MANAGING BLOOD TRANSFUSION

PURPOSES:
1. Provides replacement of blood products to increase client's fluid volume,
hemoglobin, and hematocrit for improved circulation and oxygen distribution
2. Prevents over administration of blood products or the development of
complications associated with a transfusion

EQUIPMENT:

• Blood transfusion tubing (blood Y set with in-line filter)

• 250- to 500-mL bag/bottle normal saline
• Packed cells or whole blood, as ordered
• Blood warmer or coiled tubing and pan of warm water (optional)
• Order slips for blood
• Flow sheet for vital signs (for frequent checks)
• Nonsterile gloves
• Materials for IV start
• Alcohol or povidone swabs, or approved antiseptic cleansing agent

ASSESSMENT:
Assessment should focus on the following:

• Baseline vital signs; circulatory and respiratory status

• Skin status (e.g., rash)
• Physician's orders for blood component to be infused & blood type, amount, and
rate of blood administration
• Size of IV catheter or need for catheter insertion
• Baseline laboratory studies, such as complete blood count, type and cross-match
• History of blood transfusions and reactions (including type of reaction, treatment,
and client's response to treatment), if any
• Religious or other personal objections that client has to receiving blood
• Compatibility of client to blood (matching blood sheet numbers to name band)

STEPS RATIONALE EXCELLENT VERY GOOD FAIR POOR

GOOD
5 4 3 2 1
1. Perform hand Reduces microorganism
hygiene and organize transfer; promotes
equipment. efficiency
2. Explain procedure to Helps decrease anxiety
client, particularly the
need for frequent vital
sign checks.
3. Prepare blood
transfusion tubing:
• Open tubing Prepares for infusion of
package and close saline before and after
drip transfusion
regulators/roller
clamps (which may
be a clamp, roller,
or screw). Note
colors of caps over
tubing spikes.

• Remove cap to Establishes connection

reveal spike on between tubing and saline
one side of blood solution; clears air from
tubing. Remove tubing
tab from normal
saline bag/bottle
and insert tubing
spike. Remove cap
from end of
tubing, open saline
regulator 1, prime
drip chamber and
tubing with saline,
and close saline
regulator.

• Replace cap on Maintains sterility of

tubing end and system
place on bed near
IV catheter.

4. Insert IV if one is Decreases hemolysis;

not already present; if allows free flow of blood
IV catheter is present,
verify that it is of
adequate size
(catheter should be
20 gauge or larger
and make sure IV
catheter gauge and
solution are
 appropriate to
administer blood).
5. Don gloves if not Reduces risk of infection
already on and transmission; permits
remove dressing access for connection of
enough to expose blood tubing
catheter hub.
6. Disconnect infusion Connects blood tubing
tubing from hub and directly to catheter;
connect blood tubing preserves previous infusion
to catheter hub; tubing for future use
discard or place
needle cap over
previous infusion
tubing tip.
7. Open saline Maintains patency of
regulator/roller clamp catheter
fully and regulate to a
rate that will keep
vein open (15 to 30
mL/hr) until blood is
available.
8. Obtain blood and
perform safety checks
with other nurse:
• When blood arrives, Verifies that the client's
check blood and name, ABO group, Rh
client information, type, and unit number
comparing blood and computer match
package with order
slip and checking
client name,
hospital number,
blood type,
computerized blood
ID number, and
expiration date.

• Check client's name Ensures transfusion to

band: name and correct client
hospital number (or
emergency
department
number on name
 band if typing and
cross-matching
were done in
emergency
department). If
discrepancies are
noted, notify the
blood bank
immediately and
postpone
transfusion until
problems are
resolved.

• Check for correct Prevents transfusion of

identification unmatched blood. Failure
information WITH A to identify the blood
SECOND NURSE product or client properly
AND AT CLIENT'S is often linked to severe
BEDSIDE. Identify transfusion reactions.
client first and do Recent JCAHO guidelines
so verbally as well reflect the goal of better
as by checking client identification
appropriate written procedures, including
forms of verbal verification.
identification.
Include the client in
the verbal
identification
process.
• Make sure that the As blood components
blood is left at room warm, bacterial growth
temperature for no also increases.
more than 30
minutes before
starting the
transfusion

9. Complete blood Provides legal record of

bank slip with date blood verification
and time of
transfusion initiation
and nurses checking
information.
10. Check and record Provides baseline vital
pulse, respirations, signs before transfusion
blood pressure, and
temperature.
11. Invert the blood Accesses blood for
bag gently several administration
times to mix the cells
with the plasma (If
whole blood is to be
administered) and
Remove cap to reveal
spike on other side of
blood tubing and
insert spike into port
on blood bag.
12. Close Prevents saline from
regulator/roller clamp infusing into blood bag
(#1) on normal saline and allows blood tubing
side of tubing and to fill with blood
open blood
regulator/roller clamp
(#1) on blood side of
tubing
13. Regulate drip rate
to deliver the
following: (Check if,
physician has ordered
a specific drip rate)
• A maximum of 30 Identifies possible
mL of blood within reaction. Most reactions
the first 15 occur within the first 15
minutes minutes of the infusion.

• One half to one Delivers blood volume in 2

quarter of the to 4 hours
volume of blood
each hour (62 to
125 mL/hr
depending on
client tolerance of
volume change
and volume of
 blood to be
infused)

• If client has poor Allows slower infusion of

tolerance to total unit without
volume change, violating 4-hour
check to see if transfusion time limit
blood bank will
divide unit in half
so 8 hours may be
used to infuse the
total unit.

14. Check vital signs Allows prompt detection

particularly the of transfusion reaction
temperature again 15
minutes after
beginning the
transfusion, then
every half hour or
hourly until
transfusion is
completed (see
agency policy); check
at the completion of
delivery of each unit
of blood. Remind
client to call the
nurse any unusual
symptoms are felt
during the
transfusion (e.g.
chills, nausea, itching,
rash, dyspnea or back
pain)
15. When blood Clears blood line for
transfusion is infusion of other fluid;
complete, clamp off maintains sterility for
blood regulator/roller future transfusions
clamp (#1), open
saline regulator/roller
clamp #1, and begin
infusing saline
solution. Remove
empty blood bag and
recap blood tubing
spike.
16. Fill in time of Complies with agency
completion on blood regulations for
bank slip, and place confirmation of blood
copy of slip with administration
empty bag, or place
other copy of slip on
chart. (If no further
blood is to be given,
replace blood
transfusion tubing
with IV tubing or
infusion cap.)
17. During and after Allows for prompt
transfusion, monitor detection and early
client closely for signs intervention should a
of a transfusion problem arise
reaction. Check vital
signs every 4 hours
for 24 hours (or per
agency policy).
18. Position client Promotes client comfort
appropriately and and safety
raise side rails if
indicated.
19. Discard supplies, Prevents spread of
remove gloves, and microorganisms
perform hand
hygiene.

STUDENT COMMENTS CI SIGNATURE ABOVE PRINTED

SCORE NAME/DATE
Table 5.1 Transfusion Reactions
Type of Reaction Signs and Symptoms Actions
Allergic reaction Rash, chills, fever, Turn off blood transfusion (decreases
indicates incompatibility nausea, or severe further infusion of incompatible or
between transfused red hypotension (shock) contaminated blood).
cells and host cells Remove blood tubing and replace
with tubing primed with normal saline
(maintains catheter patency).
Infuse normal saline at slow rate
(maintains IV patency). Notify
physician immediately.
Pyrogenic reaction Nausea, chilling, fever, See Allergic reaction.
indicates sepsis and and headache (usually
subsequent renal noted toward end of
shutdown or after transfusion)
Circulatory overload Cough, dyspnea, Slow blood transfusion rate and
indicates acute distended neck veins, notify the physician (decreases
pulmonary edema or and crackles in lung workload of the heart and avoids
heart failure bases further overload).
Take vital signs frequently (every 10
to 15 minutes until stable), and
perform emergency treatment as
needed or ordered (detects and
treats resulting shock or cardiac
insufficiency).
Remove and send remaining blood
and blood tubing to blood bank with
completed blood transfusion forms.
Send first voided urine specimen to
laboratory (confirms hemolytic
reaction if red blood cells are
present).
Monitor I&O, particularly urinary
output (detects renal shutdown
secondary to reaction).

DOCUMENTATION:
The following should be noted on the client's chart:

• Date and initiation and completion times for each unit of blood transfused
• Blood component infused (packed cells or whole blood) and amounts
• Initial and subsequent vital signs
• Presence or absence of transfusion reaction and actions taken
• State of client after transfusion and current IV fluids infusing, if any
• IV catheter size and location; condition of IV site
• Instructions given and client's understanding of instructions