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Uploaded by

sharawybakr4
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‫ألبوم صور فوتوغرافية‬

‫بواسطة ‪Toshiba‬‬
Definition:
A blood transfusion is the IV
administration of a component
of blood or whole blood.
To increases blood volume after surgery,
trauma, or hemorrhage.
To increases the number of red blood cells in a
patient with severe anemia.
To provide platelets to patients with low platelet
counts caused by treatment with chemotherapy.
To provide clotting factors in plasma for patient
with hemophilia.
 Assess the patient for the indication of the blood
product to be given, that is, low hematocrit or
platelet count.
 Verify the health care provider's order for the type
of blood product to be given.
 Review the patient's transfusion history, especially
any reaction for pre-transfusion medication to be
given.

 Review the baseline vital signs in the patient's medical


record to compare with vital signs during transfusion.
 Assess the type, integrity and patency of the venous
access in place.
 Verify that a large- bore catheter (18 gauge) is to be
used.
 Review institution policy and procedure for the
administration of blood productions.
 Ensure that the patient has signed an informed consent
release that includes potential risks and benefits.
Remember

o indication of the blood product to be given.

 health care provider's order.

 patient's transfusion history.

 baseline vital signs.

 type, integrity and patency of the venous access in place.

 institution policy and procedure.

 an informed consent
o Teach the patient the rationale for the blood
transfusion, the anticipated length of the
transfusion and the need for frequent vital
sign monitoring while the transfusion is
running.
o Instruct the patient to notify the nurse if he
or she experiences any signs of reaction such
as itching, swelling, dizziness, dyspnea, chest
pain or infiltration of the IV.
o Teach the patient and caregiver about the
signs and symptoms of long-term
reaction, as delayed hemolysis and the
need to report them to the health care
provider immediately.
•Back pain.
•Bloody urine.
•Chills.
•Fainting or dizziness.
•Fever.
•Flank pain.
•Flushing of the skin.

Equipment
 gloves

Gown

I.V pole

Y –tube (blood
transfusion set).

Normal saline
solution.

 whole blood or
packed RBCs
• Wash hands.

• Identify the patient and explain procedure to


the patient.
• Provide for patient's privacy.
• Maintain body mechanics.
• Verify the health care provider's order for
the transfusion.
• Explain procedure to the patient.
• Action: Review side effects ( dyspnea,
chills, headache, chest pain, itching) with
patient and ask him or her to report these
to the nurse.
• Rationale: Prompt reporting of a side
effect will lead to earlier discontinuation
of transfusion and minimize the
reaction.

• Rationale: Have the patient


sign consent forms.
• Rationale: Most institution
requires the patient to sign a
consent form.
Rationale: Prevents bacterial growth and

destruction of red blood cells


• Action: Verify and record the blood product and
identify the patient with another nurse.
- Patient's name, blood group, RH type.
- Cross matches compatibility.
- Donor blood group and RH type.
- Unit and hospital number.
- Expiration date and time on blood bag.
- Type of blood product compared with health care
provider's order.
.
Rationale: Strict verification procedure
will reduce the risk of administering blood
products to the wrong patient. If there is an
error during this procedure, notify the
blood bank and do not administer the
product

• Action: Instruct patient to empty the bladder.


• Rationale: A urine specimen after initiation of the
transfusion will be needed if a transfusion
reaction occurs.
• Wash hands and put on gloves.
• Action: Open blood administration kit and move
roller clamp to off position.
• Rationale: A closed roller clamp prevents accidental
spilling of blood
• Action: For Y-tubing set:

• Spike the normal saline bag and open

the roller clamp on Y- tubing connected

to the bag and the roller clamp on the

un used in let tube until tubing from the

normal saline bag is filled. Close clamp

on unused tubing.

Rationale: The Y- tubing allows the nurse to switch

from infusing normal saline to blood. This is especially

helpful when multiple transfusions are given. Follow

institutional guidelines for the number of units that can

be given before tubing needs to be changed. Dextrose

solutions are not used with blood transfusions as

they can clot the donor blood


1. Action: Squeeze side of drip chamber and allow
filter to partially fill.
- Open lower roller clamp and allow tubing to fill
with normal saline to the hub.
- Removes all air from tubing system.
- Close lower clamp.
- Prevents waste of IV fluid.

- Invert blood bag once or twice. Spike blood bag and


open clamps on let tube to allow blood to cover the
filter completely.
- Equal distribution of cells prevents clumping, which
can lead to clotting of cells. Fragile blood cells may be
damaged if they drop on a un covered filter.
- Close lower clamp.
- Prevents blood from flowing until tubing is attached to
venous catheter.
• Action: For single-tubing set:
- Spike blood unit.
Rationale: Attaches tubing to blood unit.
- Squeeze drip chamber and allow the filter to fill
with blood.
Rationale: A correctly filled drip chamber
enables an accurate drip count.

- Open roller clamp and allow tubing to fill


with blood to hub.
Rationale: Prevents air from being forced
into the vein.
- Prime IV tubing with normal saline and
piggyback it to the blood administration set
with a needle and secure all connections with
tape.
Rationale: The blood product should not be
piggyback into the normal saline line to avoid
forcing blood cells through both a needle and
a venous catheter.
• Action: Attach tubing to venous catheter
using sterile precautions and open lower
clamp.
Rationale: Allows the blood product to be
infused into the patient's vein.

• Action: Infuse the blood at a rate of 2-5

ml/min according to the health care

provider's order.

Rationale: Packed red blood cells usually

run over 1.5 -2 hours, whole blood runs over

2-3 hours.
1. Action: Remain with patient for first 15-30 minutes

and monitoring vital signs every 5 minutes for 15

minutes, then hourly until 1 hours after the infusion is

completed or per institution policy.

Rationale: If a reaction occurs, it generally happens

during the first 15-30 minutes. Changes in vital signs

can warm of a transfusion reaction

• Action: After blood has infused, allow the

tubing to clear with normal saline.

• Rationale: The patient will receive all the

blood that is left in the tubing.


• Action: Appropriately dispose

of bag, tubing and gloves. Wash

hands.

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