San Lorenzo Ruiz College

College Of Nursing
Ormoc City

BLOOD TRANSFUSION

Definition: the infusion of the whole blood from a healthy person into a recipient vein

Purpose:
To restore blood fluid and blood volume after severe hemorrhage following surgery
To restore capacity of the blood to carry oxygen to increase number of RBC
To provide clotting factors to help control bleeding in patient with hemophilia
To provide protein and nutritive elements
To combat infection due to increase/defective white cells
Equipment:

Blood administration set 250 cc DW 0.9 NSS Alcoholized cotton

Gauge 18-19 needles
Alcohol swabs Small cloth to cover BT set
Tape or plaster
Scissors
Tourniquet
Tissue paper

Procedure rationale
1. Check the patient's chart Check for the following:

a. Physician's order

b. Number of blood units

c. Type of infusion d. Blood typing

e. Cross matching
2. Go
to the patient's room and explain the reason for
transfusion and component to be given.

3. Instruct the patient to report flushing, chills,

headache, nausea, and difficulty in breathing.

4. Leave the patient's room and go to the nurse's

station.

5. Check the blood typing and cross matching have

been completed and that the blood is ready in the
blood bank.

6. Make a requisition form for the transfusion.

7. Obtain the blood unit from the laboratory with the

laboratory technologist check the requisition form and
laboratory records against the blood unit for essential
data:
8.
a. patient's name
b. blood group and type
c. blood unit and serial number
d. expiration date of the blood

Check the blood bag for bubbles; darkness and

sediments.

9. With another registered nurse or medical doctor

check again the requisition form and the laboratory
record with blood unit and signed form.

10. See to it that the blood is placed in a room

temperature.

11. Prepare the necessary equipment for the

procedure:
 blood administration set
 250 cc DW 0.9 NSS
 gauge 18-19 needle
 alcohol swaps
 tape plaster
 scissors
 tourniquet
 tissue paper

12. Prime the blood administration set with normal

saline. Ensure all air bubbles are out of tubings.

13. Bring all equipments to the patient's room.

14. Take v/s.

15. Rotate the blood bag gently.

16. With blood administration set ready, pull back the

taps.

17. Carefully spike the part and hang the unit if the
patient needs a venipuncture, select a vein and insert
an IV needle and tubing.

18. Fill the drip chamber by squeezing its flexible

side. Make sure that the filter is submerged in the
blood.
 if the patient has a primary IVF which is
compatible with blood place an 18 gauge
needle at the end of the blood.

19. Give the blood transfusion slowly for the first 15

minutes. Approximately 20gtts/min or 100
 cc/hr. adult-20 gtts/mnin
 children 10-15 gtts/min

20. Observe the patient closely for adverse reaction

(Chilling, backaches, nausea, vomiting tachycardia,
skin rash, HPN, stay with patient for the first 15
minutes.

21. If there are no side effects, administer blood unit at

prescribed rate.

22. Continue to monitor the patient throughout the

transfusion.

23. After the transfusion, flush the line with normal

saline. Infuse the primary solution and adjust the drip
to desired rate.

24. Remove the blood unit bag and administration set.

If the second bag is to be transfused, obtain the unit
and follow the same procedure.

25. Take v/s.

26. Document the following:

a. time of infusion

b. length of infusion c. donor number and types

of products infused

c. response to therapy e. adverse reaction

d. intervention on reaction