Blood Transfusion

Ms. Norissa T.
Legaspi,
RN
Clinical Advancement
DEFINITION
BLOOD TRANSFUSION
- It is the introduction of whole
blood or blood components into the
venous circulation
INDICATION
• To replace blood components to
restore the blood’s ability to
transport oxygen and carbon
dioxide
WE GIVE BLOOD WHEN
THERE IS…
•Hemorrhage
•Trauma
•Burns
•Restoring and maintaining the volume of
blood in the body
TRANSFUSING BLOOD
PRODUCTS
Two ways to administer blood and

blood products:
1. Peripheral I.V. line
2.Central Venous Line
BLOOD PRODUCTS
1.RBC
2.Plasma
3.Platelets
4.Leukocytes
5.Plasma proteins such as immune
globulin, albumin, and clotting factor.
SLMC POLICY
STATEMENT
• All blood and/or blood components
shall be handled properly by all
Associates from Blood Bank and
Transfusion Service (BBTS) and
from all Nursing Units for the
achievement of the blood
transfusion desired effect or
outcome
SPECIFIC POLICIES
1. All units of blood/blood
components for transfusion shall
be claimed from BBTS without
delay, by the Nursing Aide or any
authorized personnel designated
by the respective units.
SPECIFIC POLICIES
2. Both the BBTS Medical
Technologist and the Nursing
Aide or the designated
authorized personnel shall be
responsible in ensuring that the
blood/blood components being
issued/received are correct. Both
shall ensure that the name of the
patient and blood type requested
and issued is the same
SPECIFIC POLICIES
3. Nursing Units shall handle the
blood/blood components at the
patient floors as follows:
Red Blood Cells
• Nursing floors must not keep these
components in the ordinary ward
refrigerator
• Prior to transfusion, RBC
containing must be kept at an air
conditioned room at a maximum of
30 mins
PLATELET
CONCENTRATE
• Must be kept at an air conditioned
room for a maximum period of 4
hours before transfusion
CRYOPRECIPITATE
• Must be infused immediately
NURSING RESPONSIBILITIES
BEFORE TRANSFUSION
1. Verify blood component with the
Physician’s order
2. Identify the intended recipient
3. Match the following information:
- Patient name against the patient
information on the green compatibility
tag accompanying the blood unit
- Number written on the green
compatibility tag with that stamped on
the blood unit
- Patient’s ABO/Rh type on the green
compatibility tag with those of the
blood unit
4. Completing the data in the green

compatibility tag and securing the
signature of the person giving the
transfusion
NURSING REPONSIBILITIES
5. Check the blood’s expiration date

6. Check the vital signs
NURSING ALERT!
Administer the pre-medication if
indicated or as ordered.
IMPLEMENTATION
Preparation:
1. Prepare the client
- Introduce self and verify the clients
identity
- Explain the procedure and its purpose
- If the client has an IV solution, check
whether needle & solution are
appropriate
NURSING ALERT:
• In case you need to perform
venipuncture, start an infusion of
normal saline (preferred needle
size #18 to #20)
IMPLEMENTATION
• Performance
1. Obtain the correct blood
component
- If any information does not match
exactly, notify the charge nurse
and blood bank. Don’t administer
blood with discrepancies
IMPLEMENTATION
2. Verify the client’s identity
- Check patient identifiers
IMPLEMENTATION
3. Set up the equipment:
- Ensure that the blood filter inside
the drip chamber is suitable for
the blood components
RATIONALE:
BLOOD FILTERS
- Are designed to trap/filter clots
IMPLEMENTATION
- Put on gloves
- Close all clamps
- Using a twisting motion, insert the
spike
- Prime the tubing
IMPLEMENTATION
5. Start the infusion:
- If an IV solution incompatible, stop
the infusion
IMPLEMENTATION
6. Prepare the blood bag
- Invert the blood bag gently to mix
the cells
NURSING ALERT:
• Rough handling can damage the
cells
IMPLEMENTATION
7. Establish the blood transfusion
8. Observe the client closely for the
first 15 to 10 mins
NURSING ALERT:
• Note adverse reactions, such as
chilling, nausea, vomiting, skin rash
or tachycardia
(Identifying such reactions promptly
helps minimize the consequences)
IMPLEMENTATION
9. Document relevant data
- Record starting the blood, including
vital signs, type of blood, site of
the venipuncture, size the needle,
and drip rate
10. Monitor the client
- 15 mins after initiating the
infusion, check the vital signs. If
there are no signs of reaction,
establish the required flow rate
REMINDER!!!
Do not transfuse a unit of blood for
longer than 4 hours
11. Terminate the transfusion
- Put on gloves
- Often open a normal saline solution
in case of delayed reaction
- Discard the administration set
- Remove the green form from the blood
bag and attach it to the blood bank
sheet.
NURSING CONSIDERATIONS
HOSPITAL POLICIES
BLOOD TRANSFUSION REACTIONS
• Stop the transfusion.

• Keep the intravenous line open with
0.9% normal saline.
• Remain with the client, observing signs
and symptoms and monitoring vital signs
as often as every 5 minutes.
• Notify the physician or the resident-on-
duty and blood bank immediately.
5. Prepare to administer emergency
medications (such as antihistamines,
antipyretics, corticosteroids, vasopressors &
fluids as prescribed).
6. Do not re-start blood if anaphylactic

symptoms are present.
6. If transfusion is terminated, follow protocol
in reporting blood transfusion reactions:
 Draw blood sample in red topped tube,

collect urine specimen and send these
together with all used and unused blood
and tubing properly labeled to the Blood
Bank accompanied by the Transfusion
Reaction Form (accomplished by the
Resident on Duty).
– Collect a second sample of urine after 5
hours and send it to Blood Bank properly
labeled.
• Document all pertinent data observed

and nursing care rendered.
RISK MANAGEMENT
Patient receiving transfusion is still at risk
for life-threatening complications, such
as:
1. Hemolytic Reaction – destroys red blood
cells, as little 10ml infused, symptoms can
occur quickly. Headache, chest pain, chills,
back pain and fever. *Always adhere
strictly to policy and procedure for
assessing vital signs during transfusion.
RISK MANAGEMENT
(CONT.)
2. Exposure to infectious disease such as
HIV and Hepatitis
*Always protect yourself from exposure to
transmissible disease
* The Center for Disease Control and
Prevention Guidelines recommend
wearing gloves, a mask, goggles, and a
gown when transfusing blood, in case of
blood spills or sprays.
Transfusion Reaction
Investigation
• Concerned Nursing Associates shall

immediately report to Blood Bank and
Transfusion Service (BBTS) any transfusion
reactions noted from patients.
• BBTS shall immediately investigate reported

blood transfusion reaction as follows:
– Medical Technologist (MT) shall request
Nurse to collect post transfusion blood
sample and urine specimen.
– MT shall check identification of patient

and of donor blood of the following:
– ABO and Rh type

– Donor serial numbe
– Expiration date
• MT shall do ABO testing, Crossmatching and
Direct Antiglobulin Testing (DAT)
procedures on the pre- and post-
transfusion blood samples.
•
• MT shall perform gram stain and culture
from the donor’s blood bag to check the
possibility of bacterial contamination.
e. MT shall retrieve and review the result of
Crossmatching procedure performed before
blood transfusion. The same shall be
correlated to the Blood Bank Reaction form
and the laboratory results for post
transfusion blood specimen.
f. All laboratory test results and the

accomplished Blood Transfusion Reaction
Form shall be submitted to the Pathologist of
BBTS for final review and interpretation.
• BBTS shall not issue blood/blood
components to the patient until the
investigation is completed.
REMEMBER
•No I.V. solution other than normal saline
(0.9% sodium chloride) should be given
with blood.
•Other isotonic solutions may cause cells to
clump.
•Always use blood filters on blood products
to avoid infusing fibrin clots or cellular
debris that forms in the blood bags.
•Use gauge 16 or 18 I.V. catheter.
REMEMBER
* Risk of contaminations and
sepsis increases 4 hours after a
transfusion begins.
REFERENCES:
• Fundamentals of Nursing – Kozier and
Erb
• Fundamentals of Nursing – Lippincott
• Handbook of Nursing Procedures-
Springhouseb

Blood Transfusion

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Ms. Norissa T.

Two ways to administer blood and

4. Completing the data in the green

5. Check the blood’s expiration date

• Stop the transfusion.

6. Do not re-start blood if anaphylactic

 Draw blood sample in red topped tube,

• Document all pertinent data observed

• Concerned Nursing Associates shall

• BBTS shall immediately investigate reported

– MT shall check identification of patient

– ABO and Rh type

f. All laboratory test results and the

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