ROHILKHAND COLLEGE OF NURSING, BAREILLY

Procedure checklist
Blood Transfusion
S. No. Content 1 2 3 4 5
1. Check physician's orders, patient's condition, and history of transfusion/infusion
reaction, reason for present transfusion, etc.
2. Identify patient
3. Check availability of blood with the blood bank.
4. Explain the procedure to the patient, need for transfusion, blood product to be
given, approximate length of time, desired outcome, etc. Emphasize the need
for patient to report unusual symptoms immediately. Obtain informed consent
from patient.
5. Obtain blood from blood bank in accordance with agency policy. If transfusion
cannot begin immediately, return product to blood bank. Blood which is out of
refrigerator for more than 30 minutes, above 10 degree centigrade cannot be re-
issued. Never store blood in unauthorized area-like ward refrigerator. Blood
must be stored in refrigerated unit at carefully controlled temperature (4°C).
6. Encourage patient to empty bowel and bladder and assist to a comfortable
position. Collect urine specimen.
7. Ensure privacy.
8. Wash and dry hands.
9. Check vital signs and record.
10. Don disposable gloves.
11. Insert IV cannula (20/22G), if not already present in a large peripheral vein and
initiate infusion of normal saline solution using blood transfusion set.
12. Inspect the blood product (By 2 nurses) for
a. Identification number:
b. Blood group and type c. Expiry date
d. Compatibility
e. Patient's name
f. Abnormal color, clots, excess air, etc.
13. Warm blood, if needed, using special blood warmer or immerse partially in
tepid water.
14. If blood product is found to be correct, Stop the saline solution by closing roller
clamp. Remove insertion spike from saline container and insert spike into blood
container.
15. Start infusion of blood product slowly, at the rate of 25 to 50 ml per hour for
the first 15 minutes. Stay with patient for first 15 minutes. Check vital signs
every 15 minutes for first 30 minutes, or as per agency policy.
16. Increase infusion rate if no adverse reactions are noticed. The flow rate should
be within safe limits.
17. Assess the condition of patient every 30 minutes and if any adverse effect is
observed stop transfusion and start saline. Send urine sample, blood sample and
remaining blood product in container with transfusion set, back to the blood
bank.
 18. Complete transfusion and administer saline (as per physician's order), if no
adverse reaction is observed.
19. Dispose blood product container and set in appropriate receptacle.
20. Wash hands.
21. Record the following: Product and volume transfused, identification number
and blood group: Time of administration started and completed. Name and
signature of nursing staff carrying out procedure, and patient's condition. If
agency policy requires remove label from blood bag and paste it on patient's
record.
22. Assist patient to comfortable position.
23. Do not administer medication through the same line, where blood product is
transfused. Start another IV line medications are to be infused, because of
possible incompatibility and bacterial contamination. Blood transfused should
be completed over a period of 4 hours from the time of initiation.
24. Cover the blood bag with a towel when it hangs on the IV pole.
25. Gently rotate the blood bag periodically to prevent clumping of cells.
26. When rewarming the blood by immersing in tap water, do not immerse the
blood bag fully into the water as it may cause hemolysis.
27. Rewarming of blood may be done by covering the blood bag with a blanket
28. Premedication such as Avil may be prescribed.
TOTAL SCORE
OBTAINED SCORE
PERCENTAGE
REMARK
Name of the student_____________________________ Date_________________

Course__________________________________ Class ________________

Name of Instructor/Evaluator: _______________________ Ward/Unit________________

Signature: __________________________

6- Highly Satisfactory – 85-100 Percentage

5 -Satisfactory – 69 – 84 Percentage
4 -Moderately Satisfactory- 52 to 68 Percentages
3 - Moderately Unsatisfactory- 35 to 51 Percentages
2 -Unsatisfactory – 18 to 34 Percentages
1 -Highly Unsatisfactory – 0-17 Percentage

Note:
1. 1, 2, 3, 4, 5 denoting attempt made by the students
2. Each statement will be score by Yes/No and yes contain 1 point & no contain zero point
3. Students who get 85 % or above will get full satisfactory and below will have to make attempt till the
candidate get 85% or above

Remarks by Evaluator: ________________________________________________________

PRINCIPAL