BLOOD TRANSFUSION SCRIPT 20.

Prepare the blood bag by inverting the blood bag gently

several times to mix the cells with the plasma.
21. Close the roller clamp of the filter set.
A. PREPARATION 22. Attach a needle at the other end of the filter set.
1. Check the doctors order with the request. 23. Expose the part of the blood bag by pulling back the tabs.
2. Check patient’s name, serial number, blood type, Rh group, 24. Insert the spike of the filter set into the blood bag.
the blood donor’s number and the expiration date of the 25. Open the clamp of the blood bag to prime the tubing then
blood together with the head nurse. closes the clamp.
3. Observe the blood for abnormal color, clumping, gas 26. Close the clamp on the IV saline solution.
bubbles and extraneous material. 27. Insert the needle of the blood bag to the Y- port of the
4. Ensure that consent for blood transfusion was signed. saline IV bottle then opens the clamp of the blood bag
5. Determine if there is no known allergies or previous adverse 28. Regulate the blood slowly for the first 10 minutes at 15
reactions to BT drops per min.
6. Introduce self to patient. 29. Observe the patient closely for the first 15 minutes for any
7. Verify patient’s name. reactions and take appropriate nursing action.
8. Inform patient of the procedure and its importance. 30. Readjust the flow rate of the blood transfusion after 10 min.
9. Perform handwashing.
10. Check baseline vital signs.
11. Assemble articles and equipment needed at the bedside. C. MAINTAINING A BLOOD TRANSFUSION
12. Position patient accordingly. 31. Monitor the patient’s vital signs every fifteen minutes for
one hour after initiating the transfusion.
32. Assess the patient including vital signs every 30 minutes for
B. INITIATIONG BLOOD TRANSFUSION the next three hours until blood transfusion is finished.
13. Don on gloves. 33. Alert senior nurse if there is any untoward reaction during
14. Close all the clamps. the transfusion.
15. Insert the piercing pin (spike) into a container of 0.9 percent
saline solution using a twisting motion.
16. Hang the IV container on the IV pole. D. TERMINATING BLOOD TRANSFUSION
17. Squeeze the drip chamber of the normal saline until it 34. Don on clean gloves.
covers one-third of the drip chamber 35. Clamp the blood tubing and disconnects needle from the Y-
18. Expel any residual air in the tubing. port
19. Start the saline solution. 36. Open the saline infusion clamp.
37. Adjust the saline drip to desired rate
38. Check vital signs.

E. AFTER CARE
39. Put patient in a comfortable position.
40. Discard the blood administration set according to agency
policy.
41. Dispose needles in a labeled, puncture-resistant container.
42. Follow agency protocol for appropriate disposal of the blood
bag.
43. Remove gloves.
44. Discard gloves accordingly.

F. DOCUMENTATION
45. Document the procedure and all nursing assessment.
a. Reason for the transfusion
b. Whether consent was signed
c. Time when blood transfusion was initiated
d. Type of blood transfused, amount, blood type, Rh factor,
serial number, expiration date and rate of flow
e. Any medication given prior to transfusion
f. Baseline vital signs
g. Any untoward reaction during the transfusion
h. Time when transfusion was terminated