Definition of Blood Transfusion:
Introduction of whole blood, or components of blood (e.g. Plasma, erythrocytes) into the venous circulation.PURPOSES OF A BLOOD TRANSFUSION:
– To restore blood volume after hemorrhage/loss during surgery or trauma.
– Restore capacity of the blood to store O2
– Provide plasma factors to aid in clotting e.g. Fresh frozen plasma.
– Human RBCs have antigens and plasma has antibodies that can cause transfused blood to agglutinate or clot, which can be fatal.
E.g. Blood group A has anti B antibodies – if the client is given B type blood his antibodies will stick to the antigen receptors on the transfused blood – causing them to agglutinate or stick together causing severe reaction. Both antigens make AB
– Neither antigen makes O
– To avoid incompatibility we TYPE AND CROSSMATCH the blood sample of donor and recipient to get a compatable match.
– Type AB – UNIVERSAL RECIPIENT (No Anti A or Anti B antibodies)
– Type O – UNIVERSAL DONOR
Risks and Complications of Giving a Blood Transfusion:
a. Hemolytic Reaction
Occurs when blood is incompatable.
Can happen quickly.
Symptoms include: chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia and hypotension.
– Stop transfusion immediately.
– Run normal saline.
– Do vital signs, call MD.
– Documentation to blood bank.
– Remaining specimen to blood bank.
b. Febrile reaction
Sensitivity of client to WBC, platelets and protein.
Fever, chills, warm flushed skin, headache, anxiety and muscle pain.
– Discontinue transfusion.
– Give antipyretic.
– Notify physician.
c. Allergic Reaction
Sensitivity to plasma proteins.
Can be severe or mild.
Flushing, itching, urticaria, wheezing can progress to severe chest pain, SOB,
-Initially slow the transfusion.
-Call MD immediately.
-Give antihistamines as ordered.
-Continue to monitor patient.
-If reactions increase, stop transfusion immediately, do VS, call MD.
d. Circulatory Overload
Too much product given, or given too quickly.
Cough, dyspnea, crackles in lungs, tachycardia and hypertension.
– Stop infusion.
– Raise clients head.
– Administer O2.
– Call MD.
e. Sepsis or contaminated blood
High fever, chills, vomiting, diarrhea and hypertension.
– Stop transfusion.
– Call MD.
– Perform blood work as ordered.
– Patient may not show symptoms of contaminated blood e.g. HIV, hepatitis until later date. Patient must be aware of risk of transmission before giving transfusion.
1. Check doctor’s order for what product to transfuse.
2. Obtain consent.
3. Explain risks of procedure to patient.
4. Verify patient.
5. Provide client privacy.
6. Type and cross match client.
7. Obtain blood from blood bank or facility at hospital when ready.
8. Obtain blood administration set, Y tubing with filter and bag of normal saline.
9. Start IV for transfusion if not yet ready – gauge # 18 or # 20.
10. Prime tubing with normal saline.
11. Cover filter in drip chamber fully with NS and slightly above filter.
12. Obtain full set of Vital signs, BP, T, P, R.
13. Check blood from blood bank to clients wrist hand and hospital number for verification with another nurse CO – SIGN FORM IF NECESSARY.
14. Observe blood for date, type, Rh factor, abnormal color or deposits.
15. DO NOT ADMINISTER BLOOD IF IT DOES NOT MATCH WITH CLIENT NAME, NUMBER, AND TYPE OR LOOKS ABNORMAL.
16. Make sure blood is refrigerated until just before transfusion = not at room temperature for longer than 30 minutes.
17. Close all clamps on the Y tubing set.
18. Pierce the blood bag.
19. Hang from IV pole.
20. Open clamp from blood bag to drip chamber to allow for flow of blood transfusion.
21. Initially infuse very slowly for the first 20 minutes, approx. 20 drops per minute.
22. Observe client closely for any reaction.
23. Obtain VS to hospital policy.
Q 15 min X 2
Q 30 min X 2
Q hourly until done
24. Maximum time for transfusion is 4 hours, can be given over 2 – 3 hours in normal adult, however Doctor’s orders may specify time.
25. If client has reaction, follow directions as stated previously.
26. When transfusion is completed, remove bag, flush tubing
with NS, continue IV if ordered or remove or block IV off
as per order.
27. Document in vital signs sheet and nurse’s notes.
28. Follow hospital protocol to discard blood bag.
Documentation of Blood Product Transfusion
Vital Signs or Flow sheet
Intake and Output IV Record for Amount of Blood Absorbed
Date/Time Nurses Notes
Nov 25, 2006
0900 # 18 gauge IV initiated to left forearm. First unit #2343333 of PRBC initiated at 0830.
Patient tolerating transfusion well, no signs of reaction at this time. VS stable; patient informed to call nurse if any itching, discomfort, difficulty of breathing or other untoward signs occur. ———CQuttainah, RN
1230 Transfusion completed; client tolerated procedure well, no evidence of reaction, VS stable. IV NS restarted at 100cc/hr as per order.——— CQuttainah, RN
1300 Post transfusion CBC taken and sent to lab.———— CQuttainah, RN
Call MD with Results of Post Transfusion CBC