Blood transfusion (BT) therapy involves transfusing whole blood or blood components (specific portion

or fraction of blood lacking in patient). Learn the concepts behind blood transfusion therapy and the
nursing management and interventions before, during and after the therapy.

Advantages

Principles

Blood Components

Objectives

Nursing Interventions

Complications

Assessment findings

Nursing Diagnosis

Planning and Implementation

Nursing Interventions

Evaluation

Advantages

Avoids the risk of sensitizing the patients to other blood components.

Provides optimal therapeutic benefit while reducing risk of volume overload.

Increases availability of needed blood products to larger population.

Principles

Whole blood transfusion

Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration
of blood volume when there is no time to prepare or obtain the specific blood components needed.

Packed RBCs
Should be transfused over 2 to 3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it
may be necessary for the blood bank to divide a unit into smaller volumes, providing proper
refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin
approximately 1%, hemactocrit 3%.

Platelets

Administer as rapidly as tolerated (usually 4 units every 30 to 60 minutes). Each unit of platelets should
raise the recipient’s platelet count by 6000 to 10,000/mm3: however, poor incremental increases occur
with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction,
and hypertension.

Granulocytes

May be beneficial in selected population of infected, severely granulocytopenic patients (less than
500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged
suppressed granulocyte production.

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Plasma

Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is
required, other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are preferred.
Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become
unstable after thawing.

Albumin
Indicated to expand to blood volume of patients in hypovolemic shock and to elevate level of circulating
albumin in patients with hypoalbuminemia. The large protein molecule is a major contributor to plasma
oncotic pressure.

Cryoprecipitate

Indicated for treatment of hemophilia A, Von Willebrand’s disease, disseminated intravascular

coagulation (DIC), and uremic bleeding.

Factor IX concentrate

Indicated for treatment of hemophilia B; carries a high risk of hepatitis because it requires pooling from
many donors.

Factor VIII concentrate

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Indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV
transmission.

Prothrombin complex

Indicated in congenital or acquired deficiencies of these factors.

Blood Components
Component

Additional Info

Packed RBCs 100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one
unit of whole blood

Leukocyte-poor packed RBCs Indicated for patients who have experience previous febrile no
hemolytic reactions

Platelets either HLA (human leukocyte antigen) matched or unmatched

Granulocytes Contains basophils, eosinophils, and neutrophils

Fresh frozen plasma Contains all coagulation factors, including factors V and VIII

Single donor plasma Contains all stable coagulation factors but reduced levels of factors V and VIII;
the preferred product for reversal of Coumadin-induced anticoagulation.

Albumin A plasma protein.

Cryoprecipitate A plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin

Factor IX concentrate A concentrated form of factor IX prepared by pooling, fractionating, and freeze-
drying large volumes of plasma.

Factor VIII concentrate A concentrated form of factor IX prepared by pooling, fractionating, and freeze-
drying large volumes of plasma.

Prothrombin complex Contains prothrombin and factors VII, IX, X, and some factor XI.

Objectives

To increase circulating blood volume after surgery, trauma, or hemorrhage

To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia

To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets,
albumin)

Nursing Interventions

Verify doctor’s order. Inform the client and explain the purpose of the procedure.

Check for cross matching and typing. To ensure compatibility

Obtain and record baseline vital signs

Practice strict asepsis

At least 2 licensed nurse check the label of the blood transfusion. Check the following:

Serial number

Blood component

Blood type

Rh factor

Expiration date

Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried
diseases and therefore, safe from transfusion.

Warm blood at room temperature before transfusion to prevent chills.

Identify client properly. Two Nurses check the client’s identification.

Use needle gauge 18 to 19 to allow easy flow of blood.

Use BT set with special micron mesh filter to prevent administration of blood clots and particles.

Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually
occurs during the first 15 to 20 minutes.

Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory
rate)

Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate
medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.

Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose
based IV fluids cause hemolysis.

Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse
quickly (20 minutes) clotting factor can easily be destroyed.

Observe for potential complications. Notify physician.

Complications

1. Allergic Reaction – it is caused by sensitivity to plasma protein of donor antibody, which reacts with
recipient antigen.
Assess for:

Flushing

Rash, hives

Pruritus

Laryngeal edema, difficulty of breathing

2. Febrile, Non-Hemolytic – it is caused by hypersensitivity to donor white cells, platelets or plasma

proteins. This is the most symptomatic complication of blood transfusion

Assess for:

Sudden chills and fever

Flushing

Headache

Anxiety

3. Septic Reaction – it is caused by the transfusion of blood or components contaminated with bacteria.

Assess for:

Rapid onset of chills

Vomiting

Marked Hypotension

High fever

4. Circulatory Overload – it is caused by administration of blood volume at a rate greater than the
circulatory system can accommodate.
Assess for:

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Rise in venous pressure

Dyspnea

Crackles or rales

Distended neck vein

Cough

Elevated BP

5. Hemolytic reaction – it is caused by infusion of incompatible blood products.

Assess for:

Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.

Chills

Feeling of fullness

Tachycardia

Flushing

Tachypnea

Hypotension

Bleeding

Vascular collapse
Acute renal failure

Assessment findings

Clinical manifestations of transfusions complications vary depending on the precipitating factor.

Signs and symptoms of hemolytic transfusion reaction include:

Fever

Chills

low back pain

flank pain

headache

nausea

flushing

tachycardia

tachypnea

hypotension

hemoglobinuria (cola-colored urine)

Clinical signs and laboratory findings in delayed hemolytic reaction include:

fever

mild jaundice

gradual fall of hemoglobin

positive Coombs’ test

Febrile non-hemolytic reaction is marked by:

Temperature rise during or shortly after transfusion

Chills

headache

flushing
anxiety

Signs and symptoms of septic reaction include;

Rapid onset of high fever and chills

vomiting

diarrhea

marked hypotension

Allergic reactions may produce:

hives

generalized pruritus

wheezing or anaphylaxis (rarely)

Signs and symptoms of circulatory overload include:

Dyspnea

cough

rales

jugular vein distention

Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously,
depending on the disease.

Characteristics of GVH disease include:

skin changes (e.g. erythema, ulcerations, scaling)

edema

hair loss

hemolytic anemia

Reactions associated with massive transfusion produce varying manifestations

Nursing Diagnosis

Ineffective breathing pattern

Decreased Cardiac Output

Fluid Volume Deficit

Fluid Volume Excess

Impaired Gas Exchange

Hyperthermia

Hypothermia

High Risk for Infection

High Risk for Injury

Pain

Impaired Skin Integrity

Altered Tissue Perfusion

Planning and Implementation

Help prevent transfusion reaction by:

Meticulously verifying patient identification beginning with type and crossmatch sample collection and
labeling to double check blood product and patient identification prior to transfusion.

Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.

Beginning transfusion slowly ( 1 to 2 mL/min) and observing the patient closely, particularly during the
first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).

Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of
bacterial growth at warm room temperatures.

Preventing infectious disease transmission through careful donor screening or performing pretest
available to identify selected infectious agents.

Preventing GVH disease by ensuring irradiation of blood products containing viable WBC’s (i.e., whole
blood, platelets, packed RBC’s and granulocytes) before transfusion; irradiation alters ability of donor
lymphocytes to engraft and divide.

Preventing hypothermia by warming blood unit to 37 C before transfusion.

Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter
(20-40-um size) in the blood line to remove these aggregates during transfusion.
On detecting any signs or symptoms of reaction:

Stop the transfusion immediately, and notify the physician.

Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible
IV drug infusion.

Send the blood bag and tubing to the blood bank for repeat typing and culture.

Draw another blood sample for plasma hemoglobin, culture, and retyping.

Collect a urine sample as soon as possible for hemoglobin determination.

Intervene as appropriate to address symptoms of the specific reaction:

Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated
with RBC hemolysis and hemoglobinuria.

Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-
poor blood products may be recommended for subsequent transfusions.

In septic reaction, treat septicemia with antibiotics, increased hydration, steroids and vasopressors as
prescribed.

Intervene for allergic reaction by administering antihistamines, steroids and epinephrine as indicated by
the severity of the reaction. (If hives are the only manifestation, transfusion can sometimes continue but
at a slower rate.)

For circulatory overload, immediate treatment includes positioning the patient upright with feet
dependent; diuretics, oxygen and aminophylline may be prescribed.

Nursing Interventions

If blood transfusion reaction occurs: STOP THE TRANSFUSION.

Start IV line (0.9% NaCl)

Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy.

The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as
every 5 minutes.

Notify the physician immediately.

The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and
steroids as per physician’s order or protocol.

Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of
RBC hemolysis.

Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory
for analysis.

Evaluation

The patient maintains normal breathing pattern.

The patient demonstrates adequate cardiac output.

The patient reports minimal or no discomfort.

The patient maintains good fluid balance.

The patient remains normothermic.

The patient remains free of infection.

The patient maintains good skin integrity, with no lesions or pruritus.

The patient maintains or returns to normal electrolyte and blood chemistry values.