Saint Francis of Assisi College

COLLEGE OF NURSING
045 Admiral Village Talon III, Las Pinas City
INITIATING, MAINTAINING AND TERMINATING BLOOD TRANSFUSION
NAME OF STUDENT: __________________

YEAR/SECTION: ___________

SCORE: _______

PROCEDURE
Verify doctors order and signed informed consent for the procedure.
Obtain blood product from blood bank. Inspect for abnormal color, cloudiness, clots,
and excess air. Read instructions on the product label regarding storage and
infusion. Check expiration date.
3. Check the requisition form and the blood bag label with another nurse and compare
the clients name, blood type and Rh group, serial number and the expiration date.
4. Check if the patient has Normal Saline as main intravenous line and if the
venipuncture set used is Gauge 18 or 19
5. Prepare the equipment:

Blood product

Blood Administration Set

Needle Gauge 18 or 19

Alcohol swab

Micropore tape

Pair of clean gloves

SET UP THE INFUSION EQUIPMENT
6. Wash hands and put on clean gloves
7. Invert the blood bag gently several times to mix the cells with plasma.
8. Close the clamp of the BT set
9. Expose the port on the blood bag by pulling back the tabs and spike the BT set
tubing into the blood bag.
10. Squeeze the drip chamber until it is full
11. Prime the tubing until no air is present
12. Attach the needle to tubing tip and prime again
INITIATE TRANSFUSION
13. Introduce yourself and verify the clients identity.
14. Inform the patient of the procedure, blood product to be given, approximate length
of time, and desired outcome.
15. Provide for client privacy.
16. Obtain and record baseline vital signs, defer if temperature is greater than 37.8
degrees Celcius
17. Suspend the blood bag
18. Attach the blood tubing to the main intravenous line
19. Regulate the main line to KVO
20. Infuse the blood slowly for the first 15 minutes at 20 drops/minute
21. Remain at bedside 15-30 minutes. If there are no signs of adverse effect, increase
flow to the prescribed rate. Make sure the unit is transfused within 4 hours.
22. Observe the patient closely and check vital signs at least hourly until 1 hour after
transfusion. Note and report signs of adverse effect such as chilling, nausea,
vomiting, skin rash or tachycardia. If reaction occurs, stop transfusion and send
blood bag to blood bank for
TERMINATE THE TRANSFUSION
23. Put on clean gloves.
24. Clamp the and disconnect the blood tubing from the main intravenous line
25. Flush and adjust the flow rate of the main line to the prescribed rate
26. Discard the administration set, according to agency practice.
27. Remove gloves
28. Monitor post-transfusion vital signs
29. Document the following:

Blood and Rh Type

Serial Number

Expiration Date

Time infusion is started and completed

Vital Signs

Client reaction

YES

NO

REMARKS

1.
2.

Comments:

_____________________
Clinical Instructor

_________________________
Student