Blood Transfusion

Purpose
to restore or replace blood volume
to increase oxygen carrying capacity of
blood
to combat infections if decreased WBCs
to prevent bleeding if platelets decreased

Nursing Management
1. Verify Doctors order
2. Check if client gave consent
3. Obtain
blood from blood bank if IV access is
available
maintained with normal saline
return to blood bank when infusions n/a
blood may not be returned to bank in 20
mins
do not keep blood inside nursing
refrigerator

4. Properly refrigerated
Platelets 5 days
RBCs 5 7 days, 250cc

5. Proper blood typing and cross-matching
ABO
Blood
Group
Compatible Incompatible
A A, O B, AB
B B, O A, AB
AB A, B, AB, O none
O O only A, B, AB
O universal donor
AB universal recipient
85% of population is Rh+

6. Aseptically assemble all materials needed
BT set with filter to prevent
administration of blood clots and other
particulates
PNSS to prevent hemolysis
gauge 18 19 large bore needle to
prevent hemolysis and allows easy flow
of blood

7. Practice Strict Asepsis

8. Instruct another RN to re-validate the ff
Name of client (verify ID band)
Blood components
Blood typing and cross matching
Rh factor
Serial number
expiration date
Screening test
VDRL for STDs
HBsAg for HepB
Malarial Smear for malaria

9. Check blood for presence of bubbles,
cloudiness, sediments, and dark color may
indicate contamination

10. Never warm blood products! ROOM TEMP
ONLY!
warming only done if you have
dewarming device
warming only done during emergency
situations if massive blood loss
massive transfusion

11. Transfusion should be completed in 4 hours
because blood exposed at room temp more
than 2 hours causes blood deterioration

12. Start infusion slowly. Regulate at KVO (10-
15gtts/min) at 100cc/hr to prevent
circulatory overload. Remain at the bedside
for 15 30 minutes. Adverse reactions
usually occur during the first 15 20 minutes.

13. Monitor V/S before, during, and after
transfusion. Altered V/S indicates adverse
reaction

14. Avoid mixing or administering drug at BT line
to prevent hemolysis

15. Administer PNSS before, during, or after BT.
Never administer IV fluids with dextrose =
hemolysis
16. Observe for potential complications and
Notify Physician

Protocol for Suspected reaction
Stop infusion immediately
Start IV line! Keep IV line open with PNSS
(0.9% Normal Saline).
IV access must be needed for administration of
emergency drugs
Notify Physician
Monitor V/S every 5 minutes
Obtain urine specimen and have it tested for
Hgb to indicate RBC hemolysis.
Save blood transfusion set and labels.
Send unused blood and BT set to the blood
bank
Administer antihistamine, diuretics,
bronchodilators as ordered.
Make relevant documentation
Complications of BT
Complications Manifestations
Pyrogenic
most common
Flushing
Fever
Muscle pain
Chills
Anaphylactic Urticaria
Rash, Hives
Pruritus
Wheezes
Shock
Hemolytic
infusion of
incompatible blood
products
Low back pain 1
st
sign,
response of kidney
Fever
Chills
Flushing
Pain
Circulatory Overload Rales or Crackles
Moist Cough
Dyspnea
Distended Neck vein
Hyperthermia
Elevated BP
Sepsis components
contaminated by
bacteria
Chills
High Fever
Vomiting
Hypertension