PERFORMANCE CHECKLIST LEVEL II

2nd Semester

Name of Student: ____________________________________________

Section & Group No.: ________________________

MANAGING BLOOD TRANSFUSION

Definition:
 Provides replacement of blood products to increase client’s fluid volume, hemoglobin,
and hematocrit for improved circulation and oxygen distribution.
 Prevents over administration of blood products or the development of complications
associated with a transfusion.

Materials Needed:
 Blood transfusion tubing (blood Y set with in-line filter)
 1L Normal saline solution (0.9 NaCl)
 Packed cells or whole blood (as ordered)
 Blood crossmatching result
 Vital signs flow sheet (for monitoring)
 Non-sterile gloves
 Alcohol swabs
 Needle gauge 18/ gauge 21
 Hand/face Towel

Procedures Done Not Remarks

done
ASSESSMENT
1. Review physician’s order for type, amount and rate of
infusion
2. Baseline vital signs, circulatory, respiratory and skin status.
3. Baseline complete blood count, blood type and cross-match
result.
PLANNING
1. Determine the equipment that you will need
2. Wash your hands.
3. Gather materials needed
IMPLEMENTATION
1. Explain the procedure to the client particularly the need for
frequent vital sign checks.
2. Request blood/blood component from hospital blood bank
with same blood type with the patient/recipient.
3. Secure result of blood typing and cross matching from the
laboratory.
4. Warm blood at a room temperature by wrapping the blood
bag with a towel. Blood should be transfused not more than
20 minutes from the time it arrives from the blood bank.
5. Have a co-nurse countercheck the compatible blood to be
transfused with the cross matching result:
 Name and identification number
 Clients’ blood group and Rh type
 Donor’ blood group and Rh type
 Cross match compatibility
 Blood unit and serial component
 Expiration date of blood product
6. Give pre-medication 30 minutes before transfusion if any is
ordered
7. Wash hands and don gloves

8|Page
 PERFORMANCE CHECKLIST LEVEL II
2nd Semester

8. Initiate an IV line with appropriate IV catheter with Plain

NSS, anchor catheter properly and regulate rate
9. Open compatible blood aseptically. Open packaging of the
blood transfusion set (BT administration set), close the roller
clamp and attach a large bore needle.
10. Spike the blood bag carefully. Hang the blood bag in the IV
pole.
11. Fill the drip chamber of the BT administration set into half
then prime tubing and remove bubbles.
12. Disinfect the Y injection port of the main line IV tubing and
insert the needle from the BT administration set and secure
with adhesive tapes.
13. Close IV fluid of Plain NSS or regulate to KVO while
transfusion is on going.
14. Transfuse the blood (4-6 hrs) via injection port at 10-12 gtts
initially for 15 minutes then regulate at ordered rate.
15. Observe for any untoward signs and symptoms (flushed
skin, chills, elevated temperature, itchiness, urticaria and
dyspnea) if any occurs, STOP the infusion, open IV line with
NSS and report to the physician.
16. Remove gloves.
17. Swirl the bag once in a while.
18. If blood is consumed, don gloves. Close roller clamp of BT
set then disconnect from IV line.
19. Regulate the IVF as ordered.
20. Discard used BT equipment to proper bins.
21. Remove gloves and wash hands.
EVALUATION
1. Carry out post BT order such as rechecking hemoglobin and
hematocrit levels, bleeding time etc.
DOCUMENTATION
1. Document observations and interventions done

__________________________ _______________________________ ---------------------

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature

9|Page