CHAPTER 52 / Fluid, Electrolyte, and AcidBase Balance 1501

catheter in a small vein causing irritation of the vein. Chemicalphlebitis occurs when a vein becomes inflamed by irritating orvesicant solutions or medications. Bacterial phlebitis is inflam-mation of the vein and a bacterial infection, which can becaused by poor aseptic technique during insertion of the IVcatheter and/or breaks in the integrity of the IV equipment. SeeBox 528 for common signs and symptoms of infiltration, ex-travasation, and phlebitis.

The INS developed a phlebitis scale to be used when docu-menting phlebitis (Table 5211). Prevention strategies forphlebitis include practicing good hand hygiene, assessing thelength of time needed for the infusion therapy and consideringalternatives (e.g., midline catheter or PICC) for long-term ther-apy, choosing the smallest catheter, stabilizing the catheter, us-ing an in-line filter, adding a buffer to known irritatingmedications and hypertonic solutions, and following recom-

mended time frames for changing solutions and IV equipmentand rotating infusion sites (Phillips, 2010, p. 558).

BLOOD TRANSFUSIONSIV fluids can be effective in restoring intravascular (blood) vol-ume; however, they do not affect the oxygen-carrying capacityof the blood. When red or white blood cells, platelets, or bloodproteins are lost because of hemorrhage or disease, it may benecessary to replace these components to restore the bloodsability to transport oxygen and carbon dioxide, clot, fight infec-tion, and keep extracellular fluid within the intravascular com-partment. A blood transfusion is the introduction of wholeblood or blood components into venous circulation.

Blood Groups. Human blood is commonly classified into fourmain groups: A, B, AB, and O. The surface of an individuals redblood cells contains a number of proteins known as antigens thatare unique for each person. Many blood antigens have been iden-tified, but the A, B, and Rh antigens are the most important in de-termining blood group or type. Because antigens promoteagglutination or clumping of blood cells, they are also known asagglutinogens. The A antigen is present on the RBCs of peoplewith blood group A, the B antigen is present on the RBCs of peo-ple with blood group B, and A and B antigens are both present onthe RBCs in people with group AB blood. Neither antigen is pres-ent on the RBCs of people with group O blood.

Preformed antibodies to RBC antigens are present in theplasma; these antibodies are often called agglutinins. Peoplewith blood group A have B antibodies (agglutinins); A antibod-ies are present in people with blood group B; and people withblood group O have antibodies to both A and B antigens. Peo-ple with group AB blood do not have antibodies to either A orB antigens (Table 5212). These naturally occurring antibodiesare responsible for the rapid and severe reaction that occurs whenABO-incompatible blood is administered (Phillips, 2010, p. 700).Rhesus (Rh) Factor. The Rh factor antigen is present on theRBCs of approximately 85% of the people in the United States.Blood that contains the Rh factor is known as Rh positive (Rh);blood that does not contain the Rh factor is known as Rh nega-tive (Rh). In contrast to the ABO blood groups, Rh blood doesnot naturally contain Rh antibodies. However, after exposure toblood containing Rh factor (e.g., an Rh mother carrying a fetuswith Rh blood, or transfusion of Rh blood into a client who isRh), Rh antibodies develop. Subsequent exposure to Rh bloodplaces the client at risk for an antigenantibody reaction and he-molysis of RBCs.

BOX 528 Signs and Symptoms of Common LocalComplications of Infusion Therapy

INFILTRATION Coolness of skin around site Skin blanching Edema at, above, or below the insertion site Leakage at insertion site Absence of or pinkish blood return Difference in size of opposite hand or arm

EXTRAVASATION Pain, tenderness, or discomfort Edema at, above, or below the insertion site Skin blanching Change in temperature of skin at insertion site Burning at insertion site Feeling of tightness below the site

PHLEBITIS Redness at the site Skin warm Swelling Palpable cord along the vein Increase in temperature

From Infiltration and Extravasation, by L. Hadaway, 2007, American Journal of Nursing,107(8), pp. 6472; and Manual of I.V. Therapeutics (5th ed.), by L. D. Phillips, 2010,Philadelphia, PA: F. A. Davis Company.

TABLE 5212 The Blood Groups with Their ConstituentAgglutinogens and Agglutinins

BLOODTYPES

RBC ANTIGENS(AGGLUTINOGENS)

PLASMA ANTIBODIES(AGGLUTININS)

A A BB B AAB A and B O A and B

TABLE 5211 Phlebitis Scale

GRADE CLINICAL CRITERIA

0 No clinical symptoms1 Erythema at access site with or without pain2 Pain at access site, with erythema and/or edema3 Pain at access site with erythema and/or edema,

streak formation, and palpable venous cord4 Pain at access site with erythema and/or edema,

streak formation, palpable venous cord 1 inch inlength, purulent drainage

From Infusion Nursing Standards of Practice, by Infusion Nurses Society, 2006, Journal of InfusionNursing, 29(1), S1S92.

1502 UNIT 10 / Promoting Physiological Health

CULTURALLY RESPONSIVE CARE Blood and Blood Products

Jehovahs Witnesses do not receive blood or bloodproducts. Blood volume expanders are acceptable if theyare not derivatives of blood.

Christian Scientists do not ordinarily use blood or bloodproducts.

From Transcultural Concepts in Nursing Care (5th ed.), by M. M. Andrews and J. S. Boyle,2008, Philadelphia, PA: Lippincott Williams & Wilkins. Reprinted with permission.

Blood Typing and Crossmatching. To avoid transfusingincompatible red blood cells, both blood donor and recipientare typed and their blood crossmatched. Blood typing is doneto determine the ABO blood group and Rh factor status. Thistest is also performed on pregnant women and neonates to as-sess for incompatibility between their blood types (particularlyRh factor incompatibilities).

Because blood typing only determines the presence of theABO and Rh antigens, crossmatching is also necessary prior totransfusion to identify possible interactions of minor antigenswith their corresponding antibodies. RBCs from the donorblood are mixed with serum from the recipient; a reagent(Coombsserum) is added, and the mixture is examined for vis-ible agglutination. If no antibodies to the donated RBCs arepresent in the recipients serum, agglutination does not occurand the risk of a transfusion reaction is small.Selection of Blood Donors. Screening of blood donors isrigorous. Criteria have been established to protect the donor frompossible ill effects of donation and to protect the recipient fromexposure to diseases transmitted through the blood. Blooddonors are unpaid volunteers. Potential donors are eliminated bya history of hepatitis, HIV infection (or risk factors for HIV in-fection), heart disease, most cancers, severe asthma, bleedingdisorders, or seizures. Donation may be deferred for people whohave malaria, have been exposed to malaria or hepatitis, are ane-mic, have high or low BP, have low body weight, or who arepregnant, have had recent surgery, or take certain medications.

Blood and Blood Products for Transfusion. Most clientsdo not require transfusion of whole blood. It is much more com-mon for clients to receive a transfusion of a particular bloodcomponent specific to their individual needs. Table 5213 listssome of the common blood products that may be transfused.Transfusion Reactions. Transfusion of ABO- or Rh- incom-patible blood can result in a hemolytic transfusion reaction,which causes destruction of the transfused RBCs and subsequentrisk of kidney damage or failure. To avoid hemolytic transfusionreactions, blood from the donor and from the recipient is tested forcompatibility. This is referred to as a type and crossmatch. Otherforms of transfusion reactions may also occur, including febrile orallergic reactions, circulatory overload, and sepsis. Because therisk of an adverse reaction is high when blood is transfused, clientsmust be frequently and carefully assessed before and during trans-fusion. Many reactions become evident within 5 to 15 minutes ofinitiating the transfusion, but reactions can develop any time dur-ing a transfusion; for this reason clients are most closely monitoredduring the initial period of the transfusion. Stop the transfusion im-mediately if signs of a reaction develop. Keep the line open withnormal saline. Do not use the saline attached to the Y-set tubing be-cause the filter contains blood and you do not want to give theclient who is experiencing an acute transfusion reaction anotherdrop of blood. Instead, use new IV tubing. Disconnect the infusiontubing from the hub of the IV catheter and replace with the new IVtubing. Do not piggy back the new tubing into the access port ofthe transfusion tubing, as it is possible that some of the blood prod-uct could be administered to the client. Hydrate the client with nor-mal saline and notify the primary care provider. Continue tomonitor vital signs (Phillips, 2010; Kyles, 2007). Possible transfu-sion reactions, their clinical signs and symptoms, and nursing im-plications are listed in Table 5214.

The hospital must have a protocol relating to transfusion re-actions. Common measures include: Notify the blood bank Examine the label on the blood container to check for errors

in identifying the client, blood, or blood component

TABLE 5213 Blood Products for Transfusion

PRODUCT USE

Whole blood Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume andall blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors.

Packed red blood cells (PRBCs) Used to increase the oxygen-carrying capacity of blood in anemias, surgery, and disorderswith slow bleeding. One unit of PRBCs has the same amount of oxygen-carrying RBCs as aunit of whole blood. One unit raises hematocrit by approximately 2% to 3%.

Autologous red blood cells Used for blood replacement following planned elective surgery. Client donates blood forautologous transfusion 45 weeks prior to surgery.

Platelets Replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets aremost effective. Each unit should increase the average adult clients platelet count by about5,000 platelets/microliter.

Fresh frozen plasma Expands blood volume and provides clotting factors. Does not need to be typed andcrossmatched (contains no RBCs). Each unit will increase the level of any clotting factor by2% to 3% in the average adult (Phillips, 2010, p. 730).

Albumin and plasma protein fraction Blood volume expander; provides plasma proteins.Clotting factors and cryoprecipitate Used for clients with clotting factor deficiencies. Each provides different factors involved in

the clotting pathway; cryoprecipitate also contains fibrinogen.

CHAPTER 52 / Fluid, Electrolyte, and AcidBase Balance 1503

TABLE 5214 Transfusion Reactions

REACTION: CAUSE CLINICAL SIGNS NURSING INTERVENTION*

Hemolytic reaction:incompatibility betweenclients blood and donorsblood

Fever or chills, flank pain,and reddish or brownurine, tachycardia,hypotension

1. Discontinue the transfusion immediately.Note: When the transfusion is discontinued, the blood tubing must beremoved as well. Use new tubing for the normal saline infusion.

2. Maintain vascular access with normal saline, or according to agencyprotocol.

3. Notify the primary care provider immediately.4. Monitor vital signs.5. Monitor fluid intake and output.6. Send the remaining blood, bag, filter, tubing, a sample of the clients

blood, and a urine sample to the laboratory.Febrile reaction: sensitivityof the clients blood towhite blood cells, platelets,or plasma proteins; doesnot cause hemolysis

Fever; chills; warm,flushed skin; headache;anxiety; nausea

1. Discontinue the transfusion immediately.2. Keep the vein open with a normal saline infusion.3. Notify the primary care provider.4. Give antipyretics as ordered.

Allergic reaction (mild):sensitivity to infusedplasma proteins

Flushing, urticaria, with orwithout itching

1. Stop the transfusion immediately. Keep vein open with normal saline.2. Notify the primary care provider.3. Administer medication (antihistamines, steroids) as ordered.

Allergic reaction (severe):antibodyantigen reaction

Dyspnea, stridor,decreased oxygensaturation, chest pain,flushing

1. Stop the transfusion immediately.2. Keep the vein open with a normal saline solution.3. Notify the primary care provider immediately.4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed.5. Administer medications and/or oxygen as ordered.

Circulatory overload: bloodadministered faster than thecirculation can accommodate

Dyspnea, hypotension,orthopnea, crackles (rales),distended neck veins.tachycardia, hypertension

1. Stop the transfusion immediately.2. Place the client upright.3. Notify the primary care provider.4. Administer diuretics and oxygen as ordered.

Sepsis: contaminated bloodadministered

High fever, chills,vomiting, diarrhea,hypotension, oliguria

1. Stop the transfusion.2. Keep the vein open with a normal saline infusion.3. Notify the primary care provider.4. Administer IV fluids, antibiotics.5. Obtain a blood specimen from the client for culture.6. Send the remaining blood and tubing to the laboratory.

*Nurses should follow the agencys protocol regarding interventions. These may vary among agencies.

Obtain laboratory specimens (e.g., blood work, urine sample) Send blood container (whether or not it contains any blood),

attached infusion set, and IV solution to the blood bank(American Association of Blood Banks [AABB], 2009, p. 79).

Administering Blood. Special precautions are necessarywhen administering blood. When a transfusion is ordered, thenurse or other personnel obtain blood in plastic bags from theblood bank just before starting the transfusion. One unit ofwhole blood is 500 mL; a unit of paced red blood cells(RBCs) is 200 to 250 mL. Do not store the blood in the refrig-erator on the nursing unit; lack of temperature control maydamage the blood. Once blood or a blood product is removedfrom the blood bank refrigerator, it must be administered

within a limited amount of time (e.g., packed RBCs shouldnot hang for more than 4 hours after being removed from theblood bank refrigerator). Follow agency policies for verifyingthat the unit is correct for the client. The U.S. Food and DrugAdministration (2009) requires blood products to have barcodes to allow for scanning and machine-readable informa-tion on blood and blood component container labels to helpreduce medication errors.

Blood is usually administered through an #18- to #20-gauge IV needle or catheter; using smaller needles may slowthe infusion and damage blood cells (although a smallergauge needle may be necessary for small children or clientswith small, fragile veins). Blood administration sets (Y-sets)are used to keep the vein open while starting the transfusion

1504 UNIT 10 / Promoting Physiological Health

SAFETY ALERT2010 National Patient Safety Goals (NPSGs)Goal 1: Improve the accuracy of patient identification.Goal 01.03.01: Eliminate transfusion errors related topatient misidentification.

Before initiating a blood or blood component transfusion: Match the blood or blood component to the order. Match the patient to the blood or blood component. Use a two-person verification process.

From The Joint Commission, 2010 National Patient Safety Goals, Hospital.

CLINICAL ALERTNormal saline must always be used when giving a bloodtransfusion. If the client has an infusion of any other IVsolution, stop that infusion and flush the line with saline priorto initiating the transfusion, or establish IV access through anadditional site. Solutions other than saline can cause damageto the blood components.

and to flush the line with normal saline before the blood en-ters the tubing (Figure 5233 ).

The infusion tubing has a filter inside the drip chamber. Atransfusion should be completed within 4 hours of initiation. Themaximum time for use of a blood filter is 4 hours (Phillips,2010). The AABB (2009) states: With the exception of 0.9%sodium chloride, no drug or medication should be added to bloodor blood components unless they have been approved by theFDA or there is documentation that the addition is safe and doesnot adversely affect the blood or blood component." (p. 42). If anadditional unit needs to be transfused, follow agency guidelines.A new blood administration set is to be used with each compo-nent (Phillips, 2010). New IV tubing is used for administeringother IV fluids following a transfusion.

PURPOSES To restore blood volume after severe hemorrhage To restore the oxygen-carrying capacity of the blood To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates, which prevent or treat bleeding

Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set

SKIL

L 52

6

Status of infusion site Blood test results such as hemoglobin value or platelet count Any unusual symptoms

ASSESSMENTAssess Vital signs Physical examination including fluid balance and heart and

lung sounds as manifestations of hypo- or hypervolemia

In some agencies, written consent for transfusion isrequired. Check policy and obtain as indicated.

Know the purpose of the transfusion. Plan to begin the transfusion as soon as the component is

ready. Type and crossmatch can take several hours.

PLANNING Review the client record regarding previous transfusions.

Note any complications and how they were managed (e.g.,allergies or previous adverse reactions to blood).

Confirm the primary care providers order for the numberand type of units and the desired speed of infusion.

To initiate, maintain, and terminate a blood transfusion, seeSkill 526.

Adapter

Y-Injection site

Slide clamp

Main flow rateclamp

Blood filterchamber

Drip chamber

Upperclamps

Spikes

To salinesolution

Toblood

Figure 5233 Schematic of a Y-set for blood administration.

CHAPTER 52 / Fluid, Electrolyte, and AcidBase Balance 1505SKILL 526

Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Setcontinued

Equipment Unit of whole blood, packed RBCs, or other component Blood administration set IV pump, if needed 250 mL normal saline for infusion IV pole Venipuncture set containing an 18- to 20-gauge needle or

catheter (if one is not already in place) or, if blood is to beadministered quickly, a larger catheter

Alcohol swabs Tape Clean gloves

Note any premedication ordered by the primary careprovider (e.g., acetaminophen or diphenhydramine).Schedule their administration (usually 30 minutes prior tothe transfusion).

DelegationDue to the need for sterile technique and technicalcomplexity, blood transfusion is not delegated to UAP.The nurse must ensure that the UAP knows whatcomplications or adverse signs can occur and shouldbe reported to the nurse. In some states only RNs canadminister blood or blood products.

Open the main flow rate clamp, and prime the tubingwith saline.

Close both clamps.6. Start the saline solution.

If an IV solution incompatible with blood is infusing,stop the infusion and discard the solution and tubingaccording to agency policy.

Attach the blood tubing primed with normal saline tothe IV catheter.

Open the saline and main flow rate clamps and adjustthe flow rate. Use only the main flow rate clamp toadjust the rate.

Allow a small amount of solution to infuse to makesure there are no problems with the flow or with thevenipuncture site. Rationale: Infusing normal salinebefore initiating the transfusion also clears the IVcatheter of incompatible solutions or medications.

7. Obtain the correct blood component for the client. Check the primary care providers order with the

requisition. Check the requisition form and the blood bag label with

a laboratory technician or according to agency policy.Specifically, check the clients name, identificationnumber, blood type (A, B, AB, or O) and Rh group, theblood donor number, and the expiration date of theblood. Observe the blood for abnormal color, RBCclumping, gas bubbles, and extraneous material.Return outdated or abnormal blood to the blood bank.

With another nurse (most agencies require an RN),verify the following before initiating the transfusion(Phillips, 2010, p. 747): Order: Check the blood or component against the

primary care providers written order. Client identification: The name and identification

number on the clients identification band must beidentical to the name and number attached to theunit of blood.

Unit identification: The unit identification numberon the blood container, the transfusion form, andthe tag attached to the unit must agree.

ABO and Rh type: The ABO group and Rh type onthe primary label of the donor unit must agree withthose recorded on the transfusion form.

Expiration: The expiration date and time of thedonor unit should be verified as acceptable.

Compatibility: The interpretation of compatibilitytesting must be recorded on the transfusion formand on the tag attached to the unit.

IMPLEMENTATIONPreparation If the client has an IV solution infusing, check whether the IV

catheter and solution are appropriate to administer blood.The preferred catheter size is 18 to 20 gauge, and thesolution must be normal saline. Dextrose (which causes lysisof RBCs), Ringers solution, medications and other additives,and hyperalimentation solutions are incompatible. Refer tostep 5 below if the infusing solution is not compatible.

If the client does not have an IV solution infusing, checkagency policies. In some agencies an infusion must berunning before the blood is obtained from the blood bank.In this case, you will need to perform a venipuncture on asuitable vein (see Skill 521) and start an IV infusion ofnormal saline.

Performance

1. Prior to performing the procedure, introduce self andverify the clients identity using agency protocol. Explain tothe client what you are going to do, why it is necessary,and how he or she can participate. Instruct the client toreport promptly any sudden chills, nausea, itching, rash,dyspnea, back pain, or other unusual symptoms.

2. Provide for client privacy and prepare the client. Assist the client to a comfortable position, either sitting

or lying. Expose the IV site but provide for client privacy.

3. Perform hand hygiene and observe other appropriateinfection control procedures.

4. Prepare the infusion equipment. Ensure that the blood filter inside the drip chamber is

suitable for the blood components to be transfused.Attach the blood tubing to the blood filter, if necessary.Rationale: Blood filters have a surface area largeenough to allow the blood components through easilybut are designed to trap clots.

Apply gloves. Close all the clamps on the Y-set: the main flow rate

clamp and both Y-line clamps. Insert the piercing pin (spike) into the saline solution. Hang the container on the IV pole about 1 m (39 in.)

above the venipuncture site.

5. Prime the tubing. Open the upper clamp on the normal saline tubing,

and squeeze the drip chamber until it covers the filterand one third of the drip chamber above the filter.

Tap the filter chamber to expel any residual air in thefilter.

Continued on page 1506

Blood Transfusion: Skill Checklist

1506 UNIT 10 / Promoting Physiological HealthSK

ILL

526

Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Setcontinued Note adverse reactions, such as chills, nausea,

vomiting, skin rash, dyspnea, back pain, or tachycardia.Rationale: The earlier a transfusion reaction occurs,the more severe it tends to be. Promptly identifyingsuch reactions helps to minimize the consequences.

Remind the client to call a nurse immediately if anyunusual symptoms are felt during the transfusion suchas chills, nausea, itching, rash, dyspnea, or back pain.

If any of these reactions occur, report these to thenurse in charge, and take appropriate nursing action.See Table 5214 on page 1503.

11. Document relevant data. Record starting the blood, including vital signs, type of

blood, blood unit number, sequence number (e.g., #1of three ordered units), site of the venipuncture, sizeof the catheter, and drip rate.

SAMPLE DOCUMENTATION1/21/2011 1400 1 unit of PRBCs (#65234) hung to be infusedover 3 hours. IV site in (L) forearm with 19 G angiocath. VStaken (see transfusion record). Informed to contact nurse ifbegins to experience any discomfort during transfusion. Statedhe would use the call light. ________________ C. Jones, RN.

12. Monitor the client. Fifteen minutes after initiating the transfusion (or

according to agency policy), check the vital signs. Ifthere are no signs of a reaction, establish the requiredflow rate. Most adults can tolerate receiving one unitof blood in 1 1/2 to 2 hours. Do not transfuse a unit ofblood for longer than 4 hours.

Assess the client, including vital signs, per agencypolicy. If the client has a reaction and the blood isdiscontinued, send the blood bag and tubing to thelaboratory for investigation of the blood.

13. Terminate the transfusion. Apply clean gloves. If no infusion is to follow, clamp the blood tubing.

Check agency protocol to determine if the bloodcomponent bag needs to be returned or if the bloodbag and tubing can be disposed of in a biohazardcontainer. The IV line can be discontinued or cappedwith an adaptor or a new infusion line and solutioncontainer may be added. If another transfusion is tofollow, clamp the blood tubing and open the salineinfusion arm. Check agency protocol. A new bloodadministration set is to be used with each component(Phillips, 2010, p. 751).

If the primary IV is to be continued, flush themaintenance line with saline solution. Disconnect theblood tubing system and reestablish the IV infusionusing new tubing. Adjust the drip to the desired rate.Often a normal saline or other solution is kept runningin case of delayed reaction to the blood.

Measure vital signs.

14. Follow agency protocol for appropriate disposition of theused supplies. Discard the administration set according to agency

practice. Dispose of blood bags and administration sets.

If any of the information does not match exactly, notifythe charge nurse and the blood bank. Do not administerblood until discrepancies are corrected or clarified.

Sign the appropriate form with the other nurseaccording to agency policy.

Make sure that the blood is left at room temperature forno more than 30 minutes before starting thetransfusion. Agencies may designate different times atwhich the blood must be returned to the blood bank if ithas not been started. Rationale: As blood componentswarm, the risk of bacterial growth also increases. If thestart of the transfusion is unexpectedly delayed, returnthe blood to the blood bank after 30 minutes. Do notstore blood in the unit refrigerator. Rationale: Thetemperature of unit refrigerators is not preciselyregulated and the blood may be damaged.

8. Prepare the blood bag. Invert the blood bag gently several times to mix the

cells with the plasma. Rationale: Rough handling candamage the cells.

Expose the port on the blood bag by pulling back thetabs.

Insert the remaining Y-set spike into the blood bag. Suspend the blood bag.

9. Establish the blood transfusion. Close the upper clamp below the IV saline solution

container. Open the upper clamp below the blood bag. The blood

will run into the saline-filled drip chamber. If necessary,squeeze the drip chamber to reestablish the liquidlevel with the drip chamber one-third full. (Tap the filterto expel any residual air within the filter.)

Readjust the flow rate with the main clamp. Remove and discard gloves. Perform hand hygiene.

10. Observe the client closely for the first 15 minutes. It is recommended that transfusions of RBCs be started

at 5 mL/min for the first 15 minutes of the transfusion.Rationale: This small amount is enough to produce asevere reaction but small enough that the reactioncould be treated successfully (Phillips, 2010, p. 749).

Exposing the port on the blood bag by pulling back the tabs.

CLINICAL ALERTIt is safer to have one nurse read the information forverification to the other nurse; this avoids errors that canbe made if both nurses look at the tags together.

CHAPTER 52 / Fluid, Electrolyte, and AcidBase Balance 1507SKILL 526

Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Setcontinuedsigns. If the primary IV infusion was continued, recordconnecting it. Also record the transfusion on the IVflow sheet and intake and output record.

SAMPLE DOCUMENTATION

4/21/2011 1420 c/o feeling warm, headache, & backache. Skinflushed. T 102.6F, BP 140/90, P 112, R 28. Approximately50 mL PRBCs (#65234) infused over past 20 minutes. Infusionstopped. IV tubing changed, NS infusing at 15 mL/hr. Blood &attached tubing sent to blood bank. Dr. Riley notified.___________________________________C. Jones, RN

a. On the requisition attached to the blood unit, fill inthe time the transfusion was completed and theamount transfused.

b. Attach one copy of the requisition to the clientsrecord and another to the empty blood bag ifrequired by agency policy.

c. Agency policy generally involves returning the bagto the blood bank for reference in case ofsubsequent or delayed adverse reaction.

Remove and discard gloves. Perform hand hygiene.

15. Document relevant data. Record completion of the transfusion, the amount of

blood absorbed, the blood unit number, and the vital

Report significant deviations from normal to the primarycare provider.

EVALUATION Perform follow-up based on findings or outcomes that

deviated from expected or normal for the client. Relatefindings to previous data if available.

EvaluatingUsing the overall goals identified in the planning stage of maintain-ing or restoring fluid balance, maintaining or restoring pulmonaryventilation and oxygenation, maintaining or restoring normal bal-ance of electrolytes, and preventing associated risks of fluid, elec-trolyte, and acidbase imbalances, the nurse collects data toevaluate the effectiveness of interventions. Examples of desiredoutcomes for the identified goals are found in Identifying NursingDiagnoses, Outcomes, and Interventions on pages 1476 and 1477.

If desired outcomes are not achieved, the nurse, client, andsupport person if appropriate need to explore the reasons beforemodifying the care plan. For example, if the outcome Urineoutput is greater than 1,300 mL per day and within 500 mL of

intake is not achieved, questions to be considered might in-clude the following:

Have other outcome measures for the goal of achieving fluidbalance been met?

Does the client understand and comply with planned fluidintake?

Is all urinary output being measured? Are unusual or excessive amounts of fluid being lost by an-

other route (e.g., gastric suction, excessive perspiration,fever, rapid respiratory rate, wound drainage)?

Are prescribed medications being taken or administered asordered?

NURSING CARE PLAN Deficient Fluid Volume

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*

Nursing AssessmentMerlyn Chapman, a 27-year-old sales clerk, reports weakness,malaise, and flu-like symptoms for 34 days. Although thirsty,she is unable to tolerate fluids because of nausea andvomiting, and she has liquid stools 24 times per day.

Physical Examination Diagnostic DataHeight: 160 cm (53) Urine specific gravity: 1.035Weight: 66.2 kg (146 lb) Serum sodium 155 mEq/LMild fever: 38.6C (101.5F) Serum potassium 3.2 mEq/LPulse: 96 beats/min Chest x-ray negativeRespirations: 24/minuteScant urine outputBP: 102/84 mmHgDry oral mucosa, furrowed tongue, cracked lips

Deficient Fluid Volumerelated to nausea, vomiting,and diarrhea as evidenced bydecreased urine output,increased urineconcentration, weakness,fever, decreased skin/tongueturgor, dry mucousmembranes, increased pulserate, and decreased bloodpressure

Electrolyte & Acid/Base Balance[0600] as evidenced by nodeviation from normal range:

Serum electrolytes

Fluid Balance [0601] as evidencedby not compromised:

24-hour intake and outputbalance

Urine specific gravity Blood pressure Pulse rate Temperature Skin turgor Moist mucous membranes

Continued on page 1508

NURSING CARE PLAN Deficient Fluid Volumecontinued

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Electrolyte Management: Hypokalemia [2007]

Obtain specimens for analysis of altered potassium levels(e.g., serum and urine potassium) as indicated.

Urine and serum analysis provides information about extracellularlevels of potassium. There is no practical way to measureintracellular K.

Administer prescribed supplemental potassium (PO, NG, orIV) per policy.

Low potassium levels are dangerous and Mrs. Chapman mayrequire supplements.

Monitor for neurologic and neuromuscular manifestations ofhypokalemia (e.g., muscle weakness, lethargy, altered level ofconsciousness).

Potassium is a vital electrolyte for skeletal and smooth muscleactivity.

Monitor for cardiac manifestations of hypokalemia (e.g.,hypotension, tachycardia, weak pulse, rhythm irregularities).

Many cardiac rhythm disorders can result from hypokalemia. It iscritical to monitor cardiac function with hypokalemia.

Electrolyte Management: Hypernatremia [2004]Obtain specimens for analysis of altered sodium levels (e.g.,serum and urine sodium, urine osmolality, and urine specificgravity) as indicated.

Urine analysis provides information about retention or loss ofsodium and the ability of the kidneys to concentrate or diluteurine in response to fluid changes.

Provide frequent oral hygiene. Oral mucous membranes become dry and sticky due to loss offluid in the interstitial spaces.

Monitor for neurologic and neuromuscular manifestations ofhypernatremia (e.g., lethargy, irritability, seizures, andhyperreflexia).

Hypernatremia, as a result of low fluid volume, creates ahypertonic vascular space, which causes water to move out of thecells, including brain cells. This accounts for neurologic symptoms.

Monitor for cardiac manifestations of hypernatremia (e.g.,tachycardia, orthostatic hypotension).

The heart responds to a loss of fluid by increasing the heart rateto compensate with an increase in cardiac output. Low fluidvolume leads to a fall in blood pressure.

Fluid Management [4120]Weigh daily and monitor trends. Weight helps to assess fluid balance.Maintain accurate I & O record. Accurate records are critical in assessing the clients fluid balance.Monitor vital signs as appropriate. Vital sign changes such as increased heart rate, decreased blood

pressure, and increased temperature indicate hypovolemia.Give fluids as appropriate. As her nausea decreases encourage her oral intake of fluids as

tolerated, again to replace lost volume.Administer IV therapy as prescribed. Mrs. Chapman has signs of severe fluid volume deficit. She will

probably require IV replacement of fluid. This is especially truebecause her oral intake is limited because of nausea and vomiting.

EVALUATION

Outcomes met. Mrs. Chapman remained hospitalized for 48 hours. She required fluid replacement of a total of 5 liters. Her bloodpressure increased to 122/74, pulse rate decreased to a resting level of 74, and respirations decreased to 12/minute. Her urineoutput increased as the fluid was replaced and was adequate at 0.5 mL/kg per hour by the time of discharge. The urine specificgravity was 1.015. Lab work on the day of discharge was K: 3.8 and Na: 140. She had elastic skin turgor and moist mucousmembranes. She was taking oral fluids and was able to discuss symptoms of deficient fluid volume that would necessitate hercalling her health care provider.

*The NOC # for desired outcomes and the NIC # for nursing interventions and selected activities are listed in brackets following the appropriate outcome or intervention. Outcomes, interventions,and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

1. What action would you take if Mrs. Chapmans heartbecame irregular?

2. Mrs. Chapman is responding inappropriately to yourquestions; she seems to be confused. What do youthink is happening?

APPLYING CRITICAL THINKING

3. Offer suggestions for ways to help Mrs. Chapmanincrease her oral intake.

4. Mrs. Chapman asks why you weigh her every morning.How do you respond?

See Critical Thinking Possibilities answers on student resource website.

Appl

ying

Crit

ical

Thi

nkin

g: A

nsw

ers

1508 UNIT 10 / Promoting Physiological Health