BLOOD TRANSFUSION

PURPOSE
 Provide replacement of blood products to
increase client’s fluid volume, hemoglobin, and
hematocrit for improved circulation and oxygen
distribution.

 Prevents overadministration of blood products

or the development of complications associated
with a transfusion.
 EQUIPMENT
 Blood transfusion tubing (blood Y set with in-
line filter)
 250 to 500ml bag/bottle Normal Saline
 Packed cells or whole blood as ordered
 Blood warmer or pan of warm water (optional)
 Order slips for blood
 Low sheets for VS (for frequent checks)
 Non sterile gloves
 Materials for IV start
 Alcohol or Povidone Iodine
 SPECIAL CONSIDERATIONS
 Two RN’s should check that the correct blood is
being given to the correct client.
 Infuse a whole unit of packed RBC’s or whole
blood over no longer than 4 hours (the maximum
transfusion time)
 Begin the blood transfusion within half an hour
after obtaining the blood from the blood bank.
 If infusing blood rapidly, it should be warmed.
 The nurse is responsible for all aspects of care,
including monitoring for complications.
 Procedure cont.
 If discrepancies are noted, notify the blood bank
immediately and postpone transfusion until problems are
resolved.
 Check again by the SECOND NURSE.
5. Note the time of transfusion initiation and nurse’ checking
information.
6. Check and record pulse, respirations, BP, and
temperature.
7. Remove cap of blood bag, insert spike into port on blood
bag. Hang.
8. Close regulator of Saline solution and open roller clamp on
blood side of tubing.
9. Regulate drip to deliver the ff:
 PROCEDURE:
1. Perform hand hygiene and organize equipment.
2. Explain procedure to client, particularly the need for
frequent vital signs checks.
3. Prepare BT tubing.
 Open tubing package and close drip regulators.
 Open the tab of the Saline solution, spike, and hang.
 Prime the drip chamber and tubing with saline
 Regulate to KVO.
4. Obtain blood and perform safety checks.
 Compare blood package with order slip.
 Check client name, hospital number, blood type,
expiration date.
 Check for correct identification
 Procedure Cont.
 A maximum of 30ml of blood within the first fifteen minutes.
 4-hr transfusion time limit can be violated if client has poor
tolerance to volume change. (run for 8 hours)
10. Check Vital signs again 15 minutes after beginning
transfusion. Then every half hour or hourly until transfusion is
completed.
11. When BT is complete, clamp off blood regulator and begin
infusing NSS. Remove empty blood bag and recap blood
tubing spike.
12. Document time of completion.
13. Monitor client closely Q4h for any signs of transfusion
reaction.
14. Position client appropriately
15. Discard supplies, remove gloves, wash hands.
 TRANSFUSION REACTIONS
 Allergic reactions rashes, chills, fever, nausea,
or severe hypotension
(shock)
 Actions: Turn off blood transfusion; replace tubing
with primed saline solution; infuse NSS at very slow
rate; Notify Physician immediately.

 Pyrogenic reaction Nausea, chilling, fever, and

headache (usually toward
the end or after BT).
 Actions: Same as allergic reaction
Transfusion reactions cont..

 Circulatory Overload Cough, dyspnea,

distended neck vein, crackles in lung bases.
 Slow BT rate and notify physician. Take VS q15
until stable.
 Send first voided urine to the lab to confirm
hemolytic reaction if RBC are present.
 Monitor I and O. particularly urine output.
END