Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

Name: _______________________________________ Date: ________________

Year and Section: _____________________________ Grade: _______________

PROCEDURE CHECKLIST: INITIATING, MAINTAINING, AND

TERMINATING A BLOOD TRANSFUSION USING A Y-SET

Instruction: Below is the grading scale which will be used in rating your performance.
5 - Excellent - 95 – 100
4 - Very Satisfactory - 88 – 94
3 - Satisfactory - 82 – 87
2 - Fair - 76 – 81
1 - Needs Improvement - 70 – 75

ASSESSMENT:
 Vital signs; oxygen saturation is often included.
 Physical examination including fluid balance and heart and lung sounds as
manifestations of hypo- or hypervolemia.
 Status of infusion site and patency of vascular access device.
 Blood test results such as hemoglobin value or platelet count.
 Any unusual symptoms

PLANNING:

 Review the client record regarding previous transfusions. Note any complications and
how they were managed (e.g., allergies or previous adverse reactions to blood).
 Confirm the primary care provider’s order for the number and type of units and the
desired speed of infusion.
 In some agencies, written consent for transfusion is required. Check policy and obtain as
indicated.
 Know the purpose of the transfusion.
 Plan to begin the transfusion as soon as the component is ready. Typing and
crossmatching can take several hours.
 Note any premedication ordered by the primary care provider (e.g., acetaminophen or
diphenhydramine). Schedule their administration (usually 30 minutes prior to the
transfusion).

EQUIPMENTS:

 Unit of whole blood, PRBCs, or other component

 Blood administration set
 IV pump, if needed (use EIDs that have a labeled indication for blood transfusion)
 250 ml normal saline for infusion
 IV pole
 Venipuncture set containing a # 20- to #24- gauge catheter (if one is not ready in place)
 Alcohol swabs
 Tape
 Clean gloves

PROCEDURE 5 4 3 2 1 REMARKS
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES

1. Verify the physician’s written order and

make a treatment card according to hospital
policy.
2. Observe the 10 R’s when preparing and
administering any blood or blood
components.
3. Explain the procedure/rationale for giving
blood transfusion to reassure patient and
significant others and secure consent. Get
patient histories regarding previous
transfusion.
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 cross matching and blood
result of transmissible Disease.
6. Using a clean lined tray, get compatible
blood from hospital blood bank.
7. Wrap blood bag with clean towel and keep it
at room temperature.
8. Have a doctor and a nurse assess patient’s
condition. Countercheck the compatible
blood to be transfused against the cross-
matching sheet noting the ABO grouping
and RH, serial number of each blood unit,
and expiry date with the blood bag label and
other laboratory blood exams as required
before transfusion.
9. Get the baseline vital signs- BP, RR, and
Temperature before transfusion. Refer to
MD accordingly.
10. Give pre-meds 30 minutes before
transfusion as prescribed.
11. Do hand hygiene before and after the
procedure.
12. Prepare equipment needed for BT (IV
injection tray, compatible BT set, IV
catheter/ needle G 19/19, plaster,
tourniquet, blood, blood components to be
transfused, Plain NSS 500cc, IV set, needle
gauge 18 (only if needed), IV hook, gloves,
sterile 2×2 gauze or transplant dressing, etc.
13. If main IVF is with dextrose 5% initiate an IV
line with appropriate IV catheter with Plain
NSS on another site, anchor catheter
properly and regulate IV drops.
14. Open compatible blood set aseptically and
close the roller clamp. Spike blood bag
carefully; fill the drip chamber at least half
full; prime tubing and remove air bubbles (if
any). Use needle g.18 or 19 for side drip (for
adults) or g.22 for pedia (if blood is given to
the Y-injection port, the gauge of the needle
is disregarded).
15. Disinfect the Y-injection port of IV tubing
(Plain NSS) and insert the needle, from BT
 Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
administration set and secure with adhesive
tape.
16. Close the roller clamp of IV fluid of Plain
NSS and regulate to KVO while transfusion
is going on.
17. Transfuse the blood via the injection port
and regulate at 10-15gtts/min initially for the
first 15 minutes of transfusion and refer
immediately to the MD for any adverse
reaction.
18. Observe/Assess patient on an on-going
basis for any untoward signs and symptoms
such as flushed skin, chills, elevated
temperature, itchiness, urticaria, and
dyspnea. If any of these symptoms occur,
stop the transfusion, open the IV line with
Plain NSS and regulate accordingly, and
report to the doctor immediately.
19. Swirl the bag gently from time to time to mix
the solid with the plasma N.B one B.T set
should be used for 1-2 units of blood.
20. When blood is consumed, close the roller
clamp, of BT, and disconnect from IV lines
then regulate the IVF of plain NSS as
prescribed.
21. Continue to observe and monitor patient
post transfusion, for delayed reaction could
still occur.
22. Re-check Hgb and Hct, bleeding time, serial
platelet count within specified hours as
prescribed and/or per institution’s policy
23. Discard blood bag and BT set and sharps
according to Health Care Waste
Management (DOH/DENR).
24. Fill-out adverse reaction sheet as per
institutional policy.
25. Remind the doctor about the administration
of Calcium Gluconate if patient has several
units of blood transfusion (3-5 more units of
blood).

Date/Time: ___________________________

Facilitator: ____________________________