MENG LYVOUCHHEANG, RN
DEFINITION
⚫ABlood transfusion is the infusion of
whole blood or blood components such
as plasma, RBCs, or platelets into the
venous system.
PURPOSES
To increase blood volume after surgery, trauma, or
hemorrhage.
To increase the number of red blood cells in a patient with
severe chronic anemia.
To provide platelets to patients with low platelet counts
due to treatment with chemotherapy.
To provide clotting factors in plasma for patients with
hemophilia or disseminated intravascular coagulopathy
(DIC).
To replace plasma proteins such as albumin.
To replace fresh frozen plasma in case of DIC.
INDICATIONS
Hemorrhage
Trauma
Burns
Sever anemia
Plasma proteins or clotting factor deficiency.
Leukopenia
Pathological conditions which result in decreased
blood cells.
CONTRAINDICATIONS
Decreased cardiac output
Active infection
Fluid overload
Renal failure
RATE OF INFUSION FOR
COMPONENTS OF BLOOD
PRODUCTS INFUSION RATES
Whole blood and red blood cells 1 unit over 2-3 hours
platelets 30- 60 minutes
Fresh frozen plasma 200ml/hour or slowly
cryoprecipitate 1-2 ml/min
⚫ Whole blood and red blood cells:-
⚫ Platelets:-
⚫ Fresh frozen plasma:-
⚫ Cryoprecipitate:-
NURSING ASSESSMENT
⚫ Assess the patient for the indication of the blood transfusion.
⚫ Verify the physicians order for the type of blood product to be
given.
⚫ Review the patients transfusion history, especially any reactions,
or pre transfusion medications to be given.
⚫ Review the baseline vital signs in the patients medical record in
order to compare with vital signs during the transfusion.
NURSING ASSESSMENT
⚫ Assess the type, integrity, and patency of the venous access.
⚫ Verify that a large-bore catheter (18 gauge ) has been used to
prevent heamolysis.
⚫ Review hospital policy and procedure for the administration of
blood products.
PREPARATION OF EQUIPEMNTS
⚫ A Clean tray containing,
Blood administration set with filter
Intravenous solution of 0.9% sodium chloride (NS)
Disposable gloves
Adhesive tape to secure IV line
Kidney basin
Medication card as per policy
Syringe with distilled water or normal saline or heparin flush to flush in case of
block in the line.
⚫ Blood product in the container for transfusion along with the compatibility
forms and blood details.
⚫ Iv pole
⚫ A sterile tray containing emergency medications
⚫ Infusion pump if needed.
⚫ Vital signs tray
NURSING PROCEDURE
Verify the physicians order for the transfusion.
Explain the procedure to the patient.
Ensure that the consent forms are signed.
Inform about the side effects (dyspneoa, chills, headache, chest
pain, itching) to the patient and ask him/her to report to the
nurse.
NURSING PROCEDURE
Obtain baseline vital signs.
Obtain the blood product from the blood bank and ensure that
it is initiated within 30 minutes.
Verify and record the blood product and identify the patient
with another nurse.
Patient name, blood group, and Rh type
Cross – match compatibility
Donor blood group and Rh type
Unit and hospital number
Expiration date and time on blood bag
Type of blood product compared with physicians or
qualified practitioners order
Presence of clots in blood
Instruct the patient to empty the bladder.
Monitor vital signs.
Wash hands and put on gloves.
Open blood administration kit/set and move roller
clamps to a closed position and administer prescribed
medicines.
for single- tubing set:
Spike blood unit.
Squeeze drip chamber and allow the filter to fill with
blood.
Open roller clamps and allow tubing to fill with blood
to the hub.
Prime another IV tubing with normal saline and
piggyback it to the blood administration set with a
needle and secure all connections with tape.
For dubble-tubbing set:
Spike the second into the normal saline bag or bottle.
Squeeze the drip chamber and allow the filter to fill
with normal saline.
Attach tubing to venous catheter using sterile
precautions and open lower clamp.
Infuse the blood at a rate of 2-5 ml/min according to
the physicians order.
Remain with the patient for the first 15-30 minutes,
monitoring vital sighs every 5 minutes for 15 minutes,
the every 15 minutes for 1 hour, and then hourly until 1
hour after the infusion is completed.
After the blood has been infused, allow the tubing to
clear with normal saline.
Appropriately dispose off bag, tubing and gloves.
Wash hands.
Document the procedure.
RECORDING AND REPORTING
⚫ Record the date and time of blood transfusion.
⚫ Mention the details of the transfusion including type
of blood, blood group, bag number, starting time,
ending time, flow rate, and any adverse reactions
during the transfusions.
⚫ Record the vital signs before, during and after the
transfusion.
NURSES RESPONSIBILITES
A. Observe for signs of transfusion reaction.
B. Observe the patient and laboratory values to
determine response to transfusion.
C. Monitor IV site and status of infusion each time
when vital signs are taken.
COMPLICATIONS
COMPLICATIONS SIGNS AND NURSES
SYMPTOMS MANAGEMENT
1. Allergic reactions Rashes, flushing, hives, • Stop the infusion
pruritis, laryngeal edema, immediately.
and dyspnea
2.Nonhemolytic febrile Sudden chills, fever , • Keep vein open with the
reaction flushing, headache and normal saline
anxiety
3. Septic reaction Rapid onset of chills, • Notify the physicians
vomiting, hypotension, immediately
and fever
4. Circulatory overload Cough, dyspnea, • Administer
distended neck veins, antihistamine
crackles and elevated parenterally as needed
blood pressure and as per order.
5. Hemolytic reaction Low back pain,
tachypnea, hypotension
SAMPLE DOCUMENTATION
⚫ 11.03.2021 , 10.00 am
⚫ Explained the procedure to the patient. Ensured that
the consent form was signed. Instructed the patient to
empty the bladder. Checked for bag number, grouping
and cross-matching.
⚫ After premedication, whole blood (as prescribed)
B+ve, bag no.****was transfused to Mr. X at ……am.
Vitals were monitored frequently and the patient was
observed for transfusion reactions. The transfusion
ended at ….pm. Patient felt comfortable.
