Western Mindanao State University

College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

Western Mindanao State University

College of Nursing
Zamboanga City
Name: __________________________________ Rotation ___________________
Section: _________________________________ Date: _____________________

Evaluation Checklist
BLOOD TRANSFUSION
STEPS 1 2 3 4
1. Verify doctor’s written prescription and make a treatment card
according to hospital policy
2. Get patient histories regarding previous transfusion
3. Explain the procedure / rationale for giving blood transfusion to assure
patient and significant others and secure consent.
4. Explain the importance of the benefits on Voluntary Blood Donation
(RA 7719-National Blood Service Act of 1994)
5. Request prescribed blood / blood components from blood bank to
include blood typing and X – matching and blood result of
transmissible disease
6. Call the blood bank for the availability of blood/blood components
7. Using a clean lined tray, get compatible blood from hospital blood
bank
8. Wrap blood bag with clean towel and keep it at room temperature
9. Observe fourteen (14) R’s when preparing and administering any blood
or blood components
10. Have a doctor and a nurse assess patient’s condition.
Countercheck the following:
10.1 ABO grouping
10.2 RH
10.3 Serial No.
10.4 Expiry date with the blood ag label and
10.5 Other laboratory blood exams as required before transfusion
(Hgb & Hct)
11. Get the baseline vital signs –
 BP, RR, and Temperature before transfusion.
11.1 Refer to attending physician accordingly
12. Give pre – med 30 minutes before transfusion as prescribed.
13. Do hand hygiene
14.Prepare equipment needed for BT
14.1 IV injection tray
14.2 Compatible Blood Transfusion set
14.3 IV cannula / needle gauge 18/19
14.4 Plaster
14.5 Tourniquet
14.6 Blood / blood components to be transfused
14.7 Plain NSS 500 cc
14.8 IV Set, needle gauge 18 (only if needed)
14.9 Gloves
14.10 Sterile gauze 2x2 or transparent dressing
14.11 Scissors
 Western Mindanao State University
College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

15. Initiate an IV line of plain NSS on another site with appropriate IV

catheter if main IVF is dextrose 5%.
16.Anchor catheter properly and regulate IV drops
17. Don on gloves.
18. Open compatible blood set aseptically
19. Close roller clamp
20.Spike blood bag carefully; fill the drip chamber at least half full
21.Prime tubing and remove air bubbles (if present)
22. Use needle gauge 18 or 19 for side drip (for adults) or gauge 22 for
pediatrics. Disregard the use of needle if blood is given through the Y
injection port
23. Disinfect the Y – injection port of IV tubing (plain NSS).
24. Insert the needle from the Blood Transfusion administration set and
secure with adhesive tape.
25. Remove gloves and discard properly.
26. Close roller clamp of IV fluid of plain NSS while transfusion is going on
27. Transfuse the blood via the injection port.
28. Regulate at 10-15gtts/min initially for 1 5 minutes and then at the
prescribed rate (usually based on the patient’s condition).
29.Wash hands
30. Monitor the patient within the first 5-10 minutes of transfusion and refer
immediately to the attending physician for any adverse reaction.
31.Observe / assess patient on an on – going basis for any untoward signs
and symptoms such as:
31.1 flushed skin
31.2 chills
31.3 elevated temperature
31.4 itchiness
31.5 urticaria
31.6 Dyspnea
31.7 Stop the transfusion if any of the above signs and symptoms are
observed
31.8 Open the IV line with plain NSS and regulate accordingly
31.9 Report to the doctor immediately
32. Swirl the bag gently from time to time to mix the solid with the plasma.
33. One blood set should be used for every 1-2 units of blood.
34. Close the roller clamp of blood transfusion.
35. Disconnect from IV lines once blood is consumed.
36. Regulate the IVF of plain NSS as prescribed
37. Continue to observe and monitor patient post transfusion, for delayed
reaction can still occur
38. Re – check Hgb and Hct
38.1 Bleeding time
38.2 Serial platelet count within specified hour as prescribed / and or per
institution’s policy
39. Discard blood bag, Blood Transfusion set and sharps according to the
Health Care Waste management (DOH / DENR).
40. Wash hands
41. Fill out adverse reaction sheet as per institutional policy
42. Remind the doctor about the administration of calcium gluconate if
patient has several units of blood transfusion ( 3-5 more units of blood)
43. Document the procedure.
 Western Mindanao State University
College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

BLOOD TRANSFUSION

280 ---1.0
Total Score: ____________________________
96-100 - 268 - 280 - 1.0
91-95 - 255 - 267 - 1.25 Rating: ________________________________
86-90 - 242 - 254 - 1.5
81-85 - 229 - 241 - 1.75 Student’s Signature: ____________________
76-80 - 214 - 228 - 2.0
71-75 - 200 - 213 - 2.25 C.I.’s Signature: ________________________
66-70 - 186 - 199 - 2.5
62-65 - 173 - 185 - 2.75 Remarks: ________________________________
60-61 - 168 -172 - 3.0 _______________________________
________________________________
_______________________________

Prepared By: Level IV FACULTY

Noted By: Sarah Jane C. Demayo, PhD, RN

Level III- Coordinator

Maria Socorro C. Domingo, DNS, MAN, RN

Recommending Approval: Clinical Coordinator

Approved By: Mary Joselyn C. Biong, DPA, MN

OIC-Dean