Download HEALTH SERVICES CODE: B.1.3 NURSING PROCEDURE TITLE

CODE: B.1.3
HEALTH SERVICES
NURSING PROCEDURE
TITLE: BLOOD & BLOOD PRODUCTS -
IV and IM ADMINISTRATION –
A.
B.
C.
D.
Rh (D) IMMUNE GLOBULIN
Prior to Obtaining Rh(D) Immune Globulin
Obtaining Rh(D) Immune Globulin
Administration of Rh(D) Immune Globulin
Following Administration of Rh(D) Immune
Globulin
CATEGORY: RN – SNP – IV administration
RN – General – IM administration
LPN – General – IM administration
PURPOSE
IV or IM administration:
 Prevention of Rh alloimmunization by pregnancy or other obstetrical conditions, or
transfusion.
 Suppresses the active antibody response and formation of anti-Rh (D) antibodies in a Rh
(D) negative person exposed to Rh positive blood via transfusion of platelets. It may be
considered if Rh positive RBC units have been administered to an Rh negative patient, in
consultation with transfusion medicine or clinical hematology.
IV administration only:
 Treatment of Immune Thrombocytopenic Purpura (ITP) in Rh positive patients with intact
spleen.
NURSING ALERT:
The product is indicated in Rh -negative women:
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
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
In pregnancy at 28 weeks gestation.
Within 72 hours in the following situations:
After delivery if the baby is Rh (D) positive or unknown, after spontaneous or induced
abortion, amniocentesis, cordocentesis, chorion villus sampling, external version, ruptured
tubal pregnancy, abdominal trauma, or transplacental bleeding.
Administer as soon as possible in the case of maternal bleeding due to threatened abortion.
If administered early in pregnancy, recommended to administer at 12 week intervals in order
to maintain adequate levels of passively acquired anti-Rh.
If more than 72 hours has elapsed, administer as soon as possible up to 28 days.
Approved:
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CODE B.1.3
NURSING ALERT CONT.
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Postpartum, dosage is determined by the Transfusion Department based on the
quantification of feto-maternal haemorrhage.
WinRho® SDF liquid contains maltose, which can give falsely high blood glucose levels in
certain types of blood glucose test systems.
When the interval between administration of Rh (D) immune globulin and MMR is less than
14 days serologic testing should be done 2 months later to assess the immune response
and need for repeat MMR.
EQUIPMENT
1.
2.
3.
4.
5.
6.
A.
1.
2.
3.
Group and Screen
Physician order or Authorization for Anti-D Immunoglobulin for Antenatal Cases
RQHR 013 (Appendix D)
Consent/ Refusal for Administration of Blood/ Blood Components and/ Plasma
Protein Products RQHR 1163 (Appendix A) or Consent to Diagnostic and Treatment
Procedures RQHR 370 (Appendix B) or Consent to Diagnostic and Treatment
Procedures Outpatient and Ambulatory (Appendix C) or Consent for administration
of Blood/ Blood Components and/or Plasma Protein Products Wallet card
(Appendix E)
Rh (D) immune globulin from Transfusions Department
Personal protective equipment (PPE) as appropriate
Notification of Administration of Blood and/ or Blood Products RQHR 425 (Appendix
F)
IV administration:
1 - 6 mL syringe with blunt needle
2 -12 mL syringes with 5 mL of normal saline solution in each
Alcohol swabs
B. IM administration:
1. 1 – 6 mL syringe with appropriate needle for IM use (1” 25 gauge needle)
2. Alcohol and chlorhexidine swabs
PROCEDURE
A.
Prior to Obtaining Rh (D) Immune Globulin
1.
Verify physician’s order.
NOTE:
Fetal Assessment Unit utilizes the Authorization for Anti- D
Immunglobulin for Antenatal Cases RQHR 013 (Appendix D) when
obtaining physician’s order.
Approved: April 1, 2015
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CODE B.1.3
2.
Check chart for completed Consent/ Refusal for Administration of Blood/ Blood
Components and/ or Plasma Protein Products RQHR 1163 (Appendix A) or other
appropriate consent form. Consent is considered valid for the entire pregnancy and
postpartum period.
NURSING ALERT:


Prophylaxis of Rh immunization: Do not administer to patients who are Rh (D) positive,
Rh (D) negative women who are Rh sensitized (has developed anti Rh (D) antibodies),
patients with a history of anaphylactic or other severe systemic reaction to immune
globulins, patients who are hypersensitive to this drug or any ingredient in the formulation, or
who are IgA deficient.
Treatment of ITP:
 Do not administer to patients who are Rh (D) negative, splenectomized, patients with a
history of anaphylactic or other severe reaction to immune globulins, patients who are
hypersensitive to this drug or any ingredient in the formula, IgA deficient, elderly patients
with underlying cardiac, renal, or hepatic co-morbidities, and/ or those with evidence of
autoimmune haemolytic anemia (Evan’s Syndrome), Systemic Lupus Erythematosus
(SLE) or anti-phospholipid antibody syndrome.
 Obtain physician order for CBC 8 hours following administration of IV dose.
 Monitor closely for 8 hours post administration for complaints of back pain, shaking,
chills, fever or discoloured urine.
 If CBC report indicates hemoglobin is reduced by greater than 10g/L, notify transfusion
department to investigate possible transfusion reaction.
3.
Provide patient with hand out Rh (D) Immune Globin CEAC 1148 (Appendix G).
4.
Inform patient of use and side effects.
5.
Ask patient the following screening questions before giving this product.
▪ Have you had a splenectomy?
▪ Do you have any allergies?
▪ Was there a reaction to previous blood products or human globulin?
▪ Have you received any vaccines in the last three months?
B. Obtaining Rh (D) Immune Globulin
1. Stamp blood requisition with patient’s addressograph. Include the required blood
product on the requisition.
2. Present requisition to Transfusion Department.
NOTE: Any RQHR employee certified to transport blood and blood products
may obtain product from Transfusion Department. Volunteers are
not regarded as RQHR employees.
Approved: April 1, 2015
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HEALTH SERVICES
CODE B.1.3
NURSING ALERT:
All blood products must be CHECKED AT BEDSIDE BY TWO INDIVIDUALS from following
designations:
 Registered nurse (RN)
 Registered psychiatric nurse (RPN)
 Licensed practical nurse (LPN)
 Nurse practitioner (NP)
 Medical doctor (MD)
 Perfusionist
 Nursing student – under supervision of instructor, RN/RPN/LPN
 Grad nurse (GN), Advanced Care Paramedic, or competent trained adult for home
infusion) may check blood only if checking with an RN/RPN/LPN (see Policy 4.2.4 –
Administration of blood products , in RQHR Policy Manual).
NOTE: For areas that do not have two individuals of the above designations
available, an identified and trained designate approved by the Transfusion
Department may check blood with an RN.
C. Administration of Rh (D) Immune Globulin
1.
2.
Inspect the integrity of the product, including the physical appearance and expiration date.
NOTE:
Do not use solutions that appear cloudy or contain deposits. Do not use if
expired. Contact Transfusions Department if any concerns.
NOTE:
Liquid Rh (D) immune globulin does not require reconstitution.
Verify at the bedside by two individuals:
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


3.
Client name
MRN
Date of birth against transfusion record
Verbal validation
Attach pink copy of transfusion tag to transfusion record. (Appendix H)
IV ADMINISTRATION
1.
Initiate IV access and saline lock if not already done.
NOTE: If an IV is already in progress, stop infusion and flush with normal
saline.
2. Obtain and document baseline vital signs (BP, HR, RR and Temp).
3. Administer and monitor as per product monogragh.
Approved: April 1, 2015
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CODE B.1.3
4. Flush with normal saline after administering WinRho®SDF Liquid to ensure dose
has been completely administered to patient.
5. Observe for adverse reaction for at least 20 minutes after administration. For
treatment of ITP, observe patient for 8 hours following administration. See following
nursing alert regarding side effects.
IM ADMINISTRATION
NOTE: Liquid Rh (D) immune globulin does not require reconstitution.
1.
Administer and monitor as per product monograph.
NOTE: The gluteal region should not be used as an injection site due to the risk of a
sciatic nerve injury.
2.
Administer solution when it has reached room temperature. Liquid Rh (D) immune
globulin must be administered within 4 hours of issue.
3.
Observe patient for adverse reaction for at least 20 minutes after administration. See
following nursing alert regarding side effects.
NURSING ALERT:
IM Administration: Reactions to WinRho® SDF are rare in Rh- negative individuals. Side
effects may include:
 Discomfort or slight swelling at injection site
 Slight elevation in temperature.
IM and IV Administration: Adverse reactions are rare and include following signs and
symptoms. If you observe any of these symptoms, notify MRP immediately. Complete
Saskatchewan Hospitals Transfusion Adverse Events Form (Appendix H). This form can be
obtained from the Transfusion Home page intranet site:
http://rhdintranet/Transfusions/public/Forms/SK%20AE%20form.pdf
 Hives
 Rash
 Chest tightening
 Wheezing
 Shortness of breath
 Feeling light headed or dizzy when standing (sudden drop in blood pressure)
For Treatment of ITP:
Most commonly reported side effects include:
 Pain/swelling at injection site
 Headache
 Chills
 Fever
 Nausea and vomiting
 Arthralgia
Approved: April 1, 2015
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CODE B.1.3
NURSING ALERT CONT.
Adverse reactions are rare and include the following signs and symptoms. If you observe any of
these symptoms, notify MRP immediately. Complete Saskatchewan Hospitals Transfusion
Adverse Events Form (Appendix H). This form can be obtained from the Transfusion Home
page intranet site: http://rhdintranet/Transfusions/public/Forms/SK%20AE%20form.pdf
 Back pain
 Discoloured or darkened urine
 Decreased urine production
 Jaundice
 Facial swelling
 Wheezing, chest pain, or shortness of breath
 Decrease in haemoglobin
D.
Following Administration of Rh (D) Immune Globulin
1.
Document:





2.
date and time product given
product and lot#
amount of Rh (D) immune globulin given
site and route
signature of nurse
Complete Notification of Administration of Blood and/or Blood Products
RQHR 425. Ensure that the patient signs it and receives the yellow copy of the
form (Appendix F).
NOTE: If MMR has been administered post partum, check with physician
regarding the need for a requisition for rubella titer in 8 weeks’ time to
determine rubella immune status.
Approved: April 1, 2015
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CODE B.1.3
REFERENCES
Product Insert: WinRho® SDF (July 28, 2010).. Rh (D) Immune Globulin (Human) for
Injection. Cangene Corporation, Winnipeg, Canada.
Public Health Agency of Canada (May 12, 2013) Canadian Immunization Guide. Retrieved
from http://www.phac-aspc.gc/publicat/cat/cig-gci/p01-10-eng.php
Rh Program of Nova Scotia on-line documents, accessed October 15, 2014:
a. Guidelines for Perinatal Antibody Screening and WinRho Administration
(http://rcp.nshealth.ca/sites/default/files/resourcesreports/RhGuidelines Mar 2010.pfd)
b. How to Administer Rho (D) Immune Globulin
(http://rcp.nshealth.ca/sites/default/files/resourcesreports/RhWinRhoInstructions Dec2011.pfd)
Revised by:
Date:
Revised by:
Date:
Shirley Martin, CNE Mother Baby Unit, Wendy Williams, CNE
PAC/DAS & Day Surgery Units, Judy Hoff, MLT Supervisor,
Laboratory
October 4, 2010
Jana Poitras, CNE Mother Baby Unit, Anita MacPherson, CNE 5E,
Janelle Thomson, CNE Women’s Health Centre, Paula Van Vliet,
Transfusion Safety Manager, Laboratory Services
November 3, 2014
Approved by RQHR Procedure Committee:
Date:
Keywords:
WinRho
April 1, 2015
Regina Qu’Appelle Health Region
Health Services
Nursing Procedure Committee
Approved: April 1, 2015
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APPENDIX A
CONSENT/REFUSAL FOR ADMINISTRATION
OF BLOOD/BLOOD COMPONENTS AND/OR
PLASMA PROTEIN PRODUCTS
CLIENT OR SUBSTITUTE DECISION MAKER
I, _______________________________________________________GIVE CONSENT for administration of blood/ blood components
Print name of client or decision maker)
or ______________________________________________________ to __________________________________________________.
(Specify blood products)
(Print name of client)
I have been advised of the nature, consequences, benefits, and material risks associated with the administration of blood products and have
been advised of any reasonable alternatives that may be available for my (or the client’s) condition. I have been informed of the
consequences of refusing the administration of blood products. I have had the opportunity to seek clarification and have had my questions
answered.
Signed: _______________________________________________________
(SIGNATURE OF CLIENT OR SUBSTITUTE DECISION MAKER)
Date: _______________________________________
(DD/MM/YYYY)
Telephone Permission Date: _____________________
Relationship to Client: __________________________________
Date: ________________________________________
Witness: _____________________________________________
(Competent Adult)
REFUSAL OF BLOOD OR BLOOD PRODUCTS
I DO NOT consent to the administration of blood or blood products to myself or ______________________________________________
(NAME OF CLIENT)
Signed: __________________________________________________Date: _______________________________________________
(SIGNATURE OF CLIENT OR SUBSTITUTE DECISION MAKER)
(DD/MM/YYYY)
PHYSICIAN / AUTHORIZED NURSE PRACTITIONER (NP)
The risks of administration of blood/blood components and/or plasma protein products (blood products) have been explained to the client or
substitute decision maker. The nature, consequences, benefits, material risks, and the reasonable alternatives, including the consequence(s)
of refusing the administration of blood products has been discussed with the client or substitute decision maker.
 INFORMATION PAMPHLET GIVEN TO CLIENT
This consent will remain valid per course of treatment up to 1 year or upon hospitalization discharge.
______________________________________________
(PRINT NAME OF PHYSICIAN / AUTHORIZED NP)
_____________________________________________________
(SIGNATURE OF PHYSICIAN / AUTHORIZED NP)
PHYSICIAN
FOR USE IN EMERGENCY SITUATIONS WHERE CAPACITY CANNOT BE DETERMINED AND INFORMED CONSENT CAN NOT BE
OBTAINED (TRANSFUSION OF FULLY CROSSMATCHED DONOR RED BLOOD CELLS AND OTHER BLOOD PRODUCTS).
I certify that any delay in administering this transfusion will seriously endanger the health or life of the patient.
____________________________________________
(SIGNATURE OF PHYSICIAN OR PHYSICIAN DESIGNATE)
__________________________________________
(DD/MM/YYYY)
USE OF UNCROSSMATCHED DONOR RED CELLS
I am aware the risk of transfusion of uncrossmatched donor red blood cells is greater than the risk of fully crossmatched donor red
blood cells. It is my clinical judgment, the risk of awaiting fully crossmatched donor red blood cells is greater than the risk of
administering uncrossmatched donor red blood cells.
Physician Signature: _______________________________
Date: _________________________
(STARS EVENT Number: ____________________________)
CALL RGH TRANSFUSIONS (306)766-4474 AND FAX FORM TO (306)766-4004 WHEN UNCROSSMATCHED RBCs required.
RQHR 1163 (03/14)
White Copy- Chart
Code: B.1.3
Date: October 2010, November 2014, April 2015
Yellow - Patient
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Duration of Consent:
For the purposes of transfusion medicine in Saskatchewan, the duration of consent is for either one
admission or, if a patient suffers from a chronic condition, for one course of treatment within 12
months, so long as the patient’s condition or medical knowledge in general about the condition has
not significantly changed. (Approved by the Senior Medical Officer Committee on May 11, 2011.) 1
List of products for which the Blood Products Consent form is required:
Some Products must have approval by Transfusion Physician on Call
.
Require Blood Products Consent
Red Blood Cells, Leukocyte Reduced (LR),
including washed and irradiated RBC
Platelets, including apheresis and buffy coatderived platelets (Pooled Platelets LR)
Plasma components, including Apheresis Fresh
Frozen Plasma, Frozen Plasma,
Cryosupernatant Plasma, Cryopreciptiate,
Solvent Detergent (S/D) Plasma
Albumin
Hyperimmune Globulins: Anti-D IG (WinRho
SDF), Anti-VZIG, Anti-HBIG, IMIG, Anti-CMV
IG, Hepatitis A Immune Globulin
Immune Globulins, including intravenous (IVIG)
and subcutaneous formulations
C1-Esterase Inhibitor
Prothrombin Complex Concentrates (octaplex,
Beriplex)
Factor Concentrates:
Anti-Inhibitor Coagulant Complex (FEIBA NF)
Antithrombin
FVII Special Access
FVIII/vWF (Humate-P, wilate)
FIX
FXI Special Access
FXIII Special Access
Fibrinogen Special Access
Protein C Special Access
Fibrin Sealants:
Tisseel
Evicel
Artiss
Do not require Blood Products Consent
Factor Concentrates:
rFVIIa (NiaStase RT)
rFVIII (Advate, Helixate FS, Kogenate FS, Xyntha)
rFIX (BeneFIX)
For new or other products not listed,
please contact Transfusions Department at 306-766-4474.
RQHR 1163 (03/14)
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX B
Code: B.1.3
Date: October 2010, November 2014, April 2015
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Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX C
Code: B.1.3
Date: October 2010, November 2014, April 2015
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Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX D
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX E
Consent for administration of Blood/Blood Components
and/or Plasma Protein Products
Name: ____________________________________________________
PHN: _____________________________________________________
Diagnosis: ______________________________________________________
Consent Obtained on (DD/MM/YYYY):_________________________
Consent will expire one year from date obtained.
For the purposes of transfusion medicine in
Saskatchewan, the duration of consent is for
either one admission or, if a patient suffers
from a chronic condition, for one course of
treatment within 12 months, so long as the patient’s
condition or medical knowledge in general about the
condition has not significantly changed.
(Approved by the Senior Medical Officer Committee
on May 11, 2011.)
Please show card to the medical/nursing staff
upon admission to hospital.
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX F
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX G
RH (D) Immune Globulin
What is the (Rhesus factor) Rh factor?

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
This is an antigen found on red blood cells. Those that have the Rh factor” have a positive
(+) blood type and those that do not have a negative (-) blood type.
Having “Rh negative” blood is not usually a problem. Approximately 15% of all people are
Rh negative.
If “Rh positive” blood is given to an “Rh negative” individual, the body may form antibodies
against the Rh factor.
If you are Rh(D) negative when you become pregnant and your fetus has blood that is “Rh
positive”, your body may form antibodies against the positive Rh factor. These antibodies
may cause serious problems in future pregnancies.
Products made from human plasma may contain infectious agents such as viruses. The
manufacturing process is designed to inactivate and eliminate possible infectious agents.
How Can You Protect Yourself Against Developing These Antibodies?

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Rh Immune Globulin is given to prevent your body from developing harmful Rh antibodies.
All women should be tested early in pregnancy to determine if they have a Rh negative
blood type. Those women with an Rh negative blood type receive a dose of this product
during pregnancy. They receive another dose after the pregnancy if the baby has a Rh
positive blood type. If the pregnancy results in unexpected bleeding, miscarriage or
abortion, this product is required.
Individuals who are “Rh negative” and have been exposed to “Rh positive” blood may
require this product.
This product may be used to treat a number of blood disorders.
Who Should not Receive This Product?
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People with a history of hypersensitivity to plasma products.
People with known isolated immunoglobulin A (IgA) deficiencies.
People with allergies to human globulin, polysorbate 80, glycine, Triton X-100, Tri-n-butyl
phosphate.
Your doctor, nurse, or midwife are aware of other medical conditions where Rh (D)
immune globulin is not recommended.
CEAC 1148
December 2012
Page 1 of 2
Code: B.1.3
Date: October 2010, November 2014, April 2015
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Do Reactions Occur After Receiving This Product?

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
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Most people do not have a reaction.
Mild reactions:
- There may be swelling, soreness, and redness where the needle was given. Cold face
cloths to the area reduce discomfort.
- Fever may occur. If necessary, use acetaminophen to reduce fever.
Moderate reactions (occasional)
o Tingling sensation, abdominal or back pain, paleness, diarrhea, joint pain, muscle pain,
high blood pressure, dizziness, sleeplessness, itchiness, rash, and sweating may
occur.
Severe reactions (rare)
o Any medicine carries a small risk of a serious reaction
o These reactions could include difficulty breathing, shock, or death.
What Should I do After Receiving This Product?



Canadian immunization guidelines recommend a 15 minute wait after any type of
immunization.
Seek medical attention if you become moderately or severely ill and inform them of the
recent administration of this product.
Tell your doctor, nurse, or midwife as soon as possible about any reaction.
Before Giving This Product, Screening Includes the Following Questions:




Have you had a splenectomy?
Do you have any allergies?
Have you had a reaction to previous blood products or human globulin?
Have you received any vaccines in the last three months?
For more information about this product call your doctor, nurse, or midwife.
Page 2 of 2
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX H
Code: B.1.3
Date: October 2010, November 2014, April 2015
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APPENDIX I
Code: B.1.3
Date: October 2010, November 2014, April 2015
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Code: B.1.3
Date: October 2010, November 2014, April 2015
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