Transfusing Blood Products

• To safely transfuse whole blood, packed erythrocytes (RBCs), platelets, fresh frozen plasma so that special deficiencies such as anemia and bleeding disorders can be corrected.

• An informed consent must be obtained before transfusing blood.
• Baseline vital signs must be obtained.
• The nurse should remain with patient during the first 15 minutes of blood transfusion to assess for adverse reaction.
• Blood must be verified by two nurses or a nurse and a physician prior to transfusion.
• Medications should never be administered via blood transfusion tubing. A separate IV site should be used to administer medications.
• Monitor for fluid overload and transfusion reactions.
• No more than two units of blood should be administered via one blood administration set and/or filter—see protocol.
• Stop transfusion if reaction occurs—change tubing and keep IV patent with 0.9% sodium chloride.
• Return blood container and tubing to blood bank if reaction occurs.
• Obtain first voided urine specimen after a transfusion reaction and send to lab.

Special Considerations

Elderly Patient

• Infuse blood at a slower rate for better tolerance and prevention of complications (i.e., circulatory overload, pulmonary edema, and congestive heart failure).

Pediatric, Confused, Comatose, and Mentally Challenged Patients

• Monitor closely and often for adverse reactions since they often cannot communicate effectively if problems occur.

Home Health Patient

• The registered nurse should stay with the patient throughout the entire process of blood transfusion and 1–2 hours post-transfusion to monitor for adverse reactions. An additional RN would be indicated for this procedure to check blood and patient information prior to administration.

Cultural Considerations

• Some religious groups do not receive blood transfusions and blood products, (e.g., Jehovah's Witness).

Relevant Nursing Diagnoses

• Fluid volume deficit related to hemorrhage from trauma, GI bleeding, and/or surgery
• Fluid volume excess related to rapid infusion of blood
• At risk for decreased cardiac output related to circulatory overload and/or transfusion reaction

• Transfusion will be completed for time frame ordered and no longer than 4 hours
• Symptoms of an allergic reaction to blood will be recognized early and prompt intervention initiated
• Improvement in serum hemoglobin and hematocrit will be noted following transfusion

• Blood unit or other blood product
• Bag of 0.9% sodium chloride IV solution
• Y-set blood tubing with filter
• Antimicrobial swabs
• Clean gloves
• Infusion pump, if needed
• Blood warmer, if needed
• Protective clothing, if needed

• Identify patient; explain purpose, procedure and how patient can assist.
• Decreases anxiety; meets patient's right to be informed; encourages cooperation and participation.
• Obtain informed consent.
• An informed consent is an INS standard—the patient should be aware of what is involved in the procedure and his or her role in the procedure and should be made aware of symptoms indicating a reaction to the transfusion.
• Establish that patient has a patent large-bore IV catheter.
• Blood should be transfused via a minimum of a 20-gauge IV catheter to provide adequate flow rate and prevent lysis of RBCs.
• Prime blood administration tubing with 0.9% sodium chloride solution.
• IV solutions other than 0.9% sodium chloride may result in damage to RBCs or precipitate clots.
• Obtain blood from agency blood bank.
• Blood should remain at properly stored temperature until time of transfusion. Blood should be returned to blood bank if the unit will not be given within 20–30 minutes—see protocol of agency.
• Wash hands.
• Reduces transmission of infectious microorganisms.
• Verify the following information with another nurse or a physician:
• Patient's name and identification number.
• Blood component blood type and Rh factor.
• Crossmatching numbers.
• Expiration date of blood.
• Any blood product must be verified as to correct blood component, correct type, expiration date, and correct patient to receive this blood.
• Obtain vital signs—temperature, pulse, respiration, blood pressure and record on transfusion flow form.
• Provides baseline of vital parameters.
• Spike the blood container on the blood administration tubing Y opposite of the 0.9% sodium chloride solution container, pushing tip of tubing straight up into the blood bag entry port—make sure the “Y” leading to the sodium chloride solution is turned OFF prior to spiking the blood bag.
• Spiking the blood container in a straight motion prevents puncture to blood bag.
• Priming the blood set is an INS standard—see fourth item of this procedure.
• Prime the blood administration tubing with blood and then initiate transfusion at 5 mL/min. for the first 15 minutes of the transfusion.
• Blood transfusion reactions are more common during the first 15 minutes of the transfusion thus the transfusion rate is slower initially.
• Monitor and record the temperature, pulse, respiration, and blood pressure at 5-minute intervals for the first 15 minutes of transfusion.
• Diligent monitoring of the patient during blood transfusion is necessary to ascertain adverse effects of the transfusion and institute early intervention. The patient is more susceptible to an adverse reaction within the first 15 minutes of transfusion.
• Monitor patient for any signs or symptoms of an adverse reaction to the transfusion (itching, hives, rash, urticaria, pain in lumbar-sacral region, chest pain, or decreased blood pressure, increased pulse or respiratory distress) at 5-minute intervals and record on transfusion flow form.
• Diligent monitoring of the patient during blood transfusion is necessary to ascertain adverse effects of the transfusion and institute early intervention.
• If a reaction occurs, stop the transfusion, notify physician, and change IV tubing and keep vein open with 0.9% sodium chloride solution.
• Prepare to administer medications, return blood and tubing to blood bank, and obtain blood and urine specimens.
• Continuing the transfusion may result in more severe reaction. An IV access must be maintained in the event that patient requires IV medication—not changing tubing will result in furthering transfusion reaction.
• Treat reaction and identify type of reaction.
• After the initial 15 minutes of transfusion, as long as there are no signs of transfusion reaction, the rate of flow can be increased to complete the transfusion during the time indicated by the physician or agency policy.
• Rate of infusion is based on the blood volume, hemodynamic and cardiac status of the patient. The total transfusion must not exceed 4 hours (this includes the initial 15 minutes transfusion).
• The T, P, R, and BP and clinical status of the patient should continue to be assessed and recorded every 15 minutes for the first hour and then every 30 minutes until completion of the transfusion.
• A transfusion reaction may occur at any time during the transfusion.
• At completion of the blood transfusion, turn off flow control on “Y” section leading to blood bag and open the flow control to the 0.9% sodium chloride solution. Flush the blood administration tubing until a light pink fluid is noted.
• Flushing blood tubing with sodium chloride solution ensures that patient receives all of blood.
• If no further blood is to be transfused, change tubing or cap IV line with prn adaptor.
• IV site can be maintained for further use. Blood tubing should be utilized only for transfusion of blood.
• Dispose of blood container and tubing according to agency protocol.
• Blood container should be returned to blood bank if transfusion reaction occurs, otherwise can be discarded in contaminated waste (check protocol of agency).
• Remove gloves and wash hands.
• Prevents transmission of infectious microorganisms.
• Reposition patient as needed.
• Promotes patient comfort.

Evaluation and Follow-Up Activities

• Blood was transfused correctly
• Patient did not experience any adverse reactions
• Patient's blood count has improved

Key Points for Reporting and Recording

• Notification of adverse reactions, if occurred, and report to physician and orders indicated
• Date and time of completion of transfusion