NCM 109 RLE – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)

BLOOD TRANSFUSION

DEFINITION: It is the introduction of whole blood or components of the blood (eg, plasma or
erythrocytes) into the venous circulation.

PURPOSES:
• To restore blood volume after severe hemorrhage.
• To restore the capacity of the blood to carry oxygen.
• To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet
concentrates which prevent or treat bleeding.

PRINCIPLES:
• A client’s blood will be tested before a transfusion to determine whether blood type is
A, B, AB or O and whether the blood is Rh positive or Rh negative. The donated blood
used for transfusion must be compatible with client’s blood type.
• Never add any medications to any blood products.
• Blood transfusions are usually done in a hospital, an outpatient clinic or a doctor's
office. The procedure typically takes one to four hours, depending on which parts of the
blood one must receive and how much blood needed.

EQUIPMENT:
• Unit of whole Blood or blood component product.
• Blood administration set
• Container of normal saline solution
• IV pole
• Venipuncture set – usually gauge 18 or 19 needle or catheter is used
• Alcohol swabs
• Hypoallergenic Plaster
• Gloves
 PROCEDURE
1. Verify the doctor’s order for blood
transfusion. It should be checked by 2
nurses.
2. Check if consent has been signed.
3. Assess vital signs (BP, Temperature,
Pulse, Respiration, any previous
reactions to a blood transfusion,
specific signs related to the client’s
pathology and reason for the
transfusion).
RATIONALE
Confirm that the order addresses the indication
for transfusion, the preparation of the product,
and administration requirements (including the
start time and rate of infusion). Confirm that the
order and the medical record are labeled with
the patient's first and last name and unique
identification number.
This consent provides a structure for a patient to
make an informed choice regarding the
indications, risks, possible alternatives, and
benefits of a blood transfusion. It permits the
patient to participate more fully in treatment
decisions.
To secure baseline data for comparison.

4. Prepare the client.

▪ Explain the procedure and its To allay fears, increase client’s understanding,
purpose and cooperate during the procedure and its
▪ Instruct to report any sudden treatment.
chills, nausea, itching, rash,
dyspnea, or other unusual
symptoms.
▪ If the client has an IV solution
infusing, check the infusion
set, the solution and the
needle is compatible with
blood transfusion. A blood set
with a blood filter, a gauge 18
or 19 needle and 0.9% NaCl is
recommended. Any other
medications are incompatible.

5. Prepare the equipments. To save time, energy, and effort.

6. Obtain the correct blood product
ordered for the client. Check for: Check requisition form and the blood bag label
▪ Blood type with a laboratory technician or according to
▪ Rh group agency policy.
▪ The blood donor number
▪ Expiration date
 ▪ Abnormal color – dark color,
cloudiness
▪ ABC clumping
▪ Gas bubbles
▪ Extraneous materials
7. Type and crossmatch the blood. 2
nurses should verify the following on This is to ensure correct blood product to be
the crossmatch result: administered. Two nurses will compare
▪ Client’s name and laboratory blood type record with client’s
identity.
identification number
Should not transfuse any blood product that
▪ The serial number
doesn't match the patient's assigned
▪ The ABO group and Rh on the identification number. Plasma, platelets, and
blood bag label blood derivatives can also cause serious
▪ the expiration date and time; and transfusion reactions and must be administered
the date and time of blood issue. with care.
▪ Wear gloves or transport the
blood product units in a
container that prevents direct
contact with the blood unit bag.
8. Verify the client’s identity – ask the Check arm band present. 2 nurses are also
client to state his/her full name. required to do the verification
9. Wash hands. Prevents infection from the care provider to the
client.
10. Set up the infusion equipment:
▪ Close all clamps first before Ensure that the blood filter inside the drip
inserting the tubing to the chamber is suitable for whole blood or the blood
solution. components to be transfused.
▪ If using straight line set, start
first with PNSS. The blood
product follows establishing
patent IV line.
▪ If using a Y-set, attach the
PNSS to one of the two spikes.
Connect the blood product to
the spike only after patent IV
line is established.
▪ Use the IV sets provided with
the blood component if
available.
11. Prime tubing with PNSS. Never mix medications with blood or blood
products. If the patient requires IV medications
during transfusion, start a separate IV line for the
administration of blood products so that the
patient can simultaneously receive the
 therapeutic benefits of the blood product and the
medication.

If using a blood warming device or an electronic

12. Wash hands again if necessary.
13. Put on gloves and prepare for
venipuncture. Procedure is the same
as with starting an IV line.
infusion device, insert the tubing into the device
and operate the device according to the
manufacturer's instructions for use.
Prevents infection from the care provider to the
client.
To reduce the risk of contamination of health-
care workers hands with blood and other body
fluids.

14. Prepare the blood bag.

▪ Warming the blood product to Blood products should be transfused within

room temperature is done by
wrapping it with clean towel.
▪ Invert the blood bag gently
several times to mix the cells.
Rough handling can damage
the cells.
▪ Connect the blood product to
tubing.
30 minutes after exposure to room
temperature. RBC hemolysis begins after 2
hours exposure to room temperature.
Hemolysis of RBC could cause release of
potassium into the blood stream which can
result of hyperkalemia. Prolonging exposure
to room temperature could also increase the
risk of bacterial growth in the blood product.

▪ If using straight line set,

remove PNSS first. Remove by
first closing the clamp, then
kinking the tubing just below
the drip chamber, and then
pulling out the tubing.
Immediately insert the tubing
to the blood product. Apply
twisting motion if necessary.

▪ If using a y-set, connect the

blood product to the other
end of the tubing. The clamp
near the spike and the clamp
below the drip chamber
 should be closed prior to the
insertion.
▪ Suspend the bag.
15. Establish blood transfusion.
▪ Straight line set - open the
clamp after insertion of the
blood product.

▪ Y-set – open the clamp near

the spike first and then allow
the blood product to drip into
the saline filled drip chamber.
Once drip chamber is 1/3 full,
open the clamp below the drip
chamber. Regulate flow rate To ensure completion of the transfusion within 4
slowly to about 5ml/minute or hours.
20 drops per minute for the
first 15 minutes.
16. Stay with the client and observe
him/her closely for 15-30 minutes. To monitor for signs and symptoms of a
▪ Take v/s every 15 minutes transfusion reaction because, if a major
after the infusion started. incompatibility exists or a severe allergic reaction
such as anaphylaxis occurs, signs and symptoms
usually appear before transfusion of the first 50
▪ Take note of any adverse
mL of the unit.
reactions during these times.
The earlier these reactions If a reaction occurs, stop the transfusion
appear, the more serious they immediately and notify transfusion services and
tend to become. the client’s attending physician.

▪ Ask the client if he/she feels

anything unusual.
17. If no untoward effects are observed,
regulate the flow rate according to
prescribed rate.
▪ Most adults can tolerate
receiving up to 1 unit in 1-2
hours.
▪ For elderly, infusion should be
slower. 1 unit should be
transfused 3-4 hours or
depending on the hospital and
blood product protocols.
Closely monitor the flow rate and inspect the IV
insertion site for signs of infiltration. If you
observe signs of infiltration, immediately stop the
transfusion, disconnect the administration set,
and aspirate fluid from the catheter using a small
syringe. Remove the catheter and estimate the
volume of fluid infiltrated. Notify the practitioner
and insert a new IV catheter in a different
location to prevent an interruption in transfusion
therapy.
 ▪ Do not transfuse a unit of
blood for more than 4 hours.
18. Invert the bag occasionally. To mix solid and liquid elements.

19. Take v/s every 30 minutes for 1 hour

Observe the patient periodically during the
until transfusion is complete.
transfusion to identify early signs and
Continue monitoring hourly 3 hours
symptoms of a possible transfusion
after the infusion. (for elderly, check
reaction. Monitor vital signs during the
v/s every 15 minutes throughout the
transfusion, as directed by your facility and
transfusion).
as the client's condition warrants.

20. Ask the client to report signs of any
transfusion reaction
21. If more than 1unit of blood is
required, use new blood transfusion
set for every unit of blood that
follows.
22. Follow-up post blood transfusion
orders such as requesting blood
examinations.
23. Document all relevant data including
assessments before and after
procedure.
TERMINATION OF THE BLOOD
TRANSFUSION
Because blood transfusion reactions can occur
after a transfusion is complete, teach the patient
and family (if applicable) about signs and
symptoms of a transfusion reaction. Tell them to
be alert to the possibility of a delayed reaction
and advise them to report signs and symptoms
promptly to the practitioner.
Follow manufacturer's instructions regarding
changing of transfusion administration set and
filters.
To determine effectiveness of the
transfusion.

24.Check the doctor’s order and the chart if

transfusion is already complete.

25. Wash hands and wear clean gloves.
Prevents infection from the care provider to the
client.
To reduce the risk of contamination of health-
care workers hands with blood and other body
fluids.
26. If no more transfusion follows, terminate
the blood line like that of terminating an IV
line.

27. If the primary IV is to be continued, flush

the maintenance line with the saline solution.
Disconnect the blood tubing system from the
primary system and then regulate to the
prescribed rate.

28. Discard blood bag and blood transfusion

set per hospital protocol.

29. Remove gloves and then wash hands. Tell the client and significant other/s to be alert
Again, monitor vital signs for any delayed or to the possibility of a delayed reaction and advise
untoward reactions. them to report signs and symptoms promptly to
the practitioner.
30. Document any relevant data. Appropriate documentation provides an accurate
Record the date and time of the transfusion; reflection of nursing assessments, changes in
confirmation that informed consent was clinical state, care provided and pertinent patient
obtained; the indications for the transfusion; information to support the multidisciplinary team
to deliver great care.
any premedication administered; the donor
identification number; the type and amount
of transfusion product transfused; the
amount of normal saline solution infused; the
patient's vital signs before, during (if
required), and after the transfusion; your
check of all identification data; and the
patient's response. Document any
transfusion reaction, the name of the
practitioner notified, time of notification,
interventions performed, and the patient's
response to those interventions. Document
teaching provided to the patient and family
(if applicable), their understanding of that
teaching, and any need for follow-up
teaching.
REFERENCE:

AABB. (2018). Primer of blood administration. (Level VII). Retrieved from:

https://procedures-lww com.library.xu.edu.ph/lnp/view.do?pId=5684718&s=p

Berman, A., Snyder, S.J, & Frandsen, G. (2020). Kozier & Erb's Fundamentals of Nursing: Concepts,
Process and Practice. Pearson

Lippincott Williams & Wilkins. (2013). Lippincott's nursing procedures (6th Ed.). Wolters
Kluwer/Lippincott Williams & Wilkins Health.
Retrieved from:
https://procedures-lww com.library.xu.edu.ph/lnp/view.do?pId=5684718&s=p

Standard 47. Infiltration and extravasation. Infusion therapy standards of practice (8th
ed.). (2021). Journal of Infusion Nursing, 44(Suppl. 1), S142–S1147. Retrieved
July 2021
from https://doiorg.library.xu.edu.ph/10.1097/NAN.0000000000000396 (Level III)

Standard 64. Blood administration. Infusion therapy standards of practice (8th ed.). (2021). Journal of
Infusion Nursing, 44(Suppl. 1), S191–S194.
Retrieved July 2021 from:
https://doi-org.library.xu.edu.ph/10.1097/NAN.0000000000000396 (Level VII)
 NCM 109 RLE – CARE OF MOTHER, CHILD, AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)
PERFORMANCE RATING SCALE
BLOOD TRANSFUSION

SCALE DESCRIPTION INDICATORS

4 Very Good Student performs behaviors/tasks reflecting the highest level of
performance: consistent, independent, effective
3 Good Student performs behaviors/tasks reflecting mastery of performance
with minimal supervision
2 Fair Student performs behaviors/tasks reflecting development and
movement towards mastery of performance with help or direct
supervision in some aspect
1 Needs Student performs behaviors/tasks reflecting beginning level of
Improvement performance; tasks not done properly majority of the time but
demonstrate understanding of concepts involved with tasks

DEFINITION: It is the introduction of whole blood or components of the blood (e.g., plasma or
erythrocytes) into the venous circulation.

PURPOSES:
• To restore blood volume after severe hemorrhage.
• To restore the capacity of the blood to carry oxygen.
• To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet
concentrates which prevent or treat bleeding.

PRINCIPLES:
• A client’s blood will be tested before a transfusion to determine whether blood type is
A, B, AB or O and whether the blood is Rh positive or Rh negative. The donated blood
used for transfusion must be compatible with client’s blood type.
• Never add any medications to any blood products.
• Blood transfusions are usually done in a hospital, an outpatient clinic or a doctor's
office. The procedure typically takes one to four hours, depending on which parts of the
blood one must receive and how much blood needed.
EQUIPMENT:
• Unit of whole Blood or blood component product
• Blood administration set
• Container of normal saline solution
• IV pole
• Venipuncture set – usually gauge 18 or 19 needle or catheter is used
• Alcohol swabs
• Hypoallergenic Plaster
• Gloves

PROCEDURE 4 3 2 1 REMARKS
1. Verify the doctor’s order for blood transfusion. It should be
checked by 2 nurses.
2. Check if consent has been signed.
3. Assess vital signs (BP, Temperature, Pulse, Respiration,
any previous reactions to a blood transfusion, specific
signs related to the client’s pathology and reason for the
transfusion).
4. Prepare the client.
▪ Explain the procedure and its purpose
▪ Instruct to report any sudden chills, nausea,
itching, rash, dyspnea, or other unusual
symptoms.
If the client has an IV solution infusing, check the
infusion set, the solution and the needle is compatible
with blood transfusion. A blood set with a blood filter, a
gauge 18 or 19 needle and 0.9% NaCl is recommended.
Any other medications are incompatible
5. Prepare the equipments.
6. Obtain the correct blood product ordered for the client.
Check for:
▪ Blood type
▪ Rh group
▪ The blood donor number
▪ Expiration date
▪ Abnormal color – dark color, cloudiness
▪ ABC clumping
▪ Gas bubbles
▪ Extraneous materials
7. Type and crossmatch the blood. 2 nurses should verify
the following on the crossmatch result:
▪ Client’s name and identification number
▪ The serial number
▪ The ABO group and Rh on the blood bag label
▪ the expiration date and time; and the date and time
of blood issue.
Wear gloves or transport the blood product units in a
container that prevents direct contact with the blood unit
bag.
8. Verify the client’s identity – ask the client to state
his/her full name.
9. Wash hands.
10. Set up the infusion equipment:
▪ Close all clamps first before inserting the tubing
to the solution.
▪ If using straight line set, start first with PNSS. The
blood product follows establishing patent IV line.
▪ If using a Y-set, attach the PNSS to one of the
two spikes. Connect the blood product to the
spike only after patent IV line is established.
Use the IV sets provided with the blood component if
available.
11. Prime tubing with PNSS.
12. Wash hands again if necessary.
13. Put on gloves and prepare for venipuncture. Procedure
is the same as with starting an IV line.
14. Prepare the blood bag.
▪ Warming the blood product to room
temperature is done by wrapping it with clean
towel.
▪ Invert the blood bag gently several times to mix
the cells. Rough handling can damage the cells.
▪ Connect the blood product to tubing.
▪ If using straight line set, remove PNSS first.
Remove by first closing the clamp, then kinking
the tubing just below the drip chamber, and then
pulling out the tubing. Immediately insert the
tubing to the blood product. Apply twisting
motion if necessary.
▪ If using a y-set, connect the blood product to the
other end of the tubing. The clamp near the
spike and the clamp below the drip chamber
should be closed prior to the insertion.
 ▪ Suspend the bag.
15. Establish blood transfusion.
▪ Straight line set - open the clamp after insertion
of the blood product.
▪ Y-set – open the clamp near the spike first and
then allow the blood product to drip into the
saline filled drip chamber. Once drip chamber is
1/3 full, open the clamp below the drip chamber.
Regulate flow rate slowly to about 5ml/minute
or 20 drops per minute for the first 15 minutes.
16. Stay with the client and observe him/her closely for 15-
30 minutes.
▪ Take v/s every 15 minutes after the infusion
started.
▪ Take note of any adverse reactions during these
times. The earlier these reactions appear, the
more serious they tend to become.
▪ Ask the client if he/she feels anything unusual.
17. If no untoward effects are observed, regulate the flow
rate according to prescribed rate.
▪ Most adults can tolerate receiving up to 1 unit in
1-2 hours.
▪ For elderly, infusion should be slower. 1 unit
should be transfused 3-4 hours or depending on
the hospital and blood product protocols.
▪ Do not transfuse a unit of blood for more than 4
hours.
18. Invert the bag occasionally, to mix solid and liquid
elements.
19. Take v/s every 30 minutes for 1 hour until transfusion is
complete. Continue monitoring hourly 3 hours after the
infusion. (For elderly, check v/s every 15 minutes
throughout the transfusion.)
20. Ask the client to report signs of any transfusion
reaction
21. If more than 1unit of blood is required, use new blood
transfusion set for every unit of blood that follows.
22. Follow-up post blood transfusion orders such as
requesting blood examinations, to determine
effectiveness of the transfusion.
23. Document all relevant data including assessments
before and after procedure.
 TERMINATION OF THE BLOOD TRANSFUSION
24. Check the doctor’s order and the chart if transfusion is
already complete.
25. Wash hands and wear clean gloves.
26. If no more transfusion follows, terminate the blood line
like that of terminating an IV line.

27. If the primary IV is to be continued, flush the

maintenance line with the saline solution. Disconnect
the blood tubing system from the primary system and
then regulate to the prescribed rate.
28. Discard blood bag and blood transfusion set per hospital
protocol.
29. Remove gloves and then wash hands. Again, monitor
vital signs for any delayed or untoward reactions.

30. Document any relevant data.

Record the date and time of the transfusion;
confirmation that informed consent was obtained; the
indications for the transfusion; any premedication
administered; the donor identification number; the type
and amount of transfusion product transfused; the
amount of normal saline solution infused; the patient's
vital signs before, during (if required), and after the
transfusion; your check of all identification data; and the
patient's response. Document any transfusion reaction,
the name of the practitioner notified, time of
notification, interventions performed, and the patient's
response to those interventions. Document teaching
provided to the patient and family (if applicable), their
understanding of that teaching, and any need for follow-
up teaching.
TOTAL /
Actual Score/Total Score x 100

A (92 – 100)
A- (84 – 91.99)
B (76 – 83.99)
B- (68 – 75.99)
C (60 – 67.99)
F (< 60)

Student’s Signature : ________________________

Clinical Instructor’s Signature : ________________________