Nursing Department
Objectives
1. Indentify the purpose of blood transfusion
2. Discuss blood transfusion
3. Explain the different types of blood components
4. Explain the preparation of blood transfusion
5. Discuss the nursing process of blood transfusion
6. Explain the special consideration in elderly blood
transfusion.
Definition
an injection of a volume of blood, previously taken
from a healthy person, into a patient .
The transfer of blood or blood components from one
person ( the donor) into the bloodstream of another
person ( the recipient).
Purpose :
Treating blood loss
Blood loss may result from injury, major surgery, or
diseases that destroy red blood cells or platelets, two
important blood components.
If too much blood is lost (low blood volume), your
body cannot maintain a proper blood pressure, which
results in shock.
Transfusing Blood Products
To safely transfuse whole blood, packed erythrocytes
(RBCs), platelets, fresh frozen plasma so that special
deficiencies such as anemia and bleeding disorders
can be corrected.
PREPARATION
An informed consent must be obtained before
transfusing blood.
● Baseline vital signs must be obtained.
● The nurse should remain with patient during the first
15 minutes of blood transfusion to assess for adverse
reaction.
Blood must be verified by two nurses or a nurse and a
physician prior to transfusion.
Medications should never be administered via blood
transfusion tubing. A separate IV site should be used
to administer medications.
Monitor for fluid overload and transfusion reactions.
No more than two units of blood should be
administered via one blood administration set and/or
filter—see protocol.
Stop transfusion if reaction occurs—change tubing
and keep IV patent with 0.9% sodium chloride.
Cont…
Return blood container and tubing to blood bank if
reaction occurs.
Obtain first voided urine specimen after a transfusion
reaction and send to lab.
Special Considerations
Elderly Patient
Infuse blood at a slower rate for better tolerance and
prevention of complications (i.e., circulatory overload,
pulmonary edema, and congestive heart failure).
Cont…
Pediatric, Confused, Comatose, and Mentally
Challenged Patients
Monitor closely and often for adverse reactions since
they often cannot communicate effectively if
problems occur.
RELEVANT NURSING
DIAGNOSES
Fluid volume deficit related to hemorrhage from
trauma, GI bleeding, and/or surgery
Fluid volume excess related to rapid infusion of blood
At risk for decreased cardiac output related to
circulatory overload
and/or transfusion reaction
EXPECTED OUTCOMES
Transfusion will be completed for time frame ordered
and no longer than 4 hours
Symptoms of an allergic reaction to blood will be
recognized early and prompt intervention initiated
Improvement in serum hemoglobin and hematocrit
will be noted following transfusion
EQUIPMENT/SUPPLIES
• Blood unit or other blood product
• Bag of 0.9% sodium chloride IV solution
• Y-set blood tubing with filter
• Antimicrobial swabs
• Clean gloves
• Infusion pump, if needed
• Blood warmer, if needed
• Protective clothing, if needed
IMPLEMENTATION
Identify patient; explain purpose, procedure and how
patient can assist.
Obtain informed consent.
Establish that patient has a patent large-bore IV
catheter.
Prime blood administration tubing with 0.9 %
sodium chloride solution.
• Obtain blood from agency blood bank.
• Wash hands.
• Verify the following information with another nurse
or a physician:
• Patient’s name and identification number.
• Blood component blood type and Rh factor.
• Cross matching numbers.
• Expiration date of blood.
Obtain vital signs—temperature, pulse,
respiration, blood pressure and record on
transfusion flow form.
Spike the blood container on the blood
administration tubing Y opposite of the 0.9% sodium
chloride solution container, pushing tip of tubing
straight up into the blood bag entry port—make sure
the “Y” leading to the sodium chloride solution is
turned OFF prior to spiking the blood bag.
Prime the blood administration tubing with blood
and then initiate transfusion at 5 mL/min. for the first
15 minutes of the transfusion.
Monitor and record the temperature, pulse,
respiration, and blood pressure at 5-minute intervals
for the first 15 minutes of transfusion.
Monitor patient for any signs or symptoms of an
adverse reaction to the transfusion (itching, hives,
rash, urticaria, pain in lumbar-sacral region, chest
pain, or decreased blood pressure, increased pulse or
respiratory distress) at 5-minute intervals and record
on transfusion flow form.
If a reaction occurs, stop the transfusion, notify
physician, and change IV tubing and keep vein open
with 0.9% sodium chloride
solution.
Prepare to administer medications, return blood and
tubing to blood bank, and obtain blood and urine
specimens.
After the initial 15 minutes of transfusion, as long as
there are no signs of transfusion reaction, the rate of
flow can be increased to complete the transfusion
during the time indicated by the physician or agency
policy.
The T, P, R, and BP and clinical status of the patient
should continue to be assessed and recorded every 15
minutes for the first hour and then every 30 minutes
until completion of the transfusion.
At completion of the blood transfusion, turn off flow
control on “Y” section leading to blood bag and open
the flow control to the 0.9% sodium chloride solution.
Flush the blood administration tubing until a light
pink fluid is noted.
If no further blood is to be transfused, change tubing
or cap IV line with prn adaptor.
Dispose of blood container and tubing according to
agency protocol.
Remove gloves and wash hands.
Reposition patient as needed.
EVALUATION AND FOLLOW-UP
AC T I V I T I E S
Blood was transfused correctly
Patient did not experience any adverse reactions
Patient’s blood count has improve
KEY POINTS FOR REPORTING AND
RECORDING
Notification of adverse reactions, if occurred, and
report to physician and orders indicated
Date and time of completion of transfusion
