PERFORMANCE EVALUATION TOOL FOR INITIATING, MAINTAINING AND

TERMINATING BLOOD TRANSFUSION

Directions: Below is a list of criteria to evaluate the student's skill in blood transfusion. Indicate your
evaluation by writing the score using the following descriptive scale.
0 – not done 1 - incorrectly done 2 - correctly done

Student’s Name:________________________________ Date: _____________________

Group No.: _____

PREPARATION 0 1 2 Remarks
1. Assess
- Clinical signs of reaction
- Manifestations of hypervolemia
- Status of infusion rate
- Any unusual sign
- Vital signs for baseline data

2. Determine:
- That a signed consent form was obtained
- Any known allergies or previous adverse reaction
to blood
-
3. Assemble equipment:
- Blood product
- Blood transfusion set
- Normal saline for infusion
- IV pole
- Venipuncture set containing a #18 0r #19 gauge
needle
- Chlorhexidine solution
- Alcohol swabs
- Tape
- Clean gloves
4. Prepare the client, introduce yourself and verify
the client’s identity
- Explain the procedure and its purpose to the client.
Instruct the client to report promptly any sudden
chills, nausea, itching, rash, dyspnea, back pain or
any other unusual symptoms.
- If the client has an intravenous solution infusing,
check weather needle and solution are appropriate
to administer blood.
 - If the client does not have an IV solution infusing,
check agency policies.
PROCEDURE
1. Obtain the correct blood component of the client.
- Check the primary care provider’s order with the
requisition
- Check the requisition form and the blood bag label
with the laboratory technician, or according to
agency policy. Specifically check the client’s
name, identification number, blood type and Rh
group, the blood donor number and the expiration
date of the blood. Observe the blood for abnormal
color, RBC clumping, gas bubbles, and extraneous
material. Return outdated or abnormal blood to the
blood bank.
- With another nurse compare the laboratory blood
record with others.
• the client’s name and identification number
• the number of the blood bag label
• the ABO group and Rh type on the blood
bag label
- if any of the information does not match exactly,
notify the charge nurse and the blood bank. Do not
administer blood until discrepancies are corrected
or clarified.
- Sign the appropriate form with the other nurse,
according to agency policy.
- Make sure that the blood is left at room
temperature for no more than 30 minutes before
starting the transfusion.
2. Verify the client’s identity
- Check the client’s armband for name
3. Set up the infusion equipment.
- Ensure that the blood filter inside the drip chamber
is suitable for whole blood or the blood
components to be transfused. Attach the blood
tubing to the blood filter, if necessary.
- Put on gloves
- Close all the clamps on the Y-set: the main flow
rate clamp and both Y-line clamps.
- Using a twisting motion, insert the piercing
pin(spike) into the container of saline solution
- Hang the container on the IV pole about 1m(3 feet)
above the planned venipuncture site.
4. Prime the tubing.
- Open the upper clamp on the normal saline tubing,
and squeeze the drip chamber until it covers the
filter and 0ne-third of the drip chamber above the
filter
- Tap the filter chamber to expel any residual air in
the filter
- Remove the adapter cover at the tip of the blood
administration set
- Open the flow rate clamp and prime the tubing
with saline
- Close both clamps
5. Start the saline solution.
- If an IV is incompatible with blood is infusing,
stop the infusion and discard the solution and
tubing, according to agency policy
- Attach the blood tubing primed with normal saline
to the IV catheter
- Open the saline and main flow rate clamps, and
adjust the flow rate. Use only the main flow rate
clamp to adjust the rate
- Allow a small amount of solution infuse, to make
sure there are no problems with the flow or with
venipuncture site
6. Prepare the blood bag.
- Invert the blood bag gently several times to mix
cells with plasma
- Expose the part of the blood bag by pulling back
the tabs
- Insert the remaining Y-set spike into the blood bag
- Suspend the blood bag
- Close the upper clamp below the IV solution on
the Y-set
- Open the clamp of the blood arm of the Y-set and
prime the tubing
7. Establish the blood transfusion
- The blood will run into the saline-filled drip
chamber. If necessary, squeeze the drip chamber to
reestablish the liquid level with drip chamber 1/3
full
- Re-adjust the flow rate with the main clamp
8. Observe the client closely for the 1st 5-10 minutes
- Turn the blood slowly for the 1st 15 minutes at 20
drops per minute
- Note adverse reactions such as chilling, nausea,
vomiting, skin rash or tachycardia
- Remind the client to call a nurse immediately if
any unusual symptoms are felt during the
transfusion
- If any of these reactions occur, report them to the
nurse in charge and take appropriate nursing action
9. Document relevant data. Record:
- Starting the blood
- Vital signs
- Type of blood
- Blood unit number
- Site of venipuncture
- Size of needle
- Drip rate
10. Monitor the client.
- Fifteen minutes after initiating the transfusion,
check the vital signs of the client. If there are no
signs of a reaction, establish the required flow rate.
Do not transfuse a unit longer than 4 hours.
- Assess the client including vital signs every 30
minutes or more often, depending on the health
status until 1 hour post transfusion. If the client has
a reaction and the blood is discontinued, send the
blood bag to the laboratory for investigation of the
blood.
11. Terminate the transfusion
- Put on clean gloves
- If no transfusion is to follow, clamp the blood
tubing and remove the needle. If another
transfusion is to follow, clamp the blood tubing
and open the saline infusion arm
- If the primary IV is to be continued, flush the
maintenance line with saline solution. Disconnect
the blood tubing system and reestablish the
intravenous infusion using new tubing. Adjust the
drip to the desired rate.
- Discard the administration set, according to agency
policy. Needles should be placed in a labeled
puncture resistant container designed for such
disposal. Blood bags and administration sets
should be bagged and labeled before being sent for
decontamination and processing.
- Remove gloves
- Monitor vital signs
12. Follow agency protocol appropriate disposition of
the blood bag.
 - On the requisition attached to the blood unit, fill in
the time the transfusion was completed and the
amount transfused
- Attach one copy of the requisition to the client’s
record and another to the empty blood bag
- Return the blood bag and requisition to the blood
bank
13. Document relevant data. Record:
- Completion of the transfusion
- The amount of blood
- The blood unit number
- Vital signs
- If the primary intravenous infusion was continued,
record connecting it
- Also record the transfusion on the IV flow sheet,
and intake and output record.
TOTAL

Remarks:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
____________________.
_________________________________________
Name and Signature of Clinical Instructor