PROCEDURE CHECKLIST

Chapter 38, Skill 38-09: Preparing, Initiating, and Monitoring Infusion of Blood
and Blood Products

Check () Yes or No

PROCEDURE STEPS YES NO COMMENTS

1. Verifies that informed consent has been
obtained.
2. Assesses the patient’s IV site and IV access
device, which must be 20 gauge or larger. If this
is not in place, initiates another IV to use for
blood infusion.
3. Verifies with a second nurse that the
physician’s order matches the blood components,
including patient ID number, blood product
identification number, blood type and Rh factor,
and blood expiration date.
4. Gathers needed equipment and supplies: blood
administration Y-set, container of blood product
that you have previously verified, container of
IV normal saline (NS), alcohol wipes, tape, and
clean exam gloves. Inspects packages for
intactness and expiration dates.
5. Opens Y-set and closes the clamps on both of
the Y-shaped branches. Labels the tubing with
the date and time.
6. Dons clean examination gloves.
7. Removes the cap from one of the piercing pins
and spikes the NS solution bag using sterile
technique.
8. Primes the entire Y-set with NS solution.
9. Removes the cap from the remaining piercing
pin and spikes the blood product container
without contamination.
10. If infusing packed red blood cells, dilutes
with NS back through the Y-set until desired
consistency. Then closes roller clamp to blood
and NS.
11. Follows the “Initial Implementation Steps.”
12. Aseptically connects the NS-primed Y-set to
the IV cannula in the patient’s vein.
13. Opens only the clamp to the NS and sets it to
infuse at TKO rate or as dictated by facility
policy.

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14. Removes gloves and discards in appropriate
receptacle.
15. Assesses the patient’s vital signs. Reports
any abnormal results to the physician before
beginning blood transfusion. Proceeds as
directed by physician.
16. If vital signs are normal, closes the NS clamp
and opens the blood clamp. Starts the transfusion
at a rate of 2 to 5 mL/min for the first 15 minutes
or according to facility policy.
17. Remains with the patient for the first 15
minutes, assessing vital signs every 5 minutes
and monitoring for reaction. Should reaction
occur, stops blood immediately and opens NS
clamp and performs appropriate nursing actions.
18. If no reaction, increases the rate of infusion
to complete within 2 to 4 hours according to
facility policy. Does not allow blood to hang
longer than 4 hours.
19. Assesses vital signs every 30 minutes during
the remainder of transfusion, or more often
according to facility policy.
20. When transfusion is complete, dons clean
gloves and closes the blood clamp. Opens the NS
clamp and flushes the line.
21. Follows facility policy for disposing of
empty blood bag.
22. Removes gloves and discards in appropriate
receptacle.
23. Assesses one final set of vital signs.
24. Follows “Ending Steps.”
25. Documents the transfusion procedure,
including all assessment findings, any reactions
experienced, vital signs, volume infused, time
the transfusion was completed, and patient’s
condition post-transfusion.

Recommendation: Pass _____ Needs more practice _____

Student: Date:

Instructor: Date:

Copyright © 2015, F. A. Davis Company