatsoever, known or not known or anticipated, that I may have, now or any time in the future, arising out of
or related in any way to my voluntary refusal of blood. This release of liability shall be binding on my heirs, executors, agents,
or anyone claiming through me or on my behalf.

_________________________________ __________________________
(Patient or Legal Guardian Signature) (Date)

_________________________________________________
(Witness)

This form applies to individuals over the legal age of 18, or those who have been declared emancipated or mature minor
I hereby reverse the above decision and will accept blood transfusion therapy. I agree to accept the following: (please initial)
______All blood products. ______Red blood cells

_______Plasma ______Platelets

______________________________ _____________ ____________


(Patient or Legal Guardian Signature) (Date) (Time)

_____________________________________________ ______________________________________________
(Witness) (Witness)

Form No. 120235


Revised 3/02
3/02

23
Nursing Standards of Care and Diagnoses for Anemia

Definition:
Anemia is a hemotalogic condition in which there is an inadequate number of circulating cells or decreased
quality or quantity of hemoglobin, reflecting a disease state or altered body function rather than a disease per se.

Causes:
1. Insufficient production or defective synthesis of erythrocytes.
2. Increased destruction and/or loss of erythrocytes that exceeds RBC production.

Focused Assessments:

Physical Findings
1. General Appearance
Weakness
Fatigue
General malaise
Shortness of breath
Dryness of skin
Pallor of skin and mucous membranes

2. Neurological
Peripheral numbness
Paresthesia
Ataxia
Poor coordination
Restlessness
Confusion
Headache

3. Cardiovascular
Tachycardia
Palpitations
Dyspnea
Dizziness
Orthopnea
Exertional dyspnea

4. Pulmonary
Shortness of breath
Dyspnea on exertion
Tachypnea: rapid and deep at onset, shallow later on
5. Integumentary

24
Dryness of skin and hair

6. Gastrointesinal
Atrophic glossitis
Heartburn
Anorexia
Nausea and vomiting
Chronic diarrhea
Weight loss

7. Psycho-Social Problems
Anxiety
Fear of death
Stress
Fear of unknown

8. Potential complications
CHF evidenced by cardiomegaly, hepatomegaly or peripheral edema (especially ankles)
Infection
Renal failure
Hemorrhage

Laboratory Diagnostic Studies


EKG
CXR – pulse oximetry on admission
CBC
Iron Profile Study
SMA 18
Medical Management
Medications
Anemia Protocols (see Physician Order Sheet)
Vitamins: folic acid
B12
C
Blood transfusion if patient consents
Fluid/Nutrition
Diet high in protein and iron

Oral and parenteral fluids to maintain adequate tissue hydration and renal perfusion
Diet/enteral therapy
Oxygen Treatment – Supplemental Oxygen per pulmonary guidelines
Bedrest
Telemetry if indicated
Surgery to stop bleeding
Heparin Lock/Venous access

25
Nursing Diagnosis #1
Anxiety R/T hospitalization; fear of unknown, pain, diagnosis and treatment, post-hospital care.

Interventions:
A. Assess client for S/S of fear and anxiety every eight (8) hours and PRN
B. Encourage verbalization of feelings and concerns
C. Implement measures to reduce fear and anxiety and relieve pain
1. Provide emotional supports
2. Orient to surroundings, equipment and hospital routines
3. Explain treatments and procedures in simple terms to promote understanding
4. Provide quiet, calm environment
5. Medicate for pain
6. Maintain contact with family/significant other
7. Consult pastoral care and/or CBMS coordinator for spiritual care as part of the healing process

Expected Outcomes:
Client will experience a reduction in fear, anxiety and pain, as evidenced by:
A. Relaxed facial expression and body movements
B. Verbalization of feeling less anxious or fearful
C. Verbalization of an understanding of hospital routines, diagnosis, diagnostic procedures and treatments
D. Relief of pain
E. Ability to rest

Nursing Diagnosis #2
Sensory/perceptual alterations R/T tissue hypoxia of the nervous system

Interventions:
A. Provide a safe environment
B. Assist patient with ambulation and position changes
C. Maintain warm environment
D. Direct patient to call for assistance with ambulation PRN

Expected Outcomes:
Patient can change position and ambulate without dizziness or damage to limbs; has no complaints of
headache or sensitivity to cold; patient seems relaxed and can concentrate on conversations and instructions

Nursing Diagnosis #3
Impaired gas exchange: fatigue and weakness R/T impaired oxygen-carrying capacity of blood, with
possible compensatory increased cardiac output.

Interventions:
A. Help patient plan periods of activity balanced by periods of uninterrupted rest
B. Monitor pulse, blood pressure and respirations q80
C. Assess response to activity
D. Increase activities patient performs in small increments until tolerance level is reached

26
Expected Outcomes:
Patient will increase activity level without evidence of increased pulse rate, lowered blood pressure, chest
pain or shortness of breath

Nursing Diagnosis #4
Alteration in nutrition: less than body requirements R/T weakness, fatigue, glossitis, stomatitis and/or
anorexia

Interventions:
A. Maintain balanced diet as ordered, high in protein and iron
B. Provide six small feedings if easily fatigued
C. Administer vitamins if ordered
D. Avoid constipation: increase fluids and provide bulk foods
E. Administer oral hygiene before and after meals; use soft-bristled toothbrush and dilute mouth rinse
F. Administer iron therapy as ordered
ORAL: use straw to prevent staining teeth if liquid preparation is used
IV: administer test dose as ordered; give cautiously. Remain with patient during test dose.
Observe for symptoms of shock.
G. Weigh patient daily

Expected Outcomes:
Patient will maintain and/or return to weight indicated for age, height and body. Build within approximate
time frame.

Nursing Diagnosis #5
Knowledge deficit regarding disease process, medicine, nutrition and activities permitted

Interventions:
A. Discuss medications: name, dosage, schedule, purpose, side-effects to report
(nausea, vomiting, diarrhea or constipation)
B. Explain need to continue iron therapy even though feeling well
C. Discuss color of stools expected and explain need to avoid constipation
D. Explain need to avoid foods that interact with iron such as milk or antacids
E. Teach patients principles of energy conservation. Consult O.T. as ordered

Expected Outcomes:
Patient will demonstrate knowledge of disease process, compliance with medication routine, and awareness
of proper nutrition and activity

Reference:
Tucker, S.M., Canobbio, M.M., Paquette, E.V. and Wells, M.G. (1992), Patient Care Standards, Nursing
Process, Diagnosis, and Outcome, St. Louis, Mosby 04/96

27
28
Example of DPA for Jehovah’s
Witnesses

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