Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
Name: ___________________________________________ Grade: _________
Year & Section: ____________________________________ Date: __________
Group No: ________________________________________
PROCEDURE CHECKLIST
BLOOD TRANSFUSION
PURPOSES
• To restore blood volume after severe hemorrhage
• To restore the oxygen-carrying capacity of the blood
• To provide plasma factors, such as antihemophilic factor (AHF) or factor VIII, or platelet concentrates,
which prevent or treat bleeding
ASSESSMENT
Assess
• Vital signs
• Physical examination including fluid balance and heart and lung sounds as manifestations of hypo- or
hypervolemia
• Status of infusion site
• Blood test results such as hemoglobin value or platelet count
• Any unusual symptoms
Equipment
• Unit of whole blood, packed RBCs, or other component
• Blood administration set
• IV pump, if needed
• 250 mL normal saline for infusion
• IV pole
• Venipuncture set containing a #14- to #22-gauge catheter (if one is not already in place)
• Alcohol swabs
• Tape
• Clean gloves
PLANNING
• Review the client record regarding previous transfusions. Note any complications and how they were
managed (e.g., allergies
or previous adverse reactions to blood).
• Confirm the primary care provider’s order for the number and type of units and the desired speed of
infusion.
• In some agencies, written consent for transfusion is required. Check policy and obtain as indicated.
• Know the purpose of the transfusion.
• Plan to begin the transfusion as soon as the component is ready. Typing and crossmatching can take
several hours.
• Note any premedication ordered by the primary care provider (e.g., acetaminophen or diphenhydramine).
Schedule their administration (usually 30 minutes prior to the transfusion).
IMPLEMENTATION
Preparation
• If the client has an IV solution infusing, check whether the IV catheter and solution are appropriate to
administer blood. The IV catheter size ranges between #14 and #22 gauge, and the solution must be normal
saline. Dextrose (which causes lysis of RBCs), Ringer’s solution, medications and other additives, and
hyperalimentation solutions are incompatible. Refer to step 6 below if the infusing solution is not
compatible.
• If the client does not have an IV solution infusing, check agency policies. In some agencies an infusion
must be running before the blood is obtained from the blood bank. In this case, you will need to perform a
venipuncture on a suitable vein (se Skill 52–1) and start an IV infusion of normal saline.
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
PERFORMANCE
PROCEDURE DONE NOT REMARKS
DONE
1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what you
are going to do, why it is necessary, and how he or she can participate.
Instruct the client to report promptly any sudden chills, nausea, itching,
rash, dyspnea, back pain, or other unusual symptoms.
2. Provide for client privacy and prepare the client.
• Assist the client to a comfortable position, either sitting or lying.
Expose the IV site but provide for client privacy.
3. Perform hand hygiene and observe other appropriate infection
prevention procedures.
4. Prepare the infusion equipment.
• Ensure that the blood filter inside the drip chamber is suitable for
the blood components to be transfused. Attach the blood tubing to
the blood filter, if necessary. Rationale: Blood filters have a surface
area large enough to allow the blood components through easily
but are designed to
trap clots.
• Apply gloves.
• Close all the clamps on the Y-set: the main flow rate clamp and
both Y-line clamps.
• Insert the piercing pin (spike) into the saline solution.
• Hang the container on the IV pole about 1 m (39 in.) above the
venipuncture site.
5. Prime the tubing.
• Open the upper clamp on the normal saline tubing, and squeeze
the drip chamber until it covers the filter and one third of the drip
chamber above the filter.
• Tap the filter chamber to expel any residual air in the filter.
• Open the main flow rate clamp, and prime the tubing with saline.
• Close both clamps.
6. Start the saline solution.
• If an IV solution incompatible with blood is infusing, stop the
infusion and discard the solution and tubing according to agency
policy.
• Attach the blood tubing primed with normal saline to the IV
catheter.
• Open the saline and main flow rate clamps and adjust the flow
rate. Use only the main flow rate clamp to adjust the rate.
• Allow a small amount of solution to infuse to make sure there are
no problems with the flow or with the venipuncture site.
Rationale: Infusing normal saline before initiating the transfusion
also clears the IV catheter of incompatible solutions or
medications.
7. Obtain the correct blood component for the client.
• Check the primary care provider’s order with the requisition.
• Check the requisition form and the blood bag label with a
laboratory technician or according to agency policy.
Specifically, check the client’s name, identification number, blood
type (A, B, AB, or O) and Rh group, the blood donor number, and
the expiration date of the blood. Observe the blood for abnormal
color, RBC clumping, gas bubbles, and extraneous material. Return
outdated or abnormal blood to the blood bank.
• With another nurse (most agencies require an RN), verify the
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
following before initiating the transfusion
a. Order: Check the blood or component against the primary care
provider’s written order.
b. Transfusion consent form: Ensure the form is completed per
facility policy.
c. Client identification: The name and identification number on
the client’s identification band must be identical to the name and
number attached to the unit of blood.
d. Unit identification: The unit identification number on the blood
container, the transfusion form, and the tag attached to the unit
must agree.
e. Blood type: The ABO group and Rh type on the primary label
of the donor unit must agree with those recorded on the
transfusion form.
f. Expiration: The expiration date and time of the donor unit
should be verified as acceptable.
g. Compatibility: The interpretation of compatibility testing must
be recorded on the transfusion form and on the tag attached to the
unit.
h. Appearance: There should be no discoloration, foaming,
bubbles, cloudiness, clots or clumps, or loss of integrity of the
container.
CLINICAL ALERT!
It is safer to have one nurse read the information for verification to the
other nurse; this avoids errors that can be made if both nurses look at
the tags together.
• If any of the information does not match exactly, notify the charge
nurse and the blood bank. Do not administer blood until discrepancies
are corrected or clarified.
• Sign the appropriate form with the other nurse according to agency
policy.
• Make sure that the blood is left at room temperature for no more than
30 minutes before starting the transfusion. Agencies may designate
different times at which the blood must be returned to the blood bank if
it has not been started.
Rationale: As blood components warm, the risk of bacterial growth
also increases. If the start of the transfusion is unexpectedly delayed,
return the blood to the blood bank after 30 minutes. Do not store blood
in the unit refrigerator.
Rationale: The temperature of unit refrigerators is not precisely
regulated and the blood may be damaged.
8. Prepare the blood bag.
• Invert the blood bag gently several times to mix the cells with the
plasma. Rationale: Rough handling can damage the cells.
• Expose the port on the blood bag by pulling back the tabs.
• Insert the remaining Y-set spike into the blood bag.
• Suspend the blood bag.
9. Establish the blood transfusion.
• Close the upper clamp below the IV saline solution container.
• Open the upper clamp below the blood bag. The blood will run
into the saline-filled drip chamber. If necessary, squeeze the drip
chamber to reestablish the liquid level with the drip
chamber one third full. (Tap the filter to expel any residual air
within the filter.)
• Readjust the flow rate with the main clamp.
• Remove and discard gloves.
• Perform hand hygiene
10. Observe the client closely for the first 15 minutes.
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
• Phillips and Gorski (2014) report that the AABB recommends that
“transfusions of RBCs be started at 1–2 mL/min for the first 15
minutes of the transfusion”
Rationale: This small amount is enough to produce a severe
reaction but small enough that the
reaction could be treated successfully.
• Note adverse reactions, such as chills, nausea, vomiting, skin rash,
dyspnea, back pain, or tachycardia.
Rationale:
The earlier a transfusion reaction occurs, the more severe it tends
to be. Promptly identifying such reactions helps to minimize the
consequences.
• Remind the client to call a nurse immediately if any unusual
symptoms are felt during the transfusion such as chills, nausea,
itching, rash, dyspnea, or back pain.
• If any of these reactions occur, report these to the nurse in charge,
and take appropriate nursing action.
11. Document relevant data.
• Record starting the blood, including vital signs, type of blood,
blood unit number, sequence number (e.g., #1 of three ordered
units), site of the venipuncture, size of the catheter, and drip rate.
SAMPLE DOCUMENTATION
1/21/2015 1400 1 unit of PRBCs (#65234) hung to be infused over 3
hours. IV site in (L) forearm with 20 G angiocath. VS taken (see
transfusion record). Informed to contact nurse if begins to experience
any discomfort during transfusion. Stated he would use the call light
–––––––––––––––––––––––––––––––––––––––––– C. Jones, RN
12. Monitor the client.
• Fifteen minutes after initiating the transfusion (or according to
agency policy), check the vital signs. If there are no signs of a
reaction, establish the required flow rate. Most adults can tolerate
receiving one unit of blood in 1.5 to 2 hours. Do not transfuse a unit
of blood for longer than 4 hours.
• Assess the client, including vital signs, per agency policy. If the
client has a reaction and the blood is discontinued, send the blood
bag and tubing to the laboratory for investigation of the blood.
13. Terminate the transfusion.
• Apply clean gloves.
• If no infusion is to follow, clamp the blood tubing. Check agency
protocol to determine if the blood component bag needs to be
returned or if the blood bag and tubing can be disposed of in a
biohazard container. The IV line can be discontinued or capped
with an adapter or a new infusion
line and solution container may be added. If another transfusion is
to follow, clamp the blood tubing and open the saline infusion arm.
Check agency protocol. A new blood administration
set is to be used with each component
• If the primary IV is to be continued, flush the maintenance
line with saline solution. Disconnect the blood tubing system
and reestablish the IV infusion using new tubing. Adjust the
drip to the desired rate. Often a normal saline or other solution
is kept running in case of delayed reaction to the blood.
• Measure vital signs.
14. Follow agency protocol for appropriate disposition of the used
supplies.
• Discard the administration set according to agency practice.
• Dispose of blood bags and administration sets.
a. On the requisition attached to the blood unit, fill in the time the
transfusion was completed and the amount transfused.
Republic of the Philippines
CAMARINES SUR POLYTECHNIC COLLEGES
Nabua, Camarines Sur
COLLEGE OF HEALTH SCIENCES
b. Attach one copy of the requisition to the client’s record and
another to the empty blood bag if required by agency policy.
c. Agency policy generally involves returning the bag to the blood
bank for reference in case of subsequent or delayed adverse
reaction.
• Remove and discard gloves.
• Perform hand hygiene.
15. Document relevant data.
• Record completion of the transfusion, the amount of blood
absorbed, the blood unit number, and the vital signs. If the primary
IV infusion was continued, record connecting it. Also record the
transfusion on the IV flow sheet and intake and output record.
SAMPLE DOCUMENTATION
4/21/2015 1420 c/o feeling warm, headache, & backache. Skin flushed.
T 102.6°F, BP 140/90, P 112, R 28. Approximately 50 mL PRBCs
(#65234) infused over past 20 minutes. Infusion stopped. IV tubing
changed, NS infusing at 15 mL/hr. Blood & attached tubing sent to
blood bank. Dr. Riley notified. –––––––––––––– C. Jones, RN
EVALUATION
• Perform follow-up based on findings or outcomes that deviated from expected or normal for the client. Relate
findings to previous data if available.
• Report significant deviations from normal to the primary care provider.
Clinical Instructor: ________________________
