Blood Transfusion

Order Blood

Patient ID
Name
DOB
Gender
HN

Background Info
Why?
What type?
How much?
Special requirements eg CMV -ve
Needed when?
Needed where?

Legal
Requesting doctor
Bleep
Signature

Sample
Confirm ID
Name
DOB
Gender
HN

Checks
Verbally confirm with patient
Confirms matches wristband 
Matches requesting form
Label tube
NO PRE-PRINTED LABELS on TUBE

Send sample to blood bank

Pre-transfusion Checks
Match ID on blood pack to any form of patient ID
Sign out blood

Check pack
Record patient obs before transfusion
Verbal check with patient
Check with wristband
Check with compatibility form
Check form with blood pack

Record
Why transfusion
Date and time
Sign pre-transfusion checks

Transfusing...
Blood
- within 4hrs from ridge
- within 30mins from out of fridge
- over 3-4hrs
- after platelets

Platelets
- ASAP
- over 30-40mins

Reactions
Symptoms?
Stop and get help
Obs
- Temp <1.5 degrees, slow transfusion and give paracetamol
- Mild urticaria - chlorphenamine 10mg IV and slow transfusion
- ABO incompatibility - stop, return to blood bank, IV fluids, urine output, furosemide if necess
- Severe allergy - stop, return, IV chlorphenamine 10mg, O2, salb nebs, adrenaline
- ?bact - blood cultures, BSp antibiotics

IV Drug Administration

WIPERNA

Wash hands

Hello____
My name is______
I'm a _____

Explain
I was wondering if I could give you some medication - would that be alright? I believe you have a cannula already in site, so we don't need to use an injection and we can use that.

Check name/nameband/prescription chart/allergies

Check infusion site
?redness
?swelling
?pain

Ex/Nm/Nb/Pc/All/Cann

Equipment
Clean tray
2 sterile needles
2 alco swabs
2 syringes

Saline
Drug
Dilutent - sterile water

Sharps bin

& Assemble

Reconstitute
Check prescription chart with drug name, dose, strength, volume, route, time, date, signature - if not signed, not legal to give - therefore find doctor who prescribed it

Check with leaflet or trust drug administration policy

Check name, strength, volume of drug

Check expiry dates x3 - saline/dilutent/drug

Double check with another person

Pc/Lt/Dg/ExpD/x2P

Reconstitute according to guidelines

What you want / Got x What's it in

Wash hands

Glove

Needle + syringe

Flip cap off ampoule

Wipe wth alc swab

Aspirate sterile water

Inject into ampoule

Agitate

Draw up drug

Draw up flush

Distinguish CAREFULLY

WH/Gl/N&S/FpCp/Wp/SW/Amp/Agit/Flh/Dist

Patient

Recheck name, nameband, prescription chart, allergies

Wash hands

Change gloves

Remove port cap

CLEAN BUNG with alco swab and allow to dry

Flush with 5ml saline

?resistence, pain, swelling, leakage around cannula, back flow of blood on aspiration

Inject drug - over recommended time

1ml

Feeling ok? Watch for adverse effects - flushing, resp difficulties, tachycardia

... if occurs...

Stop injection

W/D back into syringe

Get help

Stay with patient

... if added to IV infusion

Fill in additive label and stick onto bag

Date/Time/Drug/Signature

Finish flush

Replace bung/cap

Rc-N/Nb/Pc/All
WH/Gl/Bg/CB/Fs/Dg/AE/Fs/Bg

Thank you

Tidy away

Wash hands
Complete prescription chart and fluid chart - sign

Inform nurse if delayed reaction

Venepuncture

WIPERNA

Hello ______
My name is_______
How are you?

Explain
I was wondering if I could take some blood from you, just so we can do some tests on it, and hopefully help with your care. Have you had this done before? It's not painful, but you will feel a sharp scratch - but I'll warn you, and let you know when it's all over. You don't have to look. Are you okay with needles? Any questions?

Check nameband
I'm just going to get the equipment

Prepare Equipment
Clean tray inside and outside

Tourniquet
Alco swab
Needle
Vacutainer
Blood Bottles
Gauze/cotton wool
Plaster

Wash hands
Assemble equipment
 - attach needle to vacutainer

Prepare Patient
Pt comfortable
Arm exposed from elbow
Lying next to them

Wrap tourniquet
Select vein
Alco swab skin

Cm/Ex/Re/Tq/V/Alc

Gloves
Stabilise vein
Sharp scratch!
Angle - 45 degrees
Reduce angle

Swap hands if necess
Grab bottles

Collect blood
Fill bottle
Remove bottle

Removes tourniquet
Remove needle
Flip back top if attached vacutainer
Sharps bin

Gl/SV/SS!/45/Bt/xTq/xN/Shp

Pressure
Plaster
Invert bottles

Pr/Pl/IB

Thank you
Are you okay?

Label bottles

Suturing

WIPERNA

Hello, I'm________
I'm a_________
How are you?

Explain
Okay, I understand you had an accident. It seems that you'll need a few stitches for your wound, just to help it heal properly, and reduce scar formation, hopefully. This involves using a small needle and special thread, and we'll use LA to help ensure that you're not in pain. Does that sound okay? You're happy for us to go ahead? Are you alright with needles?


I'll just get my equipment.

... Wash hands...
Equipment
Sterile gloves

Lignocaine 1% LA (max 3mg/kg)
Syringe
Green needle

Orange needle

Sterile water/Saline
Gauze
Syringe
Suture pack
-tray
-needle holder
-scissors
-curved scissors
-toothed forceps (skin only)
-non-toothed forceps (needle only)
Suture Needle

Sharps box

Prepare Equipment
Wash hands

Open suture pack with sterile technique

Drop pair of gloves, syringes, sutures and needles into field

Put antiseptic solution into bowl

Sterile gloves on

WH/SF/SW/Gl

Prepare Patient
Questions - tetanus, allergy, LA ?
Inspect wound for debris/dirt - clean and debride if present
X-ray - potential of foreign body
Cleanse/irrigate wound and surrounding skin

0.9% saline soaked gauze/in syringe or with chlorhexidine/betadine (high risk contamination)

Swab held with forceps/hand

Centre outwards

Postion pt so they're comfortable

Cover wound with drape with hole in it - sterile field

Q/Insp/Clean/SF

Anaesthetic
Select syringe and attach the 21G green needle
Draw up 10ml of 1% lignocaine
Dispose of green needle
Attach orange needle

Inject LA into skin encompassing wound approx 0.5-1cm from its edge
Aspirate needle on inserting to ensure a vessel has not been entered
Fan shape around wound

Wait 5-10mins for anaesthetic to work - test area
Ask pts after signs of LA toxicity eg tingling in mouth, metallic taste, dizziness or light headaches, ringing in ears or difficulty in focusing eyes

Max lignocaine = 3mg/kg
Lasts approx 30 mins

Lg/Fan/Wt

Suturing
Mount needle
Grasp curved needle with needle holder (short. blunt forceps with straight jaw)
Hold needle 2/3 along shaft from tip
Perpendicular to needle holder
Hold needle holder with thumb and ring finger, with index to stabilise

Pass through skin about 0.5cm wound edge at middle of wound
Use forceps to pick up skin (toothed) - above hand
Pass N perpendicularly
Full thickness through skin to the base of the wound - xbacteria
Pull suture threat through hole, leaving 2-3cm tail behind
Pass N through opposite skin edge using forceps to hold the skin
Not too tight or loose
Make sure exit hole opposute insertion hole, and 0.5cm from edge
Put needle in sterile tray

Tie knot
- double throw
- needle holder parallel to wound
- wind two loops of long end of suture in a clockwise motion around the needle holder
- needle holder to 12 o'clock
- pull short end of stitch through the loops using the mouth of the needle holder
down to 6 o'clock
- pull knot gently down to the skin, opposing the two sides of wound at the same time

- tighten so skin edges are apposed but without tension

2nd throw - single

3rd throw - single
- single throws in opposite direction
Suture material can then be cut to complete the stitch
- 1cm
- ensure the knots created are everted and spaced 5-10mm apart
- knots on same size
- good opposition - no pie crust or puckering

Halves
- offer to place the next suture (rule of halves) half-way between the present suture and the distal, medial end of the wound. Repeat until the wound closed

Mount/SgKn/Hvs

Tidy Up
Dressing
- dry dressing
- Tetanus immunity if wound contaminated / pt has not had booster in last 10years

Document
- detail of sutures
- polypropelene

Dispose of waste
inform pt that sutures can be removed in 10days

Tell the patient to attend GP
- if any worries (red, oozing wound, stitches come out etc)
- and to in about 7-10 days time for stitches removal./or come back to A&E

Dr/Tt/Doc/Disp/GP

Thank you
Any questions?

Sutures
- scalp
3/0, non absorbable
7 days

- trunk
3/0, non absorbable
10 days

- limbs
4/0, non absorbable
10 days

- hands
5/0, non absorbable
10days

- face
6/0 non absobable
3-5days

Deep wounds
Absorbable eg monocryl, vicryl, dexon
Superficial wounds
Monofilament non-absprbable
eg Nylon (Ethilon) or Prolene

Male Catheterisation

WIPERNA

Hello________
My name is_______________
I'm a doctor
How are you feeling?

I was wondering whether I could catheterise you? Do you know what a catheter is?
We insert a small plastic tube to reach your bladder through your penis, so we can collect the urine into a bag. It helps us monitor how you are doing, and means you won't have to get up to go to the loo. We'll use local anaesthetic so it won't be painful, but it might be uncomfortable at first. Any concerns? Okay - so you're happy with us to go ahead?


I'll just go get my equipment ready

Equipment
Catheter pack
Foley catheter 16/18 - smallest cath poss

Catheter bag

Trolley
Sterile gloves x2
Lignocaine gel 2%
Sterile water/saline
Syringe x2
Bin

Prepare Trolley
Wash hands - 7 stage
Put on apron
Clean trolley - top & bottom
Open cath pack and slide onto trolley, preparing sterile field

Place equipment into sterile field

Attach yellow disposable bag onto side of trolley/move bin nearby

Pour sterile water into small bowl with swabs

Fill syringe with 10mls and place outside sterile field if not already within pack

Put on sterile gloves

Put on disposable gloves

WH/Ap/CT/CP/SF/SW/GL/GL

Prepare Patient
Expose + reposition
Make hole in drape and place onto pt - 2nd sterile field
Wrap gauze around shaft and keep in sling, with left hand raised
Retract foreskin
Clean penis - holding swabs in right hand/with forceps and wipe out from meatus x2
Dispose
Warn anaesthetic
Insert LA (lignocaine 2%) - squeeze 5ml into urethra
Hold for 3-5mins to give time for the anesthetic to work
Discard top gloves

E+R/SF/SL/FSK/x2Cl/LA/Wait/xGl

Catheter
Place receiver dish inbetween legs/attach catheter to bag
Open catheter
Insert catheter into urethra - ANTT
 - touch plastic only
 - massage out and into urethra
 - if necess when negotiating prostate, lower penis
 - if resistance ask pt to breathe deeply
 - move till bifurcation
 - by now urine should start emptying into plastic/kidney dish
Inflate balloon - 1ml of sterile water
Any pain?
Continue to fill with remaining 9ml
Withdraw catheter to make sure balloon becomes lodged into neck of bladder
Attach catheter bag if not yet attached

Dish/Cath/Ball/WD/Bag

Finishing Off
Restore foreskin/ask pt to (avoid paraphimosis)
Thank pt

Cover them up

Throw away remaining waste

Document:
A) date & time
B) size and type of catheter
C) amount of water in balloon
D) ?problems

E) residual volume of urine intially collected

Tests - dipstick & MSU
10ml from sampling port

Fsk!!/TY/Cov/Cl/DocRV/Ix

Peak Flow

WIPER

Hi, my name is _______, I'm a doctor here. It's very nice to meet you.

Find the Problem
I understand you have symptoms that might suggest asthma. In order to rule help us to rule in or rule out the diagnosis we do a test called the Peak Flow test. Have you had this test before? Are you happy with your understanding of asthma? Are you happy with doing this test?

This is a peak flow meter. It's just a simple tube that measures how well the air flows out of your lungs, and whether you have any difficulty pushing it out. If you have asthma this shows as being less than normal for a person of your height, sex and age.

Demonstrate
I'll show you how to use it, to help you understand how to do it.
First we reset the pointer to make sure that it's one zero.
We stand up for the test. We put a fresh mouthpiece into the meter.
Breathe in fully deeply, as much as you can. Hold the meter level in front of you making sure your fingers don't cover over the pointer. Make a tight seal with your mouth on the mouthpiece. Blow as hard as you can and as fast as you can, like blowing out the candles on a cake. We're not concerned about how long or how much you blow out. Okay? Like so.

We'll do the test 3 times, and take the highest reading as your score.

General Advice

We record like thus and if we record it in a diary we can keep of track of how your breathing is throughout the day. Asthma tends to vary quite characteristically through the day, and can help us make a diagnosis and see how you are doing on medication.

The best time to take a peak flow are first thing in the morning, and before you go to bed. Also take it when you are experiencing symptoms such as coughing or wheezing.

Repeat Relevant Parts

Would you like to have a go?

ICE
Do you have any questions, concerns or expectations?

We'll need to follow-up to see how you've coped with the medication and if your symptoms have improved.


What factors affect PEFR?
- height
- age
- sex
- acute and chronic resp disease
- smoking

Using Inhalers

Hi, my name is______
I'm a final year student.
How are you today?

Find the Problem
Okay, from your symptoms and peak flow recording we believe you might have asthma. What do you know about asthma? How do you feel about it?

Asthma is a condition of the lung where you can get difficulty breathing. We find sensitive airways, that react by narrowing when they become irritated, making it difficult for air to move in or out. It's this narrowing that causes the chest tightness and wheezing that you've been experienced.

We can do something to help with these symptoms. To help with this condition we can prescribe you salbutamol, which is given in a blue inhaler. It works by opening up the airways so air can move more freely. By being given in an inhaler we can deliver the medicine exactly where it needs to be. Is that okay?

What do you know about inhalers? Have you ever used one before?

Demonstrate
Okay, I'm going to show you how to use the inhaler, because technique is very important in ensuring you get the most out of it and to help your lungs as much as possible. Use it when you art feeling wheezy or tightness of the chest.
First we shake the inhaler with the cap on to mix the medicine properly. We remove the cap from the mouthpiece and hold the inhaler like so, between your thumb and index finger, with your index finger on the canister.
Take a big breath in and fully breathe out. Put the mouthpiece in your mouth. At the same time as you breath in push down on the top of the inhaler. Hold your breath for ten seconds afterwards.

Repeat if necessary after 1 minutes.
Gargle/rinse out your mouth if you are using a steroid inhaler.

Mild side-effects of salbutamol include fast heart rate, shakiness and headaches. If they are worrying you should again come back to us.
Salbutamol can be taken 2 puffs as needed, up to 4 times a day, as the maximum. If you need more than that you should return to us, as we might need to try something else, perhaps combining it with another inhaler.

Does that sound okay to you?

Repeat Relevant Parts
Can you show me know how you would use it?
Can you tell me when should you use it?

General Advice
There may be some leaflets I can give you to help your understanding, and to take home with you.

ICE
Do you have any questions, ideas, concerns, expectations?

We'll review you in a while to see how you are doing with it, and if your symptoms have improved.
Does that sound okay?

Thank you!

Using A Spacer

Hello, my name is....
I'm one of the doctors here.
How are you feeling today?

Find the problem
I understand that you've been having some problems in using an inhaler - tell me a bit about that.
How are your symptoms? You understand that it's important to use - for your asthma? Can you show me you trying to use it?

It's really important that you're able to take your inhaler if you need it but I can see that you're having problems with it. This isn't an uncommon issue for people, it can be fiddly, so there is a device we can use to help you called a spacer. The spacer makes it easier to deliver the medicine to your lungs.

Demonstrate
I'll demonstrate what to do...

The spacer is made up of two parts which slot together easily.

On one end you can attach the inhaler, and on the other side you have the mouthpiece
Shake your inhaler well and attach it to the far end
Release 1 puff into the spacer
Don't worry the medicine stays inside
Make tight with your mouth on the mouthpiece
Breathe deeply in and hold for 10s
Breathe out slowly all the while keeping your mouth attached

Wait 30s before next dose
Do this for three or four times
This should be enough to get the medicine into your lungs

Repeat Relevant Parts
Can you show me how you would use this?

General Advice
In caring for the spacer wash it once a week warm water, and leave it to drip dry
Don't use any detergents as this can cause static inside the spacer, which makes it less effective
Store the device in its box in a cool area to prevent scratches
We should relace the device every 6-12months of use to make sure you have optimum delivery of the drugs

ICE
How does that sound?
Do you have any ideas? concerns? expectations?

We'll follow you up to see how you're doing

Thank you!

Cannulation

WIPERNA

Hello my name is _______
I'm a __________
How are you doing?

Is it alright if I put a cannula in your arm? Have you ever had one before?
It's a small plastic sterile tube that we insert into a vein, that acts like a port, that we leave there.
We use it to transport the fluids through.it's not painful, but you probably feel a small scratch. Do you have a problem with needles? Are you fine with me to go ahead?

Checks:
Nameband/dob/name/hospital number

I'm just going to get my equipment.

Equipment
Tray

Gloves

Tourniquet

Alco swab

Cannula (16G grey - 18G green - 20G pink)

10ml syringe

Saline 0.9%
Green needle

Bung
Tegiderm
Sharps bin

Prepare Equipment
Clean tray inside & out
Wash hands
Open cannula
Open bung
Draw up saline

CT/WH/Eq/Flu

Prepare Patient
Roll up sleeve
Pt comfortable?
Tourniquet (clench fist - promote venous filling)
Select vein and direction (distal to proximal)
Clean area with swab

Put on gloves/alcohol gel gloves/change gloves

Tq/V/Alc/W+G

Cannula Bit
Stabilise vein
'sharp scratch'!!!
Cannula - shallow angle 25-35
Flashback?
Lower cannula
Advance by 2mm
Withdraw needle slightly watch blood track along cannula
Advance plastic sheathing
Take off tourniquet
Press over vein above cannula
Remove needle
Bung over cannula

SS!/25-35/FBl/AdvPl/xTq/OutN/Bung/Flush

Secure
Needle into sharps bin
Apply tegiderm over cannula
Flush!

Sec/Sharps/Saline

Finishing Off
Thank pt, make sure they're comfortable

Document:
Cannula gauge
Location
Operator
Site

Dispose waste

Resite immed if signs of inf/phlebitis
Otherwise ev. 72hrs

T/Doc/Disp/Resite