Definition

• It is the transfusion of whole blood or its

components such as blood cells and
plasma from one person (donor) to
another person (recipient).
• This involves two procedures – the
collection of blood from the donor and the
administration of blood to the recipient.
 Purposes
• To restore the blood volume when there is
sudden loss of blood due to haemorrhage.
• To raise the haemoglobin level in cases of
severe anaemia.
• To treat deficiencies of plasma proteins,
clotting factors and haemophilic globulin
etc.
 Preparation of the articles
A tray containing:
• A blood transfusion set
• Mackintosh with towel
• Blood/ blood components with cover received
from blood bank with the name of recipient
• Alcohol swabs in a bowl
• Disposable gloves.
• Infusion stand (I.V stand)
• Kidney tray
 Procedure
• Check the doctor’s order, patient’s condition
and history of transfusion/ transfusion
reaction, reason for present transfusion, etc.
• Check the availability of blood with blood
bank and confirm blood has been typed and
cross matched.
• Identify patient.
• Explain the procedure to the patient, need
for transfusion, desired outcome, etc.
 Cont..,
• Emphasize the need for patient to report
unusual symptoms immediately.
• Obtain informed consent from the patient.
• Obtain blood from blood bank in
accordance with agency policy.
• If transfusion cannot begin immediately,
return product to blood bank.
• Blood out of refrigerator for more than 30
minutes, above 10⁰C cannot be reused.
 Cont..,
• Never store blood in unauthorized area – like
ward refrigerator since blood must be stored
in refrigerated unit at carefully controlled
temperature (4 ⁰C).
• Encourage patient to empty bowel and
bladder and assist to a comfortable position.
• Ensure privacy.
• Wash and dry hands.
• Check vital signs and record.
 Cont..,

• Wear gloves.

• Insert I.V cannula (18G/ 19G) if not

already present in a large peripheral vein
and initiate infusion of normal saline
solution using blood transfusion set.
 Cont..,
Inspect the blood product (by 2 nurses) for
the following
• Identification number
• Blood group and type
• Expiry date
• Compatibility
• Patient’s name
• Abnormal colour, clots, excess air, etc.
 Cont..,
• Warm blood if needed using special blood
warmer or immerse partially in tepid water/ keep
the blood at room temperature for 30 minutes.
• If blood product found to be correct stop saline
solution by closing roller clamp.
• Remove insertion spike from saline container
and insert spike into blood container.
 Cont..,
• Start infusion of blood product slowly, at
the rate of 25 to 30 ml per hour for the first
15 minutes.
• Check the vital signs for every 15 minutes
for first 30 minutes, or as per agency
policy.
• Increase infusion rate if no adverse
reactions are noticed. The flow rate should
be within the safe limits.
 Cont..,
• Assess the condition of the patient every 30 minutes
and if any adverse effect is observed stop
transfusion and start saline. Send urine sample,
blood sample and remaining blood product in
container with transfusion set, back to the blood
bank.
• Complete transfusion and administer saline (as per
doctor’s order) if no adverse reaction is observed.
 Cont..,
• Dispose blood product container and set in
appropriate receptacle.
• Assist patient to comfortable position.
• Wash hands.
Record the following:
• Product and volume transfused.
• Blood group Rh type.
• Time of administration and end time.
• Name and signature of the nursing staff
carrying out procedure and patient’s
condition.
 Cont..,
• If agency policy requires removal of label
from blood bag and paste it on patient
record.
Special considerations:
• Do not administer medication through the
same line, where blood product is
transfused.
• Start another I.V line if medications are to
be transfused, because of possible
incompatibility and bacterial contamination.
 Cont..,
• Blood transfusion should be completed over
a period of 4 hours from the time of initiation.
• Cover the blood bag with a towel when it
hangs on the I.V pole.
• Gently rotate the blood bag periodically to
prevent clumping of cells.
 Cont..,

• Keep emergency drugs (e.g.

Antihistamines, Lasix, adrenaline, etc.)
• When rewarming the blood by immersing
in tap water, do not immerse the blood
fully into the water as it may cause
haemolysis.
 Nursing observation and management
during blood transfusion
S.I Reaction Signs and Nursing management
No symptoms
1. Allergic • Hives, • Stop transfusion immediately
reaction itching, and keep vein patent with
anaphylaxis normal saline.
• Notify physician fast.
• Administer antihistamine
parentally as necessary.
2. Febrile • Fever and • Stop transfusion immediately
reaction: chills and keep vein patent with
fever, • Headache normal saline.
developing • Malaise • Notify physician.
during • Treat symptoms.
infusion
 Cont..,
S.I Reaction Signs and Nursing management
No symptoms
3. Haemolytic • Immediate • Stop transfusion
transfusion: onset immediately & keep vein
Incompatib • Facial patent with normal saline.
ility of flushing • Notify physician stat.
blood • Fever, chills • Obtain blood sample from
product • Headache site.
• Low- back • Obtain first voided urine.
pain • Treat shock if present.
• shock • Send remaining blood in
bag, tubing and filter to lab.
• Draw blood sample for
serologic testing and send
urine specimen to lab.
 Cont..,
S.I Reactio Signs and Nursing
N n symptoms management
o
4. Circulator • Dyspnoea • Slow or stop
y • Dry cough transfusion.
overload • Pulmonary • Monitor vital signs.
oedema • Notify physician .
• Place patient in
upright position with
feet dependent.
 Cont..,
S.I Reaction Signs and Nursing management
No symptoms
5. Bacterial • Fever • Stop transfusion
reaction: • Hypertension immediately.
Bacteria • Dry, flushed • Notify physician.
present in skin • Obtain culture of patient’s
blood. • Abdominal blood and return blood in
pain. bag to lab.
• Monitor vital signs.
• Administer antibiotics stat.
Thank you all for listening