Management of

Altered
Cardiovascular
Function
NFDN 2003 – UNIT 7
SLO’s

1. Identify which determinants of health may influence outcomes for the client with altered
cardiovascular function.

2. Identify assessment findings common to clients with altered cardiovascular function.

3. Describe factors that increase the risk of altered cardiovascular function.

4. Identify common diagnostic tests used to assess the client with altered cardiovascular function.

5. Explore safe practices and procedural requirements in the use of Doppler and Vein finder

6. Describe pharmacologic and non-pharmacologic therapies commonly used for the client with
altered cardiovascular function.

7. Identify common complications associated with altered cardiovascular function.

8. Explain specifically what components of care you may need to collaborate on with the client,
family, and the interdisciplinary team in the assessment, formulation of priority nursing
diagnoses, planning, implementation, and evaluation of care of the client with altered
cardiovascular function.

9. Describe the role and responsibilities of the practical nurse when managing care for the client
with altered cardiovascular function.
 SLO’s Cont’d

10. Describe the purpose, indication for, and nursing care associated with:
o ECG monitoring
o Telemetry
o Holter monitor
o Blood transfusion:
 Components of blood products commonly transfused
 Obtaining blood and blood products from the blood bank,
 Identification of client
 Initiation of transfusion and the role of the practical nurse during initiation
 Monitoring the client during transfusion
 Maintaining the transfusion
 Discontinuing transfusion
o Phlebotomy (blood draw)

11. Identify specific health teaching that may be required for the client with altered cardiovascular function.
 SLO’s Cont’d

12. Indicate how you plan to integrate the nursing metaparadigm, nursing process, cultural competence, and
critical thinking practices to demonstrate safe, quality, nursing care for:
o Blood transfusions:
 Describe the ethical, legal, cultural, and religious considerations related to the administration of
blood and blood products.
 Obtaining blood and blood productrs from blood bank
 Identification of the client
 Monitoring the client during transfusion
 Maintaining, and discontinuing the transfusion
o Phlebotomy (blood draw)

13. Outline what pertinent information is required to document and report to members of the interdisciplinary
team regarding the client with altered cardiovascular function
Cardiovascular System – System review
Cardiovascular System – System review

▪ Transport system
▪ Right & left pump simultaneously
▪ Right side of heart
▪ Where does this deliver blood to? Why?
▪ Left side of heart
▪ Where does this deliver blood to? Why?
Cardiovascular System – System review

▪ Systole – chambers contract, AV valves close (S1),

semilunar valves open
▪ Atrial kick
▪ Diastole – chambers relax, AV valves open, semilunar
valves close (S2)
▪ Blood on right side is deoxygenated
▪ Blood on the left side is oxygenated
 Cardiovascular System – System review

▪ Electrical impulses are sent from the SA

node (top right atria) to the AV node
(bottom right atria) to the Bundle of His
▪ SA node stimulates contraction of the
atria
▪ AV node sends electrical transmission
(delay to allow Atria to fully contract) to
the Bundle of His which stimulates
contraction of the ventricles
▪ Contraction occurs through
depolarization
Cardiovascular System – System review

▪ Arteries
▪ Carry oxygenated blood
▪ Strong, tough & can withstand higher pressure
▪ More elastic fibers to stretch with systole &
diastole
▪ Vascular smooth muscle contracts and dilates to
control blood flow

▪ Veins
▪ Parallel the arteries
▪ Lie closer to the skin surface
▪ Carry deoxygenated blood & waste products from
tissues
▪ Low pressure system
▪ Flow via skeletal muscle contraction, intraluminal
valves, and pressure gradient caused by breathing
Cardiovascular System – Automatic Nervous System review
Fill in the blank
Sympathetic Nervous System Parasympathetic Nervous System

▪ __________ HR ▪ __________ HR
▪ __________ Conduction Impulses ▪ __________ Conduction Impulses
▪ __________ A & V Contractions ▪ __________ change in vessel
▪ Vaso__________ in response to
Sstimulation of the α-adrenergic
receptors
▪ Vaso__________ in Decreased
stimulation to the α-adrenergic
receptors
 Age Related Considerations

▪ Cardiovascular disease is the leading cause of

death in people over 85
▪ It is the most common cause of hospitalization
and the second leading cause of death in adults
younger than age 85.
▪ the amount of collagen in the heart increases
and elastin decreases.
▪ affect the myocardium’s ability to stretch
and contract.
▪ Pacemaker cells decrease – at 75 you only have
10% of the “normal” number of pacemaker cells
▪ Contributes to more frequent dysrhythmias.
▪ Blood vessels thicken and loose elasticity
▪ Contribute to increased SBP and Pulse
Pressure
Age Related Considerations – Assessment
findings
 Risk Factors for Heart Disease

Nonmodifiable Modifiable Medication/Supplement

• family history or • Obesity • NSAIDS

premature • Smoking • Corticosteroids
cardiovascular disease • High salt intake/poor • Oral Contraceptives/sex
• Increasing age diet hormones
• Race • Sedentary lifestyle • Vasoconstricting
• Gender (men & • Continued exposure to Decongestants
postmenopausal stress • Antidepressants (MAOIs,
women) • Elevated blood glucose SNRIs, SSRIs,)
• Hypertension level • Midodrine
• Diabetes • Nonadherence • Calcineurin inhibitors
• Erythropoietin
• Stimulants – Cocaine
Cardiovascular
Nursing
Assessment

14
Health History – Cardiac Emergency

▪ MI, new onset Arrythmia,

▪ Nurse obtains by using a few
specific questions
▪ Onset and severity of chest
discomfort
▪ Associated symptoms and
current medications
▪ Simultaneously the nurse
observes general appearance,
heart rate & rhythm, BP,
Health History – Stable Patient

▪ Complete health history done

during initial contact
▪ Useful to have spouse/ partner
attend interview
▪ Initial demographic information
regarding age, gender, and ethnic
origin is obtained
Non-Cardiac Medications that affect Cardiac System

- Anticancer agents
- Dysrhythmias, tachycardia, heart failure, cardiomyopathy
- Antipsychotics
- Dysrhythmias, orthostatic hypotension, hypertension, cardiac arrest, prolongation of QT
- Corticosteroids
- Hypotension, edema, potassium depletion, hypertension, thrombophlebitis
- Hormone therapy, oral contraceptives
- Myocardial infarction, thromboembolism, stroke, hypertension
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Hypertension, myocardial infarction, stroke, heart failure
- Psychostimulants (Cocaine, Amphetamines)
- Tachycardia, angina, myocardial infarction, hypertension, dysrhythmias
- Tricyclic antidepressants
- Dysrhythmias, orthostatic hypotension
Cardiovascular System – System review

▪ Blood Pressure
▪ Arterial Blood Pressure (BP)
▪ Measurement of pressure exerted by blood against arterial system
▪ Systolic Blood Pressure (SBP)
▪ Pressure exerted against arteries as heart contracts
▪ Diastolic Blood Pressure (DBP)
▪ Residual pressure against arteries during ventricular relaxation
▪ Mean Arterial Pressure (MAP)
▪ Amount of pressure exerted during one cardiac cycle.
▪ (SBP + 2DBP) / 3
▪ Pulse Pressure
▪ Difference between SBP and DBP
 Cardiovascular Nursing Assessment – Assessment
Abnormalities - Inspection

▪ Distended neck veins

▪ Elevated right atrial pressure;
right-sided heart failure
▪ Central cyanosis
▪ Inadequate O2 saturation of
arterial blood as result of
pulmonary or cardiac disorders
▪ Peripheral cyanosis
▪ Reduced blood flow because of
heart failure, vasoconstriction,
cold environment
https://www.medicalnewstoday.com/articles/320320
Cardiovascular Nursing Assessment – Assessment
Abnormalities - Inspection

▪ Clubbing of nail beds

▪ Endocarditis, congenital defects,
prolonged O2 deficiency
▪ Venus and Arterial Ulcers
▪ Poor venous or arterial blood flow
▪ Varicose veins
▪ Incompetent valves in vein
Cardiovascular Nursing Assessment – Assessment
Abnormalities - Pulse

▪ Bounding
▪ Hyperkinetic state (fever, anxiety),
anemia, hyperthyroid
▪ Thready
▪ Blood loss, decreased cardiac
output, aortic valve disease,
peripheral arterial disease
▪ Irregular
▪ Dysrhythmia
▪ Pulsus Alternans
▪ Heart Failure
Cardiovascular Nursing Assessment – Assessment
Abnormalities - Pulse
▪ Absent
▪ Atherosclerosis, thrombus, trauma, embolus

▪ Thrill
▪ Aneurysm, aortic regurgitation, Arteriovenous
fistula

▪ Rigidity
▪ Atherosclerosis

▪ Tachycardia
▪ Exercise, anxiety, shock, increased need for
cardiac output, hyperthyroidism

▪ Bradycardia
▪ Rest, SA or AV node damage, athletic condition,
medication induced hypothyroidism
 Cardiovascular Nursing Assessment – Assessment
Abnormalities - Extremities

▪ Cold ▪ Decreased Capillary Refill

▪ Peripheral arterial obstruction, decreased ▪ Reduced arterial perfusion, anemia
cardiac output, anemia
▪ Asymmetrical Circumference
▪ Pitting Edema ▪ Thrombophlebitis, varicose vein,
▪ Fluid in tissues, Venous return disruption lymphedema
 Cardiovascular Nursing Assessment – Assessment
Abnormalities - Auscultation

▪ Pulse Deficit
▪ Dysrhythmia

▪ Arterial Bruit
▪ Arterial obstruction or aneurysm

▪ S3
▪ Left ventricular failure, volume overload, M-A-or T
Valve regurgitation

▪ S4
▪ Ventricular hypertrophy, aortic stenosis, HPTN, CAD

▪ Murmur
▪ Valve disorder, abnormal blood flow

▪ Pericardial Friction Rub

▪ Pericarditis
Diagnostic Tests
Diagnostic Tests – Non-Invasive Studies

Chest Radiograph (X-Ray)

 Assesses: Contour, size and

configuration of heart
 Use to: Diagnose displacement
or enlargement of heart,
Precordial Effusion, or
Pulmonary congestion
 Nursing Care: Jewelry or metal
objects removed as can
obstruct views
 Diagnostic Tests – Non-Invasive Studies

Electrocardiography
(ECG, or EKG)
 Assesses: Records Cardiac activity
(3 - 5 – 12 - 15 leads available)
 Used to: Identify cardiac
dysrhythmias, cardiac hypertrophy,
pericarditis, MI, pacemaker
performance
 Nursing: Apply Electrode, instruct
patient to remain still https://www.conectmed.com/12-leads-ecg-ekg-placement-with-10-leads-ecg-cable.html
ECG Analysis

P Wave: ______________________
_____________________________

PR Interval: ___________________
_____________________________

QRS Interval: __________________

_____________________________

ST Segment: __________________
_____________________________

T Wave: ______________________
_____________________________

QT Interval:____________________
_____________________________
12 Lead ECG
12 Lead ECG
Lead II – ECG - Normal Sinus Rhythm

P Wave: ___________________________________________________

PR Interval: ________________________________________________

QRS Interval: _______________________________________________

ST Segment: _______________________________________________

T Wave: ___________________________________________________

QT Interval:_________________________________________________
Lead II – ECG - Atrial Fibrillation

P Wave: ___________________________________________________

PR Interval: ________________________________________________

QRS Interval: _______________________________________________

ST Segment: _______________________________________________

T Wave: ___________________________________________________

QT Interval:_________________________________________________
Diagnostic Tests – Non-Invasive Studies

Ambulatory Electrographic Monitoring (Holter

Monitor)
 Portable continuous ECG Monitoring over
longer period (24-48hrs), stored and viewed
later
 Inpatient or Outpatient
 Nursing: Electrodes applied, education on
keeping a diary on activities/symptoms to
correlate to views later
Trans telephonic Event Recorder (“tele”)
 Portable ECG Monitoring continuous monitoring
sent in real time to a monitor to be reviewed.
 Inpatient only
 Nursing: Apply Electrodes, Monitor rhythm/ECG
Diagnostic Tests – Non-Invasive Studies

Stress Test
 Assesses: Demand on coronary
arteries during physical stress.
 Used to Diagnose
cardiovascular diseases
 Nursing: Educate on procedure,
Monitor vitals and ECG changes
throughout and after.
 Contraindicated: Women,
patients who are physically
unable to exercise, Caffeine,
smoking, β-Adrenergic blockers
Diagnostic Tests – Non-Invasive Studies

Echocardiography (Ultrasound)

 Assesses: Cardiac configuration,

valvular structure and motion,
chamber size and contents,
cardiac muscle thickness,
pericardial sac, ascending aorta,
ejection fraction
 Nursing: Educate on procedure,
NPO status if completed
transesophageal
Diagnostic Tests – Non-Invasive Studies

Doppler (Ultrasound)

 Assesses: degree of blood flow

– can assess both arterial and
venous blood flow.
 SOUND Bedside test
 Nursing: Education, jelly
 Diagnostic Tests – Blood Studies

▪ Creatine Kinase (CK) ▪ Blood lipid

▪ Troponin ▪ Enzyme released during
myocardial tissue injury
▪ C-Reactive Protein (CRP)
▪ Soluble Proteins that transport
▪ Cholesterol lipids
▪ Triglycerides ▪ Protein released after MI
▪ Lipoproteins (LDL, HDL) ▪ Mixture of Fatty Acids
▪ Inflammatory marker predicts
Cardiac disease/events

Match the test to descriptor

 Diagnostic Tests: Coagulation Studies

▪ Assessment of extrinsic coagulation by

▪ Activated Partial Thromboplastin measurement of factors I, II, V, VII, and
X
time (aPTT)
▪ Assessment of intrinsic coagulation by
▪ D-Dimer measuring factors I, II, V, VIII, IX, X, XI,
and XII
▪ International normalized ration
▪ Count of number of circulating platelets
(INR) ▪ measure a fragment of fibrin that is
formed as a result of fibrin degradation
▪ Platelet count and clot lysis
▪ Prothrombin time (PT) ▪ Standardized system of reporting PT

Match the test to descriptor

Diagnostic Tests: Hematologic Study

Complete Blood Count (CBC)

▪ WBC – total number of Leukocytes
▪ Platelet – Total Number of Platelets
▪ Hemoglobin – Measures the 02 carrying capacity of RBC’s
▪ Hematocrit – Measure the packed cell volume of RBC’s
▪ Totally RBC Count – Number of circulating RBC’s
▪ WBC Differential
▪ Neutrophils > Eosinophils > Basophils > Lymphocytes > Monocytes
Common Cardiac
Diseases
Hypertension

SBP => 140mmHg OR DBP=>90mmHg

Modifiable

Leads to development of Cardiovascular Disease

Hypertension - Complications

Injury to internal organs

Heart: Aorta Kidneys Brain

Myocardial Ischemia
Inflammation and Reduces blood flow,
or infarction, left Aneurysm, acute
Ischemia, renal TIA, Stroke,
heart failure, aortic syndromes
failures aneurysm
atherosclerosis
Hypertension – Nursing Care

Monitor BP

Encourage and Monitor Nutritional Therapy

• Restrict Sodium Intake

• Restrict intake of Cholesterol and Sat fats
• Adequate Potassium
• Adequate Calcium and Magnesium

Encourage Lifestyle changes

• Tobacco cessation
• Alcohol Moderation
• Increase Activity

Education on Medications

• Diuretics
• Adrenergic Inhibitors
• Angiotensin Inhibitors

Encourage family support

 Coronary Artery Disease

Wide spread Atherosclerosis of the blood vessels

Fibrous “plaque” formation on inside of blood vessels

Caused by: tobacco use, hyperlipidemia, hypothyroidism,

hypertension, toxins, diabetes, hyperhomocysteinemia, and
infection
Coronary Artery Disease – Complication

The plaque can

Narrows and clogs Chronic Stable
rupture off causing
arteries Angina
an embolism

Myocardial
Slows flow of blood MI, Stroke
Ischemia
Coronary Artery Disease – Nursing Care

Encourage Diet and Lifestyle changes

• Limit saturated fats and cholesterol intake

• 150min/week of moderate intensity activity

Medication Educations

• Statins,
• Antiplatelet,
• Nitrates
• Beta Blocks
• Calcium Channel Blockers
• Adenosine Diphosphate Receptor Antagonist
• Heparins
• Fibrinolytic Therapy

Education on potential procedures

• Coronary Artery Stent

• Coronary Artery Bypass Graft (CABG)

Education on S/S of MI

• Include family / support

CABG
Stent
Myocardial Infarction

Ischemia causing irreversible myocardial cell death

NSTEMI

STEMI

Characterized by Severe Immobilizing pain, Nausea and Vomiting,

Most common in early morning

Manifested by: prolonged elevated BP and HR

Myocardial Infarction – Complications

Dysrhythmi Heart Cardiogenic

Pericarditis
a Failure Shock

Decreased Inadequate O2
Inflammation
Can be fatal pumping and Nutrients
of pericardium
action of heart to tissues
Myocardial Infarction – Nursing Care

Rapid Diagnosis and Treatment extremely important

Obtain ECG

• Detect dysrhythmia

Educate about condition

Administer Medications

• Nitroglycerin, ASA, Morphine – first line

• Fibrinolytic Therapy

Monitor Vitals

• Maintain 02 sats >90%

Encourage Bedrest

Education on Potential procedures

• Percutaneous Coronary intervention

Heart Failure

Impairment of cardiac pumping, filling or both

previously called Congestive heart failure

Associated with
• Hypertension, Coronary artery disease, or myocardial infarction

Caused by
• Anemia, infection, dysrhythmia, Pulmonary embolism, Pulmonary disease,
nutritional deficiencies, hypervolemia
Two types
• Right and left
Heart Failure

Left Sided Heart Failure Right Sided Heart Failure

▪ Most common ▪ Back flow of blood into right
atrium and venous circulation
▪ Left ventricular dysfunction
▪ Blood flows back through left atrium ▪ Caused by left sided heart failure
and pulmonary veins
▪ S/S
▪ S/S ▪ ____________________
▪ ____________________ ▪ ____________________
▪ ____________________ ▪ ____________________
▪ ____________________ ▪ ____________________
▪ ____________________ ▪ ____________________
Heart Failure – Nursing Care

Monitor 02 saturations

Encourage Exercise and Activity

• 30-45min 3-5times/week
• Be realistic

Education on Medications

• Diuretics
• ACE inhibitors
• Neprilysin inhibitor
• Beta Blockers

Diet Education and Weight Loss

• Low salt diet

Education on potential Procedures/devices

• Cardiac Resynchronization Therapy (pacemaker)

• Implanted Cardioverter-Defibrillator
• Mechanical Circulatory Support

Educate about condition / adherence to therapies

Infective Endocarditis

Infection of heart valves or of the endocardial surface of the heart

Risk Factor
• Prosthetic valves, acquired valvular disease, cardiac lesions
• Organisms entering bloodstream
S/S
• Low grade fever, chills, weakness, malaise, anorexia, back pain, weight loss,
headache
Complications
• Mitral or Aortic Murmurs
• Heart Failure
• Emboli formation
Infective Endocarditis – Nursing Care

Assessments

• Mental status, dyspnea, chest pain

Encouraging physical and emotional rest

• Compression stockings
• ROM exercises
• DB & C exercise

Administering/Educating on Medications

• Antibiotic therapy

Education on reducing risk of reinfection

Educate about condition / adherence to therapies

Valvular Heart Disease

Stenosis Regurgitation
▪ Valve orifice is restricted forward ▪ Incomplete closure of valve
flow results in backflow of blood
▪ Aortic Stenosis common in ▪ Mitral regurgitation common in
elderly elderly
▪ Leads to Heart Failure, acute ▪ Leads to Heart Failure, acute
pulmonary edema, pulmonary edema,
thromboembolism and thromboembolism and
endocarditis. endocarditis.
Valvular Heart Disease

Treatment
• Valve replacement
• Mechanical - manufactured
• Biological – bovine, porcine, and human tissue
Nursing Care
• Educate about condition / adherence to therapies
• Activity
• Appropriate exercise encouraged
• Strenuous exercise to be avoided
• Medications
• Digoxin, Beta-adrenergic Blockers, Antidysrhythmic
• Prophylactic antibiotic therapy
• Anticoagulant therapy
Peripheral Artery Disease - Complications

Highest risk for

Emboli related Poor/non healing Critical Limb
ischemia (along wounds Ischemia
with CAD)

MI, Ischemic Arterial Ulcers or Surgical treatment

Stroke Gangrene necessary
Peripheral Artery Disease

▪ Thickening of artery walls – progressive narrowing of arteries in

extremities.
▪ Risk Factors / Associations
▪ Age, diabetes, coronary artery disease, smoking, kidney disease,
hypertension, hyperlipidemia, obesity, hyperhomocysteinemia,
sedentary lifestyle, stress.
▪ S/S
▪ Intermittent claudication, thin shiny taut skin, hair loss on extremities,
Pedal, popliteal or femoral pulses diminished/absent, 6 P’s
▪ Segmented blood pressure – decrease > 30mmHg
Peripheral Artery Disease – Nursing Care

Educate about condition / adherence to therapies

Education on lifestyle changes

• Healthy body weight, regular (appropriate) physical activity, smoking cessation, BP

control, diabetic management

Education on medications

• ACE Inhibitors, Antiplatelet therapy, Hemorrheologic agents

Education on potential Procedures

• Stent, atherectomy, Cryoplasty

• Peripheral artery bypass
• Amputation
Anemia

Deficiency in number of erythrocytes, or quality of quantity of hemoglobin, or

the volume of packed RBC

Can be described in Morphological or Etiological classification

Etiological Classification
• Decreased Erythrocyte Production
• Blood Loss
• Increased Erythrocyte Destruction

Risk Factors
• Elderly Men
• Changes for each Etiological classification
Treatment and Preventions

Pharmacological

Non-Pharmacological
BLOOD
TRANSFUSIONS
Blood Transfusions – Why?

1. ___________________________

2. ___________________________

3. ___________________________
https://transfusionnews.com/2017/07/26/systematic-review-recommends-
standard-ratios-of-blood-products-for-massive-transfusion/
▪
▪
▪
▪
▪
▪ Manufactured Products
▪
▪
▪
▪
▪ Components of Blood
▪ Whole Blood or
▪ Intravenous administration of
Blood Transfusion
Blood Transfusion – Blood Groups and Types

▪ ABO Blood Types

▪ A, B, O, and AB

▪ Rh Factor
▪ + and -

Blood types
Autologous Blood Transfusion

▪ Donation of own blood for a surgical procedure

▪ Obtained up to 5 weeks prior to surgery
▪ Donate ability depends on body's ability to maintain
acceptable hematocrit.
▪ Blood can be salvaged during surgery and reinfused
▪ Decreased risk of complications and exposure to
infection agents
 Blood Transfusion Reaction Types

Febrile Non-Hemolytic Acute Hemolytic Transfusion –

Bacterial
Transfusions Reaction Transfusion Reaction Associated Circulatory
Contamination
(FNHTR) (AHTR) overload (TACO)
• Most common - • Rare – but can be • Blood contaminated • Shortness of Breath
Inflammation fatal with bacteria and Volume
reaction • ABO-Incompatibility • S/S: Overload
• Managed with • S/S: • Managed with
analgesics and slower infusions,
antihystamine pre/post transfusion
• S/S: diuretics
• S/S:
• Acute hemolytic transfusion reaction
• Bacterial Contamination

Pain
• Acute Hemolytic transfusion reaction
• Febrile non-hemolytic transfusion
reaction
Transfusion reactions | Professional Education (bloo
.ca)
Blood Transfusion – Transfusion Reaction

Nursing Care
• STOP
• Remove line and replace with NS
• Monitor vitals
• Notify MRP
• Stay with patient
• Save Blood and line
• Record/document
Blood Transfusion - Cross Matching

▪ Lab Test to ensure blood compatibility

▪ Issues a BB Number that is Patient Specific
▪ Even if patient knows blood type and Rh factor it still
needs to be cross-matched to make sure that a donor
supply will not cause a reaction in the patient. Need to
know:
▪ Type, Rh, antibodies. TEST for viruses
73
Blood Transfusion – Nursing Role

▪ Physicians order and Consent must be obtained

▪ _________________________
▪ Assess cultural/religious background
▪ Explain procedure and side effects
▪ Ensures Crossmatch is complete
▪ Ensure appropriate IV access
▪ ____________________
▪ ____________________
▪ Ensure appropriate equipment
▪ ____________________
▪ ____________________
▪ Administer any Pre-transfusion Medication
▪ ____________________
▪ ____________________
Blood Transfusion – Nursing Role

▪ Obtain Blood from Storage/Lab

▪ ______________________
▪ Obtain Patients baseline
▪ ______________________
▪ Complete Blood Check DO NOT REMOVE TAG
▪ ______________________
▪ ______________________
▪ ______________________
▪ Administer Blood
▪ ______________________
▪ Monitor for Transfusion Reaction
Blood Transfusion – Nursing Role

▪ Ensure transfusion record is completed

▪ If NO reaction discard blood tubing and bag into biohazard
▪ Return copy of transfusion record to lab.
▪ If reaction return blood bag/tubing/tag to lab for analysis.
▪ Return copy of transfusion record – and reaction record to lab
▪ Continue to monitor according to facility policy
▪ Administer post transfusion medication
▪ _____________________________
Blood Transfusion – Emergency transfusion

▪ If ABO and RH is known then

specific group of unmatched
released to be administered
▪ If ABO and RH unknown type O-
Negative or O-Positive
unmatched blood is
administered.
▪ O-Neg given to female children
or females of childbearing
potential or pregnant persons
Critical Thinking: Integration Theory and Practice

Nursing
Nursing
Metaparadig
Concepts
m

Determinants
Art and of Health to
Science of Patient
Nursing Outcomes In
this unit