Blood Transfusion

Nursing Procedure

*Whole blood transfusion replenishes the circulatories:

Volume Oxygen-carrying capacity

*Packed Red Blood Cells (RBCs) restores:

Oxygen-carrying capacity

Both treat decreased hemoglobin and hematocrit.

Two nurses must identify the:

1. Patient2. Blood products

before administering a transfusion (to prevent errors & potentially fatal reaction)

If a patient is a Jehova’s Witness, a transfusion requires special written permission.

Equipments needed

1. Blood recipient set (filter & tubing with drip chamber for blood, or combined set)

Equipments needed

2. I.V. pole3. Gloves4. Gown5. Face Shield

Equipments needed

6. Multi-lead tubing

Equipments needed

7. Whole blood or packed RBC’s

Equipments needed

8. 250 ml of Normal Saline Solution

Equipments needed

9. Venipuncture equipment, if necessary (should include 20G or larger catheter)

Equipments needed

10. optional: ice bag, warm compresses

Getting Ready

Avoid obtaining either whole blood or packed RBC’s until you’re ready to begin the transfusion

Prepare the equipment when you’re ready to start the infusion.

The Procedure

Explain the procedure to the patientMake sure an informed consent has

been signedRecord baseline vital signs

The Procedure

Obtain whole blood or packed RBCs from the blood bank within 30 minutes of the transfusion start time.

The Procedure Check the

expiration date on the blood bag, & observe for abnormal color, RBC clumping, gas bubbles, & extraneous material. Return outdated or abnormal blood to the blood bank.

The ProcedureCompare the name & number on the

patient’s wristband with those on the blood bag label.

The ProcedureCheck the blood bag

identification number, ABO blood group, and Rh compatibility.

Also, compare the patient’s blood bank identification number, if present, with the number on the blood bag.

The Procedure Identification of blood & blood

products is performed at the patient’s bedside by two licensed profesionals, according to the facility’s policy.

The ProcedureWash your hands.Put on gloves, a gown, & a face shield.

Remove IV administration set and fluid from packaging

Remove the cover from the selected spike and the cover from the bottle/bag of fluid.

The Procedure

Then insert the spike of the line you’re using for the normal saline solution into the bag of saline solution aseptically.

When fluid drips out of the end of the distal tubing turn off the infusion rate clamp.

The Procedure

Using a Y-type set, close all the clamps on the set.

The Procedure

Next, open the port on the blood bag & insert the other spike.

The Procedure

Hang the bags on the I.V. pole,

The Procedureopen the clamp on the line of saline

solution,

The Procedure squeeze the drip chamber until it’s

half full.

The ProcedureIf the patient doesn’t have an I.V. line

in place, perform venipuncture, using a 20G or larger-diameter catheter.

The Procedure

Avoid using an existing line if the needle or catheter lumen is smaller than 20G.

Ventral venous access devices also may be used for transfusion therapy.

The Procedure

If you’re administering whole blood, gently invert the bag several times to mix the cells.

The Procedure

Attach the prepared blood administration set to the venipuncture device, & flush it with normal saline solution.

The Procedure

Then close the clamp to the saline solution, & open the clamp between the blood bag & the patient.

The Procedure

Adjust the flow clamp closest to the patient to deliver the blood at the calculated drip rate.

The ProcedureRemain with the patient, & watch for

the signs of a tranfusion reaction, such as fever, chills, & wheezing.

The Procedure

If such sign develop, record vital signs and stop the transfusion.

The ProcedureInfuse saline solution at a moderately

slow infusion rate, & notify the doctor at once.

The Procedure

If no signs of a reaction appear within 15 minutes, you’ll need to adjust the flow clamp to the ordered infusion rate.

The Procedure

A unit of RBCs may be given over 1-4 hours as ordered.

The Procedure

After completing the transfusion, you’ll need to put on gloves & remove & discard the used transfusion equipment.

The Procedure

Then remember to reconnect the original I.V. fluid, if necessary, or disconnect the I.V. infusion.

The Procedure

Return the empty blood bag to the blood bank, & discard the tubing & filter.

The Procedure

Record the patient’s vital signs.

Practice Pointers

Although some microaggregate filters can be used for up to 10 units of blood, always replace the filter & tubing if more than 1 hour elapses between transfusions.

Practice Pointers

When administering multiple units of blood, use blood warmer to avoid hypothermia.

Practice Pointers

For rapid blood replacement, know that you may need to use a pressure bag.

Practice Pointers

If you’re administering packed RBCs with Y-type set, you can add saline solution to the bag to dilute the cells by closing the clamp between the patient & the drip chamber & opening the clamp from the blood

Practice Pointers

Then lower the blood bag below the saline solution container & let 30-50ml of saline solution flow into the packed cells.

Practice Pointers

Finally, close the clamp to the blood bag, rehang the bag, rotate it gently to mix the cells & saline container

Documenting Blood Transfusion

In your notes, record:Date & time of the transfusion.Type & amount of transfusion

product.Patient’s vital signs.Your check of all identification data.Transfusion reaction & nursing

actions taken.

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