The Chinese University of Hong Kong

The Nethersole School of Nursing

Bachelor of Nursing Programme
NURS3144 Nursing in the Hospital II 2015 2016
Lab Day: Transfusion of blood & blood products
Learning Outcomes:
At the end of this lab day, students will be able to:

identify common blood products used in transfusion therapy.

perform a thorough assessment before blood transfusion.

demonstrate competency in setting up a blood giving set.

demonstrate competency in administration of blood product.

Activities
1. Display different types of infusion set and blood products.
2. Video show :
Priming of blood giving set
Administration of blood transfusion
3. Based on the following scenario, practise on:
setting up a blood giving set
administering blood product
Mr. Cheung Man, a 44-year-old man, is admitted to a medical ward for gastrointestinal tract
bleeding. He complains of abdominal pain and dizziness. Blood is taken for complete blood
picture, renal function test, liver function test and crossmatch. The laboratory result shows that
the haemoglobin level is 7.8 g/dl. Dr. Lam prescribes transfusion of 1 unit of packed red blood
cells to Mr. Cheung Q4H stat.

Guidelines on Blood Transfusion

* This is guidelines only, the actual steps may be different in various clinical settings.
Blood transfusion
1. Check the prescription on the progress sheet vs patients wrist band
2. Explain the reasons of transfusion and the procedure to the patientask for patient's name in an open question
low Hb in lab blood test
3. Inquire for allergic history
Show psychological support like close monitoring
4. Explain the possible risks of transfusion (haemolytic reactions, contracting infectious diseases
e.g., HIV, hepatitis B/C) and transfusion reactions (fever, hypotension, chills, oliguria/
haematuria, dyspnea, tachycardia, chest/back pain, skin rash etc)
5. Confirm the consent for transfusion (written & verbal)
6. Inquire for blood group and any previous transfusion reaction
7. Check drip site for any infiltration, patency of the blood giving set and any bubble in the set
Check whether is NS, expiry, precipitation, patent
8. Obtain pre-transfusion vital signs (temp, BP/P, resp) connection
(kinks?), dripping chamber, any air bubbles, S/S of
9. Ask for any discomfort obtain latest V/S from MEWS chart infiltration and infections (redness, swelling, warmness)
10. Wash hands
11. Prepare transfusion equipment
12. Verify the blood product by 2 nurses:
Progress sheet vs intravenous fluid infusion MAR
Intravenous fluid infusion MAR vs transfusion note
Transfusion note vs blood unit (WBN / DIN & product code, expiry / cancellation date)
Blood unit vs patients wristband
13. Verify by 2-D scanner:
Scan 2-D barcode on patients wristband
Scan 2-D barcode on the compatibility label of the blood unit
Scan 1-D barcode on the blood unit near the labelling of blood group
14. Cross check the generated transfusion label with the compatibility label on the blood unit and
patients wristband
15. Affix the transfusion label onto the transfusion note
ask for verbal consent again before initiating the procedures, check BGS again
16. Don gloves can be verbal
if contam., inform assessor for a new BGS and blood unit
17. Proper setting up of the blood unit clamp NS before transfusing blood
full rate first, pinkish then slower rate (1 min 20 drops), observe for 10 seconds, adjust
18. Commence transfusion slowly
infusion rate afterwards
19. Check for any abnormality (e.g. infiltration, signs of incompatibility)
20. Adjust to prescribed transfusion rate
21. Instruct patient to report any signs of reaction
22. Ensure patient safety and comfort by proper positioning and respond to patients verbal and
non-verbal cues
education, e.g. call bell, 15 min. return to monitor and
23. After care of patient and equipment Patient
take V/S
24. Wash hands
25. Monitor and evaluate the outcomes of transfusion (e.g., check temp, BP/P 15 min after starting
transfusion)
26. Documentation (transfusion note, intravenous fluid infusion MAR, progress sheet, intake and
output chart)
27. Report the progress of transfusion any abnormality (1 simple sentence as ending is enough)
I/O - time + date + signature (commence time only)
MAR - fill in serial number in additive column; drip rate (Q4H/Q8H); real-time documentation
Invite assessor to counter-sign afterwards

Special issues in blood transfusion

1.

All blood or blood components should be administered through a sterile blood transfusion set.

2.

Only one blood unit should be removed from a blood storage refrigerator each time just before
transfusion unless rapid transfusion is required under emergency situation.

3.

No drug should be added into the blood or blood component units.

4.

Only 0.9% sodium chloride should be added to the blood components or given through the
same administration set under normal circumstances.

5.

Transfusion of whole blood or red cells should be started within 30 minutes of blood or
component issued.

6.

Transfusion of platelets and fresh frozen plasma should be commenced as soon as possible to
preserve the maximum viability and activity of the platelets and coagulation factors.

7.

All blood components should normally be infused within 4 hours unless specified on product
label or information sheet.

8.

The blood administration set must be changed at least every 12 hours, or after a maximum of
four units of whole blood or packed cell have been given, or when the flow rate becomes
inadequate, whichever earlier.

9.

Retention of the empty bags for 24 hours (preferably at 4) after transfusion is recommended
for investigation of transfusion reaction if necessary, and then they should be discarded
according to hospital policy for disposing as clinical waste.

HA Transfusion Guideline 3.0

Issued date:1 September 2015