BLOOD TRANSFUSIONSNursing Procedures and Policies

BEFORE THE TRANSFUSION Remember to…Identify your patientAssess patient’s history with transfusions and

previous reactions Note concurrent health problems Obtain medical order for pretransfusion

medication if necessary

Check that the patient’s blood has been typed and cross-matched Check the ABO group and Rh type compatibility

Begin IV line with normal salineReview the signs and symptoms of a transfusion

reaction with the patient Advise patient to report any chills, itching, hives, swelling,

rash, shortness of breath, fever, low back pain, nausea, or anything unusual

Use blood within 30 minutes after its arrival from the blood bank

Establish a baseline Obtain vital signs Auscultate lungs Assess for JVD

BEFORE THE TRANSFUSION Remember to…

BEFORE THE TRANSFUSION2 nurses must verify the following with the

medical record, patient ID band, and the blood product label:Medical order for blood transfusion Informed consentPatient identification numberPatient nameBlood group and typeExpiration date Inspection of blood product for clots or unusual

color

FIRST 15 MINUTES OF TRANSFUSIONBegin running the transfusion slowly

10 gtts/min

Stay with patientObserve patient for adverse effects

i.e. flushing, dyspnea, itching, hives, rash, or any unusual comments

At the end of15 minutes, reassess vital signs

AFTER THE FIRST 15 MINUTES OF TRANSFUSION If no adverse effects occur…Increase the flow rate as orderedAssess frequently for any signs of adverse

reaction i.e. restlessness, hives, nausea, vomiting, torso or

back pain, shortness of breath, flushing, hematuria, fever, chills, etc.

Infuse blood within 4 hours after its arrival from the blood bank to prevent risk for bacterial contamination

Monitor vital signs at regular intervals

IF YOU SUSPECT A REACTION...1. STOP blood transfusion2. Quickly replace the blood tubing with new IV

tubing primed with normal saline Slowly administer normal saline for IV infusion at 40

mL/hour

3. Carefully assess the patient Obtain vital signs and compare with baseline Assess respiratory status Assess for changes in mental status Make note of adverse reactions

4. Notify MD and blood bank

TRANSFUSION REACTIONSSigns and Symptoms

Type of Reaction Nursing Actions

HivesItchingUrticariaFlushingAnaphylaxis

Allergic reaction 1. Stop transfusion and maintain IV line with normal saline

2. Notify MD3. Administer

antihistamine parenterally as necessary

Allergic reactions are the most common type of transfusion reaction

TRANSFUSION REACTIONSSigns and Symptoms

Type of Reaction Nursing Actions

FeverChillsHeadacheMalaise

Febrile reaction 1. Stop transfusion and maintain IV line with normal saline

2. Notify MD3. Treat symptoms

TRANSFUSION REACTIONSSigns and Symptoms

Type of Reaction Nursing Actions

Immediate onsetFlushingFeverChillsHeadacheLow back painApprehensionDyspneaHypotensionShock

Hemolytic reaction 1. Stop transfusion and maintain IV line with normal saline

2. Notify MD3. Collect blood

sample from site4. Collect first voided

urine sample5. Treat shock if

present6. Send unit, tubing,

and filter to lab

TRANSFUSION REACTIONSSigns and Symptoms Type of Reaction Nursing ActionsDyspneaOrthopneaTachycardiaSudden anxietyJVDDry coughCrackles at the base of lungsHypertensionPulmonary edema

Circulatory overload 1. Slow or stop transfusion

2. Monitor vital signs3. Notify MD4. Elevate head of

bed and lower feet

TRANSFUSION REACTIONSSigns and Symptoms

Type of Reaction Nursing Actions

FeverChillsHypertensionDry, flushed skinAbdominal pain

Bacterial reaction 1. Stop transfusion2. Collect blood

culture from patient and return blood bag

3. Monitor vital signs4. Notify MD5. Administer

antibiotics

AFTER THE TRANSFUSIONObtain vital signsDispose properly of used materials Document:

Blood transfusion Type of blood product Patient’s reaction throughout transfusion

Vital signs Lungs sounds Patient’s subjective response

Complications Transfusion volume

ReferencesBlood transfusion bag [Online image]. (2009). Retrieved from http://americaninvetors.blogspot.com/ 2009/02/blood-transfusion.htmlBlood transfusions [Online image]. Retrieved from http://magazine.nursing.jhu.edu/2012/05/blood- transfusionIV normal saline [Online image]. Retrieved October 20, 2013 from http://www.keyhostnet.com/ safetynett5/index.php?route=product/product&product_id=153Nurses at the heart of transfusion safety [Online image]. (2011). Retrieved from http://thebloodytruth.com/nursing-the-art-and-science-of-safe-transfusionRedding, D. J. (2006). 060427-M-0000C-001 [Online image]. Retrieved October 20, 2013 from http:// www.1stmlg.marines.mil/Photos/tabid/8621/igphoto/252242/Default.aspxSmeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (12th ed., pp. 967-972). China: Wolters Kluwer Health.Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of Nursing (7th ed., pp. 1458-1460, 1482-1485). Philadelphia, PA: Wolters Kluwer Health.[Untitled image of blood bag and patient]. Retrieved from http://www.daviddarling.info/encyclopedia/B/blood_transfusion.html[Untitled image of sharps container]. Retrieved October 20, 2013 from https://www.armstrongmedical.com/index.cfm/go/product.detail/sec/1/ssec/8/cat/5/scat/ 14/fam/2305