ADMINISTERING BLOOD AND BLOOD COMPONENTS

EQUIPMENT

• Tourniquet
• Iodine-containing skin antiseptic
• Needle or venous catheter
• Y-type blood infusion set
• 170-µ filter
• Normal saline
• Blood product as described

PROCEDURE
Nursing Action
Rationale

Preparatory phase

1.
Inform the patient of the procedure,
blood product to be given, approximate
length of time, and desired outcome.
1.
Instruct the patient to report unusual
symptoms immediately.

2.
Obtain and record baseline vital signs.
2.
If the patient's clinical status permits,
delay transfusion if baseline temperature
is greater than 101.7° F (38.7°C).

3.
Prepare infusion site. Select a large vein
that allows patient some degree of
mobility. Start the prescribed I.V.
infusion.
3.
Antecubital veins are not recommended
for lengthy infusions. Prolonged
restriction of arm movement is
uncomfortable and inconvenient for the
patient. In the event of an acute reaction,
the I.V. catheter should be maintained
with normal saline.

DRUG ALERT Crystalloid solutions

other than 0.9% saline and all
medications are incompatible with blood
products.
They may cause agglutination or
hemolysis.

4.
Obtain blood product from blood bank.
P.966

P.967

Nursing and Patient Care Considerations

• Infuse at the prescribed rate. Generally, a unit can be given to an adult in 90 to 120
minutes. Pediatric patients are usually transfused at a rate of 2 to 5 mL/kg per hour.
• To reduce the risk of bacterial contamination and sepsis, RBCs must be transfused within
4 hours of leaving the blood bank.
• Observe closely (particularly during first 15 to 30 minutes) for the most common acute
complications associated with packed RBCs, allergic and febrile transfusion reactions.
Signs and symptoms of the more serious, but rare, hemolytic transfusion reaction are
usually manifested during infusion of the first 50 mL