Procedure Guidelines for Blood Transfusion

1. Assess the client for the indication of the blood product to be given, that
is, low hematocrit or platelet count. This will enable more specific evaluation
of response to the transfusion.
2. Review the client's transfusion history, especially any reactions or pre-
transfusion medications to be given. If prior reaction has occurred, pre-
medications may be given to prevent a subsequent reaction.
3. Verify the physician's order for the type of blood product to be given.
4. Inform the patient of the procedure, blood product to be given,
approximate length of time, and desired outcome.
5. Instruct the patient to report unusual symptoms immediately. Review side
effects (dyspnea, chills, headache, chest pain, itching) with client and ask
him or her to report these to the nurse. Prompt reporting of a side effect will
lead to earlier discontinuation of transfusion and minimized the reaction.
6. Have the client sign consent forms per agency protocol.
7. Obtain client's vital signs just before procuring blood product from blood
bank. If the patient's clinical status permits, delay transfusion if baseline
temperature is greater than 38.7°C.
8. Prepare infusion site. Select a large vein that allows patient some degree
of mobility. Start the prescribed I.V. infusion (preferably normal saline).
Solutions other than normal saline may be incompatible with blood product
and may cause agglutination or hemolysis.
9. Patency of the I.V. line should ALWAYS be ensured before transfusion. An
18- or 20-gauge IV cannula should be used when transfusing whole blood or
PRBCs. For platelets & FFP, a 22-gauge or larger bore IV cannula is used.
(TIP: You may refer to color-code on the IV cannula to determine if gauge of
cannula is appropriate for IV line that has already been started a few days
prior to transfusion; DON'T use an existing line if the cannula is smaller than
gauge-20 when transfusing whole blood or PRBCS)
10. Obtain blood product from the blood bank within 30 minutes of the
transfusion start time to prevent bacterial growth and destruction of red
blood cells. If transfusion cannot begin immediately, return product to blood
bank. Blood out of proper storage (above 10°C) for more than 30 minutes
cannot be reissued. NEVER store blood in unauthorized refrigerators, such as
those on the nurse's station.
11. Verify and record the blood product with another nurse. Full name and
signatures of RNs (including date & time) are recorded on a hospital-
approved blood transfusion form. During clerical check, one nurse should be
reading ONLY the label on the blood bag & the other nurse reading ONLY the
blood transfusion form, reading out loud the following information
simultaneously:
Client or Recipient information:
Name, Age, Sex & Blood Type (ABO group & Rh type)
Ward/Room number & Case/Hospital ID number.
Type of blood product compared with physician’s order (if whole blood,
PRBCs, FFP, etc.) Screening & Cross-matching compatibility Results (there is
a separate form for this usually issued with the blood unit; cross-matching
may not be needed on some blood products/units; some patients may also
defer screening of blood unit by signing a waiver; but cross-matching is
Always IMPERATIVE)
Information on Donor blood:
Unit Source (refers to the name of the blood bank who issued the unit)
Bag number (found on label of blood bag)
Segment number (series of letters or numbers imprinted along the tubing of
the blood bag)
ABO blood group (if type A, B, AB or O)
Rh type (if positive/”+” or negative/”-“)
Date & time of collection
▪ Date & time of expiry
Appearance of the unit/blood product (observe for abnormal color, RBC
clumping, gas bubbles,
Extraneous material & other impurities; take note that platelets are normally
cloudy)
Volume of blood product or unit (to validate this, the nurse will use a spring
scale or weighing scale; weight in grams is equal to volume of biood bag in
milliliters/mL or cc)
12. Any inconsistency, discrepancy or irregularity noted by the two nurses
during the clerical check should be reported to blood bank immediately.
Always return outdated/abnormal blood or wrong blood product/unit to the
blood bank.
13. Perform hand hygiene and assemble needed equipment.
14. Using aseptic technique, prime the blood unit using appropriate blood or
platelet administration set.
- Spike blood unit (making sure roller clamp on administration set is closed)
Squeeze drip chamber and allow the filter (if present) to fill with blood
Open roller clamp and allow tubing to fill with blood to the hub. Attach hub
to a filtered- needle (usually gauge 18 to 20) if not transfusing on a
needleless device.
15. If client’s main line is NOT normal saline (PNSS), prepare a disposable
syringe filled with 10 cc or more
Of normal saline. This will be used to flush the tubing before & after
administration of blood product.
16. Put on appropriate personal protective equipment & assemble needed
materials before approaching
Client’s room.
17. Verify patient identification.
Ask the patient to state his or her full name and compare with name on wrist
band. If the patient is unable to state his or her name, verify identity with an
individual familiar with the patient. Verify client blood type (ABO group & Fh
type) & other essential information
18. Obtain & record client’s vital signs immediately before transfusion to
establish baseline.
19. Review the procedure and signs/symptoms of transfusion reaction before
commencing transfusion.
20. Reassure client & entertain questions to allay anxiety.
21. Close the clamp of the client’s main IV line.
22. Wipe the Y-port of the main IV line with alcohol swab.
23. Flush the tubing of main IV line with 10 cc or more of normal saline by
injecting it onto the Y-port. 24. Piggyback blood administration set with a
needle to the Y-port of the main IV line and secure all connections with
adhesive tape.
25. Initially, start the infusion slowly (about 2 mL/minute). Acute transfusion
reactions are usually manifested during infusion of the initial 50-100 mL of
blood. Remain at bedside for 15-30 minutes. If signs of blood transfusion
develop, STOP the transfusion immediately & record vital signs. Infuse saline
solution at a moderately slow infusion rate, and notify the physician at once.
26. If no signs of a reaction appear within 15 minutes, you’ll need to adjust
the flow clamp to the ordered infusion rate (usually 10 to 20 gtts/min).
Continue to monitor if blood is infusing adequately at prescribed flow rate.
Transfusion of a unit of blood should NOT exceed 4 hours to avoid bacterial
growth.
27. Monitor client’s vital signs throughout the blood transfusion every 15
minutes for the first 30 minutes, then every 30 minutes for 1 hour, then
hourly until 1 hour after the infusion is completed, or per institution policy.
Also continue monitoring for blood transfusion reactions.
28. An accepted blood infuser or pressure infuser (see illustration below]
may be used to facilitate infusion especially when the flow rate on blood
administration set slows down (as what usually occurs when transfusing
packed RBCs) & there is still blood product remaining in the bag.
29. Inflating the blood infuser will apply pressure on the blood bag which
facilitates infusion of remaining contents. NEVER squeeze the blood bag with
your hands & DO NOT OVERINFLATE the bag of pressure infuser (usually not
exceeding 300 torr or not exceeding marked line on pressure indicator). Be
aware that excessive pressure may develop, leading to broken blood vessels
and extravasation, with Hematoma and hemolysis of the infusing RBCs.
30. After blood has infused, close the clamp of the blood administration set
and remove tubing with Needle from the Y-port of the IV main line.
31. If main line is NOT normal saline, DON’T open the clamp of the main IV
line yet. Flush it again first with 10 cc or more of normal saline to clear blood
from the line.
32. If main IV line is saline, simply open the clamp of the main IV line and
allow tubing to clear of blood. 33. Regulate main IV line at prescribed flow
rate.
34. Do aftercare.
35. Return the empty blood bag to the blood bank, and discard the tubing
and filter or per agency policy.
36. Record the patient’s vital signs & do appropriate documentation.
Precautions & Special Considerations:
 NO solution other than normal saline (PNSS) should be added to blood
components.
 Medications are NEVER added to blood components or piggybacked
into a blood transfusion. If the client is receiving multiple IV
medications on a strict schedule (e.g., antibiotics), consider starting a
second IV line for a lengthy blood transfusion
 Blood products should NOT be transfused simultaneously or
immediately preceding or following medications also capable of
causing allergic-type reactions. Distinguishing the etiology of the
reaction could be difficult.
 Routine blood transfusions should not be warmed as hemolysis of
blood occurs at temperatures above 40°C. Multiple rapid transfusions
& hypothermia, however, requires blood warming.
 NEVER administer blood that is too cold. DON’T warm the blood on a
hot water bath either or place it in a microwave or by other
unacceptable means. In the absence of an authorized blood warmer,
the nurse may simply wrap the blood bag with a chick towel until it is
not cold for transfusion.
 Always handle the blood bag CAREFULLY so as not to cause RBC
hemolysis.
 Platelets are administered immediately on receipt from the blood bank
and are given rapidly, usually Over 15 to 30 minutes.
 For multiple blood transfusions, always use a different blood
administration or platelet administration Set for each unit.
 Always obtain physician’s order for follow-up laboratory tests needed
post-blood transfusion to monitor effectiveness of the therapy.
 A Jehovah Witness CANNOT receive blood or blood products; this
group believes that blood transfusions have eternal consequences.
Always assess for any cultural or religious beliefs regarding blood
transfusions.