MISAMIS UNIVERSITY

Ozamiz City 7200, Philippines

Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: mu@mu.edu.ph

CERTIFIED: ISO 9001:2015 Risk Management System– DNVGL, Australia Pty Ltd.
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation
(PACUCOA)

PERFORMANCE CHECKLIST: INITIATING, MAINTAINING AND TERMINATING A BLOOD

TRANSFUSION

Name of Student: _________________________ Date: ___________________

Initiating, Maintaining And Terminating A Blood Transfusion

Able to Unable to
Procedure Perform Perform
(1 Point) (0 Point)

1. Assesses
• Vital signs
• Physical examination including fluid balance and heart and lung
sounds
• Status of infusion site
• Blood test results such as hemoglobin value or platelet count
• Any unusual symptoms

2. Reviews client record regarding previous transfusions.

• Confirms primary care provider’s order for the number and type of units
and the desired speed of infusion.
• Checks written consent for transfusion
• Identifies the purpose of the transfusion

3. Assemble equipment

4. Introduces self and verifies the clients identity using agency protocol.
• Explains the procedure to client , and how he or she can participate.
• Instructs client to report promptly any sudden chills, nausea, itching,
rash, dyspnea, back pain, or other unusual symptoms.

5. Provides client privacy and prepares the client.

6. Performs hand hygiene and observes other appropriate infection prevention
procedures.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: mu@mu.edu.ph

CERTIFIED: ISO 9001:2015 Risk Management System– DNVGL, Australia Pty Ltd.
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation
(PACUCOA)

7. Prepares the infusion equipment.

• Applies gloves.
• Closes all the clamps on the Y-set: the main flow rate clamp
• Inserts the piercing pin (spike) into the saline solution.
• Hangs the container on the IV pole about 1 m (39 in.) above the
venipuncture site.
8. . Primes the tubing.

9. Starts the saline solution.

• Attaches the blood tubing primed with normal saline to the IV catheter.
• Opens the saline and main flow rate clamps and adjust the flow rate. Uses
only the main flow rate clamp to adjust the rate.
• Allows a small amount of solution to infuse to make sure there are no
problems with the flow or with the venipuncture site.

10. Obtains the correct blood component for the client.

• Checks the primary care provider’s order with the requisition.
• Checks the requisition form and the blood bag label with a laboratory
technician or according to agency policy.
• Specifically, check the client’s name, identification number, blood type (A,
B, AB, or O) and Rh group, the blood donor number, and the expiration
date of the blood. Observe the blood for abnormal color, RBC clumping,
gas bubbles, and extraneous material..

11. With another nurse, verifies the following before initiating the transfusion:
 Order
 Transfusion Consent form
 Client identification
 Unit identification
 Blood type
 Expiration
 Compatibility:
 Appearance
12. Knowledge :
• States necessary steps for any discrepancies noted and for any
information that does not match
• Discusses nurses responsibility if transfusion is unexpectedly delayed.
 MISAMIS UNIVERSITY
Ozamiz City 7200, Philippines
Tel No. +63 88 521-0367 / Telefax No. +63 88 521-2917
E-mail Address: mu@mu.edu.ph

CERTIFIED: ISO 9001:2015 Risk Management System– DNVGL, Australia Pty Ltd.
ACCREDITED: Philippine Association of Colleges and Universities Commission On Accreditation
(PACUCOA)

13. Prepares blood bag.

14. Establish the blood transfusion.
.
15. Removes and discards gloves.
Performs hand hygiene
16. Monitors the client.
• Checks vital signs, fifteen minutes after initiating the transfusion .If there
are no signs of a reaction, establish the required flow rate.
• Assess the client, including vital signs,

17. Terminates transfusion. Applies clean gloves.

18. Disposes used supplies.

Removes and discards gloves.  Performs hand hygiene.

19.

20. Documents relevant data.

Total Score :

Highest Possible Score :

Remarks: ________________________________________________________________

_______________________ __________________________________

Signature of Student Name & Signature of Clinical Instructor

Reference: Berman, A., et al. (2016). Kozier & Erb’s Fundamentals of Nursing Concepts, Process, and Practice. 10 th
edition. Pearson.
MISAMIS UNIVERSITY