Published Oct 29, 2004
My Manager mentioned that one of the Committee's was going to be updating the blood transfusion Policy. She asked if I'd ask around in All Nurses on what other places do as far as checking vital Signs.
Currently, we check VS's before starting, after the 1st 15 min. & then Q 1 hr. until completed. Then we check again 1 hr. after infusion is complete.
We infuse the blood over 2-4 hrs., depending on the patient. The elderly with CHF for instance might get it at the slowest rate.
so, If I could get some ideas from you guys, I'd appreciate it!
purplemania, BSN, RN
Our policy is like yours. As a nurse, however, I decide who does not fit the parameter and will do vital signs more frequently for CHF, renal disease, many previous transfusions, etc. I think the policy should include frequent evaluation by the nurse.
General E. Speaking, RN, RN
HiMy Manager mentioned that one of the Committee's was going to be updating the blood transfusion Policy. She asked if I'd ask around in All Nurses on what other places do as far as checking vital Signs.Currently, we check VS's before starting, after the 1st 15 min. & then Q 1 hr. until completed. Then we check again 1 hr. after infusion is complete.We infuse the blood over 2-4 hrs., depending on the patient. The elderly with CHF for instance might get it at the slowest rate.so, If I could get some ideas from you guys, I'd appreciate it!Thanks,Mary Ann
we do VS before, then 15 min later, then 30 min after that, then hourly until complete, with a set of VS directly after the blood is done.
The blood is signed out from the lab and checked by one RN and one lab tech. When it reaches the floor, the blood is checked by the RN who signed it out and one other RN (for patient name, type, Rh factor, type of product, and unit number). We do vitals immediately before, at 15 minutes, then hourly until done, and then after blood is done and NS flush has started. But, we also do q15min checks for the duration. There is a spot on the form for q15 minute checks - you can just put a check mark with your initials or there is a line for comments (things like "pt. sleeping - easy, relaxed respirations" or "pt. eating - no complaints at this time" or "pt. up to BR - voided qs - refer to fluid balance sheet"). It is also policy that you must remain with the pt. for the first fifteen minutes. Not sure what all you are looking for but, we also do some assessment before and after like breath sounds on all pts. to form a baseline for assessing fluid overload. Our policy on time is that you have four hours from the time the blood is removed from the fridge in the lab until the end of the infusion. When done, the bag is sent back to the lab with the attached tag (comes that way) indicating time started, time ended, VS before and after, and any S&S of a transfusion reaction.
Most transfusions I've given have been on ortho/trauma patients. We check VS right before transfusion, then stay with pt for first 15 min (and run blood slow in case of rx), then check another set of VS. Then we run the rest of the blood over 1.5-2 hours. When blood finishes we check another set of VS.
At my institution, we check vital signs pre transfusion, every 5 minutes for the first 15 minutes, then every 30 minutes for the duration of the transfusion. A complete set of vital signs includes temp, BP, pulse and resp. rate. A rise of 1 degree in temp during the transfusion qualifies as a reaction and we then have to initiate our transfusion reaction protocol.
plumrn, BSN, RN
CarpeDiem2004 I'll bet you guys hate it when you have someone getting blood. That was our policy for a long time. Now it is prior to start of blood, 15 minutes after. Stay with pt for 1st 15 mins.Then hourly until completed. Then 1 hour post infusion.
Of course, more often if vitals aren't real stable. We notify doc if pt develops temp of 101. We don't do the occurrence sheet if the pt had a low grade temp prior to blood start. We call the doc for order to continue infusion and order for antipyretic, sometimes Benadryl; watch pt closely, and continue to completion unless other signs of possible reaction occur. If other signs occur, then we start the reaction procedure. So many of our post ops have normal temp elevations the 1st 48-72hrs, so we have to watch for other signs/symptoms other than fever.
Burnt Out, ASN, RN
Our policy is to get VS before we begin the transfusion (usually we do them before going to the blood bank), then 15 minutes after the infusion was started, and then when the blood is infused, we get VS again. Of course, we monitor our patient and use our nursing judgement and get VS more often if we think it is necessary.
Tweety, BSN, RN
Before, 15 minutes, midway if longer than 3 hours and after.
VivaLasViejas, ASN, RN
We do one set of VS just before starting the transfusion, stay with the pt. for the first 15 minutes to monitor for any reactions, take another set of vitals (the RN, not the CNA, does the first set), listen to lungs and do a quick assessment, then infuse the rest of the unit over 2-4 hours, checking vitals Q hour and then at the end. I also check lungs, etc. between units, especially if the pt. is elderly and/or at risk for CHF. :)
We take VS before we start infusion, 15 minutes after it starts, and an hour after it ends. Don't need to stay with the patient for the first 15 minutes, I only stay if it's the FIRST time they ever received blood. :)
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