Skill 16-6

Administering a Blood Transfusion

A blood transfusion is the infusion of whole blood or a blood component, such as plasma, red blood cells (RBCs), cryoprecipitate, or platelets, into the patient's venous circulation (Table 16-1). A blood product transfusion is given when a patient's RBCs, platelets, or coagulation factors decrease to levels that compromise a patient's health. Blood transfusions are not without risk, however. Potentially life-threatening complications include allergic reaction and anaphylactic reaction, hemolytic reaction, transfusion-related acute lung injury, circulatory volume overload, immunosuppression, and transmission of infectious diseases (Carman et al., 2018). It is important that the potential benefits of the transfusion be considered against the potential risks (American Red Cross, 2021; Carman et al., 2018). Before a patient can receive a blood product, their blood must be typed to ensure that they receive compatible blood (blood typing and crossmatching ). If incompatible, clumping and hemolysis of the recipient's blood cells result and death can occur (Table 16-2). Alternatively, a patient may receive an autologous transfusion , in which case, the potential for transfusion reaction is significantly decreased (Silvergleid, 2022). The nurse must also verify the infusion rate, based on facility policy or prescribed intervention. Follow the facility's policies and guidelines to determine if the transfusion should be administered by an electronic infusion device or by gravity/free flow. Refer to Box 16-1 in Skill 16-1 for guidelines to calculate the flow rate for gravity/free-flow infusion. Identification of patients at risk for complications and patient monitoring during and after transfusion of blood products is essential because of ongoing risk for transfusion reaction (Carman et al., 2018; DeLisle, 2018).

Delegation Considerations

The administration of a blood transfusion is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the initiation and monitoring of a blood transfusion may be delegated in certain circumstances to licensed practical/vocational nurses (LPN/LVNs) who have received appropriate training. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Blood product
Blood administration set (tubing with in-line filter, or add-on filter, and Y for saline administration)
0.9% normal saline for IV infusion
Electronic infusion pump labeled for blood transfusion
Venous access; if peripheral site, initiated with a 20- to 24-gauge catheter based on vein size (adults) (Gorski et al., 2021)
Antimicrobial wipes
Gloves
Additional PPE, as indicated
Nonallergenic tape
Second adult trained in the identification of the recipient and blood components (i.e., registered nurse, other licensed practitioner [hospital/outpatient setting]); responsible adult (home setting) to verify blood product and patient information (Gorski et al., 2021)

Assessment

Review the most recent laboratory values, in particular, the complete blood count (CBC). Ask the patient about any previous transfusions, including the number they have had and any reactions experienced during a transfusion. Inspect the VAD insertion site, noting the gauge of the IV catheter. Blood or blood components may be transfused via a 20- to 24-gauge peripheral VAD (adult) (Gorski et al., 2021). Central venous access devices (CVADs) may also be used to administer a transfusion. Baseline assessment prior to obtaining blood for transfusion should include measurement of vital signs, lung assessment, identification of conditions that may increase the risk of transfusion-related adverse reactions (e.g., current fever, heart failure, renal disease, risk of fluid volume excess), the presence of an appropriate and patent VAD, and current laboratory values (Gorski et al., 2021). Institution policies vary on the frequency of assessment. The Infusion Nurses Society Standards of Practice recommend checking the patient's vital signs within 30 minutes prior to transfusion, 15 minutes after initiating the transfusion, after the transfusion is completed, 1 hour after the transfusion has been completed, and as needed based on clinical observation of the patient's condition (Gorski et al., 2021).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Fluid imbalance
Impaired cardiac output

Outcome Identification and Planning

The expected outcomes to achieve when administering a blood transfusion are that the patient receives the blood transfusion without any evidence of a transfusion reaction or complications, and the patient exhibits signs and symptoms of fluid balance, improved cardiac output, and enhanced tissue perfusion.

Implementation

Action	Rationale
1. Verify the prescribed intervention for transfusion of a blood product. Verify the completion of informed consent documentation in the health record.	Verification of the prescribed intervention ensures the right patient receives the correct intervention.
2. Gather all equipment.	Preparation promotes efficient time management and an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Close the curtains around the bed, and close the door to the room, if possible. Explain to the patient what you are going to do and why. Ask the patient about previous experience with a transfusion and any reactions. Advise the patient to report any signs/symptoms associated with complications of transfusion therapy (e.g., uneasy feeling, pain, dizziness, rash, chills, itching, rash, or other unusual symptoms).	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Previous reactions may increase the risk for reaction to this transfusion. Any reaction to the transfusion necessitates stopping the transfusion immediately and evaluating the situation.
7. Prime the blood administration set with the normal saline IV fluid. Refer to Skill 6-1.	Normal saline (0.9% sodium chloride) is the solution of choice for blood product administration (Gorski et al., 2021).
8. Put on gloves. If the patient does not have a VAD in place, initiate peripheral venous access. (Refer to Skill 16-1.) Connect the administration set to the VAD via the extension tubing. (Refer to Skill 16-1.) Infuse the normal saline per facility policy.	Gloves prevent contact with blood and body fluids. Infusion of fluid via venous access maintains patency until the blood product is administered. Start an IV before obtaining the blood product in case the initiation takes longer than 30 minutes. Blood must be stored at a carefully controlled temperature (Hill & Derbyshire, 2021), and transfusion must begin within the length of time blood or a blood product must be returned after it is obtained from the blood bank/source, as identified by facility policy.
9. Obtain the blood product from blood bank/transfusion service according to facility policy. Verify the patient information and blood product information; inspect the blood component for abnormalities. Scan the bar codes/biometric scanning on the blood products if in use and required.	Confirmation of patient and blood component information is necessary at the time the blood component is released from the transfusion service to ensure the right patient receives the correct intervention (Gorski et al., 2021). Computerized checking systems using bar codes/radio frequency identification devices/biometric scanning on blood products are being implemented to identify, track, and assign data to transfusions as an additional safety measure (Gorski et al., 2021; Hill & Derbyshire, 2021).
10. Two registered nurses (or other practitioners trained in the identification of the recipient and blood components [i.e., licensed practitioner in the hospital/outpatient setting; responsible adult in the home setting]) compare and validate the following information in the presence of the patient with the health record, the patient identification band (hospital/outpatient setting), and the label of the blood product (Gorski et al., 2021): Prescribed intervention for transfusion of blood product Informed consent Two independent patient identifiers (e.g., patient name, patient identification number) Blood group and type Blood product donation identification number, expiration date/time, date/time of issue Inspection of the blood component: intact container, abnormal color, presence of clots, clumping, excessive air/bubbles	Verification of this information reduces the risk for error in administration. If appearance is not normal (e.g., abnormal color, clots, excessive air/bubbles, unusual odor), the product may be contaminated; return the blood to the blood bank/transfusion service (Gorski et al., 2021).
11. Obtain a baseline assessment (refer to the previous Assessment section) including a set of vital signs before beginning the transfusion.	Assessment helps identify conditions that may increase the risk of transfusion-related adverse reactions and establishes a baseline for future comparison (Carman et al., 2018; Gorski et al., 2021). The presence of fever may be a cause for delay in the administration of the blood component (Gorski et al., 2021). Any change in vital signs during the transfusion may indicate a reaction.
12. Put on gloves. Put the electronic infusion pump on “hold.” Close the roller clamp closest to the drip chamber on the saline side of the administration set. Close the roller clamp on the administration set below the infusion device. Alternatively, if infusing via gravity/free flow, close the roller clamp on the administration set.	Gloves prevent contact with blood and body fluids. Stopping the infusion prevents blood from infusing to the patient before completion of preparations. Closing the clamp to saline allows the blood product to be infused via the electronic infusion pump. Electronic infusion pumps (labeled for blood transfusion) can be used to deliver blood or blood components without significant risk of hemolysis of RBCs or platelet damage (Gorski et al., 2021).
13. Close the roller clamp closest to the drip chamber on the blood product side of the administration set. Remove the protective cap from the access port on the blood container. Remove the cap from the access spike on the administration set. Using a pushing and twisting motion, insert the spike into the access port on the blood container, taking care not to contaminate the spike. Hang the blood container on the IV pole. Open the roller clamp on the blood side of the administration set. Squeeze the drip chamber until the in-line filter is saturated (Figure 1). Remove your gloves. Perform hand hygiene.	Filling the drip chamber prevents air from entering the administration set. The filter in the blood administration set removes particulate material formed during storage of the blood. If the administration set becomes contaminated, the entire set must be discarded and replaced.
14. Start administration slowly (approximately 2-3 mL/min for the first 15 minutes (Gorski et al., 2021). Stay with the patient for the first 15 minutes of transfusion. Open the roller clamp on the administration set below the infusion device. Set the flow rate and begin the transfusion. Alternatively (if infusing by gravity/free flow), start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the blood and function of the infusion device. Inspect the insertion site for signs of infiltration.	Major transfusion reactions usually appear before the first 50 mL have been transfused, and a slow rate will minimize the volume of RBCs infused (Gorski et al., 2021). Increasing the rate after 15 minutes when there are no signs of reaction helps to ensure the completion of the transfusion within 4 hours of leaving the controlled temperature storage of the blood bank/transfusion service (Gorski et al., 2021; Hill & Derbyshire, 2021). Verifying the rate and device settings ensures the patient receives the correct volume of solution. If the catheter slips out of the vein, the blood will accumulate (infiltrate) into the surrounding tissue.
15. Observe the patient for signs/symptoms associated with complications of transfusion therapy (e.g., uneasy feeling, pain, dizziness, rash, chills, itching, rash, or other unusual symptoms) or any unusual comments.	These signs and symptoms may be an early indication of a transfusion reaction.
16. Reassess vital signs after 15 minutes (Figure 2). Obtain vital signs thereafter according to facility policy and nursing assessment.	Vital signs must be assessed as part of monitoring for possible adverse reaction. Facility policy and nursing judgment will dictate frequency. Guidelines suggest vital signs should be checked within 30 minutes prior to transfusion, 15 minutes after initiating the transfusion (Hill & Derbyshire, 2021), after the transfusion is completed, 1 hour after the transfusion has been completed, and as needed based on clinical observation of the patient's condition (Gorski et al., 2021).
17. After the observation period (15 minutes), increase the infusion rate to the calculated rate to complete the infusion within the prescribed time frame, no more than 4 hours.	If no adverse effects occurred during this time, the infusion rate is increased. Increasing the rate after 15 minutes when there are no signs of reaction helps to ensure the completion of the transfusion within 4 hours (Gorski et al., 2021). If complications occur, they can be observed, and the transfusion can be stopped immediately. Verifying the rate and device settings ensures the patient receives the correct volume of solution. Transfusion must be completed within 4 hours (Gorski et al., 2021) due to the potential for bacterial growth in a blood product at room temperature.
18. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the patient's overall condition, keeping in mind the outer limits for safe administration. Ongoing monitoring is crucial throughout the entire duration of the blood transfusion for early identification of any adverse reactions.	The rate must be carefully controlled, and the patient's reaction must be monitored frequently.
19. During transfusion, assess the patient at least every 30 minutes for adverse reactions. Stop the blood transfusion if you suspect a reaction. Quickly replace the blood tubing with a new administration set primed with normal saline for IV infusion. Initiate an infusion of normal saline for IV at a keep open rate, usually 40 mL/hr. Obtain vital signs. Notify the health care team and the blood bank/transfusion service (Gorski et al., 2021).	If a transfusion reaction is suspected, the blood must be stopped. Do not infuse the normal saline through the blood tubing because you would be allowing more of the blood into the patient's body, which could complicate a reaction. Besides a serious life-threatening blood transfusion reaction, the potential for fluid-volume overload exists in older adults and patients with decreased cardiac function.
20. When the transfusion is complete, close the roller clamp on the blood side of the administration set and open the roller clamp on the normal saline side of the administration set. Initiate infusion of normal saline. When all of the blood has infused into the patient, clamp the administration set. Obtain vital signs. Put on gloves. Cap the access site or resume the previous IV infusion (refer to Skills 16-1 and 16-5). Alternatively, disconnect the transfusion when complete without flushing the remainder of the blood in the line and flush the VAD with 0.9% sodium chloride according to facility policy. Dispose of blood-transfusion equipment or return it to the blood bank, according to facility policy.	Saline prevents hemolysis of RBCs and clears the remainder of blood in the IV line. Proper disposal of equipment reduces transmission of microorganisms and potential contact with blood and body fluids. Some guidelines suggest that flushing through the remainder of the blood in the line with 0.9% sodium chloride is unnecessary and is not recommended because it may result in particles being flushed through the filter (JPAC, 2014).
21. Remove equipment. Remove your gloves and perform hand hygiene. Ensure the patient's comfort. Lower the bed, if it is not in the lowest position.	Removing gloves properly and performing hand hygiene reduces the risk for infection transmission and contamination of other items. Positioning promotes patient comfort and safety.
22. Remove additional PPE, if used. Perform hand hygiene.	Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.
23. Monitor the patient to detect febrile or pulmonary transfusion reactions for at least 4 to 6 hours; educate patients who are not under direct observation after their transfusion about signs and symptoms of delayed transfusion reaction and the importance of reporting.	This ensures early detection and prompt intervention. Delayed transfusion reactions can occur days to weeks or months after transfusion (Carman et al., 2018; DeLIsle, 2018).

Evaluation

The expected outcomes have been met when the patient has received the blood transfusion without any evidence of a transfusion reaction or complication, and the patient has exhibited signs and symptoms of fluid balance, improved cardiac output, and enhanced peripheral tissue perfusion.

Documentation

Guidelines

Document that the patient received the blood transfusion; include the type of blood product. Record the patient's condition throughout the transfusion, including pertinent data, such as vital signs, lung sounds, and the patient's subjective response to the transfusion. Document any complications or reactions and whether the patient had received the transfusion without any complications or reactions. Document the assessment of the IV site and any other fluids infused during the procedure. Document the transfusion volume and other IV fluid intake on the patient's intake and output record.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient experiences slight increase in temperature but is exhibiting no other signs of a transfusion reaction: Notify the health care team. Document and continue to monitor. A temperature increase of 1.8°F (1°C) or higher can be the first sign of a serious transfusion reaction, and the transfusion should be stopped (Suddock & Crookston, 2021).
Patient reports shortness of breath; on auscultation, you note crackles bilaterally in the bases: Compare vital signs and lung sounds with previous vital signs and lung sounds for this patient. Obtain a pulse oximetry reading. Notify the health care team. Anticipate a possible prescribed intervention for a dose of a diuretic or decrease in the rate of the transfusion. Document and continue to assess and monitor the patient for signs and symptoms of fluid overload.
Patient is febrile (temperature increase of 1.8°F [1°C] or higher), tachycardic, and reporting a headache and/or back pain or other sign/symptom of adverse reaction: Stop the transfusion immediately (Gorski et al., 2021; Hill & Derbyshire, 2021). Disconnect the infusion and administer an infusion of 0.9% sodium chloride using a new administration set at a keep-open rate. Notify the health care team and the blood bank/transfusion service. Administer medications as prescribed. Send the blood unit, administration set, and filter to the laboratory. Obtain additional diagnostic tests, such as blood and urine tests, based on facility policy and prescribed interventions. Document and continue to monitor.

Special Considerations

General Considerations

Do not add or infuse any other solutions or medications through the same administration set with blood or blood components and do not piggyback blood administration sets into other infusion administration sets (Gorski et al., 2021).
When rapid transfusion is required, a larger-sized catheter gauge is recommended (18 to 20 gauge) (Gorski et al., 2021).
CVADs are acceptable for blood administration (Gorski et al., 2021).
Computerized checking systems using bar codes/radio frequency identification devices/biometric scanning on blood products are being implemented to identify, track, and assign data to transfusions as an additional safety measure (Gorski et al., 2021; Hill & Derbyshire, 2021).
Transfusions of platelets should be administered over 1 to 2 hours (Gorski et al., 2021).
Transfusions of plasma should be administered as quickly as tolerated by the patient or over 15 to 60 minutes (Gorski et al., 2021).
Never warm blood in a microwave. Use a blood-warming device that is indicated for this purpose, following the manufacturer's directions for use (Gorski et al., 2021). A blood warmer should be used when indicated by patient history, clinical condition, and/or prescribed therapy/intervention. Blood warmers should also be used for large-volume transfusions (Suddock & Crookston, 2021), therapeutic apheresis exchange transfusions in patients known to have significant cold agglutinins, patients with clinically significant conditions, and for neonate exchange transfusions (Gorski et al., 2021).
External compression devices, if used for rapid transfusions, should be equipped with a pressure gauge, should totally encase the blood bag, and should apply uniform pressure against all parts of the blood container. Pressure should not exceed 300 mm Hg (Gorski et al., 2021). A large-gauge catheter (PIVC) may be more effective than a pressure device to achieve rapid infusion (Gorski et al., 2021).

Infant and Child Considerations

Use an appropriate and patent VAD for transfusion for infants and children; options include the umbilical vein (neonates) or a vein large enough to accommodate a 22- to 24-gauge catheter (Gorski et al., 2021).

Community-Based Care Considerations

Transfusion of blood products in a community-based setting may be appropriate for medically stable patients with chronic conditions (Garciá et al., 2018; Sharp et al., 2021) and have been associated with low rates of individual and system adverse events (Sharp et al., 2021).

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Skill 16-6

EVIDENCE FOR PRACTICE