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Definition: Blood transfusion is the introduction of whole blood or blood components (such as serum, plasma, platelets, or erythrocytes) into the venous circulation. Indications: 1. To restore blood volume after severe hemorrhage. 2. To combat infection due to decreased or defective white cells or antibodies. 3. To restore the capacity of the blood to carry oxygen. 4. To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates, which prevents or treat bleeding. Special Considerations: 1. Confirm that there is a physicians order and assigned consent from the client. 2. Have two health care professionals confirm that the client name and ID #, and crossmatching result are correct. 3. Maintain asepsis. 4. Keep blood cold until ready for use. 5. Blood should be stored in the blood bank and not in the nurses station. 6. Do not use blood if released from blood bank for more than 30 minutes. 7. Give pre-med 30 minutes before transfusion as prescribed. 8. Dont use blood with bubbles and has been discolored. 9. Wear gloves before performing venipuncture, transfusing the blood, and when terminating blood and disposing of equipment. 10. Administer all blood products through the correct filter for prevention of emboli. 11. Monitor patient carefully throughout blood transfusion. 12. Crystalloid solutions other than 0.9% saline and all medications are incompatible with blood products. They may cause agglutination and or hemolysis. 13. Do not transfuse a unit of blood more than 4 hours.

14. Assess the client closely for transfusion reactions. Types Of Transfusion Reactions: 1. Hemolytic reaction: incompatibility between clients blood and donors blood. 2. Febrile reaction: sensitivity of the clients blood to white blood cells, platelets or plasma proteins. 3. Allergic reactions (mild): sensitivity to infused plasma proteins. 4. Allergic reaction (severe): antibody-antigen reaction. 5. Circulatory overload: blood administered faster than the circulation can accommodate. 6. Sepsis: contaminated blood administered. Blood Products For Transfusion: 1. Whole blood - Not commonly used except for extreme cases of acute hemorrhage. Replaces blood volume and all blood products: RBCs, plasma, plasma proteins, fresh platelets, and other clotting factors. 2. Red blood cells Used to increase the oxygen-carrying capacity of blood in anemias surgery, disorders with slow bleeding. One unit raises hematocrit by approximately 4%. 3. Autologos red blood cells Used for blood replacement following planned elective surgery. Client donates blood for autologos transfusion 4-5 weeks prior to surgery. 4. Platelets replaces platelets in clients with bleeding disorders or platelet deficiency. Fresh platelets most effective. 5. Fresh frozen plasma Expands blood volume and provides clotting factors. Does not need to be typed and crossmatched (contains no RBC). 6. Albumin and plasma protein fraction Blood volume expander; provides plasma protein. 7. Clotting factors and cryoprecipitate Used for clients with clotting factor deficiencies. Each provides different factors involved in the clotting pathway; cryoprecipitate also contain fibrinogen. Assessment Focus: 1. Clinical signs of reaction (sudden chills, fever, nausea, itchiness, low back pain, dyspnea). 2. Manifestations of hypervolemia. 3. Status of infusion site. 4. Any unusual symptoms.

Equipments: Unit of blood that has been correctly crossmatched Blood administration set 500 ml or 250 ml of normal saline solution for infusion IV pole # 18 or # 19-guage needle or catheter (if one is not already in place) Alcohol swab Plaster Clean glove Tourniquet

PROCEDURE 1. Verify doctors written order for blood transfusion.


2. Obtain clients consent before the transfusion. Informed consent involves explaining medical indications for transfusion, benefits, risks, and alternatives.

3. Explain the procedure and its purpose to the patient. Instruct the client to re[port promptly any sudden chills, nausea, itching, rash, dyspnea, backpain, or other unusual symptoms.

4. If the client has an IV solution infusing, check whether the needle and solution are appropriate to administer blood. The needle should be gauge # 18 or # 19, and the solution must be normal saline. 5. If the client does not have an IV solution infusing, you will

need to perform a venipuncture on a suitable vein and start an IV infusion of normal saline. 6. Request prescribed blood/blood component from the blood bank to include blood typing and X-matching result, the expiration of the blood and blood result of transmissible disease.

7. Using a clean tray, get the compatible blood from the laboratory or blood bank.

8. With another nurse, compare the laboratory blood record with a. The clients name and identification number. b. The serial # on the blood bag label. c. The ABO group and Rh type on the blood bag label or check crossmatching form. 9. Check blood bag for bubbles, cloudiness, dark color or sediments.

10. Wrap blood with clean towel and keep it at room temperature for no more than 30 minutes before starting the transfusion.

11. Verify the clients identity by asking the full name and/or checking the arm band for name and ID number.

12. Get the baseline V/S: BP, RR, Temperature before transfusion and refer to M.D accordingly.

13. Give pre-med 30 minutes before transfusion as prescribed.

14. Do hand hygiene before ad after the procedure.

15. Prepare equipment needed for the procedure.

16. Set up the transfusion equipment. a. Ensure that the blood filter inside the drip chamber is suitable for whole blood or the blood components to be transfused.

PROCEDURE 17. If the main line is with dextrose 5% initiate an IV line with appropriate IV catheter with plain NSS on another site, anchor catheter properly and allow a small amount of solution to infuse to make sure there are no problems with the flow or the venipuncture site.


18. Prepare the blood bag. Invert the blood bag gently several times to mix the cells with the plasma.

19. Expose the port on the blood bag by pulling back the tabs.

20. Spike blood bag port carefully and hang the unit. Be sure blood clamp is closed.



21. Gently squeeze the flexible sides of the drip chamber to reestablish the liquid level with drip chamber one-third full. Make sure filter is submerged in the blood.

22. Open the clamp and prime tubing and remove air bubbles if any. Use needle G 18 or G 19 for side drip (for adults) or G 22 (for pediatrics).

23. Disinfect the Y-injection port of IV tubing (PNSS) and insert the needle from BT administration and secure with adhesive tape.

24. Shut off the primary IV and begin the blood transfusion.

25. Run the blood slowly for the first 15 minutes at 20 gtts/min. Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or tachycardia.

PROCEDURE 26. Observe the client for the first 5 to 10 minutes of transfusion.


27. Remind the client to call a nurse immediately if any unusual symptoms are felt during the transfusion.

28. Document relevant data. Record time blood was started, V/S, type of blood, blood serial #, sequence # (e.g. #1 of three ordered units), site of the venipuncture, size of the needle, and drip rate.

29. Swirl the bag hourly. 30. Check the V/S of the client 15 minutes after initiating transfusion. If there are no signs of reaction, establish the required flow rate. 31. Assess the client every 30 minutes or more often, depending on the health status, until 1 hour post-transfusion.



32. If any untoward reaction or signs occur, stop the transfusion immediately and notify the physician ASAP.

33. When blood is consumed, don glove, close the roller clamp of BT set and disconnect from IV line. Flush the line with saline solution by opening the mainline and adjust the drip to desired rate.

34. Re-check Hgb, Hct, bleeding time, serial platelet count within specified time as prescribed &/or per institutions policy.

PROCEDURE 35. Discard the administration set according to agency practice. Needles should be placed in a labeled puncture-resistant container designed for such disposal. Blood bags and administration sets should be bagged and labeled before being sent for decontamination and processing.


36. Remove glove.

37. Document the procedure, pertinent observations and nursing intervention and endorse accordingly.

38. Remind the doctor about the administration of Calcium Gluconate if patient had several units of blood transfusion 936 or more units of blood).

to maintain cardiac function and prevent hypocalcaemia that may lead to citrate toxicity.