BLOOD TRANSFUSION
What is blood transfusion?
• Blood transfusion is the process of transferring
blood products into a person's circulation
intravenously. Transfusions are used for various
medical conditions to replace lost components
of the blood. (specific portion or fraction of
blood lacking in patient)
Purpose/Objectives
1. To increase circulating blood volume after
surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to
maintain hemoglobin levels in clients with severe
anemia.
3. To provide selected cellular components as
replacements therapy (e.g. clotting factors,
platelets, albumin)
NURSING
RESPONSIBILITIES
1. Verify doctor’s order.
2. Inform the client and explain the purpose of the
procedure.
3. Check for cross matching
and typing.
4. Obtain and Record baseline Vital Signs
5. Collect the Blood from the blood bank and transport to Station
6. At least 2 licensed nurse check the label of the blood transfusion.
Check the following:
a. Serial number
b. Blood component
c. Blood type
d. Rh factor
e. Expiration date
f. Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that
the blood is free from blood-carried diseases and therefore, safe from
transfusion.
a. Serial number
b. Blood component
c. Blood type
d. Rh factor
e. Expiration date
f. Screening test (VDRL,
HBsAg, malarial smear) –
this is to ensure that the
blood is free from blood-
carried diseases and
therefore, safe from
transfusion.
6. Warm blood at room temperature
before transfusion to prevent chills.
7. Identify client properly. Two Nurses check the client’s identification.
8. Use needle gauge 18 to allow easy flow of blood.
9. Use BT set with special micron mesh filter to prevent administration
of blood clots and particles.
10. Start infusion slowly at 10 gtts/min. Remain at bedside
for 15 to 30 minutes. Adverse reaction usually occurs
during the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs indicate adverse
reaction (increase in temp, increase in respiratory rate)
12. Do not mix medications with blood transfusion to
prevent adverse effects. Do not incorporate medication
into the blood transfusion. Do not use blood transfusion
lines for IV push of medication.
13. Precautions: Administer 0.9% NaCl before; during or
after BT. Never administer IV fluids with dextrose. Dextrose
based IV fluids cause hemolysis.
14. Administer BT for 4 hours (whole blood, packed RBC).
For plasma, platelets, cryoprecipitate, transfuse quickly (20
minutes) clotting factor can easily be destroyed.
[Link] for potential complications. Notify physician.
COMPLICATIONS
1. Allergic Reaction
• Flushing
• Rash, hives
• Pruritus
• Laryngeal edema, difficulty of
breathing
2. Febrile, Non-Hemolytic
• Sudden chills and fever
• Flushing
• Headache
• Anxiety
3. Septic Reaction
• Rapid onset of chills
• Vomiting
• Marked Hypotension
• High fever
4. Circulatory Overload
• Rise in venous pressure
• Dyspnea
• Crackles or rales
• Distended neck vein
• Cough
• Elevated BP
5. Hemolytic Reaction
• Low back pain (first sign). This is due to inflammatory response of the kidneys to
incompatible blood.
• Chills
• Feeling of fullness
• Tachycardia
• Flushing
• Tachypnea
• Hypotension
• Bleeding
• Vascular collapse
• Acute renal failure
NURSING RESPONSIBILITIES cont.
• Meticulously verifying patient identification
beginning with type and crossmatch sample
collection and labeling to double check blood
product and patient identification prior to
transfusion.
• Inspecting the blood product for any gas bubbles,
clothing, or abnormal color before administration.
• Beginning transfusion slowly ( 1 to 2 mL/min) and
observing the patient closely, particularly during the
first 15 minutes (severe reactions usually manifest
within 15 minutes after the start of transfusion).
• Transfusing blood within 4 hours, and changing
On detecting any signs or symptoms of reaction:
1. STOP the transfusion immediately, and notify the
physician.
2. Disconnect the transfusion set-but keep the IV line open
with 0.9% saline to provide access for possible IV drug
infusion.
3. Place the client in Fowler’s position if with Shortness of
Breath and administer O2 therapy.
4. The nurse remains with the client, observing signs and
symptoms and monitoring vital signs as often as every 5
minutes.
5. The nurse prepares to administer emergency drugs
such as antihistamines, vasopressor, fluids, and steroids
as per physician’s order or protocol.
6. Obtain a urine specimen and send to the laboratory to
determine presence of hemoglobin as a result of RBC
hemolysis.
7. Blood container, tubing, attached label, and
transfusion record are saved and returned to the
laboratory for analysis.
• If blood transfusion reaction occurs: STOP THE TRANSFUSION.
• Start IV line (0.9% NaCl)
• Place the client in Fowler’s position if with Shortness of Breath and
administer O2 therapy.
• The nurse remains with the client, observing signs and symptoms and
monitoring vital signs as often as every 5 minutes.
• Notify the physician immediately.
• The nurse prepares to administer emergency drugs such as antihistamines,
vasopressor, fluids, and steroids as per physician’s order or protocol.
• Obtain a urine specimen and send to the laboratory to determine presence
of hemoglobin as a result of RBC hemolysis.
• Blood container, tubing, attached label, and transfusion record are saved
and returned to the laboratory for analysis.
