ASSISTING BLOOD

TRANSFUSION
PREPARED BY: JUSTINE HANZEL B. NASIBOG,RN
ADMINISTRATION OF BLOOD PRODUCTS

• A. BLOOD PRODUCTS
1. PACKED RED BLOOD CELLS (PRBCs)
a. PRBCs are a blood product used to replace erythrocytes; infusion time for 1
unit is usually between 2-4hours.
b. Each unit increases the hemoglobin by 1g/dl (10mmol/L) and a hematocrit
by 3%.
c. The change in laboratory values takes 4-6hours after completion of the blood
transfusion.
d. Evaluation of an effective response is based on the resolution of the
symptoms of anemia and an increase in the erythrocyte, hemoglobin, and
hematocrit count.
 2.PLATELET TRANSFUSION
a. Platelets are used to treat thrombocytopenia and platelet dysfunctions.

b. Clients receiving multiple units of platelets can become “alloimmunized” to

different platelet antigens. These clients may benefit from receiving only platelets
that match their specific human leukocyte antigen.

c. Platelets are administered immediately upon receipt from the blood bank and
are given rapidly, usually over 15-30minutes.

d. Evaluation of an effective response is based on improvement in the platelet

counts normally evaluated 1hour and 18hour to 24 hours after transfusion; for each
unit an increase of 5000-10000mm3 is expected.
3. FRESH FROZEN PLASMA

a. Fresh Frozen Plasma may be used to provide clotting factors or volume

expansion; it contains no platelets.

b. FFP is infused within 2 hours of thawing, while clotting factors are still
viable, and is infused over a period of 15-30minutes.

c. Evaluation of an effectiveness response is assessed by monitoring

coagulation studies, particularly the PROTHROMBIN TIME and the PARTIAL
THROMBOPLASTIN TIME and resolution of hypovolemia.
 4. CRYOPRECIPITATES

a. Prepared from the FFP and can be stored for 1 year. Once thawed, the product
must be used; 1 unit is administered over 15 to 30 minutes.

b. Used to replace clotting factors, especially factor VIII and fibrinogen.

c. Evaluation of an effective response is assessed by monitoring coagulation studies

and fibrinogen levels.
 5. GRANULOCYTES

A. May be used to treat a client with sepsis or neutropenic client

with an infection that is unresponsive to antibiotics.

B. Evaluation of an effective response is assessed by monitoring the

WBC and differential counts.
 NURSING ALERT

• DOCUMENT THE NECESSSARY

INFORMATION ABOUT THE BLOOD
TRANSFUSION IN THE CLIENT’S MEDICAL
RECORD. INCLUDE THE CLIENT’S
TOLERANCE AND RESPONSE TO THE
TRANSFUSION AND THE EFFECTIVE OF
THE TRANSFUSION.
 TYPES OF BLOOD DONATIONS

• 1. AUTOLOGOUS
A. A donation of the client’s own blood before a scheduled procedure. It reduces
the risk of disease transmission and potential transfusion complications.
B. Autologous donation is not an option for a client with leukemia or bacteremia.
C. A donation can be made every 3days as long as the hemoglobin remains within
a safe range.
D. Donations should begin within 5 weeks of transfusion date and end at least 3
days before the date of transfusion.
2. BLOOD SALVAGE

A. Blood salvage is an autologous donation that involves suctioning

blood from body cavities, joint spaces, or other closed body sites.

B. Blood may need to be “washed” a special process that removes

tissue debris before reinfusion.
3. DESIGNATED DONOR

A. Designated donation occurs when recipients select their own

compatible donors.

B. Donation does not reduce the risk of contracting infections

transmitted by the blood.
COMPATIBILITY
1. The recipient’s ABO type and Rh type are identified.
2. An antibody screen is done to determine the presence of antibodies
other than anti-A and anti B.
3. CROSSMATCHING is done to determine compatibility. The crossmatch is
compatible if no RBC agglutination occurs.
4. The universal donor is O negative and universal recipient is AB
positive.
COMPLICATIONS OF BLOOD TRANSFUSION

1. TRANSFUSION REACTION
2. CIRCULATORY OVERLOAD
3. SEPTICEMIA
4. IRON OVERLOAD
5. DISEASE TRANSMISSION
6. HYPOCALCEMIA
7. HYPERKALEMIA
8. CITRATE TOXICITY
1.TRANSFUSION REACTION

• A transfusion reaction is an adverse reaction that happens as a

result of receiving a blood transfusion.

. Types of transfusion reactions include hemolytic, allergic, febrile,

or bacterial reactions (septecemia), or transfusion associated graft
versus host disease.
SIGNS OF AN IMMEDIATE TRANSFUSION
REACTION
1. Chills and diaphoresis
2. Muscle aches, back pain, or chest pain
3. Rashes, hives, itching, and swelling
4. Rapid, thready pulse
5. Dyspnea, cough, or wheezing
6. Pallor and cyanosis
7. Apprehension
8. Tingling and numbness
9. Headache
10.Nause nand vomiting, abdominal cramping and diarrhea
SIGNS OF TRANSFUSION REACTION IN
UNCONSCIOUS CLIENT

1. Weak pulse
2. Fever
3. Tachycardia or bradycardia
4. Hypotension
5. Visible hemoglobinuria
6. Oliguria or anuria
Delayed reactions
a. Reaction occurs days to years after a transfusion.
b. Signs include fever, mild jaundice, and decreased hematocrit level.
2.CIRCULATORY OVERLOAD

A. Caused by the infusion of blood at a rate too rapid for the client
to tolerate.
B. Assessment
1. Cough, dyspnea, chest pain, and wheezing
2. Headache
3. Hypertension
4. Tachycardia and a bounding pulse
5. Distended neck veins
Interventions

1. Slow the rate of infusion.

2. Place the client in an upright position, with the feet in a
dependent position.
3. Notify the PHCP
4. Administer oxygen, diuretics, and morphine sulfate as
prescribed.
5. Monitor for dysrhythmias
3.SEPTECEMIA

A. Occurs with the transfusion of blood that is contaminated with

microorganisms.
B. Assessment
1. Rapid onset of chills
2. Vomiting
3. Diarrhea
4. Hypotension
5. Shock
INTERVENTIONS

1. Notify the PCHP.

2. Obtain blood cultures and cultures of the bag.
3. Administer oxygen, IV fluids, antibiotics, vasopressors, and
corticosteroids as prescribed.
4.IRON OVERLOAD
A. A delayed transfusion complication that occurs in clients who receive multiple blood
transfusions.
B. Assessment
1. Vomiting
2. Diarrhea
3. Hypotension
4. Altered hematological values
INTERVENTIONS
5. DEFEROXAMINE is administered IV or SQ to remove accumulatad iron via the
kidneys.
6. Urine turns red as iron is excreted after the administration of deferoxamine.
Discontinued when serum iron levels return to normal.
5.DISEASE TRANSMISSION

1. The disease most commonly transmitted is hepatitis C, which

manifested by anorexia, nausea, vomiting, dark urine, and jaundice,
symptoms usually occur within 4-6 after transfusion.

2. Other infectious agents and diseases: HIV, hepatis B, human herpes

virus type 6, Epstein Barr virus, cytomegalovirus, human T-cell
leukemia, and malaria.
6.HYPOCALCEMIA

1. Citrate in transfused blood binds with calcium and is excreted.

2. Assess serum calcium level before and after the transfusion.
3. Monitor for signs of hypocalcemia
a. Hyperflexes
b. Paresthesias
c. Muscle cramps
d. (+) Trosseau and Chvostek’s sign
4. Slow the transfusion and notify the PCHP if signs of hypocalcemia occur.
• CHVOSTEK SIGN: Is a contraction of facial
muscles in response to light tap over the facial
nerve.

• TROSSEAU SIGN: a carpal spasm induced by

inflating a blood pressure cuff above the systolic
pressure for a few minutes.
7.HYPERKALEMIA

1. Stored blood liberates potassium through hemolysis.

2. The older the blood, the greater the risk of hyperkalemia.
3. Assess the date on the blood and serum potassium level before
and after the transfusion.
4. Signs of hyperkalemia includes: paresthesias, muscle cramps,
diarrhea, and dysrrhythmias.
5. Slow the transfusion and notify the PCHP if signs of hyperkalemia
occur.
8.CITRATE TOXICITY

1. Citrate, the anticoagulant used in blood products, is metabolized

by the liver.
2. Rapid administration of multiple units of stored blood may cause
hypocalcemia and hypomagnesemia.
3. High risk patients: INDIVIDUALS WITH LIVER DYSFUNCTION and
NEONATES with immature liver function.
4. Treatment includes: slowing or stopping the infusion then notify
the PCHP.
 PRIORITY NURSING ACTIONS IN TRANSFUSION
REACTION
1. Stop the infusion.
2. Change the IV tubing down to the IV site and keep the IV line open with normal
saline.
3. Notify the PCHP and blood bank.
4. Stay with client, observing signs and symptoms and monitoring vital signs as often as
every 5 minutes.
5. Prepare to administer emergency medications as prescribed.
6. Obtain a urine specimen for laboratory studies.
7. Return blood bag, tubing, attached labels, and transfusion record to the blood bank.
8. Document the occurrence, actions taken, and the client’s response.
PRECAUTIONS AND NURSING RESPONSIBILITIES
FOR BLOOD ADMINISTRATION

1. GENERAL PRECAUTIONS
A. A large volume of refrigerated blood infused rapidly through a central
venous catheter into the ventricle of the heart can cause cardiac
dysrhythmias.
B. No solution other than normal saline should be added to blood
components
C. Medications are never added to blood components or piggybacked into
the blood transfusion.
D. To avoid the risk of septicemia, infusion (1unit) should not exceed the
prescribed time of administration.
E. The blood administration set should be changed with each unit of
blood.
F. Check the blood bag for the date of expiration and collection
date.
G. Inspect blood bag for leaks, abnormal color, clots, and bubbles.
H. Blood must be administered as soon as possible (20-30minutes)
after being received from the blood bank.
I. The nurse should measure vital signs and assess lung sounds before
the transfusion and again after the first 15minutes and every
30minutes to 1 hour (per agency protocol).
 CLIENT ASSESSMENT

1. Assess for any cultural or religious beliefs regarding blood transfusion.

2. Ensure that an informed consent has been obtained.
3. Explain the procedure to the client and determine whether the client has
ever received a blood transfusion or experienced any previous reactions
to blood transfusion.
4. Check client’s vital signs.
5. If the client’s temperature is elevated, notify the PCHP before beginning
the transfusion.
 BLOOD BANK PRECAUTIONS

1. Blood will be released from the blood bank only to personnel specified
by agency policy.
2. The name and identification number of the intended recipient must be
provided to the blood bank, and documented permanent record of this
information must be maintained.
3. Blood should be transported from the blood bank to only 1 client at a
time to prevent blood delivery to the wrong client.
4. Only 1 unit of blood should be transported at a time.
 CLIENT IDENTITY AND COMPATIBILITY

1. Check the PCHP’s prescription for the administration of the blood product.
2. The most critical phase is confirming product compatibility and verifying client
identity.
3. Universal barcode systems for blood transfusion should be used to confirm
product compatibility, client identity, and expiration (client identification
requires 2 identifiers.)
4. At the bedside, the nurse asks the client to state her name or his name, and the
nurse compares the name on the identification band or bracelet.
5. The nurse checks the blood tag, label, and blood requisition form to ensure that
ABO and Rh types are compatible.
6. If the nurse notice inconsistencies when verifying client identity and
compatibility, the nurse notifies the blood bank immediately.
 ADMINISTRATION OF THE TRANSFUSION

1. Maintain standard and transmission based precautions and surgical asepsis as

necessary.
2. Insert an IV and infuse normal saline, maintain the infusion at KVO rate.
3. An 18-19 g IV needle will be needed to achieve a maximum flow rate of blood
products and to prevent damage to RBC’s; if small needle is being used, RBCs
maybe diluted with normal saline (per agency policy).
4. A central venous catheter is an acceptable venous access option for BT.
5. Blood products should be infused through administration set designed
specifically for blood.
6. Premedicate the client with acetaminophen or diphenhydramine as prescribed (if with
history of adverse reactions).
For oral medication: 30minutes before the transfusion
For IV medication: immediately before the transfusion started

7. Instruct the client to report anything unusual.

8. Determine the rate of infusion by PCHPs prescription, if not specified, by agency policy.

9. Begin the transfusion slowly under close supervision, if no reaction is noted within the
first 15minutes, the flow can be increased.
10. During the transfusion, monitor the client for signs and symptoms of a
transfusion reaction; the first 15minutes of transfusion are the most critical,
the nurse must stay with client.

11. Document the client’s tolerance to the administration of the blood

product.

12. Monitor appropriate laboratory values and document effectiveness of

treatment related to the specific type of blood product.
THANK YOU!!