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.

* 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. Patient 2. Blood products before administering a transfusion (to prevent errors & potentially fatal reaction)

Two nurses must identify the:

1. Patient

2. 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.

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)

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

Equipments needed 2. I.V. pole 3. Gloves 4. Gown 5. Face Shield

2. I.V. pole

3. Gloves

4. Gown

5. Face Shield

Equipments needed 6. Multi-lead tubing

6. Multi-lead tubing

Equipments needed 7. Whole blood or packed RBC’s

7. Whole blood or packed RBC’s

Equipments needed 8. 250 ml of Normal Saline Solution

8. 250 ml of Normal Saline Solution

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

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

Equipments needed 10. optional: ice bag, warm compresses

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.

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 patient Make sure an informed consent has been signed Record baseline vital signs

Explain the procedure to the patient

Make sure an informed consent has been signed

Record baseline vital signs

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

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.

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 Procedure Compare the name & number on the patient’s wristband with those on the blood bag label.

Compare the name & number on the patient’s wristband with those on the blood bag label.

The Procedure Check 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.

Check 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.

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

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

Wash your hands.

Put on gloves, a gown, & a face shield.

Remove IV administration set and fluid from packaging

Remove IV administration set and fluid from packaging

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

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.

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.

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.

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.

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

The Procedure Hang the bags on the I.V. pole,

Hang the bags on the I.V. pole,

The Procedure open the clamp on the line of saline solution,

open the clamp on the line of saline solution,

The Procedure squeeze the drip chamber until it’s half full.

squeeze the drip chamber until it’s half full.

The Procedure If the patient doesn’t have an I.V. line in place, perform venipuncture, using a 20G or larger-diameter catheter.

If 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.

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.

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.

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.

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.

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

The Procedure Remain with the patient, & watch for the signs of a tranfusion reaction, such as fever, chills, & wheezing.

Remain 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.

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

The Procedure Infuse saline solution at a moderately slow infusion rate, & notify the doctor at once.

Infuse 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.

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.

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.

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.

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.

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

The Procedure Record the patient’s vital signs.

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.

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 .

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.

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

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.

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

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.

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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