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vol.27 número1INDUÇÃO DE PARTO EM UM HOSPITAL UNIVERSITÁRIO: MÉTODOS E DESFECHOSUM OLHAR PARA A PREVENÇÃO DAS COMPLICAÇÕES CRÔNICAS DO DIABETES SOB AS LENTES DA COMPLEXIDADE índice de autoresíndice de assuntospesquisa de artigos
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Texto & Contexto - Enfermagem

versão impressa ISSN 0104-0707versão On-line ISSN 1980-265X

Texto contexto - enferm. vol.27 no.1 Florianópolis  2018  Epub 01-Mar-2018

http://dx.doi.org/10.1590/0104-07072018001150016 

Original Article

THE TRANSFUSIONAL THERAPY PROCESS IN THE NEONATAL INTENSIVE THERAPY UNIT: THE NURSE'S KNOWLEDGE

Estefânia de Oliveira Cherem1 

Valdecyr Herdy Alves2 

Diego Pereira Rodrigues3 

Paula Cristina de Oliveira Pimenta4 

Fernanda Dalabella Lisboa Souza5 

Juliana Vidal Vieira Guerra6 

1M.Sc. in Maternal and Child Health. Nurse, Hospital Sofia Feldman. Belo Horizonte, Minas Gerais, Brazil. E-mail: thecherem@yahoo.com.br

2Ph.D. in Nursing. Professor, Maternal, Child anal Psychiatry, Departament, Nursing School Aurora de Afonso Costa, Universidade Federal Fluminense (UFF). Rio de Janeiro, Rio de Janeiro. Brazil. E-mail: herdyalves@yahoo.com.br

3Doctoral student Programa de Pós-graduação em Enfemagem, UFF. Rio de Janeiro, Rio de Janeiro, Brazil. E-mail: diego.pereira.rodrigues@gmail.com

4M.Sc. in Maternal and Child Health. Nurse, Hospital Sofia Feldman. Belo Horizonte, Minas Gerais, Brazil. E-mail: paulacopimenta@gmail.com

5Nurse, Hospital Sofia Feldman. Belo Horizonte, Minas Gerais, Brazil. E-mail: fedolabella@yahoo.com.br

6M.Sc. in Maternal and Child Health. Nutritionist from the Municial of São João da Barra. Rio de Janeiro, Rio de Janeiro, Brazil. E-mail: julianavvguerra@yahoo.com.br.


ABSTRACT

Objective:

to analyze the knowledge of nurses from the Neonatal Intensive Care Unit regarding the transfusion therapy process.

Method:

descriptive, exploratory, qualitative study carried out in the second half of 2014 in two hospitals in the city of Belo Horizonte, State of Minas Gerais (Brazil), 35 nurses were interviewed. The data were submitted to thematic content analysis.

Results:

the thematic categories pre-transfusion process for newborns \and its connection to care obtained two subcategories: Contextualizing the practice in the indication for transfusion and in the blood compatibility exams; and Nursing care for the newborn before the transfusion procedure. Nurses cited the importance of blood bag verification, obtaining peripheral venous access, and avoiding the administration of antibiotics at the time of infusion.

Conclusion:

it was verified that nurses are aware of the pre-transfusion process, although some important steps in the care process have not been mentioned, showing the need for improved training of these professionals in the care related to transfusion therapy.

DESCRIPTORS: Blood transfusion; Transfusion of blood components; Neonatal nursing; Nursing care; Neonatal intensive care units

RESUMO

Objetivo:

analisar o conhecimento do enfermeiro da Unidade de Terapia Intensiva Neonatal acerca do processo da terapia transfusional.

Método:

estudo descritivo, exploratório, qualitativo, realizado no segundo semestre de 2014 em dois hospitais da cidade de Belo Horizonte, no Estado de Minas Gerais(Brasil). Foram entrevistados 35 enfermeiros. Os dados foram submetidos à análise de conteúdo na modalidade temática.

Resultados:

a categoria temática o processo pré-transfusional na atenção ao recém-nascido e sua interface para o cuidado obteve duas subcategorias: Contextualizando a prática na indicação transfusional e nos exames de compatibilidade sanguínea; e Os cuidados de enfermagem ao recém-nascido ante o procedimento transfusional. Com isso, os enfermeiros citaram a importância da conferência da bolsa de sangue, punção do acesso venoso periférico e a não administração de antibiótico no momento da infusão.

Conclusão:

comprovou-se que os enfermeiros têm conhecimento acerca do processo pré-transfusional, embora alguns passos importantes no cuidado não tenham sido mencionados, mostrando a necessidade de melhor capacitação desses profissionais no cuidado vinculado à terapia transfusional.

DESCRIPTORS: Blood transfusion; Transfusion of blood components; Neonatal nursing; Nursing care; Neonatal intensive care units

RESUMEN

Objetivo:

analizar el conocimiento del enfermero de la Unidad de Terapia Intensiva Neonatal acerca del proceso de la terapia transfusional.

Método:

estudio descriptivo, exploratorio, cualitativo, realizado en el segundo semestre de 2014 en dos hospitales de la ciudad de Belo Horizonte, en el Estado de Minas Gerais (Brasil). Se entrevistaron a 35 enfermeros. Los datos fueron sometidos al análisis de contenido en la modalidad temática.

Resultados:

el proceso pre-transfusional en la atención al recién nacido y su interfaz para el cuidado obtuvo dos subcategorías: Contextualizando la práctica en la indicación transfusional y en los exámenes de compatibilidad sanguínea; y los cuidados de enfermería al recién nacido ante el procedimiento transfusional. Con ello, los enfermeros citaron la importancia de la verificación de la bolsa de sangre, punción del acceso venoso periférico y la no administración de antibiótico en el momento de la infusión.

Conclusión:

se comprobó que los enfermeros tienen conocimiento acerca del proceso pre-transfusional, aunque algunos pasos importantes en el cuidado no han sido mencionados, mostrando la necesidad de una mejor capacitación de estos profesionales en el cuidado vinculado a la terapia transfusional.

DESCRIPTORES: Transfusión sanguínea; Transfusión de componentes sanguíneos; Enfermería neonatal; Atención de enfermería; Unidades de cuidado intensiva neonatal

INTRODUCTION

Transfusion therapy (TT) refers to the transfusion of specific parts of the blood that the patient really needs, opposing the use of whole blood. This is a procedure that aims to benefit several patients, as well as to optimize blood bank stocks.1

The competences and attributions of the nurse in hemotherapy are regulated by Resolution No. 306, which was proclaimed on April 25th, in 2006, by the Federal Nursing Council (COFEN), where it establishes its responsibility for the planning, execution, coordination, supervision and evaluation of hemotherapy procedures in health units, among others, in order to ensure the quality of the collected and transfused blood and blood components.2-3

The blood transfusion is of paramount importance for the medical staff and, especially, for the nursing team, since it is the nurses' responsibility to accompany the entire transfusion process.4

Even with precise indication and correct administration, TT must comply with all the recommended technical standards because there are health risks involved. The safety and quality of blood and blood components should be ensured throughout the process, from blood donation to the administration to the patient. Therefore, the importance of efficiently fulfilling the hemotherapy cycle, which begins with the collection and selection of donors, followed by serological and immunohematological screening, processing and fractionation of the collected units, dispensation, transfusion and post- transfusional.2 It is emphasized that there are two ways of obtaining blood components, the most common is the collection of whole blood, considering that the collection by apheresis is more specific and more complex, and therefore the nurse must have knowledge regarding the transfusion process.

Transfusion of blood components and blood products is a relevant technology in modern therapy and when used properly can save lives and improve patients' health.6 In several clinical situations, a blood transfusion may represent the only way to save a life or stabilize the patient's condition, but when performed improperly, it can aggravate or even lead to death. Therefore, it is a complex process, which requires professional monitoring, especially on the part of the nursing team which provides direct care to the patient.7

Safety in blood administration is dependent on the thorough and competent work and performance of the professional. Having, standardized, and available procedures to provide the team with appropriate and consistent instructions on how to proceed with transfusion patient care certainly contributes to increased transfusion safety.8

Nurses play a key role in transfusion safety as they not only administer blood transfusions but also have knowledge of the indications for transfusion and provide data checks, which are important elements in the prevention of errors, as well as informing the patient's legal guardians about the benefits and risks of transfusion therapy, such as the transmission of diseases and adverse reactions.9 So, nurses require constant training, as they must be prepared to assume their responsibilities, attributions and professional competences. Therefore, one must break with the dichotomy between practice and scientific knowledge in hemotherapy so that the risks to health are reduced.9 However, many nurses feel unprepared to perform their activities with patients who require blood transfusion.10

Thus, it is considered relevant to focus the study on this thematic, especially regarding this procedure in the Neonatal Intensive Care Unit (NICU), since the public hospitalized in this sector require specialized and continuous care for their survival and health stability. Therefore, a team with adequate levels of knowledge is essential for a safe system, so as to provide greater patient safety, since it is necessary to ensure the quality of blood throughout the entire process.5

In this context, hospitalized newborns in the NICU are a group of patients who proportionally consume more blood components. Hematransfusion in neonatology has a different approach than that of the adult because of the following characteristics: greater sensitivity to cold; greater risk of tissue anoxia; metabolic and immunological immaturity; hematological physiology; particular pathology specific to the newborn.9-10 Thus, nurse's knowledge is essential in order to promote this specialized care, assuming a commitment to health, quality of life and neonatal care.11-12

Errors made during blood transfusions can be avoided by strengthening the hospital systems and procedures related to this procedure, as well as the preparation of the professional staff involved.12 While it is impossible to eliminate the possibility of human error altogether, reducing the opportunities for them to occur can be an easily achievable goal, thus promoting better patient safety.11-12

Therefore, the study aimed to answer the following question: how do you present the knowledge of nurses working at the NICU in relation to pre-transfusion practice? As these professionals are responsible for the nursing team, they should be able to perform the TT process and provide guidance to the patient's team and family, generating safety and trust in the care process.

Therefore, the intention of this study is to present the degree of knowledge that the nurse and the nursing team possess regarding the initial stage of the blood transfusion process, as well as the level of exposure of the newborn to unnecessary risks due to lack of knowledge of the subject or technical malpractice during the procedure.

In view of the above, the study aimed to analyze the knowledge of the NICU nurses regarding the transfusion therapy process.

METHOD

A descriptive, exploratory research with a qualitative approach, considered appropriate for the objective of the study as it seeks to reveal the subjective data of the individuals in order to contribute to the nurse's knowledge of the transfusion process in the NICU.

The study participants consisted of 35 nurses from two NICUs in the city of Belo Horizonte, in the State of Minas Gerais (Brazil): Hospital Sofia Feldman and Hospital Odete Valadares, both considered reference hospitals for specialized care in neonatology.

The following inclusion criteria were established: being a nurse specialist in neonatology and acting in direct care in the health unit. The exclusion criteria took into account being a nurse with a managerial position and being absent from their assistance activities due to leave, vacations or sickness.

Those who met the inclusion criteria were invited to participate in the study by means of simple random selection, from the board of health professionals and the nurses whose subscription number had an odd last number were chosen. Following their acceptance, the participants were informed regarding the research subject and were requested to sign the Written Informed Consent Form (WICF), confirming their voluntary participation, and assuring their anonymity and privacy by using an alphanumeric code (PS1 ... PS35), thus enabling the application of the data collection instrument.

In accordance with Resolution No. 466/2012 of the National Health Council (CNS), the study was approved by the Research Ethics Committee (CEP) from the Faculty of Medicine at the Hospital Universitario Antônio Pedro (HUAP) of the Universidade Federal Fluminense (UFF), under Protocol No. 624.384 / 2014 e CAAE No. 25871814.1.0000.5243.

Data collection was performed during the second semester of 2014, with the application of a semi-structured interview, whose script contained open and closed questions regarding the blood transfusion process in the NICU. The participants' statements were recorded on a digital device, with prior authorization. Subsequently, the interviews were transcribed in full by the researcher with the purpose of ensuring the reliability of the statements. The interviews were performed by the researcher and by a neonatology nurse specialist who had received previous training. The average duration of the interviews was 30 minutes, allowing the interviewees to talk about the matter in a calm fashion.

Content analysis was chosen in order analyze the material collected for the interviews,13 which is a method of searching for information; The objective of this work is to overcome uncertainty and enrich reading, whereby the researcher observes the conditions of discourse production, making inferences regarding systematized messages and guides the context of production. The following operations are relevant to the method: 1) coding: performed from the cut-off as regards to the choice of units; enumeration, which refers to the rules of counting; of classification and aggregation, which is based around the choice of categories; 2) definition of the registration unit, which corresponds to the segment of content to be considered, which can be a sentence (provided it expresses a complete thought), a word or an affirmation about a certain subject; and 3) categorization, which is the classification operation of elements belonging to a set.13 This method of data analysis in qualitative research applies to the analysis of written texts or any communication reduced to a text or document, and aims to critically understand the meaning of communications, its manifest or latent content and explicit or hidden meanings.

After the interview transcripts, the recording unit (RU) was used as a data organization strategy. The colorimetric technique was used to group the related RUs, which allowed an overview of the theme. The interviews resulted in the following RU: request and referral of the transfusion request; blood collection to perform the cross-match; obtaining peripheral venous access; measuring vital signs; and verification of blood bags. These RUs, in turn, supported the construction of the thematic unit "pre-transfusion process", which gave rise to the following category: The pre-transfusion process in the attention to the newborn and its connection to care. This category formed two subcategories: 1) Contextualizing the practice in the indication for transfusion and the examinations of blood compatibility; and 2) Nursing care for the newborn before the transfusion procedure.

It should be emphasized that the health professional's apprehension to express their thoughts and ideas, and who felt "afraid" of being penalized by the institution, if they said something which could contradict their work, is seen as a limitation of the study

RESULTS AND DISCUSSION

The pre-transfusion process in the attention to the newborn and its connection with care

The first line of care in the pre-transfusion procedure refers to the confirmation of the transfusion by means of the medical prescription and its indication. After confirmation, the pre-transfusion process begins with the doctor's request and referral of the request for blood components, followed by blood collection for cross-matching, obtaining peripheral venous access, checking vital signs and verifying blood stock. The pre-transfusion period is the most critical period during the whole transfusion process, considering that even a "small flaw" in the identification of the blood components request form may compromise the entire process.9

Contextualizing the practice in the indication for transfusion and the blood compatibility exams

The study made it possible to identify the blood request and the forwarding the request, as the first steps towards the need for blood transfusion in the newborn, however most of the interviewees did not report the request, as described below:

[...] it happens like this, first there is the blood request, which the doctor does. We forward this request with the patient's label. And the person in charge of the blood and agent manages [...] (PS11).

[...] the doctor requests the blood and sends the request to the laboratory. The lab brings this blood to us. Then the blood is administered [...] (PS25).

The decision to transfuse the newborn is made by the physician, and he/she must write the notes in the respective medical chart and fill out the request for blood components, mentioning: data of the recipient, type of blood component requested, quantity requested, reason for the indication, if the blood component must go through some special procedure such as removing leucocytes from the blood and irradiation, which are indicated for newborns; if the patient has history of have receiving multiple transfusions or if he or she has already had any transfusion reaction;5,11 the mode of transfusion, whether it will be scheduled, routine, emergency; date of application, name, signature and enrollment number in the Regional Medical Council of the requesting physician, as well as the transfusion and gestational history and reactions to transfusion.5,9 This is the first necessary step in the transfusion process, but the participants did not highlight the "checking" of the request, which is an aspect which must be strictly observed.

Therefore, verifying the blood transfusion request is an important step in the transfusion therapy process, for the safety of the newborn, as well as for the quality of care offered. The nurse, as leader of the nursing team, is the professional who has the scientific knowledge regarding the transfusion processes and the reactions that may arise due to an error in the checking of the blood transfusion request. Therefore, in order to care for the newborn it is essential to be competent in this process.

This importance is emphasized since an inadequate blood transfusion can cause harm to the newborn, such as triggering a transfusion reaction that could have been avoided. Only one participant reported the importance of verifying the blood transfusion request

[...] when the patient is going to be transfused, the nurse must check if the medical request is properly filled out, and if it is not, it must be returned and the doctor must be asked to change it. And another thing is that we must identify this request with the patient's identification, in order to avoid problems with different patient names [...] (PS17).

An aspect which deserves to be highlighted is that an incomplete, inadequate or illegible requisition must be evaluated by the nurse, 14 as in order for the transfusion to occur, the nurse must give this request ,which must be filled in correctly, since it is constituted as a legal document and justifies the need for this procedure.15 Thus, although the medical professional is responsible for completing the requisition, it is the nurse who directs it to the appropriate measures after verifying the data, which constitutes as a double check of the patient's data, thereby increasing the safety of the transfusion procedure.5,15

Another important question is to verify the religion of the legal guardians of the newborn11 due to some religions, such as in the case of the Jehovah Witness religion which prohibits transfusion practice. However, no professional interviewed reported the importance of observing the religious issue. Failure to observe religiousness can lead to the blood preparation, and when the material arrives for the infusion of the newborn, legal guardians do not authorize the procedure, which can result in the mismanagement of resources.

After sending the request for the blood components, the doctor should request the blood sample for the blood compatibility tests. It is important that the nurse receives pays attention, since this compatibility test, according to the literature, contains important information for a safe transfusion,16 since the complications during a blood transfusion are classified as hemolytic transfusion reactions, which can be fatal, and is the main cause of immediate death related to blood transfusion.12 Some interviewees reported cross-matching, as described below:

[...] when the doctor orders the blood, we collect the baby's blood and identify the collection tube with the patient's label. (PS10).

[...] the blood components are requested after the doctor has requested the blood. He has to order the blood for the cross-match to be able to identify the blood compatibility with the blood bag that is available [...] (PS30).

Proof of compatibility is an important procedure which increases the safety of blood transfusions,5,9 and it is essential that nurses attempt to collect the cross-match because all transfusions must be made with blood that is compatible. Another important issue is that samples should be labeled at the time of collection with the full name of the recipient, the identification number or location in the service, the date of collection, and the identification of the person who performed the sample collection,17 as one in every six incompatible transfusions, is due to the sample exchange of the recipient.11 It is worth noting that no nurse mentioned the identification of the person who performed the collection, as required by the Resolution of the Collegiate Board of Directors (RDC) No. 34, dated June 11th, 2014.3 This shows that there are flaws in the identification the bottle, disrespecting what the legislation recommends.

According to participants, at the beginning of the transfusion it was shown that nurses follow some recommendations from the legislation, but lack attention to some important aspects of care related to the transfusion process. They show that they acknowledge the request, the forwarding of the blood request and the collection of blood for cross-matching, but it can be seen that there are weak points in relation to: the evaluation of religion, checking the blood request and evaluating if the information contained in the application is consistent with the newborn's data; identifying blood tube samples when cross-matching collection is required, which is a legal requirement or even the actions of the nurses faced with an extremely urgent transfusion. These facts may compromise the safety of the process and contribute to errors in the administration of blood transfusions in the newborn that can cause fatal hemolytic transfusion reactions which is the main cause of immediate death related to blood transfusion.9

In addition to these basic care measures that must be performed during the transfusion, there are others pertinent to nursing that are essential, such as the importance of having a peripheral venous access, the measurement of vital signs before starting the infusion and the checking of the blood bag, these aspects will be discussed below.

Nursing care for the newborn before the transfusion procedure

Nurses showed that they consider peripheral venous access (PVA) important, especially before the blood is delivered to the unit. In addition, they assess whether the PVA is patent, which demonstrates satisfactory care in relation to this subject, as described below:

[...] if the newborn does not have the peripheral access, I ask the professional who is responsible to provide the access [...] (PS20).

[...] the nursing team is responsible for maintaining peripheral venous access. If the baby does not have access, the technician puts the line in. And I always obtain the access before the blood reaches the unit. The blood component should be infused into an exclusive PVA [...] (PS23).

[...] first the nurse assesses if the newborn has a stable condition, I meant to say, if the newborn is stable to receive the blood. If the newborn is able, then I will check if the RN already has a PVA. If the newborn does not have access, he will receive PVA before the blood reaches the unit [...] (PS30).

It is important to have a PVA before blood arrives in the unit in order to avoid delaying the transfusion and causing damage and / or contamination to the blood cells due to longer exposure time, as the erythrocyte components should not remain at room temperature for more than 30 minutes.18 If the time surpasses 30 minutes, the component should immediately be replaced at an appropriate storage temperature. Therefore, it is important to have the PVA before the blood is delivered, as indicated by the nurses, because it is a practice that promotes the safety of the process, inhibiting the contamination, as well as promoting the best management of the resources of the transfusion unit.

In addition, nurses should obtain a PVA, preferably a gauge, because in addition to ensuring adequate flow, it prevents hemolysis.19 It is worth mentioning that the high flow pressure through the needle or small lumen catheter may cause hemolysis of the erythrocytes.20 The PVA should be selected in a location with cutaneous integrity, free of lesions and / or hematomas, avoiding sites close to the joints (especially when it is necessary to maintain venipuncture for transfusion), considering patients with difficult access.20 The health and, especially, nursing professionals, should be vigilant, periodically observing the venipuncture, keeping in mind that the increased time of exposure of the blood bag is a risk factor for bacterial growth.21 If more time is needed to initiate the infusion, the blood component should be returned to the laboratory for adequate storage conditions.20

Another important point in relation to the medicines being infused in the newborn5 is that before installing the blood component, the medical prescription/drug chart should be verified in relation to which medicines will be administered, as care must be taken with these solutions and medications.22 Nurses have highlighted the importance of not infusing blood along with other medications because the PVA should be used exclusively for blood transfusion as recommended by the legislation and as described in the following statements:

[...] you should not give the blood together with antibiotic therapy because if the patient has any reaction, I know it's going to be blood. And the food can be administered as normal [...] (PS12).

[...] the medications should not be infused during the transfusion, if the doctor orders some medicine, I stop the transfusion, I give the medication and then return to the transfusion [...] (PS17).

[...] during blood transfusion, I always advise the team not to infuse antibiotics together with the transfusion [...] (PS23).

If medication is required, the nurse should discontinue the infusion and irrigate the PVA with 0.9% saline prior to administration,23 demonstrating that he or she has knowledge about such care. Ideally, when the newborn is transfused, no medication should be given at the time of infusion, so as not to mask the symptoms if there is some transfusion reaction, since the side effects of the medications are similar to the symptoms of transfusion reactions.5,9

Thus, the entire transfusion must be accompanied by a nurse, who is the professional responsible for monitoring the vital signs, in order to compare the cases of newborns who develop a transfusion reaction, although not common, such as sudden changes in their vital signs during a transfusion.24 According to the legislation from the Ministry of Health, the NB must have its vital signs (temperature, heart rate, respiratory rate, blood pressure) evaluated and recorded before commencing the transfusion process, the professionals are in accordance with what the legislation recommends:

[...] when the blood bag is ready, the lab calls and we always take the axillary temperature before the blood is delivered to the unit. We also observe blood pressure, heart rate and oxygen saturation [...] (PS2).

[...] I ask the nursing technician to look at temperature before the bag arrives. [...] blood pressure, heart rate, and respiratory rate [...] (PS14).

[...] I always evaluate vital signs such as temperature, respiratory rate, heart rate and blood pressure before starting the transfusion. If there is a monitor available, I will leave the child connected to the monitor [...] (PS21).

This prior evaluation of vital signs has an important role in monitoring the newborn and, consequently, in the early detection of altered clinical status,25 which shows that the nurses who were interviewed are aware of the initial monitoring care of the newborns. The prior evaluation of vital signs is of paramount importance, since it follows as a parameter in the transfusional follow-up, in case the newborn presents some type of reaction, thus compromising the quality of hemotherapy.

There is no absolute contraindication regarding transfusing patients with fever.4 However, it is important to reduce fever prior to transfusion because the onset of fever may be a sign of hemolysis or another transfusion reaction.4

If there are changes in vital signs, one should take the prescribed measures and wait for normalization to begin the transfusion. After they are controlled, the vital signs should be taken hourly.26 The newborn should be maintained on pulse oximetry, since it can be of great value due to reducing emergencies, either by anticipating adverse events or by allowing the early detection of both respiratory and cardiac changes.27 Monitoring vital signs has been a standard feature in transfusion monitoring for decades.25

Another point observed in the statements was the lack of reports regarding the proper equipment for the procedure in question, a relevant item for the nurses' performance since the equipment contains a filter to contain clots, preventing their passage into the bloodstream of the patient which may cause embolism and even death.9 However, as their use was not pointed out by nurses, or even mentioned, one can infer non-compliance with this essential step in the transfusion procedure.

One of the major problems related to blood transfusion is the incompatibility error of the ABO system. Therefore, it is important to check the blood bag.11 The verification of the data contained in the blood bag label and the data of the medical records of the newborn, plus the positive identification of the recipient, must be carried out before starting the transfusion, in order to prevent its improper installation and other risks.1,5 According to the discussion regarding the blood stock conference, as per Brazilian Law RDC 34, dated June 11, 2014,3 it describes the items that should appear on the blood bag label, which should be checked the nurse before commencing the transfusion. Thus, it is up to the nurse to compare the transfusion card with the NB's medical record, especially with regard to the complete identification of the NB, ensuring that the blood component is destined for that newborn,25 confirming the correct hemotherapy for the correct patient.5,9 In addition, this label contains the new borns identification information as well as blood product data.

According to the legislation, the nurses interviewed mentioned verifying the blood bag, although they were not complying with the legislation guidelines, which pointed out the need to be rigorously check: full name of the recipient and numerical identification of the recipient, ABO group and RhD type; ABO group and RhD type of the blood component to be transfused; completion of the compatibility test; date of delivery of the blood component; and the name of the person responsible for conducting the pre-transfusion tests and person responsible for the releasing the blood . It is noteworthy that the professionals who were interviewed only referred to the identification of the recipient, ABO group and RH factor of the recipient, blood compatibility test and identification number, which are required by the legislation, as described in their statements:

[...] when we receive the bag of red blood cells / platelet / plasma concentrate, you have to check the name of the newborn, blood type of the donor and the recipient and if a compatibility test has been performed, also look at the bag number and the volume prescribed and to be received [...] (PS17).

[...] I check if the full name of the newborn is written on the bag, if it is the right patient, right volume, correct material. It is only after checking everything that I connect the blood to the child [...] (PS18).

[...] when the blood arrives, I look at the patient's name, the bed, the prescription, the volume, the blood compatibility, I look at the label on the bag, and I also check that label that comes with the blood bag. After I check the form and sign the delivery of blood and blood product booklet [...] (PS25).

This attention associated with verifying the recipient's data with those of the blood product, significantly contributes in preventing incompatibility reactions. Thus, nurses have the knowledge that verification must be performed before starting the blood transfusion, although they do not always follow all the steps which needs to be corrected in terms of care, considering that the purpose of the correct identification of the newborn, is to reduce the occurrence of incidents. Therefore, the identification process must be carried out fully and correctly to ensure that care is provided to the person for whom it is intended.11

In addition, this label must remain affixed to the blood bag so that it remains there until the end of the procedure, not obstructing the original bag information.17 Only one interviewee mentioned the need to keep the label affixed to the blood bag, as described in the following statement:

[...] the laboratory brings the blood, the nurse receives it, checks the bag, delivers it to the professional looking after the recipient, they check the blood. They keep the blood label on the bag and staple the label on prescription [...] (PS13).

This verification process is known as the "golden" moment of a transfusion, because the information of the newborn, the compatibility tests, as well as the identification data are on this card, it is up to the nurse to check if this blood is compatible or not with the newborn, with the purpose of preventing an error, or changing the newborn before infusion, and even the occurrence of hemolysis due to ABO incompatibility.5,9 This process is essential for the safety of the newborn, and it is up to the nurses to follow this step, and promote care for the newborn, as determined by the legislation of the Ministry of Health.

Therefore, once any discrepancy has been identified, the process should be discontinued and the transfusion must not be initiated.19 Faced with any abnormality encountered during the blood-bag examination and check-up procedures, the transfusion should not be performed until the problem is clarified and resolved.28

From the reports obtained, the nurses demonstrated knowledge that the blood bag should be checked prior to the installation of the blood component and peripheral venous access, before the start of the transfusion or even before the blood bag reaches the unit. They also reported concerns about stopping transfusion and not administering antibiotics at the time this procedure was being performed. And while knowing that vital signs need to be measured and evaluated before the start of the transfusion, some actions are still flawed , such as not checking all the data on the blood bag label, have been found. Since the professional who administers the blood component is the last barrier in the detection of errors prior to transfusion, it is imperative that all data is checked.15 If vital signs are within normal limits and if the blood bag data is correct, the next step is the initiating the blood transfusion.

Faced with the demand for blood transfusions in the hospital setting in the NICU and the nurse's role, the care provided to the patient during any transfusion is the nurse's responsibility.15 The nurse has as a function to execute and follow up the activities performed by the nursing technicians, principally to accompany the blood transfusion in the first few minutes.29 It is the nurse's responsibility to assure that the patient receives care free from any injuries resulting from malpractice, negligence or imprudence.30

CONCLUSION

It can be observed that nurses have knowledge regarding the transfusion therapy process but do not fully comply with what the legislation requires, such as checking the blood request, identifying the blood samples, checking all the data on the blood bag, items pointed out by professionals, but which were not performed prior to the transfusion process.

Other questions regarding the verification of the religion of the newborn's legal guardians and signing of the consent form, as they were not mentioned by any professional. In contrast, they showed satisfactory knowledge regarding the measurement of the patient's vital signs at the beginning of the transfusion, and care regarding possible medications.

Thus, the need for training and improvement of nurses in the practice of hemotherapy is confirmed, since the pre-transfusion process is highly complex and the aspects which were not strictly observed evidence that nurses do not have the full knowledge of this practice, which can result in the insecurity of this care process.

Therefore, it is the nurse's responsibility to take full account of the Resolutions of the National Sanitary Surveillance Agency and the Federal Nursing Council, whose texts can clarify the nurses role and performance during the transfusion, that is to say, the step by step nursing care before, during and after the blood transfusion, which will certainly favor the improvement of their care practice, benefiting all those involved in the transfusion process in the Neonatal Intensive Care Unit.

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Received: April 14, 2016; Accepted: February 03, 2017

Correspondence: Diego Pereira Rodrigues, Rua Desembargador Leopoldo Muylaert, 307, 24350-450 - Piratininga, Niterói, RJ. E-mail: diego.pereira.rodrigues@gmail.com

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