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- is the transfer of whole blood or blood components into the blood stream
- most often given to alleviate anemia or when the blood is low (e.g. after a
severe hemorrhage)
- in an incompatible blood transfusion, the normal components of one’s
person plasma membrane can trigger damaging antigen-antibody
responses in a transfusion recipient (when you administer incompatible
blood, the recipient antibody will destroy the antigen of the blood
causing potential complications such as blood transfusion reactions or
antibody-antigen reactions)
1. to restore blood volume after severe hemorrhage (e.g. whole blood to
replace blood volume)
2. to restore the capacity of the blood to carry oxygen (e.g. PRBC for
anemic patients)
3. to provide plasma factors which prevent or treat bleeding (e.g. platelets,
CHON’s, cryoprecipitate for bleeding disorders)

Blood Typing:
A. ABO Groups
Summary of ABO Blood Groups Interactions
Characteristics A B AB O
1. Antigen A B Both A & B Neither A nor
2. Antibody Anti-B Anti-A Neither Anti- Both Anti-A &
(Plasma) A nor Anti-B Anti-B
3. Compatible A, O B, O A, B, AB, O O
donor blood
types (no
4. Incompatible B, AB A, AB ____ A, B, AB
donor blood
(In practice, the used of the terms universal recipient and universal donor is
misleading and dangerous. Blood contains antigens and antibodies other than those
associated with the ABO system that can cause transfusion problems.)

B. RH Factor
- people whose RBC have Rh antigens are designated Rh+ (Rh positive)
- those who lack Rh antigens are designated Rh- (Rh negative)
- in blood transfusion reaction
- if an Rh- person receives an Rh+ blood.
- Its immune system starts to develop an Anti-Rh antibodies
that will remain in the blood.
- The first transfusion is not affected however, during second
transfusion of Rh+ blood; the previously formed Anti-Rh antibody will
cause hemolysis (rupture of RBC) in the donated blood.
- In Hemolytic Disease of the Newborn
- may arise during pregnancy
- results when the mother is Rh- while the fetus is Rh+
- the first born baby is not usually affected
- the mother develops anti-Rh antibody so that during the
second pregnancy when the fetus is Rh+ again, it destroy fetal RBC causing
- Normally there is no direct contact between maternal and fetal blood
- Mother is Rh- and the fetus is Rh+
- Small amount of Rh+ fetal blood leaks across the placenta
- It will go to the bloodstream of an Rh- mother
- The mother will start to make anti-Rh antibodies
- First pregnancy is not usually affected
- An injection of Anti-Rh antobidies called Anti-Rh gamma globulin
(Rhogam) should be given as soon as 72 hours after delivery to prevent
- During second pregnancy, if fetus is Rh+ again
- The anti-Rh antibodies of the mother crosses the placenta
- It enters the blood strem of the fetus
- Ensuing antigen-antibody reaction
- Hemolysis of the fetal blood (fetal RBC)
- Hemolytic disease of the newborn
- If the fetus is Rh- there is no problem, because Rh- blood does not have
the Rh antigen

Blood Typing
- Lab. Technicians type the patient’s blood and then either cross match it
to potential donor’s blood or screen it for the presence of antibody
- is done to determine the ABO blood groups and Rh factor status
- a drop of blood is mixed with different anti-sera, that contains antibody

1. one drop of blood is mixed with Anti-A serum, contains Anti-A antibody
that will agglutinate RBC of A Antigens
2. another drop of blood is mixed with Anti-B serum, contains Anti-B
antibody that will agglutinate RBC of B antigens
3. if RBC agglutinate only when mixed with Anti-A serum, the blood type is
4. if RBC agglutinate only when mixed with Anti-B serum, the blood type is
5. if both drops agglutinate, the blood type is AB
6. if neither drop agglutinate, the blood type is O
Agglutination – means “clumping of blood” specifically the clumping of RBC that is
visible to the naked eye
- it is an antigen-antibody response whereby RBC’s becomes cross linked to
one another
- mixing of incompatible blood causes agglutination

Rh factor
1. the RBC’s from the donor blood (drop of blood) are mixed with serum
from the recipient
2. a reagent is added (Coomb’s serum) that contains antibody will
agglutinate donor’s RBC
3. if the blood agglutinates, it is Rh+
4. no agglutination indicates Rh-

- it is done to identify possible interactions of minor antigens with
their corresponding antibodies
- once the patient’s blood type is known, donor blood of the same ABO
and Rh is selected
- in cross match, the possible donor’s RBC are mixed with recipient

Selection of Blood Donors:

- criteria has been established to protect the donor from possible ill-
effects of donation and to protect the recipient from exposure to
diseases transmitted through the blood or blood borne diseases.
- Potential donors must be screened for the following conditions:
a. history of hepatitis
b. HIV infection
c. Heart diseases
d. Severe asthma
e. Most cancers
f. Bleeding disorders
- donation of blood may be deferred on the following conditions:
a. people with malaria
b. has been exposed to malaria/Hepatitis
c. pregnancy
d. surgery
e. anemia
f. high or low blood pressure
g. certain drugs such as amphetamines

Blood and Blood Products:

- most client do not require transfusion of whole blood. Most often
transfusion of a particular blood component is more appropriate

Blood Products for Transfusion

Products Use
1. Whole Blood - not commonly used except for extreme
- to be infused within 4 hours cases of acute hemorrhage
- volume: 500ml/unit - replaces blood volume and all blood
- must be ABO and Rh compatible products such as RBC, plasma, plasma
proteins, fresh platelets and other
clotting factors

2. Red Blood Cells - used to increase the oxygen-carrying

- also known as PRBC capacity of blood in anemia, surgery.
- should be infused within 1 ½ to 4 hours - one unit raises hematocrit by
-volume: 300-350ml/unit approximately 4%
3. Platelets - replaces platelets in clients with
- rapid infusion or within 20 minutes bleeding disorders or platelet deficiency
(because it is easily destroyed)
- volume: 60-70 ml/unit

4. Fresh Frozen Plasma - Expands blood volume and provides

- should be infused within 15-20 minutes clotting factors
when given for bleeding or clotting - does not need to be typed and cross
factor replacement matched (contains no RBC)
- volume: 175-225 ml/unit
5. Albumin and Plasma proteins - blood volume expander and provides
- infused within 1 hour plasma proteins
- volume: 12.5 g/50 ml
6. Cryoprecipitate and Clotting factors - used for clients with clotting factor
- rapid infusion within 20 minutes deficiencies
- volume: 5-10 ml/unit
Hematocrit – male: 47-54%
- Female: 42-47%
Hemoglobin – Male: 13-18 g/dl
- Female 12-16 g/dl
Patient is recommended to undergo BT if the Hgb is 8-10g/dl.

Blood Transfusion Reactions:

Transfusion Reactions
Reaction Cause Clinical Signs Nursing Intervention
1. Hemolytic reaction Chills, fever, headache, 1. Discontinue the
- incompatibility between backache, dyspnea, transfusion immediately.
client’s blood and donor’s cyanosis, chest pain, NOTE: when the
blood tachycardia and transfusion is
- infusion of incompatible hypotension discontinued, the blood
blood products tubing must be removed as
well. use new tubing for
the normal saline infusion
2. keep vein open with
normal saline or according
to agency protocol
3. send the remaining
blood, a sample of the
client’s blood and an urine
sample to the laboratory
4. notify the physician
5. monitor vital signs
6. monitor fluid intake and
2. Febrile Reaction: Fever, chills, warm, 1. discontinue the
- sensitivity of the client’s flushed skin, headache, transfusion immediately
blood to white blood cells, anxiety and muscle pain 2. give antipyretics as
platelets or plasma ordered
proteins 3. notify the physician
- the most symptomatic 4. keep the vein open with
complication of BT a normal saline infusion
3. Allergic reaction(mild): Flushing, itching, urticaria 1. stop or slow the infusion
- sensitivity to infused and bronchial wheezing 2. notify the physician
plasma proteins 3. administer medication
(antihistamines) as
4. Allergic reaction Dyspnea, chest pain, 1. stop the transfusion
(severe): antibody-antigen circulatory collapse and 2. keep vein open with
reaction cardiac arrest open normal saline
3. notify the physician
4. monitor vital signs,
resuscitation if needed
5. administer medications
and/ or oxygen as ordered
5. Circulatory overload: Cough, dyspnea, crackles 1. place the client upright,
- blood administered (rales), distended neck with feet dependent
faster than the veins, tachycardia and 2. administer diuretics
circulation can hypertension and oxygen as ordered
accommodate 3. notify the physician
4. stop or slow the
6. Sepsis: High fever, chills, 1. stop the transfusion
- contaminated blood vomiting, diarrhea and 2. send the remaining
administered hypotension blood to laboratory
- expired blood and not 3. notify the physician
properly cross matched 4. obtain a blood specimen
form the client for
5. administer IV fluids,
6. keep the vein open with
a normal saline infusion

Administering Blood Transfusion:

1. when transfusion is ordered, obtain blood from the blood bank just before
starting the transfusion
2. do not store blood in the refrigerator on the nursery unit (lack of
temperature control may damage the blood)
3. blood is administered through a #18 or #19 gauge intravenous needle or
catheter (using a smaller needle may slow the infusion and may damage cells)
4. a Y-type blood transfusion set with in line filter is used
5. one arm of administration set connects to the blood while the normal saline
(0.9% NaCl) is attached to the other arm of the Y-type set
6. saline is used to prime the set and flush the needle before administering
blood (solution other than saline can cause damage to blood components)
7. transfusion of blood should be completed within 4 hours of initiation (the
risk of sepsis increases if blood has transfused for a longer period)
8. blood tubing is changed after every 4-6 units per agency policy
The College of Maasin
Nisi Dominus Frsutra
College of Nursing
Maasin City, Southern Leyte

Performance Checklist

Instructions: Please check on the space provided for whether the participant is
able to perform the procedure correctly or whether it is incorrectly done

CD – Correctly done ID – Incorrectly done ND – Not done

Steps CD ID ND
1. verify doctor’s written prescription and make a
treatment card according to hospital policy
2. observe ten (10) Rs when preparing and administering
any blood or blood components
3. Explain the procedure/rationale for giving blood
transfusion to reassure patient and significant others and
secure consent. Get patient’s history regarding previous
4. request prescribed blood/blood components from blood
bank to include blood typing and X-matching & blood
result of transmissible disease
5. using a clean lined tray, get compatible blood from
hospital blood bank
6. wrap blood bag with clean towel & keep it at room
7. Have a doctor and a nurse assess patient’s condition.
Countercheck the compatible blood to be transfused
against the X-matching sheet noting ABO grouping and Rh,
serial number of each blood unit and expiry date with the
blood bag label and other laboratory blood exam as
required before transfusion (Hgb & Hct)
8. get the baseline vital signs –BP, R, temperature before
9. give pre-med 30 minutes before transfusion as
10. do hand hygiene before and after the procedure
11. prepare equipment needed for BT (IV injection tray,
compatible BT set, IV catheter/ needle G 18/19, plaster,
tourniquet, blood component to be transfused, plain NSS
500cc, IV set, g 18 needle, IV hook, gloves, sterile 2x2
gauze or transparent dressing
12. if main IVF is with dextrose 5% initiate an IV line with
appropriate IV catheter with plain NSS on another site,
anchor catheter properly and regulate IV drops
13. Open compatible blood set aseptically and close roller
clamp. Spike blood bag carefully, fill the drip chamber at
least half full; prime tubing and remove air bubbles (if
any). Use needle g18 or 19 for side drip (for adults) or 22
for pedia (if blood is given through the Y injection port,
the gauge of needle is disregarded
14. disinfect the Y-injection port of IV tubing (plain NSS)
and insert the needle from BT administration set and
secure with adhesive tape
15. close roller clamp of IV fluid of plain NSS and
regulate to KVO while transfusing is going on
16. Transfuse the blood via the injection port and regulate
at 10-15 gtts. Initially for 15 minutes and then at the
prescribed rate
17. observe patient for 10-15 minutes for any immediate
18. Observe patient on an ongoing basis for any untoward
signs and symptoms such as flushed skin, chills, elevated
temperature, itchiness, urticaria and dyspnea. If any of
these symptoms occurs stop the transfusion, open the
roller clamp of the IV line with plain NSS and report to
doctor immediately
19. Swirl the bag hourly to mix the solid with the plasma.
One BT set should be used for 1-2 units of blood
20. when blood is consumed, close the roller clamp of BT
and disconnect from IV lines then regulate the IVF of
plain NSS as prescribed
21. continue to observe and monitor patient post
transfusion, for delayed reaction could still occur
22. Re-checked Hgb and Hct, bleeding time, serial platelet
count within specified hours as prescribed
23. discard blood bag and BT set and sharps according to
Health Care Waste Management
24. document the procedure, pertinent observations and
nursing intervention and endorse accordingly
Remarks: Pass___ Failed___

Name & Signature of the Student:______________

Name & Signature of the Instructor:____________