Blood Transfusion

Introduction
of whole blood or blood
components into the venous circulation.

Blood Products for Transfusion

Whole blood
Packed RBC
Autologous RBC
Platelets

Fresh Frozen Plasma

Albumin & Plasma Protein Fraction
Clotting Factors & Cryoprecipitate
Blood loss due to trauma
Heart or other major surgery
Organ Transplants
Hemophilia

Anemia

Leukemia

Disorders that destroy blood cells and bone

marrow
Rh – incompatibility in newborn babies
Informed Consent
Identification

Check cross-matching
Check the name of patient
Check the serial #
Check the expiration date
Blood Sample
O
A B
AB
Medication

Pre-BT Medication:
Acetaminophen
Diphenhydramine
Post-BT Medication:
Furosemide
Calcium Gluconate
I.V.

Vital Signs
When BT is ordered, obtain the blood from blood
bank before starting the transfusion.
Once blood/blood product is removed from the
refrigerator, there is limited time to administer it.
Verify that the unit is correct
Blood is usually administered through a #18-20
guage intravenous needle or catheter.
Y-Type blood transfusion set with an inline or
add-on filters used when administering blood.
Normal Saline is used to prime the set and flush
the needle before administering blood.
Transfusion should be completed within 4 hours.
Blood tubing is changed after 4-6 units per agency
policy.
HEMOLYTIC REACTION
Clinical Manifestation:
chills, fever, headache, backache,
dyspnea,cyanosis, chest pain, tachycardia and
hypotension.

Intervention:
Discontinue transfusion
Keep vein open with normal saline
Notify physician
Monitor Vital Signs
FEBRILE REACTION
Clinical Manifestation:
fever, chills, warm flushed skin, headache,
anxiety and muscle pain

Intervention:
Discontinue transfusion
Give antipyretics as ordered
Notify physician
Keep vein open with normal saline
ALLERGIC REACTION
Clinical Manifestation:
Flushing, itching, urticaria, bronchial wheezing
(mild)
Dyspnea, chest pain, circulatory collapse and
cardiac arrest (severe)

Intervention:
Stop the transfusion
Notify physician immediately
Keep vein open with normal saline
Monitor vital signs
Administer antihistamine as ordered (mild)
Administer medications, oxygen as ordered
(severe)
CIRCULATORY OVERLOAD
Clinical Manifestation:
cough, dyspnea, crackles, distended
neck veins, tachycardia, hypertension

Intervention:
Stop or slow the infusion
Place the client upright with feet dependent
Administer diuretics and oxygen as ordered
Notify the physician
SEPSIS
Clinical Manifestation:
high fever, chills, vomiting, diarrhea
and hypotension

Intervention:
Stop the transfusion
Send the remaining blood to laboratory
Notify the physician
Obtain blood specimen from client
Keep vein open with normal saline
Administer IV fluids, antibiotics as ordered