Bicol University Tabaco Campus

NURSING DEPARTMENT
Tabaco City

RLE EVALUATION SHEET

(SKILLS LABORATORY)

Administering a Blood Transfusion

Name: __________________________________ Rating: __________________

Group No.: ______________________________ Date: ___________________

Legend:

5 – Excellent – Carries out the procedures efficiently, systematically and

independently.
4 – Very Satisfactory – Carries out the procedures efficiently and systematically but
requires minimal guidance and supervision.
3 – Satisfactory – Carries out the procedures efficiently and systematically but
requires moderate guidance and supervision.
2 – Fair – Carries out the procedures efficiently and systematically but requires close
guidance and supervision.
1 – Needs Improvement – Carries out the procedure inefficiently and
unsystematically and requires close guidance and supervision.

Administering a Blood Transfusion

Equipment
a. IV Fluid (NSS)
b. Blood administration Set
c. Pretransfusion Medications
d. Blood Product
e. Set of Sterile Gloves
f.

Preparation
5 4 3 2 1 Comments

1. Verifies that informed consent has been secured.

2. Verifies the physician’s order, noting the indication, rate

of infusion, and any premedication orders.

Performance
5 4 3 2 1 Comments

3. Administer’s any pretransfusion medications as

prescribed.
4. Obtains IV fluid containing normal saline solution and a
blood administration set.

5. Obtains the blood product from the blood bank according

to agency policy.

6. Wears procedure gloves whenever handling blood

products.

7. Rechecks physician’c orders.

8. With another qualified nurse verifies the patient and

blood product identification, as follows:
a. If able let the patient state full name and date of birth
and compares it to what is located on the blood bank
form.
b. Compares the patient name and hospital identification
number on the patient’s identification bracelet with
the patient name and hospital identification number
on the blood bank form attached to the blood
product.
c.Compares the unit identification number located on the
blood bank form woth the identification number
printed on the blood product container.
d. Compares the patient’s blood type listed on the blood
bank form with the blood type listed on the blood
product container.
e. If all verifications are in agreement, both staff
members sign the blood bank form attached to the
blood product container. Contacts the blood bank
immediately if any discripancies occur during the
identification process and does not administer the
blood product.
f. Documents on the blood bank form the date and time
that the transfusion was begun.
g. Makes sure that the blood bank form remains attached
to the blood product container until administration is
complete.

9. Removes the blood administration set from the package

and labels the tubing with the date and time.

10. Closes the clamps on the administration set.

11.Removes the protective covers from the normal saline

solution container port and one of the spikes located on the
“Y” of the blood product administration set. Places the
spike into the ort of the solution container and opens the
roller clamp closest to that spike.

12. Hangs the Normal Saline Solution container on the IV

pole.

13. Compresses the drip chamber of the administration set

and allows it to fill up halfway.

14. Primes the administration set with normal saline.

15. Attaches the blood filter to the second “Y” port on the
 administration set and primes it with normal saline solution
by inverting it.

16. Inspects the tubing for air. If air bubbles remain in the
tubing, flicks the tubing with a fingernail to mobilize the
bubbles.

17. Gently inverts the blood product container several

times.

18. Removes the protective covers from the administration

set and the blood product port. Carefully spikes the blood
product container through the port.

19. Hangs the blood product container on the IV pole.

20. Slowly opens the roller clamp closest to the blood

product.

21. Obtains and records the patient’s vital signs, including

temperature, before beginning the transfusion.

22. Using aseptic technique, attaches the distal end of the

administration set to the IV Catheter.

23. Using the roller clamp, adjust the drip rate, as

prescribed.

24. Remains with the patient during the first 5 minutes and
then obtain vital signs.

25. Make sure that the patient’s call bell or light is readily
available and tells the nurse immediately of any signs or
symptoms of a transfusion reaction, such as back pain,
chills, itching, or DOB.

26. Monitor vital signs in 15 minutes, then again in 30

minutes and then hourly while the transfusin infuses.

27. After the unit has infused, closes the roller clamp
closest to the blood product container and opens the roller
clamp closest to the normal saline solution to flush the
administration set.

28. Closes the roller clamp and then disconnects the blood
administration set from the IV Catheter.

29. If another unit of blood is required, the second unit can

be hung with the same administration set.

If possible use the non-dominant arm

30. Discard the empty blood container and administration

set in the proper receptacle according to agency policy.

Preparing the Venipuncture (IV) Site

5 4 3 2 1 Comments

31. Warm veins by

a. Rubbing
b. Washing client’s hands under warm water
c. Apply warmed towel
 d. If limb is warm ask the patient to gently clench
and unclench their hand
e. Or gently rub up and down the vein

32. The tourniquet is applied 5 – 12cm (2 – 6 inches) above

insertion site and should not be left on for more than
2-3 minutes.

33. Apply the Palpate for a pulse distal to the tourniquet.

34. Don sterile gloves, and clean site with appropriate

solution using a circular outward movement.

35. Prepare site according to hospital policy.

Variation: Transfusion Reaction

5 4 3 2 1 Comments

36. Stop the transfusion immediately if signs or symptoms

of transfusion reaction occurs.

37. Disconnect the administration set from the IV catheter.

38. Obtain vital signs and auscultate heart and breath

sounds.

39. Maintain a patent IV cathether by hanging a new

infusion of normal saline solution, using new tubing.

40. Notify physician as soon as the blood has been

stopped and patient has been assessed.

41. Place the administration set and blood product

container with the blood bank form attached inside a
biohazard bag and send it to the blood bank.

42. Obtain blood (in the extremity opposite the infusion

site) and urine specimens.

43. Continue monitor vital signs.

44. Administer medications as prescribed.

Supervised by:

____________________________________________
ROMAN J-LOU B. CORDOVILLA, MAN, RN, RM, EMT-B
Assistant Professor II