Name: _​Zicha Celine V.

Arumpac​______________________________________________ Date: ______________

Evaluator/Signature: ________________________________________________________ Grade: _____________

BLOOD TRANSFUSION

Description:
A blood transfusion is the infusion of whole blood or a blood component, such as plasma, red blood cells, or platelets into a patient’s venous circulation. Before a patient can
receive a blood product, his or her blood must be typed to ensure that he/she receives a compatible blood. Otherwise, a serious and life-threatening transfusion reaction may occur
involving clumping and hemolysis of the red blood cells and possibly, death. The nurse must also verify the infusion rate, based on facility policy or medical orders. Follow the
facility’s policies and guidelines to determine if the transfusion should be administered by electronic pump or by gravity.

Purpose:
To treat blood loss.

Equipment:
● Blood product
● Blood administration set
● 0.9% PNSS
● IV pole
● Venous access
● Clean gloves
● Additional PPE
● Tape
● Second nurse to verify blood product and patient information
 PERFORMED
ACTION RATIONALE REMARKS
YES NO
1. Verify the medical order for transfusion of a
blood product. Verify the completion of To ensure the correct solution has been prescribed for the patient’s
informed consent documentation in the condition.
medical record. Verify any medical order for
pretransfusion medication. If ordered,
administer medication at least 30 minutes
before initiating transfusion.
2. Gather all equipment and bring to bedside. Having equipment available saves time and facilitates accomplishment of
task.

3. Perform hand hygiene and put on PPE, if Deters spread of microorganisms.

indicated.

4. Identify the patient by asking the patient’s To provide and administer care to the right patient.
name or reading the identification band.

5. Close curtains around bed and close the door To provide and promote patient’s privacy. Explanation relieves anxiety
to the room, if possible. Explain what you and facilitates cooperation.
are going to do and why you are going to do
it to the patient. Ask the patient about
previous experience with transfusion and any
reactions. Advise patient to report any chills,
itching, rash, or unusual symptoms.
6. Prime blood administration set with the To remove air from the tubing.
normal saline IV fluid.
7. Put on gloves. If patient does not have a Gloves protect against pathogens.
venous access in place, initiate peripheral
venous access. Connect the administration
set to the venous access device via the
extension tubing. Infuse the normal saline
per facility policy.
8. Obtain blood product from blood bank Blood must be spread at a carefully controlled temperature (4​°​C)​
according to agency policy.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
9. Two nurses compare and validate the
following information with the medical Most states/agencies require two registered nurses to verify information:
record, patient identification band, and the unit numbers match; also group and Rh type are the same; expiration date
label of the blood product: (after 55 days, red blood cells begin to deteriorate). Blood is never
• Medical order for transfusion of blood administered to a patient without and identification band. If clots are
product present, blood should be returned to the blood bank.
• Informed consent
• Patient identification number
• Patient name
• Blood group and type
- Rh blood type
- Date of Extraction
• Expiration date
• Inspection of blood product for clots
10. Obtain baseline set of vital signs before Any change in vital signs during the transfusion may indicate a reaction.
beginning transfusion.
11. Put on gloves. Gloves protect against pathogens.

12. Close the roller clamp closest to the drip

chamber on the blood product side of the
administration set. Remove the protective
cap from the access port on the blood
container. Remove the cap from the access
spike on the administration set. Using a Close clamp to prevent wasting blood product.
pushing and twisting motion, insert the spike
into the access port on the blood container,
taking care not to contaminate the spike.
Hang blood container on the IV pole. Open
the roller clamp on the blood side of the
 administration set. Squeeze drip chamber
until the in-line filter is saturated. Remove
gloves.
PERFORMED
ACTION RATIONALE REMARKS
YES NO
13. Start administration slowly (no more than 25
to 50 mL for the first 15 minutes). Stay with
the patient for the first 5 to 15 minutes of
transfusion. Open the roller clamp on the
administration set below the infusion device.
Set the rate of flow and begin the
Transfusion reactions typically occur during this period, and a slow rate
transfusion. Alternately, start the flow of
will minimize the volume of red blood cells infused.
solution by releasing the clamp on the tubing
and counting the drops. Adjust until the
correct drop rate is achieved. Assess the flow
of the blood and function of the infusion
device. Inspect the insertion site for signs of
infiltration.
14. Observe patient for flushing, dyspnea, These symptoms may be early indication of a transfusion reaction.
itching, hives or rash, or any unusual
comments.

15. After the observation period (5 to 15

minutes) increase the infusion rate to the
calculated rate to complete the infusion More than 4 hours leads to hemolysis.
within the prescribed time frame, no more
than 4 hours.
16. Reassess vital signs after 15 minutes​.
To determine any negative reaction.

17. Maintain the prescribed flow rate as ordered

or as deemed appropriate based on the
patient’s overall condition, keeping in mind To allow safe administration of blood.
the outer limits for safe administration.
On-going monitoring is crucial throughout
the entire duration of the blood transfusion
 for early identification of any adverse
reactions.

PERFORMED
ACTION RATIONALE REMARKS
YES NO
18. During transfusion, assess frequently for
transfusion reaction. Stop blood transfusion
if you suspect a reaction. Quickly replace the
blood tubing with a new administration set Steps to do if negative reactions occur:
primed with normal saline for IV infusion. 1. Stop Blood transfusion
Initiate an infusion of normal saline for IV at 2. PNSS
an open rate, usually 40 mL/hour. Obtain 3. Notify physician.
vital signs. Notify physician and blood bank.

19. When transfusion is complete, close roller

clamp on blood side of the administration set
Saline prevents hemolysis of red blood cells and clears remainder of blood
and open the roller clamp on the normal
in IV line.
saline side of the administration set. Initiate
infusion of normal saline. When all of blood
has infused into the patient, clamp the
administration set. Obtain vital signs. Put on
gloves. Cap access site or resume previous
Close clamp to prevent introduction of microorganisms.
IV infusion. Dispose of blood-transfusion
equipment or return to blood bank, according
to facility policy.

20. Remove equipment. Ensure patient’s

comfort. Remove gloves. Lower bed, if not
in lowest position. Promotes client’s comfort.

21. Remove additional PPE, if used. Perform

hand hygiene. To avoid spread of microorganisms.
 PERFORMED
ACTION RATIONALE REMARKS
YES NO
22. Document that the patient received the blood
transfusion; include the type of blood
product. Record the patient’s condition
throughout the transfusion, including This provides for accurate documentation of patient’s response to the
pertinent data, such as vital signs, lung transfusion.
sounds, and the subjective response of the
patient to transfusion. Document any
complications or reactions and whether the
patient had received the transfusion without
any complications or reactions. Document
the assessment of the IV site, and any other
fluids infused during the procedure.
Document transfusion volume and other IV
fluid intake on the patient’s intake and
output record.

Learner’s Reflection​: ​(What did you learn most of the activity? What is its Instructor’s Comments:
impact to you?)

1. ​ hat is the importance of this skill?

W
Blood transfusion can save a patient’s life and limit the complications
of severe blood loss.
-A lot of bleeding can lead to a seriously low hemoglobin level and
cause damage to body organs due to a lack of oxygen.
-If bleeding continues the body’s supply of platelets and plasma are
also decreased. Then, blood cannot clot and bleeding will not stop.
Blood transfusion benefits patients by treating or preventing these
situations.
2. How do you feel about the procedure?
This procedure is not new to me since I am already well acquainted
about this. It happens a lot in the hospital and even in our school. It
provides a lot of benefits especially to those who need it the most.
However, nurses play a vital role in administering blood transfusions.
As a nurse, you should know these things.

3. Which among the steps needs further explanation?

I think the looseleaf is comprehensive and informative in a way that we
can understand the procedure without any difficulty. Watching the
supplemental videos and reading the specific chapter of the book
supplemented in mole made it easier for me to imagine doing this
procedure also. Nonetheless, I think I understood the procedure well
and I'm looking forward to doing this again in the hospital setting.

4. What are the complications of Blood Transfusions and as a nurse

what are your interventions?
The healthcare industry works hard to ensure the safety of blood used
in transfusions. Blood banks ask potential donors questions about their
health, behavior and travel history. Only the people who pass the blood
donor requirements can donate blood. Donated blood is tested
according to national guidelines. If there is any question that the blood
is not safe, it is thrown away.

Even with these precautions, there’s a small chance something will go

undetected in the screening process. However, the odds of this
happening are very small. For example, your chances of getting certain
diseases from a transfusion are:

● HIV: 1 in 1.5 million donations.

● Hepatitis C: 1 in 1.2 million donations.
● Hepatitis B: 1 in 293,000 donations.
● Bacterial contamination: 1 in 100,000 transfusions.
 Other risks of blood transfusion are:
● Hemolytic reactions: the patient's own blood destroys the transfused
blood. This is due to a human error. Careful patient identification steps
are followed to make sure the correct blood is given.
● Bacterial infection (highest with platelet transfusions).
Side effects could include: itching, skin rash, fever, or feeling cold.
More serious side effects such as trouble breathing are very rare.

References:
Lynn, P. (2011). Taylor's Clinical Nursing Skills: A Nursing Process Approach. 3​rd​ Edition. Philadelphia: LWW
Smith-Temple, J & Johnson, J.Y. (2006). Nurses’ Guide to Clinical Procedures. 5​th​ Edition. Philadelphia: LWW.
Hilton, P.A. (2004). Fundamental of Nursing Skills. Philadelphia: Whurr Publishers Ltd.
Mills, E. J. (2004). Nursing Procedures. 4​th​ Edition. Philadelphia: LWW