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BLOOD TRANSFUSION

1. Verify doctor’s written prescription and


make a treatment card according to
hospital policy.

2. Observe ten (10) Rs when preparing and administering any blood or blood
components.

3. Explain the procedure/rationale for


giving blood transfusion to
reassure patient and significant
others and secure consent. Get
patient’s history regarding previous
transfusion.

4. Explain the importance of the benefits on Voluntary Blood Donation


(RA 7719 – National Blood Service Act of 1994).

5. Request prescribed blood/blood components from blood bank to include


blood typing and X-matching and blood result of transmissible disease.

6. Using a clean lined tray, get compatible blood from hospital blood bank.

7. Wrap blood bag with clean towel and keep it at room temperature.

8. Have a doctor and a nurse assess patient’s


condition. Countercheck the compatible blood to
be transfused against the X-matching sheet
noting ABO grouping and Rh, serial no. of each
blood unit, and expiry date with the blood bag
label and other laboratory blood exam as
required before transfusion (Hgb and Hct).

9. Get the baseline vital signs – BP, RR,


temperature before transfusion. Refer to
MD accordingly.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP 1
was reproduced for educational purposes of Filipino student nurses and registered nurses
who need to review and study the procedures prior to actual IVT training and practicum.
Downloaded from IVTeam Phils Hub | ivthub.blogspot.com

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

11. Do hand hygiene before and after the


procedure.

12. Prepare equipment needed for BT:

IV injection tray, IV catheter/needle G


18/19, plaster, tourniquet, gloves

compatible BT set
G 18 needle (only if needed)

blood component to be transfused

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP 2
was reproduced for educational purposes of Filipino student nurses and registered nurses
who need to review and study the procedures prior to actual IVT training and practicum.
Downloaded from IVTeam Phils Hub | ivthub.blogspot.com

Plain NSS 500 cc,


IV set

sterile 2x2 gauze


or transparent dressing

IV hook and stand

13. If main IVF is with dextrose 5% initiate


an IV line with appropriate IV catheter
with Plain NSS on another site, anchor
catheter properly and regulate IV
drops.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP 3
was reproduced for educational purposes of Filipino student nurses and registered nurses
who need to review and study the procedures prior to actual IVT training and practicum.
Downloaded from IVTeam Phils Hub | ivthub.blogspot.com

14. Open compatible blood set aseptically and close roller clamp. Spike blood
bag carefully; fill the drip chamber at least half full; prime tubing and
remove air bubbles (if any). Use needle G 18 or 19 for side drip (for
adults) or of 22 for pedia (if blood is given through the Y-injection port, the
gauge of needle is disregarded).

15. Disinfect the Y-injection port of IV tubing


(Plain NSS) and insert the needle from BT
administration set and secure with adhesive
tape.

16. Close roller clamp of IV fluid of Plain NSS


and regulate to KVO while transfusion is
going on.

17. Transfuse the blood via the injection port


and regulate at 10-15 gtts initially for 15
minutes and then at the prescribed rate
(usually based on the patient’s condition).

18. Observe patient for 10-15


minutes for any immediate
reaction.

19. Observe patient on an on-


going basis for any
untoward signs and
symptoms such as flushed
skin, chills, elevated
temperature, itchiness,
urticaria and dyspnea. If
any of these symptoms
occurs stop the
transfusion, open the roller
clamp of the IV line with
Plain NSS, and report to
doctor immediately.

20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT set
should be used for 1-2 units of blood.

21. When blood is consumed, close the roller clamp of BT, and disconnect
from IV lines then regulate the IVF of plain NSS as prescribed.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP 4
was reproduced for educational purposes of Filipino student nurses and registered nurses
who need to review and study the procedures prior to actual IVT training and practicum.
Downloaded from IVTeam Phils Hub | ivthub.blogspot.com

22. Continue to observe and monitor patient post


transfusion for delayed reaction could still occur.

23. Re-check Hgb and Hct, bleeding time, serial


platelet count within specified hours as prescribed
&/or per institution’s policy.

24. Discard blood bag and BT set and sharps


according to Health Care Waste Management
(DOH/DENR).

25. Document the procedure, pertinent observations and


nursing intervention and endorse accordingly.

26. Remind the doctor about the administration


of Ca gluconate if patient had several units
of blood transfusion (3-6 or more units of
blood).

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP 5
was reproduced for educational purposes of Filipino student nurses and registered nurses
who need to review and study the procedures prior to actual IVT training and practicum.