Blood Component Therapy

To reduce the use of blood products, antifibrinolytic agents and other

products
may be used in some situations.
Platelet concentrates, derived from fresh whole blood can increase
the platelet
level effectively. Centrifuging 500 mL of whole blood derives 1
unit of platelets, a yellow liquid that is usually 30-50 mL in
volume.
Platelet concentrates from multiple units of blood can be pooled
together for a
single administration. The degree of increase from a pooled
platelet product varies and is usually measured by performing a
platelet count within 1 hour following the transfusion.
Platelet transfusions can also be prepared by pheresing/removing the
platelets
from a single donor (blood is removed from the donor, the
platelets are removed, and the rest of the blood is reinfused into
the donor). This procedure results in 200-400 mL of platelets and
plasma. Once acquired from a donor, platelets can be stored at
room temperature for 1-5 days. Gentle agitation of the bad is
useful to prevent the platelets from adhering to the plastic.
Administration Procedure
--usually with at least a 19-gauge needle (larger needles [18 or 16]
may be preferred if rapid infusions are given). (Smaller needles can be
used for platelets, albumin, and clotting factor replacement).
Verify venous access patency before requesting the blood
component
Most blood product administration tubing is of a Y Type with a
microaggregate filter (filters our particulate) with one arm
of the Y for isotonic saline solution and the other arm of the
Y for the blood product.
Once obtained, positive identification of the donor and recipient
must be
made (dual checking system)
Make sure patient understands the procedure and the s/sx to
report and that
they have agreed with the plan.
Take vital signs prior to administration
o If abnormal (ex: elevated temp) clarify with the physician
when to administor
Blood should be administered as soon as its brought to the
patient. If its not

used within 30 mins, it should be returned to the blood

bank.
During the first 15 mins or 50 mL of blood infustion, you should
remain with
the patient. If there are untoward reactions, they are most
likely to occur at this time. The rate of infusion at this time
is no more than 2 mL/min.
After the first 15 mins, vitals are re-taken and the rate of infusion
is
goverened by the clinical condition and the product being
infused.
Observe the patient periodically throughout (ie: every 30 mins)
and up to 1
hour after the transfusion
Most patients not in danger of fluid overload can tolerate the
infusion of 1
unit of PRBCs over 2 hours. The transfusion whould not
take more than 4 hours to administer.

Acute Blood Transfusion Reactions

1) Stop the transfusion
2) Maintain a patent IV line with saline solution
3) Notify the blood bank and HCP immediately
4) Recheck identifying tags and numbers
5) Monitor vitals and urine output
6) Treat symptoms per physician order
7) Save the blood bag and tubing and send them to the blood
bank for examination
8) Complete transfusion reaction reports
9) Collect required blood/urine speciments at intervals to
evaluate for hemolysis
10) Document on transfusion reaction form and patient chart
Chest Tubes & Pleural Drainage
Chest tubes are inserted into the pleural space to remove air and
fluid and to allow the lung to re-expand
Chest Tube Insertion
Patient should be positioned seated on the edge of the bed with
arms
supported on a bedside table or supine with the midaxillary
area of t
he affected side exposed. (Chest X-Ray confirms
affected side)
Cleanse area with an antiseptic solution
Chest wall is prepared with a local anesthetic and a small incision
is made

over a rib
The chest tube is advanced up and over the top of the rib to
avoid the intercostal nerves and blood vessels that are behind
the rib inferiorly.
o If the purpose of the tube is to remove air: a smaller size
can be used (14 F to 22 F) and is directed anteriorly and
superiorly as air rises.
o If the purpose is to remove fluid, a larger size is used (28 F
to 40 F) and it is directed posteriorly and inferiorly.
The chest tube is connected to a pleural drainage system. 2
tubes may be
connected to the same drainage unit with a Y-connector.
The incision is closed with sutures and the chest tube is secured.
The wound is covered with a dressing
o Some clinicians prefer to seal the wound around the chest
tube with petroleum gauze.

Pleural Drainage Systems2 Types

1) Flutter valve connected to a drainage bag
Used for patients with chronic pleural effusions and simple
pneumothorax
Allows for ease of mobility and safety
2) Larger and contains 3 basic comparements, each with a separate
function:
The first compartment, or collection chamber, receives fluid and
air from the
pleural or mediastinal space.
The fluid stays in this chamber while the air vents to the
second
compartment.
The second compartment, the water-seal chamber, contains 2
cm of water, which acts as a one way valve.
o The incoming air enters from the collection chamber and
bubbles up
through the water.
o The water prevents backflow of air into the patient from
the system.
o Initially, brisk bubbling of air occurs in this chamber when
a
pneumothorax is evacuated.
o During normal use: there will be intermittent bubbling
during

exhalation, coughing, or sneezing due to an increase

in the patients intrathoracic pressure.
o There is normal fluctuation of the water called tidaling that
reflects
the intrapleural pressure during inspiration and
expiration.
o As the source of air in the pleural space gets smaller, it will
take more
and more positive intrapleural pressure to force air
out. Eventually, the air leak will seal and the lung will
be fully expanded.
The third comparment, the suction chamber, applies suction to
the chest drainage system.
o There are 2 types of suction control, water and dry.
o The water suction control chamber uses a column of water
with the
top end vented to the atmosphere to control the amount
of suction from the wall regulator.
This chamber is typically filled with 20 cm of water.
When the
negative pressure generated by the suction
source exceeds the set 20 cm, air from the
atmosphere enters the chamber through the
vent on top and the air bubbles up through the
water, causing a suction-breaker effect.
As a result, excess pressure is relieved. The amount
of suction
applied is regulated by the amount of water in
this chamber, and not by the amount of suction
applied to the system.
An increase in suction does not result in an increase
in
negative pressure to the system because any
excess suction merely draws in air through the
vent on the top of the third chamber.
This suction pressure is usually ordered to be -20cm
H20,
although higher pressures (-40 cm H2O) are
sometimes necessary to evacuate the pleural
space.
To initiate suction, the vacuum source is turned up
until the
gentle bubbling is present in the chamber.
Excessive bubbling does not increase the amount of
suction to

be applied, but does increase the rate of

evaporation from the column of water and the
amount of noise made by the device.
o The dry suction control chamber system contains no water.
It has a visual alert that indicates if the suction is
working.
It uses either a restrictive device or a regulator to
dial the
desired negative pressure; this is internal in the
chest drainage system.
Increasing the vacuum source will not increase the
pressure.
Nursing Management: Chest Drainage
Chest tubes may be momentarily clamped to change the
drainage apparatus
or to check for air leaks. Clamping for more than a few
moments is indicated only in assessing how the patient will
tolerate chest tube removal.
Generally this occurs 4-6 hours before the tube is removed, and
the patient is
monitored closely.
If a chest tube becomes disconnected, the most important
intervention is
reestablishment of the water-seal system immediately and
attachement of a new drainage system as soon as
possible.
Chest x-ray is used to monitor tube position and lung
reexpansion at i
ntervals.
If volumes from 1-1.5 L of pleural fluid are removed rapidly,
reexpansion
pulmonary edema or a vasovagal response with
symptomatic hypotension can occur
Chest Tube Removal
Removed when the lungs are reexpanded and fluid drainage has
ceased.
Generally suction is discontinued and the chest drain is on
gravity drainage
for 24 hours before the tube is removed
Pain medication is given 15 mins prior to removal
Removed by the physician or APN

The suture is cut and a sterile airtight petroleum jelly gauze

dressing is
prepared
Patient bears down (Valsalva Maneuver) and the tube is removed
The site is immediately covered with the airtight dressing to
prevent air from
entering the pleural space
Chest X-Ray is done to evaluate for pneumothroax and/or
reaccumulation of
fluid
Observe the wound for drainage and reinforce the dressing
Assess the patient for respiratory distress, which may signify a
recurrence of
the original problem.