Care of Mother and Child At-Risk or

with Problems (Acute and Chronic)-RLE

Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

Lesson Title: Initiating Blood Therapy-Part 2 Materials:

Learning Targets:
At the end of the module, students will be able to:
1. Discuss indications for blood therapy.
2. Describe various transfusion reactions.
3. Demonstrate the following skills on selected patients:
initiating blood therapy, implementing autotransfusion,
and monitoring for adverse reactions to transfusion.
SAS, OB book, pens
References:
Silbert-Flagg , JoAnne and Pilliteri, Adele
(2018) Maternal and Child Health Nursing, 8th
Edition. USA: Lippincott Williams and Wilkins

Perry, A. G., Ostendorf, W. R., &; Potter, P. A.

(2021). Clinical Nursing Skills and Techniques
(10th ed.). Elsevier.

Initiating Blood Therapy Video

A. LESSON REVIEW/PREVIEW

B. MAIN LESSON
MANAGING A BLOOD OR BLOOD PRODUCT TRANSFUSION REACTION
Safety considerations:
 Always review your agency’s algorithm for managing mild to severe reactions. If a reaction is mild
(e.g., fever), and without any other complications, a patient may continue the transfusion if monitored
closely. Most other transfusion reactions require the transfusion to be stopped immediately.
 A blood transfusion reaction may occur 24 to 48 hours post-transfusion.
 Each separate unit presents a potential for an adverse reaction.
 Follow emergency transfusion guidelines when dealing with an emergency blood or blood product

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

transfusion.
 Be aware of which types of blood or blood products cause the most types of transfusion reactions.
 Be aware of the types of patients at high risk for blood or blood product transfusion reactions.
 Always have emergency equipment and medications available during a transfusion. For example,
epinephrine IV should always be readily available.
STEPS RATIONALE
1. Stop transfusion immediately. The severity of a blood transfusion reaction is related
to the amount of product infused and the amount of
time it has been infusing.
2. Keep IV line open with 0.9% saline. Keeps IV site patent for emergency medications if
required.
3. Complete cardiovascular and vital signs
assessment.
Assessment monitors the type and severity of
reaction. In addition to assessment:

 Maintain good urinary output.

 Avoid fluid overload.
 Manage DIC (disseminated intravascular
coagulation) or hemorrhage if clinically
indicated.

Provide supportive measures as required (oxygen,

4. Contact physician for medical assessment and to
inform about reaction.
5. Check vital signs every 15 minutes until stable.
6. Obtain blood and urine samples as soon as
possible.
7. Check all labels, tags, forms, blood order, and
patient’s identification band to determine if there is a
clerical discrepancy.
8. Keep all blood and IV tubing for further testing by
the blood bank for verification of blood product and
patient identification.
9. Notify blood bank.
10. Document as per agency policy.
etc.).
The physician responsible for the patient must be
informed of all transfusion reactions.
Vital signs must be monitored to identify improving or
worsening condition.
Blood and urine samples can help identify the type of
blood transfusion reaction.
Clerical errors account for the majority of blood
transfusion reactions.
All blood products and IV tubing are investigated by
the transfusion services and reported as per
agency’s protocol.
Notify blood bank when an adverse reaction occurs,
even if transfusion is continued.
Document time, date, signs and symptoms, type of

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

product, notification to the physician and

management of reaction, and patient response to
management of reaction.

Documentation includes, but is not limited to:

 Transfusion reaction form

 Patient chart
 Report for transfusion services (blood bank)

Adverse event form (Patient Safety Learning System

or PSLS)

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

NAME OF STUDENT: ____________________________________________

LEVEL & BLOCK: SCHOOL YEAR & TERM:

_____________________________ ___________________________ OVERALL RATING

CHECKLIST ON INITIATING BLOOD THERAPY/TRANSFUSION

PERFORMANCE EVALUATION CHECKLIST 2

PROCEDURE PERFORMED PERFORMED UNABLE

INDEPENDENTLY WITH TO
ASSISTANCE PERFORM REMARKS
4-5 2-3 0-1
ASSESSMENT
1. Verify health care provider’s order for
specific blood or blood product, date, time
to begin transfusion, duration, and any
pretransfusion or posttransfusion
medications to administer.

2. Obtain patient’s transfusion history and

note known allergies and previous
transfusion reactions. Verify that type and
crossmatch have been completed within
72 hours of transfusion.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

3. Verify that IV cannula is patent and

without complications such as infiltration
or phlebitis.

4. Assess laboratory values such as

hematocrit, coagulation values, platelet
count.

5. Check that patient has properly

completed and signed transfusion consent
before retrieving blood.

6. Know indications or reasons for

transfusion (e.g., packed red blood cells
[PRBCs] for patient with low hematocrit
level from gastrointestinal bleeding or
surgery blood loss).

7 Obtain and record pretransfusion

baseline vital signs (temperature,
respirations, and blood pressure). If
patient is febrile (temperature greater than
37.8°C [100°F]), notify health care
provider before initiating transfusion.

8. Assess patient’s need for IV fluids or

medications while transfusion is infusing.

9. Assess patient’s understanding of

procedure and rationale.
PLANNING
10. Explain procedure to patient and
family caregiver.

IMPLEMENTATION
PRE-ADMINSTRATION PROTOCOL:
1. a. Obtain blood component from blood
bank following agency protocol (see
illustration below). Blood transfusion
must be initiated within 30 minutes

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

after release from laboratory or blood

bank.

b. Check blood bag for any signs of

contamination (i.e., clumping/clots, gas
bubbles, purplish color) and presence of
leaks.

c Verbally compare and correctly verify

patient, blood product, and type with
another person considered qualified by
your agency (e.g., RN or LPN) before
initiating transfusion. Check the following:

(1) Identify patient using two identifiers

(i.e., name and birthday or name and
account number) according to agency
policy. Compare identifiers in
MAR/medical record with information on
patient’s identification bracelet and/or ask
patient to state name.

(2) Transfusion record number and

patient’s identification number match.

(3) Patient’s name is correct on all

documents. Check identification number
and date of birth on identification band
and patient record.

(4) Check unit number on blood bag with

blood bank
form to ensure that they are the same.

(5) Blood type matches on transfusion

record and blood bag. Verify that
component received from blood bank is
same component that health care provider
ordered (e.g., packed red cells, platelets)
(see illustration below).

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

(6) Check that patient’s blood type and Rh

type are
compatible with donor blood type and Rh
type (e.g.,
Patient A+: Donor A+ or 0+).

(7) Check expiration date and time on unit

of blood.

(8) Just before initiating transfusion, check

patient
identification information with blood unit
label
information (see illustration below). Do not
administer blood to patient without an
identification bracelet.

(9) Both individuals verify patient and unit

identification record process as directed
by agency policy.

d. Review purpose of transfusion and ask

patient to report any changes that he or
she may feel during the transfusion.

e. Empty urine drainage collection

container or have patient void.

ADMINISTRATION PROTOCOL:

12. a. Perform hand hygiene and apply

clean gloves.

b. Open Y-tubing blood administration set

for single unit. Use multiset if multiple
units are to be transfused.
c. Set all clamp(s) to “off” position.

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

d. Spike 0.9% normal saline IV bag with

one of Y-tubing spikes. Hang bag on IV
pole and prime tubing. Open upper clamp
on normal saline side of tubing and
squeeze drip chamber until fluid covers
filter and one third to one half of drip
chamber (see illustration below).

e. Maintain clamp on blood product side

of Y-tubing in “off” position. Open
common tubing clamp to finish priming
tubing to distal end of tubing connector.

Close tubing clamp when tubing is filled

with saline. All three tubing clamps should
be closed.

Maintain protective sterile cap on tubing

connector.

f. Prepare blood component for

administration. Gently agitate blood unit
bag, turning back and forth, upside down.
Remove protective covering from access
port. Spike blood component unit with
other Y connection. Close normal saline
clamp above filter, open clamp above filter
to blood unit, and prime tubing with blood.
Blood will flow into drip chamber (see
illustration below). Tap filter chamber to
ensure that residual air is removed.

g. Maintaining asepsis, attach primed

tubing to patient’s VAD. Open common
tubing clamp and regulate blood infusion
to allow only 2 mL/min to infuse in initial
15 minutes.

h. Remain with patient during first 15

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

minutes of transfusion. Initial flow rate

during this time should be 2 mL/min or 20
gtt/min (using macrodrip of 10 gtt/mL).

i. Monitor patient’s vital signs at 5

minutes, 15 minutes, and every 30
minutes until 1 hr after transfusion or per
agency policy.

j. If there is no transfusion reaction,

regulate rate of transfusion according to
health care provider’s orders. Check drop
factor for blood tubing.

k. After blood has infused, clear IV line

with 0.9% normal saline and discard blood
bag according to agency policy. When
consecutive units are ordered, maintain IV
patency with 0.9% normal saline at keep
vein open (KVO) rate and retrieve
subsequent unit for administration.

l. Appropriately dispose of all supplies.

Remove gloves and perform hand
hygiene.

EVALUATION
13. Observe IV site and status of infusion
each time vital signs are taken.

14. Observe for any changes in vital signs

and any signs of transfusion reactions
such as chills, flushing, itching, dyspnea,
or rash.

15. Observe patient and assess

laboratory values to determine response
to administration of blood component.
DOCUMENTATION
16. Record pretransfusion medications,

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 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

vital signs, location and condition of IV

site, and patient education.

17. Record the type and volume of blood

component, blood unit/donor/recipient
identification, compatibility, and expiration
date according to agency policy, along
with patient’s response to therapy.
Document on the transfusion record,
nurses’ notes, electronic health record
(EHR), medication administration
record, flow sheet, and/or intake and
output sheet, depending on agency policy.

18. Record volume of normal saline and

blood component infused.

19. Report signs and symptoms of a

transfusion reaction immediately to the
health care provider.

20. Record amount of blood received by

autotransfusion and patient’s response to
therapy.

21. Report to health care provider any

intra-transfusion/posttransfusion
deterioration in cardiac, pulmonary, and/or
renal status.

22. Record vital signs before, during, and

after transfusion.

REMARKS:
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Care of Mother and Child At-Risk or
with Problems (Acute and Chronic)-RLE
Module #4 Student Activity Sheet

Name: Class number:

_________________________________________________________________ _______

Section: ____________ Schedule: Date:

________________________________________ ________________

_______________________ ______________________
CONFORME: STUDENTS SIGNATURE CLINICAL INSTRUCTOR

C. LESSON WRAP-UP
AL Strategy: Minute Paper
1. Please prepare a question or write a question in an index cards or half-sheets of paper to write
feedback to the following questions:
a. What was the most useful or the most meaningful thing you have learned this session?
b. What question(s) do you have as we end this session?

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