Blood Transfusion

Week 2 / January 24, 2022

3) Assess vital signs (BP, temp., pulse, respiration, previous rxn to
BT, specific signs related to client’s pathology and reason for
Topic Outline transfusion)
a. Secure baseline data for comparison
1 Definition 4) Prepare client. Explain procedure and purpose. Instruct to report
2 Purposes sudden chills, nausea, itching, rash, dyspnea, unusual symptoms.
3 Principles If client has IV sol infusing, check infusion set, sol and needle is
4 Equipment compatible w/ BT. Blood set w/ blood filter, gauge 18/19 needle
5 Procedure and rationale and 0.9% NaCl recommended. Any other medications are
incompatible
Definition
a. Allay fears, increase client’s understanding and
- Intro. Of whole blood /components of blood (plasma,
cooperate during procedure and treatment
erythrocytes) into venous circulation
5) Prepare equipment
Purposes
a. Save time, energy, effort
- Restore blood volume after severe hemorrhage
6) Obtain correct blood product ordered for client. Check for blood
- Restore capacity of blood to carry oxygen
type, Rh grp, blood donor no., expiration date, abnormal color
- Provide plasma factors such as antihemophilic factor (AHF) /
(dark color, cloudiness), ABC clumping, gas bubbles, extraneous
factor VIII or platelet concentrates which prevent / treat bleeding
materials
Principles
a. Check requisition form and blood bag label w/ lab
- Client’s blood will be tested before transfusion to determine
technician / acc. To agency policy
whether blood type is A, B, AB or O & whether blood is Rh+ /
7) Type and crossmatch blood. 2 nurses verify ff. crossmatch result:
Rh-; donated blood for transfusion must be compatible w/
client’s name and identification no., ABO grp and Rh on blood
client’s blood type
bag label, serial no., expiration date and time, date and time of
- Never add medications to blood products
blood issue, wear gloves / transport blood product unit in
- Done in hospital, outpatient clinic / doctor’s office; takes 1-4 hrs
container that prevents direct contact w/ blood unit bag
depending on parts of blood one must receive & how much
a. Ensure correct blood product to be administered
blood needed
b. 2 nurses compare lab blood type record w/ client’s
Equipment
identity
Unit of whole blood / blood Blood administration set
c. Not transfuse blood product that doesn’t match pt’s
component product
assigned identification no.
d. Plasma, platelets, and blood derivatives cause serious
transfusion rxn and must be administered w/ care
8) Verify client’s identity (ask full name)
a. Check arm band present
b. 2 nurses required to do verification
9) Wash hands
Container of normal saline sol. IV pole a. Prevent infection from care provider to client
10) Set up infusion equipment. Close all clamps first before inserting
tubing to sol.

If using straight line set, start first w/ PNSS. Blood product

follows establishing patent IV line.

If using Y-set, attach PNSS to one of 2 spikes. Connect blood

Venipuncture set (18 / 19 needle /
catheter)
Hypoallergenic plaster
product to spike after patent IV line established. Use IV set
provided w/ blood component if available.
Alcohol swabs a. Ensure blood filter inside drip chamber is suitable for
whole blood / blood components to be transfused
11) Prime tubing w/ PNSS
a. Never mix medication w/ blood / blood products
b. If pt require IV medications during transfusion, start
separate IV line for administration of blood products
so pt simultaneously receive therapeutic benefits of
blood product and medication
c. If using blood warming device / electronic infusion
device, insert tubing into device and operate device
acc. To manufacturer’s instructions for use
12) Wash hands again if necessary
a. Prevent infection from care provider to client
13) Put gloves and prepare for venipuncture. Procedure is same w/
Gloves
starting IV line
a. Reduce risk of contamination of worker’s hands w/
blood and other body fluids
14) Prepare blood bag. Warming blood product to room temp. done
by wrapping it w/ clean towel. Invert blood bag gently several
times to mix cells/ Rough handling can damage cells. Connect
blood product to tubing.

Procedure and rationale If using straight line set, remove PNSS first by closing clamp
1) Verify doctor’s order for BT; should be checked by 2 nurses then kinking tubing just below drip chamber and pulling out
a. Confirm order addresses indication for transfusion, tubing. Immediately insert tubing to blood product. Apply
preparation of product, & administration requirements twisting motion if necessary.
(start time & rate of infusion).
b. Confirm order and medical record are labeled w/ pt’s If using Y-set, connect blood product to other end of tubing.
first and last name and unique identification no. Clamp near spike and clamp below drip chamber should be
2) Check consent has been signed closed prior to insertion. Suspend bag.
a. Consent provide structure for pt to make informed a. Blood products transfused within 30 mins after
choice regarding indication, risks, possible exposure to room temp
alternatives, benefits of BT b. RBC hemodialysis begin after 2 hrs exposure to room
b. Permits pt to participate more fully in treatment temp.
decisions c. Hemolysis of RBC cause release of potassium into
blood stream which result to hyperkalemia

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 d. Prolonging exposure to room temp. increase risk of
bacterial growth in blood product Document teaching provided to pt and family, their
15) Establish blood transfusion understanding of teaching, need for follow-up teaching
a. Appropriate documentation provides accurate
Straight line set: open clamp after insertion of blood product reflection of nursing assessments, changes in clinical
state, care provided and pertinent pt info. To support
Y-set: open clamp near spike first and allow blood product to multidisciplinary team to deliver great care
drip into saline filled drip chamber. Once drip chamber is 1/3
full, open clamp below drip chamber. Regulate blood flow rate
slowly to about 5ml/min or 20 drops/mins for 15 1st 15 mins.
a. Ensure completion of transfusion within 4 hrs
16) Stay w/ client and observe him closely for 15-30 mins.
Take VS every 15 mins after infusion started. Take note of
adverse rxns during these times. Earlier rxn appear, more serious
tend to become. Ask client if he feels anything unusual.
a. Monitor signs and symptoms of transfusion rxn. Bc if
major incompatibility exists or severe allergic rxn
(anaphylaxis) occur, signs and symptoms appear
before transfusion of 1st 50 mL of unit
b. If rxn occurs, stop infusion immediately and notify
transfusion services and physician
17) If no untoward effects observed, regulate flow rate acc to
prescribed rate.

Adults tolerate 1 unit in 1-2 hrs.

For elderly, infusion should be slower. 1 unit transfused 3-4 hrs /

depending on hospital and blood product protocols. Do not
transfuse unit of blood more than 4 hrs
a. Closely monitor flow rate and inspect IV insertion
site for signs of infiltration
b. If observe signs of infiltration, immediately stop
transfusion, disconnect administration set, and
aspirate fluid from catheter using small syringe
c. Remove catheter and estimate volume of fluid
infiltrated
d. Notify practitioner and insert new IV catheter in diff
location to prevent interruption in transfusion therapy
18) Invert bag occasionally
a. Mix solid and liquid elements
19) Take VS every 30 mins for 1 hr until transfusion is complete.
Continue monitoring hourly 3 hrs after infusion (for elderly,
checkl VS every 15 mins throughout transfusion)
a. Observe pt periodically to identify early signs and
symptoms of possible transfusion rxn
b. Monitor VS as directed by facility and as client’s
condition warrants
20) Ask client to report signs of transfusion rxn
a. Bc blood transfusion rxn occurs after transfusion is
complete, teach pt and family about signs and
symptoms of transfusion rxn
b. Tell them to be alert to possibility of delayed rxn and
advise to report signs and symptoms promptly to
practitioner
21) If more than 1 unit of blood is required, use new BT set for every
unit of blood that follows
a. Follow manufacturer’s instructions regarding
changing of transfusion administration set & filters
22) Follow-up post blood transfusion orders such as requesting blood
examinations
a. Determine effectiveness of transfusion
23) Document all relevant data including assessments before and
after procedure

Termination of blood transfusion

24) Check doctor’s order and chart if transfusion is complete
25) Wash hands and wear clean gloves
26) If no more transfusion follows, terminate blood line like that of
terminating IV line
27) If primary IV is to be continued, flush maintenance w/ saline sol.
Disconnect blood tubing sys from primary sys and regulate to
prescribed rate
28) Discard blood bag and blood transfusion set per hospital protocol
29) Remove gloves and wash hands. Monitor VS for delayed or
untoward rxn
a. Tell client and family to be alert to possibility of
delayed rxn and advise to report signs and symptoms
promptly to practitioner
30) Document relevant data. Record date and time of transfusion,
confirmation that informed consent obtained, indications for
transfusion, premedication administered, donor identification
no., type and amount of transfusion product transfuse, amount of
normal saline sol. Infused, pt’s VS (before, during after), check
identification data, pt’s response.
Document any transfusion rxn, name of practitioner notified,
time of notification, interventions performed, pt’s response to
interventions.
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