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Blood Therapy, TPN Blood Banking

Blood banking has expanded greatly over the past 20 years. It is big business and nursing plays an important role, that of screening donors and performing the phlebotomy procedure. The nurse interviews each potential donor to elicit information about the donors health. This is to protect both the donor and the recipient.

Subjects To Be Covered That Protect The Donor and Recipient

Weight of donor: Blood volume is proportional to body weight. Persons weighing 110 lbs. or more may donate one unit of blood with no ill effects. Date since last donation: 56 day span required to allow HGB to return to normal. Hospitalizations during the last year: To uncover any reason why he should not donate. why State of present health: Check for respiratory infection, if so, reject in order to prevent recipient from organism. so,

Medications
Current medications or one's recently taken: Underlying condition is most important. condition Antibiotics, sulfonamide and antifungals: donors must be off short acting antibiotics (ORAL, SULFA, ANTIFUNGALS) short FOR 48 hrs. IM antibiotics for 4 hrs. Those taking low dose antibiotics such as for acne are acceptable. antibiotics Anticoagulants: Donor is rejected because of possible prolonged bleeding after phlebotomy and because person has prolonged underlying health problem. Anticoagulant effect does not persist in the donated blood. persist

Medications
Antihypertensives: may be accepted if BP within acceptable limits. limits. Antiparkinsonian drugs: donor deferred if he has Parkinsons. If taking drug to counteract the side effects of major If tranquilizer the donor may be accepted. Digitalis preparation: deferred due to underlying health problem. problem. Radioisotopes: deferred if donor has cancer. May be accepted if radio. was for diagnostic purposes. if

Medications
Steroids: rejected unless only for short period, as for poison ivy etc. Tranquilizers: deferred if taking MAO inhibitors because of hypotensive reactions. Other tranquilizers may donate. Vasodilators: rejected due to underlying disease, not itself.

Disease States or Conditions

Presence of heart disease: donating could cause untoward reaction. Evaluate individual, ie, undiagnosed chest pain, reaction. deferred, previous cardiac surgery for congenital defect might not be deferred. not

Shortness of breath: evaluated by donors physician, if emphysema with no heart damage, may donate. emphysema TB: active, reject. Positive skin test with no x-ray evidence, ok. x-

Disease States or Conditions

Renal disease: chronic kidney condition deferred, may weaken them. History of self limited single them. attacks of glomerulonephritis, okay. glomerulonephritis, Stomach or intestinal ulcers: any recent bleeding deferred. Bleeding disorder: deferred.

Disease States or Conditions

Diabetes: if insulin dependent, reject, donating may lead to chemical imbalance. Oral hypoglycemic chemical may donate. Fainting: blood loss may precipitate fainting. Donation may uncover latent epilepsy. Eating 4-6 hrs. uncover 4prior may alleviate. Seizures: Blood donation may precipitate seizures so they are rejected. rejected.

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Disease States or Conditions

Previous blood test for hepatitis: antigen often found in healthy people, they are rejected. Hepatitis exposure. rejected for 6 mos. Hx of use of self-injected drug abuse: rejected. selfRecent tatoo within past six mos. rejected due to possibility of hepatitis. Hx of Malaria. deferred for 3 yrs.

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Immunizations
Immunizations or vaccinations over past year. acceptable if donor received toxoids and killed viral or a bacterial vaccine and is symptom free and afebrile. Immunization for polio, rubeola, mumps or yellow fever. rubeola, Requires 2 week waiting period because they contain attenuated living organisms. living Rubella 2 mos. Rabies 1 yr.

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Other Topics to Consider

Tooth extraction or oral surgery in past 72 hours. Chance of infection. Skin disease at venipuncture site. Exposure to infectious disease. (unless immune through previous illness or immunization) such as mumps, measles, chicken pox in previous 3 as weeks. Cancer.

Persons with a malignancy are deferred because the mechanism for transmission is not completely understood. for

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General Information
Ages 17-65. 17May donate and over 65 with Dr. permission. BP. 90/50-180/100 with pulse pressure not greater than 80. 90/50Pulse. 50-100 with no irregularities. If less than 60 see if jogger. 50Temp WNL. HGB. At least 12.5 for females, 13.5 for males, HCT 38 and 41 respectively. respectively.

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Processing Blood
Procedures will vary somewhat, but there are certain standards set by FDA set 1. Blood ABO and rh grouping (know blood groups) 2. T cell lymphotropic virus 3. STS (serologic test for syphilis) 4. Hepatitis B and C 5. HIV

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Blood must have anticoagulant as well as RBC preservative. For anticoagulation heparin or citrate may be used. Heparin does not contain a preservative. Heparinized RBCs can be used for only 48 hrs. Citrate acts as an anticoagulant by binding the ionized calcium. Blood cannot clot in the absence of free ionized calcium. Preserved blood can be stored for 21, 35, or 42 days depending upon the type of preservative. upon Rare types, may be frozen and stored for years.

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Nursing Knowledge
Nurses must not only be familiar with the mechanical aspects of blood administration, but also have knowledge of other blood products. A unit of whole blood may be given to one patient or the unit may be reduced to it's various products and used in the may treatment of several patients.

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Blood Components
Blood components are the basic elements of blood obtained by mechanical separation. mechanical Components of whole blood. RBCs, plasma, platelets, and cryoprecipitate (rich in antihemophilic factor and fibrinogen). RBCs, A bag of RBCs and plasma of blood is about 450 ml. Whole blood expands intravascular volume.

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Breaking Down a Unit of Whole Blood

Spinning separates the RBCs and plasma.

The plasma is then expressed into another bag. Packed RBCs can be given to increase tissue oxygenation to the same degree as infusing a whole unit of same blood. The volume of a unit of RBCs is about 275 ml.
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Which Patients Require Whole Blood

Patients most likely to receive packed RBCs are those who need increased tissue oxygenation, but who don't need expanded intravascular volume. CHF. Elderly. Severe anemia. Anyone who would not tolerate a shift in blood volume.

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Fresh Frozen Plasma and Platelets

Fresh plasma that is less tan 6 hrs. old can be frozen and preserved for 1 yr. preserved Must be used right away as clotting proteins deteriorate rapidly. rapidly. Plasma that is less than 4 hrs. old can be spun again for platelet collection. platelet Platelets are administered to treat or prevent bleeding.

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Platelets
Platelets are kept at room temperature and may be stored up to 5 days. They can transmit infectious diseases and cause allergic and febrile reactions. febrile Platelets should be transfused as rapidly as the patient can tolerate, tolerate, Always through a filter. Cryoprecipitate should also be used with a filter. Plasma and cryoprecipitate do not contain many RBCs. Do not require compatibility testing.

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Blood Derivatives
Blood derivatives are products separated from plasma through a chemical process and include: chemical Albumin, plasma protein fraction, and gamma globulin. Albumin and plasma protein fraction are usually given for rapid expansion of blood volume and severe protein loss. They are stable at room temperature. Gamma globulin. Antibody containing part of plasma and is given to patients who have a deficiency or to prevent diseases such as measles and infectious hepatitis. Blood derivatives cannot transmit infectious diseases.

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Autologous Transfusions
Patient's undergoing elective surgery may donate their own blood. blood. Eliminates risk of infectious and immunologic complications. The same pre-transfusions precautions should be taken to decrease the possibilities if the wrong unit of blood is given. prepossibilities

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Obtaining Blood From the Blood Bank

Do not pick blood up until you will have time to hand it . This is too prevent risk of bacterial growth and maintain therapeutic effectiveness of blood components.

A unit blood can only remain in the unit for 30 min. before it is hung. is If it cannot be hung within that time, take it back to the blood bank. Make sure IV is started before even picking blood up. Pick up only one unit at a time. Blood that has exceeded 50 degrees F. cant be rebanked. rebanked.

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Administering Blood
Must have a basic knowledge of immunohematology. immunohematology. 4 main ABO groups A, B, AB, O also RH + and -. Persons with type 0 blood. Universal donors. RBCs don't contain antigens that could be destroyed by recipients antibodies. antibodies. Persons with type AB. Universal recipients because plasma does not contain antibodies that could destroy the donors RBSs. RBSs.

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Identifying the Patient and Blood Component

Before administering a blood transfusion. Patient and blood component must be identified by two health care professions. care If you are administering a blood component containing RBCs. Compare the Rh type. Check full name and identification number on patients wrist bank and compare to slip on blood bag. bank Don't transfuse if information on the wristband doesn't correspond exactly with that on the blood component. correspond

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Identifying Blood and Patient

Check the expiration date and time on the blood component. Make sure the label remains attached to the blood component until the transfusion is over. until Identifying the patient and blood component correctly is the most important step in preventing most transfusion reaction.

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Administering Blood Components

Phlebotomy procedure.

Use veins of antecubital space they are large and have tissue support for a 14 or 16 gauge needle.
Use at least a 19 - 20g. jelco. jelco.

Prep with betadine. betadine.

The only solution that may be added to blood or used with blood is 0.9% saline.

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Hanging Blood
Before starting the transfusion, turn the blood bag upside down several times to gently mix its contents. Inspect for color and consistency. Take vital signs, then start transfusion. Infuse no more than 50 ml. during first 15 minutes. Record time and date and patient's condition. Take vital signs every 5 minutes x 3, then at the end of transfusion. transfusion. The earlier a reaction occurs, the more severe it's likely to be. be.

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Hanging Blood
Transfusion rate should be as rapid as patient can tolerate. It shouldn't take more than 4 hours to transfuse a unit of blood. blood. To increase rate of flow a pressure bag may be used. Blood Warmers. A water bath or dry incubator through which blood passes in sterile, disposable, plastic coils. sterile, Usually not needed unless more than one unit of blood every 10 minutes is required. minutes Used when transfusing large amounts of blood rapidly which would set patient up for hypothermia which can result in arrhythmia's.

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Transfusion Reactions Hemolytic

Most severe. Usually caused by ABO incompatibility (Rh reaction occurs more slowly and is less severe). (Rh Antibodies in the recipients cells react with antigen on donor cells. Donor cells agglutinate and block capillaries obstructing flow of blood to vital organs. Prevention. Identify patient and blood to ensure proper match. Double check with another RN. Begin infusion at slow rate.

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Hemolytic Reaction
Signs and symptoms Immediate burning sensation along vein facial flushing, fever, chills, temp may go to 105 chest pain, rapid labored respiration, low back pain, shock Nursing actions Stop transfusion immediately, treat shock, administer fluids (colloids), O2, maintain an open IV (colloids), Recheck blood slips for error Obtain 2 blood samples from a different vein, check for hemolysis Obtain urine for hemoglobinuria, checking for renal damage. If renal damage give drugs to diurese, such as mannitol

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Allergic Reactions
Most often occur in those who have a hx of allergy.

Signs and Symptoms - Urticaria and pruritus, facial and/or glottal edema, asthma, pulmonary edema.
May result in bronchospasm or anaphylactic reactions. May administer antihistamine (Benadryl) before starting infusion in those with allergies.

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Allergic Reaction
Nursing Actions - Stop transfusion, treat life threatening reaction, administer antihistamine parenterally.

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Febrile Reaction

Does occur in persons with antibodies directed against WBC's. Washed RBC's should be used for these people.
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Febrile Reaction
Signs and Symptoms. Usually beginning 30 min. to two hr. after the administration of blood. Fever & chills. Flushing. Tachycardia. Symptoms can last for 8 to 10 hrs. but are usually transient. Treat the symptoms.

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Bacterial Reactions
Caused by contaminated blood products. Can be a catastrophic event & fatal if it isn't treated at once. Usually is a result of gram neg. organism growing in the blood.

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Bacterial Reactions
Signs and Symptoms. Fever. Severe hypotension. Pain in abd. Dry, flushed skin. Nursing Action. Stop the blood. Treat patient for shock. Administer broad spectrum antibiotics.

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Circulatory Overload
Circulatory overload is another complication of infusing blood. Occurs when the administration is either too rapid, or in too great of quantities. Signs and Symptoms of Circulatory Overload. Tightness in chest. Labored breathing. Rales. Pulmonary edema.

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Circulatory Overload
Nursing Action Stop or slow down the blood depending on the severity of the reaction Have patient sit up on the SOB so that the legs are in a dependent position Diuretics may be ordered as well as rotating tourniquets

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Other Complications
Giving massive amounts of blood or stored blood can result in complications Citrate intoxication Hypocalcemia
Metabolic acidosis

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Citrate Intoxication
Citrate is added as a preservative & an anticoagulant. Citrate binds to calcium & calcium levels drop. Signs and Symptoms. Tingling around mouth. Tetany.

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Hyperkalemia
With stored blood, over a period of time, RBCs tend to lyse Signs and Symptoms of Hyperkalemia Nausea Diarrhea Irregular pulse Cardiac arrhythmias Action Give blood that is less than seven days old

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Metabolic Acidosis
Blood that has been stored tends to gradually acidify. Some experts recommend giving one unit of fresh blood to every 4 to5 units of stored blood.

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General Nursing Interventions for Transfusion Reactions

Stop transfusion Assess patient Notify MD Notify blood bank Send blood back to blood bank Obtain blood specimens Document reaction

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Hyperalimentation Hyperalimentation
Parenteral Hyperalimentation. The intravenous delivering of essential nutrients to maintain a pt. in a positive nitrogen balance & nutritional equilibrium. Was introduced in the 60s. Standard IV therapy does not provide the patient with sufficient calories or nitrogen to meet the body's daily requirements. When caloric intake is inadequate, the body uses it's stored protein & fat for energy. Wt. Loss. Excess amts. of nitrogen in the urine.

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Hyperalimentation - Energy Requirements

To maintain basic cellular metabolic rate 600 calories/day An adult male in a resting state 1500 calories An immediate post op patient Up to 3000 calories a day Severely traumatized or burned pt: Can require up to 10,000 calories a day

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Hyperalimentation
Hyperalimentation provides. CHO in the form of dextrose. Protein in the form f amino acids. vitamins. Fat can be added as intralipids. We can completely nutritionally satisfy a patient with Total Parenteral Nutrition.
TPN IS HYPERAL WITH FATS .

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Hyperalimentation - Indications
Hyperalimentation is indicated in patients who Had bowel surgery, AIDS, hyperemesis Anorexic (severely) Who cannot be fed adequately through an NG Tube Who require more nutrients that can be provided either PO or interally, through an NG Tube

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Hyperalimentation - Considerations
Preparing of the solution. The solution is prepared per Dr.'s order. The physician writes exactly what he wants added to the

Hypertonic Dextrose. It is prepared in the pharmacy under a flow hood. A Central line or PICC must be inserted. The best position Trendelenburg because it aids in the filling of the vessels.

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Hyperalimentation - Considerations
Assisting with insertions of central line. Have patient turn their head away from the insertion site. The shoulder is then prepped with acetone & Betadine. Valsalva Maneuver to increase the intrathoracic pressure & decrease possibility of air embolism. Once the catheter is in place x-ray to confirm the placement before infusing hypertonic fluid.

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Hyperalimentation - Considerations
Administering the solution. Infuse steadily over a 24 hr. period of time to balance between insulin release & the increased concentration of glucose. Always infuse on a pump. Because Hyperalimentation concentrations are so high in dextrose, they're very conducive to bacterial growth. Solutions should be changed every twelve hrs. Tubing should be changed every 24 hrs. Some even recommend that you change the bags out every 8 hrs. Blood stream infection is a major complication with TPN.

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Hyperalimentation - Problems
Sepsis Air Embolism Valsalva when doing tubing changes When the catheter is being inserted, the head should be lower than the body Fluid Overload Rapid infusion of fluids Pneumothorax Hyperglycemia Rebound Hypoglycemia

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Hyperalimentation - Problems
Electrolyte Disturbances General Considerations Is patient receiving enough nutritionally from the Hyperal fluids? Are they getting enough calories? Don't every play catch-up with your hyperal fluids Maintain very good I & O

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Hyperalimentation
Nursing Management.

Maintinaing optimal nutrition. Steady rate. Weight. Preventing infection. Aseptic technique. Proper dressing change. Fluid balance. Home care.
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Intralipids
Like concentrated dextrose, intralipids provide a concentrated source of energy in a relatively small volume. 550 calories in a 500 CC bottle of intralipids. Fat emulsions are isotonic which means they can infuse through a peripheral line. May be given daily, sometimes 2 to 3 times a week, or added to hyperal solution. All threes ways are appropriate.

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Intralipids Nursing Management

Some sources recommend that intralipids not be infused with electrolytes because it may disturb the stability of the fat particles. Intralipids are kept in the refrigerator. Take them out for 30 min. prior to infusing. Intralipids cannot be run through a filter. Fat particles clog up the filter. Don't shake the bottle of intralipids. Can cause separation of the fat particles. Looks like a little bottle of milk.

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Intralipids - Reactions
Acute Reactions are rare when hanging intralipids. Signs and Symptoms. Fever & Chills. N & V. Headache. Chest pain. If symptoms occur, stop the intralipids & notify the physician. Intralipids will be contraindicated in patients who have a disturbance in fat metabolism such as those with pancreatitis.