BLOOD

TRANSFUSION,
BLOOD VEIN
COLLECTION & RL
TEST
Ika Yuni Widyawati
 PROSEDUR
RUMPLE LEEDE
TEST
LEARNING OUTCOME
• Menjelaskan definisi dan tujuan rumple leede
test
• Menjelaskan prosedur pelaksanaan rumple
leede test yang baik
• Menjelaskan interpretasi hasil dari rumple leede
test
 RUMPLE LEEDE TEST
(TOURNIQUET TEST)
• Membantu diagnosis: (WHO, 2009; WHO, 2011;
Grande et al., 2016)
– Selama fase awal, akut, fase demam (2-7 hari setelah
perkembangan demam)
– Rekomendasi WHO  untuk mendukung pengambilan
keputusan diagnostik
– Prosedur yang murah, cepat dan mudah dilakukan

• TT merupakan penanda kerapuhan kapiler

(WHO, 2009; WHO, 2011)
• Hasil penelitian oleh Grande et al. (2016):
– Sensitivitas 58% (95% CI; 43-71%) & spesifisitas 71% (95%
CI; 60-80%)
 RUMPLE LEEDE TEST
(TOURNIQUET TEST)
• Prosedur pelaksanaan: (WHO, 2009; WHO,
2011; CDCP, 2011)
– Alat: manset tensimeter, stetoskop, penggaris
– Cara melakukan:
– Ukur tekanan darah pasien (misal 100/70)  istirahatkan
– Kembangkan cuff manset tensimeter kembali pada titik
tengah dari sistolik dan diastolic  misal (100+70)÷2=85 mmHg.
Pertahankan selama 5 menit.
– Normalkan kembali cuff manset tensimeter, tunggu selama 2
menit
– Hitung jumlah petechiae dibawah lipatan antecubital
– Positif: bila terdapat 10 atau >> pada 1,25 cm persegi
– Dapat dilakukan pada kedua lengan  untuk perbandingan
(CDCP, 2011)
 NURSING CONSIDERATION
(Daniels, 2003)

• Communicate the patient about the procedure

– The test maybe uncomfortable, should not be
painful
• Do not perform the test:
– On the arm with a fistula or AV shunt
– On the arm of affected side with post mastectomy
• If perform this on children  assistance will be
needed
 REFERENCES
Centers for Disease Control and Prevention [CDCP]. (2011). Tourniquet Test (Vol. 6).
http://doi.org/10.1046/j.1365-3156.2002.00841.x.

Daniels, R. (2003). Delmar’s Manual of Laboratory and Diagnostic Tests. New York: Thomson
Delmar Learning. Retrieved from
https://books.google.co.id/books?id=8XzbVZuroycC&pg=PA732&lpg=PA732&dq=nursing
+consideration+on+tourniquet+test%22&source=bl&ots=oLM-
IBNuPl&sig=ojtJKfIpM974aTu4UYlvVInnqZ4&hl=en&sa=X&ved=0ahUKEwjby6OMq9PWAh
VFQo8KHa_FASIQ6AEILzAB#v=onepage&q=nursing cons

Grande, A. J., Reid, H., Thomas, E., Foster, C., & Darton, T. C. (2016). Tourniquet Test for Dengue
Diagnosis: Systematic Review and Meta-Analysis of Diagnostic Test Accuracy. PLoS
Neglected Tropical Diseases, 10(8), 1–23. http://doi.org/10.1371/journal.pntd.0004888

World Health Organization [WHO]. (2009). Dengue: Guidelines for Diagnosis, Treatment,
Prevention and Control. Geneva.

World Health Organization [WHO]. (2011). Comprehensive Guidelines for Prevention and
Control of Dengue and Dengue Haemorrhagic Fever 1st Edition. Geneva
 PROSEDUR
BLOOD
TRANSFUSION
Learning Outcomes
▪ Mengenali serologi dasar golongan darah
▪ Menjelaskan definisi, tujuan dan indikator laboratorium
▪ Mengenali produk darah, karakteristik dan indikator masing-
masing pemberian
▪ Menjelaskan prinsip utama dalam pelaksanaan prosedur
transfusi darah sebagai dasar pelaksanaan transfusi darah
yang aman
▪ Mengenali risiko transfusi darah sebagai dasar untuk
memberikan tatalksana yang tepat terkait efek samping
yang dihadapi

10
GOLONGAN DARAH

Saputra (2014)
A-B-O SEROLOGY
A-B-O SEROLOGY
 TRANSFUSI DARAH
• Pemberian produk darah atau
komponen darah secara IV
 TUJUAN PEMBERIAN
TRANSFUSI DARAH
• Mengembalikan volume darah
• Menggantikan komponen darah
• Memperbaiki kemampuan darah
mengikat O2
 INDIKATOR LABORATORIUM
Lab Test Normal Results Why is this ordered?
Type and crossmatch Based on ABO system To determine the primary
Positive = incompatibility blood group, screen for
Negative = probable antibodies and determine
compatibility donor-recipient
compatibility.
Hb (hemoglobin) Male 14-18 g/dL Hb carries oxygen in the
Female 12-16 g/dL blood. It can decrease
Critical Value: due to blood loss.
Male <13 g/dL
Female <11 g/dL
Ht (hematocrit) Male 41.5%-50.4% Ht measures the
Female 25.9%-44.6% proportion of blood
Critical Value: volume occupied by
<18% or >54% RBCs. It decreases with
blood loss and anemia.
Platelet count 150,000-400000 cells/uL Platelets initiate the
Critical Value: coagulation process. A
<50,000 cells/uL decreased amount
increases the risk for
hemorrhage.
PRODUK DARAH
Whole Blood (WB)

Packed Red Cells (PRC)

Thrombocyte/Platelet Cells (TC)

White Blood Cells (WBC)

Fresh Frozen Plasma (FFP)

JENIS PRODUK
KOMPOSISI TUJUAN INDIKASI
DARAH

WB ➢ Red Blood Cells ➢ Volume ➢ Significant

➢ White Blood replacement blood loss
Cells ➢ Increase (>25% blood
➢ Plasma oxygen-carrying lost, i.e.
➢ Platelets capacity hemorrhage)
➢ Hematocrit ➢ Newborn
➢ Clotting Factors babies with
hemolytic
disease
PRC ➢ RBCs with little ➢ Increase RBC ➢ Symptomatic
plasma mass and and chronic
(hematocrit oxygen-carrying anemia
about 75%) capacity ➢ Blood loss due
➢ Some platelets ➢ Assists the body to injury or
and WBCs to rid surgery
remain carbondioxide
and other waste
products
JENIS PRODUK
KOMPOSISI TUJUAN INDIKASI
DARAH
TC ➢ Platelets ➢ Helps to stop ➢ Decreased platelet
➢ Plasma bleeding count
➢ RBCs (restore clotting ➢ Hemophilia
➢ WBCs ability) ➢ Thrombocytopenia
➢ Essential for ➢ Platelet dysfunction
coagulation of (DIC, DSS)
blood
WBC ➢ WBCs or ➢ Increase ➢ Sepsis (not
leukocytes number of responsive to
suspended in WBC’s antibiotics)
20% of the ➢ Replaces ➢ Persistent fever
plasma WBC’s that are ➢ Granulocytopenia
functioning
abnormally
FFP ➢ Plasma ➢ Increase blood ➢ Bleeding in patients
➢ All plasma with coagulation
coagulation ➢ Replenish factor deficiencies;
factors clotting factors plasmapheresis
➢ Burn
➢ Liver Failure
➢ Severe Infection
 PROSEDUR PELAKSANAAN
• Persiapan Pasien  pastikan pasien sudah
terpasang IV line
• Persiapan Alat:
– Sarung tangan
– Darah atau komponennya
– Blood set
– Cairan NaCl 0,9%
– Infus pump (bila ada)
– Medikasi untuk pre med (bila diinstruksikan)
– Set injeksi lengkap untuk pemberian pre med
– Tempat sampah
 PROSEDUR PELAKSANAAN
• Rujuk  SPO Pelaksanaan Transfusi Darah
 Nursing Consideration
Before transfusion:
• Check physician’s orders
• Review hospital policy
• Communicate to the patient & family
• Ensure informed and written consent is provided
• Check the patient’s case note (transfusion history)
• Check laboratory values
• Understand the indications and rationale
• Verification procedure occurs with
two nurses
 Nursing Consideration
Before transfusion (con’t):
• Compatibility of blood type and Rh factor
• Inspect the blood product for discolouration, clots,
leaking, or presence of bubbles
• Check the unit number on the unit of blood and on the
form
• Check the expiration date and time on unit of blood
• Monitor vital sign
• Ask client to state first and last name
• Check patient’s identification number on wristband and
record
 Nursing Consideration
During the transfusion:
• Monitor vital signs closely during the
transfusion
• Inspect condition of IV site
• Observe for signs and symptoms of a
reaction
 Nursing Consideration
After the transfusion:
• Dispose of materials/equipment
• Observe patient for clinical
improvements
• Assess the laboratory values for
effectiveness of transfusion
 Nursing Consideration
Documentation:
• Verification procedure
• Type of blood
• Amount administered
• Vital signs
• Patient’s response to therapy
 SIDE EFFECTS
• Haemolytic Reaction:
– Acute Haemolytic Reaction
– Delayed Haemolytic Reaction
• Non Haemolytic Reaction:
– Febris
– Allergic Reaction
– Graft versus Host Disease
– Circulatory Overload
– Sepsis
 Acute Haemolytic Reaction
Mechanism Onset Signs and Symptoms
Increased temperature,
increased heart rate, heat
and pain surrounding vein,
5-15
chills, headache, nausea,
minutes
ABO, Rh chest or back pain, chest
following
incompatib tightness, dyspnea,
initiation of
ility bronchospasm, hypotension,
blood
anxiety, vascular collapse,
transfusion
hemoglobinemia,
hemoglobinuria, disseminated
intravascular coagulation
 Delayed Haemolytic Reaction

Mechanism Onset Signs and Symptoms

Immune
response
Fever, decrease in Hgb/Hct,
against
2-14 days increased bilirubin levels,
non-ABO
jaundice
donor
antigens
 Febris
Mechanism Onset Signs and Symptoms

30 minutes
after
Sensitivity to
initiation to
leukocytes
6 hours Fever, flushing, chills,
or platelets
after headache, muscle pain
in donor’s
completion
blood
of
transfusion
 Allergic Reaction
Mechanism Onset Signs and Symptoms

5-15 minutes Local erythema, gives,

Allergy to a
following urticaria, pruritus, coughing,
plasma
initiation of nausea, vomiting,
protein or
blood respiratory distress,
antigen in
transfusion, wheezing, hypotension, loss
donor’s
up to 1 hour of consciousness, cardiac
blood
after arrest
 Graft-versus-Host Disease
Mechanism Onset Signs and Symptoms

Attack of
transfused
Skin rash, fever, jaundice, liver
lymphocyt Days to
dysfunction, bone marrow
es on host weeks
suppression
lymphocyt
es
 Circulatory Overload
Mechanism Onset Signs and Symptoms
Dyspnea, cough, crackles,
Transfused Any time
tachypnea, headache,
at an during or
hypertension, tachycardia,
excessive within 1-2
increased central venous
volume or hours after
pressure, distended neck
rate transfusion
veins
 Sepsis

Mechanism Onset Signs and Symptoms

During
Bacterial transfusion Fever, chills, abdominal
contaminat to 2 hours cramping, vomiting, diarrhea,
ion after hypotension
transfusion
 Nursing Considerations
(when there is any reaction)
• Stop transfusion
• Remove tubing that contains blood product
• Infuse with 0.9% normal saline
• Monitor vital signs
• Notify physician
• Notify blood bank and return blood component
• Administer medication depending on type of reaction
– Epinephrine, antihistamines, antibiotics, antipyretics,
analgesics, diuretics, corticosteroids
 REFERENCES
Black, J. M., & Hawks, J. H. (2009). Medical Surgical Nursing:
Clinical Management for Positive Outcomes (7th Editio). St.
Louis-Missouri: Saunders Elsevier Inc.
Daniels, R. (2003). Delmar’s Manual of Laboratory and Diagnostic
Tests. New York: Thomson Delmar Learning. Retrieved from
https://books.google.co.id/books?id=8XzbVZuroycC&pg=PA7
32&lpg=PA732&dq=nursing+consideration+on+tourniquet+test
%22&source=bl&ots=oLM-
IBNuPl&sig=ojtJKfIpM974aTu4UYlvVInnqZ4&hl=en&sa=X&ved=0
ahUKEwjby6OMq9PWAhVFQo8KHa_FASIQ6AEILzAB#v=onepa
ge&q=nursing cons
Joint Commission International. (2013). Joint Commission
International Accreditation Standards for Hospitals.
Komisi Akreditasi Rumah Sakit [KARS]. (2012). Instrumen Akreditasi
Rumah Sakit Standar Akreditasi Versi 2012. Jakarta.
 REFERENCES
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I.
(2011). Medical Surgical Nursing, Assessment and
Management of Clinical Problem. New South Wales: Mosby
Inc.
Oxford University Hospitals. (2012). Blood Transfusion Policy and
Procedures.
Perry, A. G., Potter, P. A., & Ostendorf, W. (2014). Clinical Nursing
Skills & Techniques (8th ed.). St. Louis-Missouri: Mosby Inc.
Saputra, L. (2014). Visual Nursing: Hematologi & Imunologi. (A.
Said, Ed.). Tangerang: Binarupa Aksara.
World Health Organization [WHO]. (2012). Clinical Transfusion
Practice Guidelines for Medical Interns. Geneva.
 PROSEDUR
BLOOD
COLLECTION /
SAMPLING
Learning Outcomes
▪ Menjelaskan definisi dan tujuan dari prosedur
▪ Mengenali lokasi pembuluh darah terbaik untuk
pelaksanaan prosedur
▪ Menjelaskan prinsip utama dalam pelaksanaan
prosedur pengambilan sampel daarah

39
PHLEBOTOMY/VEINPUNCTURE
• Tehnik pengambilan darah vena
dengan tujuan untuk sampling darah
yang dapat dilakukan dengan cara:
– Sistem tabung hampa udara (co.:
Vacutainer)
– Spuit dengan needle biasa atau winged
butterfly needle
 PROSEDUR PELAKSANAAN
• Persiapan Pasien
• Persiapan Alat:
– Sarung tangan
– Tabung sampel darah
– Spuit (ukuran sesuai kebutuhan)
– Alkohol swab
– Tourniquet
– Bengkok
– Plester/Hypafix
Image downloaded from http://www.medical-labs.net/laboratory-tubes-color-and-common-
laboratory-tests-1021/
(Medical Laboratories, 2017)
 Nursing Consideration
Before veinpuncture:
▪ Check physician’s orders
▪ Communicate to the patient & family
▪ Verification procedure occurs with two nurses
▪ Choose the appropriate tubes for the tests
requested
▪ Select the vein properly:
▪ Large and accessible
▪ Not in bruised and scarred areas

▪ Washing hand
 Antecubital Veins (Right Arm)

Image downloaded from

http://emedicine.medscape.com/article/1998221-overview#a6
(Shlamovitz, 2015)
 Antecubital Veins (Left Arm)

Image downloaded from

http://emedicine.medscape.com/article/1998221-overview#a6
(Shlamovitz, 2015)
 Metacarpal Veins

Image downloaded from

http://emedicine.medscape.com/article/1998221-overview#a6
(Shlamovitz, 2015)
 Nursing Consideration
During the veinpuncture:
• Ask client to state first and last name
• Check patient’s identification number on
wristband and record
• Only bleed one patient at a time
 Nursing Consideration
After the veinpuncture:
• Dispose of materials/equipment
• Hand write the sample tube beside the patient,
include:
▪ Full name
▪ Date of birth
▪ Hospital number
▪ Gender
▪ Date

• Send the sample to the laboratory in the most

appropriate way for the clinical situation, i.e.
routine / emergency
 Nursing Consideration
Documentation:
• Verification procedure
• Type of blood sampling
• Date administered
• The person who taking the sample
 REFERENCES
Black, J. M., & Hawks, J. H. (2009). Medical Surgical Nursing:
Clinical Management for Positive Outcomes (7th Editio). St.
Louis-Missouri: Saunders Elsevier Inc.
Daniels, R. (2003). Delmar’s Manual of Laboratory and Diagnostic
Tests. New York: Thomson Delmar Learning. Retrieved from
https://books.google.co.id/books?id=8XzbVZuroycC&pg=PA7
32&lpg=PA732&dq=nursing+consideration+on+tourniquet+test
%22&source=bl&ots=oLM-
IBNuPl&sig=ojtJKfIpM974aTu4UYlvVInnqZ4&hl=en&sa=X&ved=0
ahUKEwjby6OMq9PWAhVFQo8KHa_FASIQ6AEILzAB#v=onepa
ge&q=nursing cons
Joint Commission International. (2013). Joint Commission
International Accreditation Standards for Hospitals.
 REFERENCES
Komisi Akreditasi Rumah Sakit [KARS]. (2012). Instrumen Akreditasi
Rumah Sakit Standar Akreditasi Versi 2012. Jakarta.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I.
(2011). Medical Surgical Nursing, Assessment and
Management of Clinical Problem. New South Wales: Mosby
Inc.
Perry, A. G., Potter, P. A., & Ostendorf, W. (2014). Clinical Nursing
Skills & Techniques (8th ed.). St. Louis-Missouri: Mosby Inc.
 Thank You
For Your Attenttion