Policy Manual sample

MDT Home Health Care Agency, Inc. 195 • The unit contents should be checked for color abnormalities and for the presence of any particulate matter. • If the integrity of the unit has been compromised and/or any abnormalities of the contents are noted, the unit should not be used and should be returned to the blood bank. An incident report needs to be completed. • Prime the IV tubing with normal saline, followed by the blood component as ordered by the physician. • Take and record the patient’s temperature, pulse, respirations and blood pressure before starting the transfusion, 15 minutes after the transfusion is started, and as appropriate based on the patient’s clinical status until the transfusion is complete. A final set of vital signs is to be recorded at the completion of the transfusion. • Adverse Reactions: • Mild: hives and pruritus  Nursing Responsibilities: ♦ Stop the transfusion ♦ Hang new tubing with normal saline to maintain IV access ♦ Administer Benadryl if ordered ♦ Notify the physician and the Clinical Supervisor ♦ Notify the blood bank and draw appropriate blood samples as directed • Anaphylaxis: shock, chest tightness, hoarseness, dyspnea, bronchospasm, abdominal cramps, severe nausea and vomiting  Nursing Responsibilities: ♦ Stop the transfusion ♦ Hang new tubing with normal saline to maintain IV access ♦ Maintain a patent airway; perform CPR if necessary ♦ Administer epinephrine 1:1000 subcutaneous as per physician orders ♦ Call emergency medical services ♦ Notify the physician and the Clinical Supervisor ♦ Notify the blood bank and draw appropriate blood samples as directed