ADMIN OF BLOOD PRODUCTS

GENERAL PRECAUTIONS
 Large volume of refrigerated blood infused rapidly thru a central catheter into the
ventricle of the heart => cardiac dysrhythmias
 Only Normal Saline solution (NSS) or 0.9% Sodium Chloride can be added to
blood components
 To avoid risk of septicemia:
 Infusion (1 unit) should not exceed 4 0
 Blood admin set should be changed every 4-6 0 *
 Always check the bag for expiration date: midnight on the day marked
 Inspect bag for leaks, abnormal color, clots and bubbles
 Blood must be admin asap (within 20-30 mins) from the blood bank, return if not
admin w/in that period
 Recommended infusion rate:
 quickly as client’s condition allows
 varies w/ blood component being infused: few RBC and platelets =
infused rapidly = caution => circulatory overload
 Assess VS and lung sounds:
 before BT
 after 1st 15 mins
 every hour until 1 0 after BT is completed

BLOOD BANK PRECAUTIONS

 Blood will be released from the blood bank only to personnel specified by agency
policy
 Name and identification # of intended recipient must be provided to the blood
bank, documented record of this info is maintained
 Blood is transported to only one client at at time (to prevent delivery to wring
client)

CLIENT IDENTITY AND COMPATIBILITY

 Most critical phase: confirming compatibility and verifying identity
 Two RN (or 1 RN and 1 LPN) check:
1. physician’s order
2. client’s identity
3. identificatin band or bracelet and number
4. verifying name and number identical on blood component tag
 At bedside, ask client to state name, compares the name to the identification band
or bracelet
 Check the blood tag, label, and blood requisition form to ensure ABO and Rh
types compatible
 Inconsisitencies, notify blood bank immediately

CLIENT ASSESSMENT
 Cultural and Religious beliefs (Jehova’s witness can’t have BT: eternal
consequences)
 Ensure informed consent is obtained
 Determine if there is previous history of BT reactions
 Check VS, renal, circulatory, and respiratory status and ability to tolerate IV
admin

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  Temperature elevation may delay BT, notify physician (may mask symptom of
acute BT reaction)

ADMIN OF BT
 Maintain standard, transmission-based, other precautions necessary
 Insert IV line and infuse NS; maintain infusion at KVO rate
 18- or 19- gauge check IV needle – maximum flow rate of blood products
(prevent damage of RBC); if smaller gauge, dilute RBC with NS
 Central catheter is an acceptable venous access option
 Always check the bag for volume of blood component
 Blood products must be infused thru admin sets designed specifically for
blood; use Y tubing or straight tubing blood admin set w/ filter (designed to trap
fibrin clots and other debris that accumulate during blood storage).
 Premedicate with Acetaminophen (Tylenol) or Diphenhydramine
(Benadryl) if w/ history of adverse rxns.
 Oral = 30 mins before BT
 IV = immediately before BT
 Instruct client to report anything unusual immediately
 Determine rate of infusion
 Begin transfusion slowly under close supervision; no rxn noted on 1st 15
mins, flow rate can be increased
 During BT, monitor for signs and symptoms for 1st 15 mins (most critical,
nurse must stay with the client)
 Major ABO compatibility exists or severe allergic rxns occur = evident
st
w/in 1 50 mL of BT
 Document client’s tolerance of BT
 Monitor lab values and document effectiveness of treatment

REACTION TO BT
 If reaction occurs:
1. Stop BT
2. Change IV tubing down to the IV site
3. Keep the IV line open w/ NS
4. Notify physician and blood bank
5. Return blood bag and tubing to blood bank
 Do not leave client alone, monitor any life threatening symptoms
 Obtain lab samples: blood or urine (free hemoglobin indicates RBC were
hemolyzed)

COMPLICATIONS OF BT
Transfusion reactions Disease transmission
Circulatory overload Hypocalcemia & Citrate intoxication
Septicemia Hyperkalemia
Iron overload

Type O- : universal donor

Type AB+ : universal recipient

STEPS IN TRANSFUSING PACKED RBC

1. Verify physician’s order
2. Get informed consent
3. Insert gauge 18- or 19- IV catheter
4. Obtain unit from blood bank

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5. Ask another RN or LPN to assist in confirming compatibility and identity
6. Assess VS and lung sounds before hanging solution