BLOOD TRANSFUSION

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A Written Report Presented To

The Faculty of the Nursing Department
Marilou Hernandez, RN, MN

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In Partial Fulfillment of Requirements in NCM 212 – RLE

By:

ABELLON, HANNA JADE

GOTO, SHIYUKI
QUIAMBAO, JOHN EMMANUEL
SALIOT, MAREANNE GABRYLLE
BSN 3B – GROUP C

November 27, 2020

What is blood transfusion?
A blood transfusion is a lifesaving procedure to replace the blood lost during a
surgery or Injury or to provide some if your body have such kind of disorders like
anemia, sickle disease, a bleeding disorder like hemophilia, or cancer (NIH, ND)
Depending on how much blood you need, a transfusion can take between 1 and
4 hours. According to WebMD, about 5 million Americans need a blood transfusion
every year, and the procedure is usually safe.

What are the indications/purposes of doing blood transfusion?

 You’ve had major surgery or a serious injury and you need to replace lost blood
 You’ve experienced bleeding in your digestive tract from an ulcer or other
condition
 You have an illness like leukemia or kidney disease that causes anemia (not
enough healthy red blood cells)
 You’ve received cancer treatments like radiation or chemotherapy
 You have a blood disorder or severe liver problems

Types of blood and blood products and indication for use:

Types
Whole blood (type A, B, AB, O, and/or Rh (+) or Rh
(-) positive or negative)
Indications
To treat volume deficiencies,
for example in acute
hemorrhage; not indicated for
correction of chronic anemia.

To expand blood volume, to

restore circulation and renal
blood flow when plasma
volume is decreased but the
red cell mass adequate, as in
acute dehydration or burns; to
replace deficient coagulation
factors in bleeding disorders.
Packed red blood cells (high hematocrit, since Used when blood volume is
approximately 80% of the plasma is removed) adequate but the red cell
mass is inadequate, as in
chronic anemia.

Washed RBCs Are free of almost all traces of

plasma, most white blood
cells, and platelets. They are
generally given to patients
who have severe reactions to
plasma (eg, severe allergies)
WBC-depleted RBCs Are prepared with special
filters that remove ≥ 99.99%
of white blood cells. They are
indicated for patients who
have
experienced nonhemolytic
febrile transfusion reactions
Platelets For clients with severe
thrombocytopenia (reduced
platelets;) Replaces platelets,
for example in Dengue
Hemorrhagic Fever.
 Albumin To expand the blood volume
rapidly when blood volume is
reduced in shock or burns;
also used to increase level of
albumin in clients with
hypoalbuminemia. Used for
bleeding associated with
deficiencies of those factors.

Prothrombin complex Used for bleeding associated

with deficiencies of those
factors
Fresh frozen plasma Fresh frozen plasma is used
to replace clotting factors and
also by patients who need to
quickly reverse the effects of
blood thinning medications.

Cryoprecipitate Is made from fresh frozen

plasma. It contains proteins,
including fibrinogen, involved
in blood clotting.
Cryoprecipitate is used in
patient where they have a
 reduced level of fibrinogen, or
where their fibrinogen is not
working property. Used as a
source of fibrinogen.

Special Considerations:
1. Blood transfusion must me matched to the client’s blood type (A, B, O, AB), Rh
group and other factors.
2. A blood product infusion should begin with 30 minutes of leaving the blood bank.
3. A blood warmer may be used if the client is in critical condition or it client is
feeling chilly before infusion.
4. Blood transfusion should be checked every 15-20 minutes to ensure that it is
running on time.
5. Blood components that are still hanging after 4 hours without refrigeration must
be discontinued.
6. In the post infusion period, the client’s urine is observed for signs of hematuria,
indicating a transfusion reaction.
7. If a transfusion reaction occurs, stop the blood, start the saline stay with the client
and immediately notify the physician. If shortness of breath occurs, start low flow
oxygen (1-2 L/min.) per agency protocol. Return the blood component bag to the
blood bank or laboratory with the transfusion reaction form.
Acute Transfusion Reactions:
Acute transfusion reactions present as adverse signs and symptoms during or
within 24 hours of a blood transfusion.
REACTION CAUSE
Acute Hemolytic reaction This happens when there
is an infusion of ABO
incompatible whole blood,
resulting to the body
attacking the red blood
cells in the blood a person
has received.
Febrile, non-hemolytic It is the sensitization to
reaction donor white blood cells,
platelets or plasma
proteins.
:
Mild allergic reaction Allergic reaction is possible Flushing, itching, urticaria
to happen, even if it is of
the correct blood type. This
happens due to the
sensitivity to foreign
plasma proteins.
Anaphylactic reaction Occurs when there is an
infusion of IgA proteins to
IgA deficient recipient who
has developed IgA
antibody.
Circulatory overload The fluid is administered
faster that the circulation
can accommodate.
Sepsis Occurs when there is a
transfusion of
contaminated blood
CLINICAL
MANIFESTATION
Chills, fever, low back
pain, flushing, tachycardia,
tachypnea, hypotension,
vascular collapse,
hemoglobinuria,
hemoglobinemia, bleeding,
acute renal failure, shock,
cardiac arrest, death
Sudden chills and fever,
headache, flushing,
anxiety and muscle pain.
(hives)
Anxiety, urticaria,
wheezing, progressing to
cyanosis, shook, possible
cardiac arrest.
Cough, dyspnea,
pulmonary congestion,
headache, hypertension,
tachycardia, distended
neck veins.
Rapid onset of chills, high
fever, vomiting, diarrhea,
and marked hypotension
 components and shock.

Equipment:
PICTURE
1. Blood transfusion
set

2. Sterile dry cotton

balls

3. Cross matching
result
4. Ordered blood
component
5. Ordered 0.9%
NSS 1L

6. Plaster

7. Working Gloves

8. Sterile OS
Procedure:
Action Rationale
1. Check the doctor’s order and ensure Verifies doctor’s prescription
that the consent form (if required) is for blood transfusion and
signed. client’s consent.

2. See that the client has a patent g. 18-

A needle smaller than g. 19 may
19 cannula in place.
break up red cells.
3. Obtain the blood product from the Prevent bacterial growth and
laboratory and initiate transfusion destruction of RBC.
within 30 minutes.

In the laboratory check the following:

a. Type of blood product
b. Client’s name, ward and room
number
c. Cross-matching compatibility
d. Donors blood group
e. Expiration date and time on blood
bag
f. Presence of blood clot

4. Wash hands and assemble equipment Deters spread of

with another nurse. microorganisms and saves
time.

5. Verify and record the blood product For safety 2 nurses must verify the
and identify the client with another order and match the numbers on the
nurse. blood component with those of the
crossmatching slip.
a. Compare the donor numbers, the ABO
group and the correct blood type on
the crossmatching slip with the label
and numbers on the blood component
bag. Verify the expiration date on the
blood component bag; check the bag
for clots.
b. Client name, room and hospital
number, blood group and RH type.
6. Don working gloves.
7. Close the clamp of the tube and insert
the spike in the port of the blood bag.
Invert the blood bag, press the filter
chamber, open the clamp and prime.
Close the clamp
8. Identify the client and explain the
procedure.
Instruct the client to empty his/her
urinary bladder.
9. Check client’s VS and known allergies.
If VS are above normal, consult the
physician.
10. If the above mainline is not a saline
solution, change it 1st with an ordered
NSS. Run it KVO rate. Keep the
bottle/bag of the mainline sterile.
11. Disinfect the injection port of the Y
tube with CB in betadine solution.
12. Insert the g. 19 needle to the port.
Wrap it with the sterile OS and Secure
with the plaster. Close the regulator of
NSS.
13. Close the regulator of NSS. Regulate
the blood flow at 20 gtts/minutes for
the first 15 minutes. Remain with the
client and monitor for at least every 5
minutes for 15 minutes. Reassess
client’s vital sign at the end of the 15
minutes. If no adverse reaction occurs,
adjust the flow rate as ordered. Take
vital sign at the end of 30 minutes and
then every 30 minutes or as directed
by agency policy, until the transfusion
is completed. Blood must be
transfused within 4 hours of release
Provides for a double-check, to
decrease the risk of error. The blood
component must not be transfused
after the expiration date. If the unit
contains clots, it should be returned
to the blood bank or laboratory.
Reduces risk of contact with blood
borne pathogens.
Priming the filter and tubing, removes
air and eases the blood flow. Care is
taken to close clamp so that none of
the blood products is accidentally
lost.
Ensures the right client to be infused.
A fresh urine specimen will be
needed if transfusion reaction occurs
(presence of hematuria).
Provides baseline data.
Combining a small amount of saline
with blood decreases the viscosity
and helps the blood infuse more
easily.
Prevents spread of contamination.
To observe for immediate as well as
delayed transfusion reactions. Most
transfusion reaction occurs within the
first 15 minutes to 30 minutes.
Ongoing assessment is needed to
detect delayed reaction.
 from the blood bank or laboratory.
NOTE: Flow rate will depend on the
flow blood product to be infused.
a. RBC – 1 unit over 2-3 hours (<4
hours)
b. Platelets – 30-60 minutes or more
slowly (<4 hours).
c. Fresh frozen plasma – 200 ml/hour
or more slowly.
14. Remind the client to call a nurse Appropriate medical and nursing
immediately if any unusual symptoms interventions can be instituted.
are felt during the transfusion.
15. If any untoward reactions occur, STOP
TRANSFUSION and report to the NOD
immediately.
16. After the transfusion, close the
regulators of both lines change NSS to
the previous solution and regulate to
the prescribed rate. Remove the blood
bag and discard appropriately.
17. Remove gloves and wash your hands.
18. Document the following: Documentation is a proof that
1. Start and completion time of treatment has been carried out and
transfusion. shows what nursing care has been
2. Amount of blood given. done.
3. Blood type and serial number.
4. Vital signs and assessment data
gathered during transfusion.
5. Transfusion reactions if any and its
nursing interventions.

SAMPLE DOCUMENTATION:
DATE SHIFT/TIME ENTRY
Nov. 27, 7-3 Initial VS taken, BP-110/90, P-80, RR-18
2020 3:00pm
3:15pm Present IVF changed to plain NSS 1L and regulated
at KVO rate.
One unit of packed RBC type O with SN01234567
started as a side drip and regulated at 20gtts/min for
the first 15 mins.
Rate increased to 30gtts/min as ordered.
No unusual signs and symptom noted. Coherent.
No complaints of any changes in feelings.
Pulse is strong and regular
No fever or chills noted. BP- 120/90
 3:30pm Transfusion flow rate maintained at 30gtts/min.
Packed RBC flowing well as regulated
BP stable at 120/90. Afebrile and conversant.

References:
Commonwealth of Australia. (n.d.). Fresh Blood Products. NATIONAL BLOOD
AUTHORITY. Retrieved from https://www.blood.gov.au/fresh-blood-products
National Heart, Lung, and Blood Institute. (n.d.). Blood Transfusion. NIH. Retrieved from
https://www.nhlbi.nih.gov/health-topics/blood-transfusion
San Pedro College Manual of Nursing Procedures
Sarode, R. (2020). Blood Products. MSD MANUAL. Retrieved from
https://www.msdmanuals.com/professional/hematology-and-
oncology/transfusion-medicine/blood-productshttps://www.webmd.com/a-to-z-
guides/blood-transfusion-what-to-know#2
WebMD LLC. (n.d.). Blood Transfusion: What to Know If You Get One. WebMD.
Retrieved from https://www.webmd.com/a-to-z-guides/blood-transfusion-what-to-
know#2