NCM 103 RLE

COMPETENCY PERFORMANCE CHECKLIST

2nd Semester, AY 2021 – 2022

Skill: Blood Transfusion Therapy

Student's Name: _____________________________ Rotation #:_________________

Group#: ________________________ Date: _____________________

No. Steps of the Procedure 2 1 0 Remarks

Gathered/Assembled equipment and materials:
Equipment
> Unit of whole blood/packed RBCs or other
component
> Blood administration set
> IV pump, if needed
1 > 250 mL normal saline for infusion
> IV pole
> Venipuncture set containing a #14 to #22 gauge
catheter
> Alcohol swabs
> Tape
> Clean gloves
Preparation
If the client has an IV solution infusing, check
whether the IV catheter and solution are appropriate
to administer blood. The IV catheter size ranges
between #14 and #22 gauge, and the solution must
be normal saline. Dextrose (which causes lysis of
2
RBCs), Ringer’s solution, medications and other
additives, and hyperalimentation solutions are
incompatible. Refer to step 6 below if the infusing
solution is not compatible.

If the client does not have an IV solution infusing,

check agency policies. In some agencies an infusion
must be running before the blood is obtained from
3 the blood bank. In this case, you will need to perform
a venipuncture on a suitable vein and start an IV
infusion of normal saline.

Performance

Prior to performing the procedure, introduce self and

verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it
4 is necessary, and how he or she can participate.
Instruct the client to report promptly any sudden
chills, nausea, itching, rash, dyspnea, back pain, or
other unusual symptoms.
Provide for client privacy and prepare the client.

> Assist the client to a comfortable position, either

sitting or lying. Expose the IV site but provide for
5
client privacy.

Perform hand hygiene and observe other appropriate

6 infection prevention procedures.

7 Prepare the infusion equipment.

 > Ensure that the blood filter inside the drip chamber
is suitable for the blood components to be
transfused. Attach the blood tubing to the blood filter,
if necessary.

> Apply gloves.

> Close all the clamps on the Y-set: the main flow
rate clamp and both Y-line clamps.

> Insert the piercing pin (spike) into the saline

solution.

> Hang the container on the IV pole about 1 m (39

in.) above the venipuncture site.

Prime the tubing.

> Open the upper clamp on the normal saline tubing,

and squeeze the drip chamber until it covers the filter
and one third of the drip chamber above the filter.

> Tap the filter chamber to expel any residual air in

8 the filter.

>Open the main flow rate clamp, and prime the

tubing with saline.

>Close both clamps.

Start the saline solution.

> If an IV solution 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.
9
> 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 to infuse to make

sure there are no problems with the flow or with the
venipuncture site.

Obtain the correct blood component for the client.

10
> 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.

> With another nurse (most agencies require an RN),

 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.

CLINICAL ALERT!

It is safer to have one nurse read the information for

verification to the other nurse; this avoids errors that
can be made if both nurses look at the tags together.

> 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. Agencies may
designate different times at which the blood must be
returned to the blood bank if it has not been started.

> If the start of the transfusion is unexpectedly

delayed, return the blood to the blood bank after 30
minutes. Do not store blood in the unit refrigerator.

11 Prepare the blood bag.

> Invert the blood bag gently several times to mix the
cells with the plasma.

> Expose the port on the blood bag by pulling back

the tabs.
 > Insert the remaining Y-set spike into the blood bag.

> Suspend the blood bag.

Establish the blood transfusion.

> Close the upper clamp below the IV saline solution

container.

> Open the upper clamp below the blood bag. The
blood will run into the saline-filled drip chamber. If
necessary, squeeze the drip chamber to reestablish
12 the liquid level with the drip chamber one third full.
(Tap the filter to expel any residual air within the
filter.)

> Readjust the flow rate with the main clamp.

> Remove and discard gloves.

> Perform hand hygiene.

1. Observe the client closely for the first 15 minutes.

> Phillips and Gorski (2014) report that the AABB

recommends that “transfusions of RBCs be started
at 1–2 mL/min for the first 15 minutes of the
transfusion”

> Note adverse reactions, such as chills, nausea,

vomiting, skin rash, dyspnea, back pain, or
tachycardia.
13
> Remind the client to call a nurse immediately if any
unusual symptoms are felt during the transfusion
such as chills, nausea, itching, rash, dyspnea, or
back pain.

> If any of these reactions occur, report these to the

nurse in charge, and take appropriate nursing action.

Document relevant data.

> Record starting the blood, including vital signs,

type of blood, blood unit number, sequence number
14
(e.g., #1 of three ordered units), site of the
venipuncture, size of the catheter, and drip rate.

Monitor the client.

> Fifteen minutes after initiating the transfusion (or

according to agency policy), check the vital signs. If
there are no signs of a reaction, establish the
required flow rate. Most adults can tolerate receiving
one unit of blood in 1.5 to 2 hours. Do not transfuse
15
a unit of blood for longer than 4 hours.

> Assess the client, including vital signs, per agency

policy. If the client has a reaction and the blood is
discontinued, send the blood bag and tubing to the
laboratory for investigation of the blood.
 2. Terminate the transfusion.

> Apply clean gloves.

> If no infusion is to follow, clamp the blood tubing.

Check agency protocol to determine if the blood
component bag needs to be returned or if the blood
bag and tubing can be disposed of in a biohazard
container. The IV line can be discontinued or capped
with an adapter or a new infusion line and solution
container may be added. If another transfusion is to
follow, clamp the blood tubing and open the saline
16 infusion arm. Check agency protocol. A new blood
administration set is to be used with each
component.

> If the primary IV is to be continued, flush the

maintenance line with saline solution. Disconnect the
blood tubing system and reestablish the IV infusion
using new tubing. Adjust the drip to the desired rate.
Often a normal saline or other solution is kept
running in case of delayed reaction to the blood.

> Measure vital signs.

3. Follow agency protocol for appropriate disposition

of the used supplies.

> Discard the administration set according to agency

practice.

> Dispose of blood bags and administration sets.

a. On the requisition attached to the blood unit, fill in

the time the transfusion was completed and the
amount transfused.
17 b. Attach one copy of the requisition to the client’s
record and another to the empty blood bag if
required by agency policy.

c. Agency policy generally involves returning the bag

to the blood bank for reference in case of
subsequent or delayed adverse reaction.

> Remove and discard gloves.

> Perform hand hygiene.

Document relevant data.

> Record completion of the transfusion, the amount

of blood absorbed, the blood unit number, and the
18 vital signs. If the primary IV infusion was continued,
record connecting it. Also record the transfusion on
the IV flow sheet and intake and output record.

Total Marks:
Equivalent

Legend:
2: done correctly and knows rationale
1: done correctly but don’t know rationale; incomplete procedure
0: not done
Evaluated by: _____________________________ Student Signature:__________________
Name & Signature of the Clinical Instructor