1.

CONFIRM THE PHYSICIAN’S ORDER FOR THE NUMBER AND TYPE OF UNITS AND DESIRED SPEED OF
INFUSION

- CHECK FOR WRITTEN CONSENT FOR TRANSFUSION

- KNOW THE PURPOSE OF TRANSFUSION

2. Inspect the tubing for kinks or obstructions to flow.

- Check if there is any redness in the iv area.

PLANNING

3. We need to perform hand hygiene to observe appropriate infection prevention measures.

4. gathering equipment will save time and can make the nurse work efficiently.

5. PLAN TO BEGIN THE TRANSFUSION AS SOON AS THE COMPONENT IS READY – this is because as the
blood components warm, there is an increase in risk for bacterial growth.

- If the transfusion is delayed, we should return it in the blood bank after 30 mins. Do not
store blood in unit refrigerator. Because the temperature is not precisely regulated and may
be damaged. TYPING, CROSSMATCHING, PREMEDICATION AS ORDERED

6. Check the primary care provider's order with the requisition.

Check the requisition form and the blood bag label with a laboratory technician or according to agency
policy. Specifically, check the client's name, identification number, blood type (A, B, AB, or O) 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 Return outdated or abnormal blood to the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.

7. verify the following before initiating the transfusion

a. Order: Check the blood or component against the primary care provider's written order.

b. Transfusion consent form: Ensure the form is completed per facility policy.

c. Client identification: The name and identification number on the client's identification band must be
identical to the name and number attached to the unit of blood.

d. Unit identification: The unit identification number on the blood container, the transfusion form, and
the tag attached to the unit must agree. e. Blood type: The ABO group and Rh type on the primary label
of the donor unit must agree with those recorded on the transfusion form.

f. Expiration: The expiration date and time of the donor unit should be verified as acceptable.

g. Compatibility: The interpretation of compatibility testing must be recorded on the transfusion form
and on the tag attached to the unit.

h. Appearance: There should be no discoloration, foaming, bubbles, cloudiness, clots or clumps, or loss
of integrity of the container.

8. Prepare the equipment as follows:

 A. If blood is to be infused using a pump, obtain one
B. Primary blood administration set
1. Turn the control on the blood tubing to the off position
2. open the entry port on the blood tag
3. Insert the administration set into the blood bag according to package directions
4. Compress the drip chamber and release it, Repeat until the filter is completely covered
with blood
5. Clear the tubing of air, and clamp and cap it with the sterile cap provided

9. ELIMINATE TRANSFUSION ERRORS RELATED TO PATIENT MISIDENTIFICATION

10. Explain to the client what you are going to do, why it is necessary, and how he or she can participate.
Instruct the client to report promptly

11. This is for us to have a record of the patient’s normal vital signs so it will be easier for us to know if
there are any adverse or severe reaction.

- - T: 36.5-37.5
- - P: 60-100
- - RR: 12-20
- - BP: 120/80

12. To observe infection prevention procedure.

13. insert new tubing ensures the bt is infusing at the correct rate

14. To keep it sterile

15.

16.

17.

18. to keep it in place and avoid leakage or obstruction in flow

19.

20. Transfusions of RBCs be started at 1-2 ml/min for the first 15 minutes of transfusion. This small
amount is enough to produce severe reaction but small enough that the reaction could be treated
successfully

21. Note adverse reactions, such as chills, nausea, vomiting, skin rash itching, headache, tightness in the
chest, shortness of breath, chills or sudden anxiety, tachycardia.

- The earlier a transfusion reaction occurs, the more severe it tends to be.

22. If transfusion reaction occurs, do the following:

a. Stop the blood. Keep the IV open with normal saline or the previous infusion
b. Recheck the vital signs
c. Notify the physician for further orders
-

23. On completion of the transfusion, remove tape, put on clean gloves, and perform one of the
following:

a. If IV is to be resumed, do the following:

1. Remove the tape from the blood tubing

2. Clamp the blood tubing, and remove it from the needle

3.Immediately connect the normal saline IV or a syringe of normal saline to flush the tubing and needle
or catheter

4. Clamp the normal saline tubing, and remove it from the needle

5. Connect the previous IV infusion

6. Release the clamp on the IV tubing; adjust the flow rate, and secure the tubing with tape

b. If the IV is to be discontinued:

1. Clamp the blood tubing, and remove the needle or other IV device

2. Check to make sure that no part of the needle has broken off and remains in the patient

3. Apply pressure, and raise the patient’s arm

4. Apply an adhesive bandage or pressure dressing

24. Monitor vital signs, and compare them with baseline measurements

- T: 36.5-37.5

- P: 60-100

- RR: 12-20

- BP: 120/80

25. Discard the blood administration set in special container. Dispose of all transfusion equipment in the
colored yellow plastic-lined containers

- This is to prevent

26. We need to perform hand hygiene to observe appropriate infection prevention measures.

Evaluation

27. Evaluate using the following criteria:

a. Correct blood product given at correct rate

b. TPR and blood pressure within normal limits and patient free of other signs of reactions
c. Patient comfortable

Documentation

28. Document the following:

a. Type and amount of blood product

b. Blood unit identification number. Usually a printed adhesive-backed tag. This is removed and attached
to the appropriate chart form

c. Time started and completed

d. Vital signs, at 5 and 15 minutes after initiation of transfusion, and on completion of transfusion

e. Flow rate

f. Pertinent patient responses and clinical observations