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Procedure (Blood Transfusion)

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220 views

Procedure (Blood Transfusion)

Uploaded by

Richard Patterson
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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The University of the West Indies

Faculty of Medical Sciences

The UWI School of Nursing, Mona

Year II Summer Semester

BScN

Administering Blood Transfusion

A blood transfusion is the infusion of whole blood or a blood component, such as plasma, red
blood cells, or platelets into a patient’s venous circulation.

Before a patient can receive a blood product, his or her blood must be typed and cross-matched
to ensure that he or she receives compatible blood. The nurse must also verify the infusion rate,
based on facility policy and/or medical order.

Assessment Morning:

Afternoon:

Obtain a baseline assessment of the patient, including vital signs, urinary output and respiratory
assessment.

Ask the patient about past history of transfusions, including any reactions experienced.

Assess the IV site, noting the size of the IV catheter (should be a 20 gauge or larger).

Equipment

Blood Product

Blood giving set

0.9% Normal Saline (for IV infusion)

IV Pole

Clean, disposable gloves

Additional PPE (eg; gown), as indicated

Tape

UWISON Revised 2011-2012 (MJW)


NURS 2026 Page 1
** A second nurse for verification of blood product and patient information**

Procedure

Action Rationale
1. Verify the medical order for the blood Verification of order ensures the patient
transfusion. receives the correct intervention.
Verify the completion of an informed
consent form.
Verify any pre-medication order (if Pre-medication is sometimes administered to
ordered, administer at least 30 minutes decrease the risk for allergic and febrile
before starting transfusion). reactions.
2. Gather necessary equipment and Having equipment available saves time.
supplies. Take to patient’s bedside. Identifying the patient ensures the right patient
3. Identify the patient. receives the treatment and helps prevent errors.
4. Wash hands. This prevents the spread of microorganisms.
5. Provide privacy (close door to This ensures the patient’s privacy.
room/close curtains around bed).
6. Explain procedure to patient. Ask Explanation encourages patient understanding,
patient about previous blood relieves anxiety and facilitates cooperation.
transfusion experience, including any Previous reactions may increase the risk for
reactions. reaction to this transfusion.
Ask patient about allergies.
Advise patient to report any chills,
itching, rash.
7. Put on disposable gloves (and Gloves prevent contact with blood and body
additional PPEs, if required) fluids.
8. Assess IV site. PPE is required based on transmission
9. Initiate 0.9% Normal Saline infusion, precautions.
volume dependent on hospital policy.
(usually 50 – 100 mL for adults)
10. Check the blood product with another
Registered nurse (using the chart,
patient’s ID band and label on the
blood product) to validate the following
information:
 Medical order for transfusion
 Informed consent
 Patient ID number
 Patient’s name
 Blood group and type
 Expiration date
Inspect the blood product for clots.

UWISON Revised 2011-2012 (MJW)


NURS 2026 Page 2
11. Obtain baseline vital signs. Any change in vital signs during the
12. Calculate drip rate. transfusion may indicate a reaction.
13. Attach blood giving set to blood bag.
(Remove protective cap from access port of
blood bag, and from the spike of the blood
giving set. Using a pushing and twisting
motion, insert the spike into the access port
of the blood bag.)
14. Hang blood bag on the IV pole.
Squeeze drip chamber to saturate same
with blood (filling the chamber halfway).
Open the roller clamp to allow blood to
prime the line.
Close roller clamp when blood product
has primed the line.
15. Attach end of primed blood giving set
to IV access. Secure with tape.
Start transfusion slowly (no more than Transfusion reactions typically occur during
25-30 mL for the first 15 minutes). this period. A slow rate will minimize the
Stay with the patient for the first 5 -15 volume of red blood cells infused.
minutes of transfusion and observe for These signs and symptoms may be an early
flushing, dyspnea, itching, rash. indication of transfusion reaction.
16. After the observation period, increase Transfusion should be completed within 4 hour
the flow rate to the calculated rate to period due to the potential for bacterial growth
complete the transfusion within the in blood product at room temperature.
prescribed time (no more than 4 hours).
Reassess vital signs after 15 minutes.
17. When the transfusion is complete, close Normal saline prevents hemolysis of red blood
the roller clamp, remove the tubing and cells.
attach administration set with 0.9% N/S

18. Obtain vital signs.


19. Appropriately dispose of blood bag, Proper disposal of equipment reduces
tubing and gloves. transmission of microorganisms and potential
Wash hands. Ensure patient’s comfort. contact with blood and body fluids.
20. Record administration of blood product
and patient’s reaction.
Documentation

 Patient received the blood transfusion (include the type of blood product).
 Patient’s condition throughout the transfusion (include pertinent data such as vital signs,
lung sounds, and any subjective response of the patient to the transfusion).
 Patient received the transfusion with or without any complications or reactions.
 The assessment of the IV site
 Transfusion volume and that of any other fluid infused during the procedure.
UWISON Revised 2011-2012 (MJW)
NURS 2026 Page 3
Reference

Lynn, P. (2011). Taylor’s Handbook of Clinical Nursing Skills. Philadelphia, PA: Wolters
Kluwer Health/Lippincott Williams Wilkins.

UWISON Revised 2011-2012 (MJW)


NURS 2026 Page 4

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