St.

Paul University Manila

(St. Paul University System)
680 Pedro Gil St., Malate, 1004 Manila, Philippines

Performance Evaluation and Procedure Checklist

SKILL TITLE: ADMINISTERING A BLOOD TRANSFUSION
NAME : _______________________________________________ SCORE: ____________
YEAR LEVEL/SECTION: _____________
DATE: ___________________

KAR: MANAGEMENT OF RESOURCES and ENVIRONMENT

JCI 1st 2nd 3rd 4th

Raw and
Competencies Standards Performance Criteria 100 90 80 Remarks
Score above
/ IPSG % % % 70%
 Identifies tasks COP 1. Validates chart for doctor’s order and client’s written
or activities that MCI consent for blood transfusion. Notes if there are
need to be medications needed to be administered prior to
accomplished transfusion.
(2.1.1)
 Adheres to PCI 2. Performs hand washing before wearing clean gloves
policies, IPSG 5 when securing the blood or blood product from the
procedures and (Reduce blood bank 30 minutes before scheduled time of
protocols on the Risk of transfusion.
prevention and Health 3. Checks blood dispensed from blood bank for bubbles
control of Care– and clots before going back to nurse station.
infection (2.4.2) Associated  Compares blood package with:
Infection) Blood bank cross match result slip:
o Client name
o Patient hospital ID number
o Blood/ blood component ordered
o Blood/Rh group
o Blood unit serial number
o Expiration date
 Ensures proper COP 4. Prepares the following supplies on a tray. Checks for
functioning of flaws and expiration date.
equipment (2.3) - Blood transfusion - Hypoallergenic tape
tubing - Towel
- Normal saline bottle - Blood Transfusion Record
- Macroset - Transfusion
- Gauge 19 or 18 Monitoring Flow sheet
hypodermic needle - Ball point pen
- IV pole - Watch
- Medical gloves - Sphygmomanometer
- 3-way stopcock - Stethoscope
- IV insertion kit - Thermometer
 Determines COP 5. Asks another nurse to accompany you in performing
tasks and Two-Person Check Policy for starting blood
procedures that transfusion.
can be safely
assigned to
other members
of the team
(2.1.4)

KAR: SAFE and QUALITY NURSING CARE

 Explains PFR 6. Once inside the client’s room, greets the client and
interventions to COP introduces self and colleague nurse. Places materials
clients and and supplies in accessible area at bedside. Explains
family before procedure and seeks consent.
carrying them
out to achieve
identified
outcomes
(1.7.3.1)
 KAR: SAFE and QUALITY NURSING CARE

JCI 1st 2nd 3rd 4th

Raw and
Competencies Standards Performance Criteria 100 90 80 Remarks
Score above
/ IPSG % % % 70%
 Obtains COP 7. Stands at the bedside. Verifies client identity using 2
comprehensive IPSG 1 patient identifiers.
client (Identify
information Patients
(1.7.1.4) Correctly)
 Acts to 8. Performs Two-Person Check Policy with another
improve clients’ nurse at bedside before the start of infusion.
health condition 8.1. Performs Patient Identity Check
or human (Patient to Blood Unit)
response o NURSE 1: Reads the patient's name, date of birth,
(1.7.3.3) age, gender and hospital number from the patient's
ID band out loud.
 Performs o NURSE 2: Confirms data read by Nurse 1 with the
nursing information on attached unit label at the back of
activities the blood bag.
effectively and 8.2. Performs Blood Unit Check
in a timely o NURSE 2: Reads package label in front of the
manner (1.7.3.4) blood bag, reading out loud the donor number,
blood/Rh group, expiry date.
o NURSE 1: Compares data read by Nurse 2 with
the data printed on the Cross Matching Result slip.
9. If everything matches perfectly, Nurse 1 and Nurse 2
sign the unit label at the back of the blood bag,
confirming the information.
AOP 10. Obtains and records baseline vital signs on the Blood
Transfusion Record Sheet*. Checks IV site for signs
of phlebitis or occlusion.
PCI 11. Administers the blood or blood product.
IPSG 5  For single-tubing set:
11.1. Opens blood administration kit and moves roller
clamps to “off” position.
11.2. Inverts blood bag once or twice. Hangs the
blood bag on an IV pole. Spikes blood bag.
11.3. Squeezes drip chamber and allows the filter to
fill with blood.
11.4. Moves roller clamp to “on” position and allows
the tubing to fill with blood to the hub.
11.5. Swabs the Y port of the blood administration set
with 70% alcohol for 30 seconds, allowing it to
dry for 30 seconds.
11.6. Primes macroset with NSS and piggybacks it to
the Y port of the blood administration set with a
G19 hypodermic needle.
11.7. Secures all connections with tape.
11.8. Infuse the blood at a rate of 2–5 ml/minute or
according to the physician’s order.
 Monitors AOP 12. Stays with client for first 15–30 minutes, monitoring
effectiveness of COP vital signs every 5 minutes for 15 minutes, then
nursing every 15 minutes for 1 hour, then hourly until 1 hour
interventions after the infusion is completed.
(1.7.4.1) 13. After transfusion, clears blood tubing with NSS.

14. If there are signs of transfusion reaction:

 Performs - Stops transfusion immediately.
nursing - Disconnects administration set-up from the IV site.
activities - Keeps vein open with new set of NSS and tubing.
effectively and - Notifies health care provider and blood bank.
in a timely - Checks if information on blood unit label and
manner (1.7.3.4) patient identification bracelet correctly match.
- Submits the blood bag and tubing plus the first
voided urine specimen to the laboratory.
 KAR: SAFE and QUALITY NURSING CARE

JCI 1st 2nd 3rd 4th

Raw and
Competencies Standards Performance Criteria 100 90 80 Remarks
Score above
/ IPSG % % % 70%
 Implements COP 15. Assists client to a comfortable position. Rechecks
nursing IPSG 6 side rails and locks of wheels.
intervention that
is safe and
comfortable
(1.7.3.2)
 Analyzes the PFR 16. Informs client that the procedure is finished and
needs of clients addresses related concerns.
(1.4.2)
 Acts to PCI 17. Disposes of soiled supplies appropriately and
improve clients’ IPSG 5 washes hands.
health condition
or human
response
(1.7.3.3)
KAR: LEGAL RESPONSIBILITY

JCI 1st 2nd 3rd 4th

Raw and
Competencies Standards Performance Criteria 100 90 80 Remarks
Score above
/ IPSG % % % 70%
 Documents COP 18. Records the date and time procedure was done.
care rendered to AOP Includes assessment of IV site, adverse reactions if
clients (4.3) occurred, and report to physician with orders
indicated. Includes initials and/or signature.

TOTAL = 26 items

NB:

JCI - Joint Commission International

IPSG- International Patient Safety Goal
PFR – Patient and Family Rights
PCI – Prevention and Control of Infection
AOP – Assessment of Patients
COP – Care of Patients
MCI - Management of Communication and Information

________________________________________ ________________________________________

Signature over printed name of Signature over printed name of

STUDENT FACULTY