Blood

Transfusion
Nursing Procedure
*Whole blood transfusion replenishes the
circulatories:

 Volume
 Oxygen-carrying capacity

*Packed Red Blood Cells (RBCs) restores:

 Oxygen-carrying capacity

Both treat decreased hemoglobin and hematocrit.

Two nurses must identify the:

1. Patient
2. Blood products

before administering a transfusion (to

prevent errors & potentially fatal reaction)
If a patient is a Jehova’s Witness, a
transfusion requires special written
permission.
 Equipments needed
1. Blood recipient
set (filter &
tubing with drip
chamber for
blood, or
combined set)
 Equipments needed
2. I.V. pole
3. Gloves
4. Gown
5. Face Shield
 Equipments needed
6. Multi-lead tubing
 Equipments needed
7. Whole blood or packed RBC’s
 Equipments needed
8. 250 ml of Normal Saline Solution
 Equipments needed
9. Venipuncture equipment, if necessary
(should include 20G or larger catheter)
 Equipments needed
10. optional: ice bag, warm compresses
 Getting Ready
Avoid obtaining either whole blood or
packed RBC’s until you’re ready to begin
the transfusion

Prepare the equipment when you’re ready to

start the infusion.
 The Procedure
Explain the procedure to the patient
Make sure an informed consent has been
signed
Record baseline vital signs
 The Procedure
Obtain whole blood or packed
RBCs from the blood bank
within 30 minutes of the
transfusion start time.
The Procedure
Check the
expiration date on
the blood bag, &
observe for
abnormal color,
RBC clumping, gas
bubbles, &
extraneous
material. Return
outdated or
abnormal blood to
the blood bank.
 The Procedure
Compare the name & number on the patient’s
wristband with those on the blood bag label.
 The Procedure
Check the blood bag
identification
number, ABO blood
group, and Rh
compatibility.

Also, compare the

patient’s blood bank
identification
number, if present,
with the number on
the blood bag.
 The Procedure
Identification of blood & blood products is
performed at the patient’s bedside by two
licensed profesionals, according to the
facility’s policy.
 The Procedure
Wash your hands.
Put on gloves, a gown, & a face shield.
Remove IV administration set and fluid from
packaging
Remove the cover from the selected spike
and the cover from the bottle/bag of fluid.
 The Procedure
Then insert the spike of the line you’re using
for the normal saline solution into the bag
of saline solution aseptically.
When fluid drips out of the end of the distal
tubing turn off the infusion rate clamp.
 The Procedure
Using a Y-type set, close all the clamps on
the set.
 The Procedure
Next, open the port on the blood bag & insert
the other spike.
 The Procedure
Hang the bags on the
I.V. pole,
 The Procedure
open the clamp on the line of saline solution,
 The Procedure
squeeze the drip chamber until it’s half full.
 The Procedure
If the patient doesn’t have an I.V. line in
place, perform venipuncture, using a 20G
or larger-diameter catheter.
 The Procedure
Avoid using an existing line if the needle or
catheter lumen is smaller than 20G.

Ventral venous access devices also may be

used for transfusion therapy.
 The Procedure
If you’re administering whole blood, gently
invert the bag several times to mix the
cells.
 The Procedure
Attach the prepared blood administration set
to the venipuncture device, & flush it with
normal saline solution.
 The Procedure
Then close the clamp to the saline solution,
& open the clamp between the blood bag
& the patient.
 The Procedure
Adjust the flow
clamp closest to
the patient to
deliver the blood
at the calculated
drip rate.
 The Procedure
Remain with the patient, & watch for the
signs of a tranfusion reaction, such as
fever, chills, & wheezing.
 The Procedure
If such sign develop, record vital signs and
stop the transfusion.
 The Procedure
Infuse saline solution at a moderately slow
infusion rate, & notify the doctor at once.
 The Procedure
If no signs of a reaction appear within 15
minutes, you’ll need to adjust the flow
clamp to the ordered infusion rate.
 The Procedure
A unit of RBCs may be given over 1-4 hours
as ordered.
 The Procedure
After completing the
transfusion, you’ll
need to put on gloves
& remove & discard
the used transfusion
equipment.
 The Procedure
Then remember to reconnect the original I.V.
fluid, if necessary, or disconnect the I.V.
infusion.
 The Procedure
Return the empty blood bag to the blood
bank, & discard the tubing & filter.
 The Procedure
Record the patient’s vital signs.
 Practice Pointers
Although some microaggregate filters can
be used for up to 10 units of blood, always
replace the filter & tubing if more than 1
hour elapses between transfusions.
 Practice Pointers
When administering multiple units of blood,
use blood warmer to avoid hypothermia.
 Practice Pointers
For rapid blood replacement, know that
you may need to use a pressure bag.
 Practice Pointers
If you’re administering packed RBCs with
Y-type set, you can add saline solution to
the bag to dilute the cells by closing the
clamp between the patient & the drip
chamber & opening the clamp from the
blood
 Practice Pointers
Then lower the blood bag below the saline
solution container & let 30-50ml of saline
solution flow into the packed cells.
 Practice Pointers
Finally, close the clamp to the blood bag,
rehang the bag, rotate it gently to mix the
cells & saline container
Documenting Blood Transfusion
In your notes, record:
 Date & time of the transfusion.
 Type & amount of transfusion product.
 Patient’s vital signs.
 Your check of all identification data.
 Transfusion reaction & nursing actions
taken.
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