blood administration

1. Administration of Blood Products
Packed Red
Cells
Dena Evans, MPH, BSN, CNE
Assistant Professor
Department of Nursing
The University of North Carolina at Pembroke
Slide 001

2. ABO Typing
Slide 002
ABO
Blood Type
Antigen
A
Antigen
B
Antibody
anti-A
Antibody
Anti-B
A yes no no yes
B no yes yes no
O no no yes yes
AB yes yes no no

3. Components

4. What can be transfused?
• Whole blood
• Plasma
• Albumin
• Thrombocytes
• Packed Red Cells

5. Comparisons
• Different components
• Different colors
• Different
administration
procedures

6. Why transfuse?
• Restore blood volume after hemorrhage
• Maintain hemoglobin levels in severe anemia
• Replace specific blood component.

7. Nursing Assessment
• You have just admitted a client from the ER. He
has D5W at 50mL/hr infusing through a 20G in
his (L) AC. He is pale, dyspneic, confused and
complains of weakness. Upon reviewing his new
labs you find his hemoglobin is 7g/dL and
hematocrit is 34%.
• What is your next action?

8. If we think ABCs…..
• Administer O2
• Call MD who says “Type, cross and infuse 1U PRBCs
over 2 hours, continue O2 @ 2L via NC, pre-medicate with
650 mg of Tylenol and 50mg of Benadryl 30 minutes
before administration .”
• Be aware that there is a difference between the order to
“Type and Cross” and the order to “Type, Cross and
Infuse.”

9. What will you need?
• Informed consent
– You cannot administer blood products without
first getting written informed consent from the
patient.
– Consent can be given for the entire hospital
stay or over a specified period of time
(outpatient).

10. Next
• Take a set of vital signs—Why?
– A temperature 100° or higher should be
reported to the MD even if it is pre-existing
– If a transfusion reaction occurs—this will be
important for careful assessment of the
situation

11. The right IV
• The size of the IV catheter is important.
• Too small = hemolysis = wasted infusion
• Need at least a 20G but preferably an
18G.

12. Tubing and Fluid
• Y-tubing
• A bag of NS (no other fluid—must be isotonic)
500 mL will suffice
• No other fluids or medications can be mixed in
this Y tubing
• Prime Y tubing with the NS

13. Next
• Go to the blood bank and get the blood
– Special procedures MUST be followed
– The Type and Cross paperwork (generated
when you sent the T/C order to the lab) must
be taken with you to pick up the unit of blood
– The paperwork has information which will be
matched up with the unit of blood in the blood
bank

14. Next
• Once in the blood bank, you tell the blood bank
employee that you are there for Mr. “X” blood.
• Following a particular order, the two of you will
verbally check her paperwork against your
paperwork against the data on the unit of blood.
• You will then be asked to sign a log book
indicating which unit you picked up.

15. Once on the Floor
• You MUST go through the same procedure with
another licensed nurse, one must be an RN.
• This is documented on paperwork you brought
with the unit of blood and that you will return with
the empty bag once the infusion is complete.

16. At the patient’s bedside
• The 5-Rights still apply here
• One difference—The addition of a bracelet from the lab
that was applied when they came to do the type and
cross.
• The verification includes patient name, hospital number,
transfusion number, ABO group and Rh type, donor
number, expiration date, and volume of blood. The
information on the blood tag is compared with that on the
blood bag itself, and the patient name on the blood tag is
compared to that of the name band and blood bank
identification band.

17. Timing
• You only have 4-hours to get the PRBCs
infused.
• Any blood not infused in 4-hours could become
contaminated.
• For this same reason, you must hang it within 30
minutes of your arrival to the floor.

18. Complications
• Volume overload
• Transfusion reactions
• Iron overload
• Infections

19. Types of Transfusion Reactions
• Acute hemolytic reactions (ABO incompatibility)
• Febrile reactions (leukocyte incompatability)
• Allergic reactions (reaction to plasma proteins—
IgM,IgA,IgD,IgG, IgE)
• Circulatory overload: Cardiac or renal insufficiency. Need
fluid balance assessment
• Sepsis: Improper handling/contamination

20. Most Common-ABO incompatibility
• Mislabeling and administering to wrong person
• Antibodies react to antigens
• Agglutination of cells occurs
• Blocks capillaries and therefore bloodflow
• Hemolysis of RBCs = free hemoglobin
• This hemoglobin is filtered by kidneys = hemoglobinuria
• Obstructs renal tubules = renal failure (flank pain)

21. Nursing Assessment During
Transfusion
• Observing for signs of transfusion reaction
• Fever, chills, elevation in temperature, nausea, itching, flank pain
• Will usually occur within the first 15 minutes of the infusion
• Note that this is when we conduct strict assessment (VS) of
the patient. Stay with the patient. Infuse slowly 2mL/min.
Elderly/cardiac—breath sounds. Lasix.
• Vitals signs per policy after first 15 but usually q15-30

22. What if the patient has a reaction? What are
your interventions?
• FIRST—Stop the transfusion
• Keep the line open with the 0.9% NS
• Call the MD and the blood bank
• Stay with the client. Monitor VS q 5minutes
• Prepare to administer emergency meds
• Collect urine specimen
• Return blood, bag, tubing, labels, transfusion record to
the blood bank

23. No reaction? Great
• Most patients who are not at risk of fluid overload
– 1 U over 2hours
– 1 U PRBCs = 250-350 mL
– How many mL/hour for a 250mL bag?

24. When you are done?
• Reasses the client– this includes vital signs and ordering another
H&H
• Complete paperwork (transfusion record)
– Vital signs
– Pre-medication
– Tolerance
– Time started/completed
– Transfusion reaction “yes” “No”
– This goes into the side of the blood bag and back to the lab.
Additional paperwork for nursing unit.

25. For your information
• There has been debate regarding the use of infusion pumps for
blood administration. Studies show (Houck & Whiteford, 2007;
Burch, 1991) that there is no clinically significant difference in blood
products administered via pump.
• Additionally, each unit of PRBCs should raise the hemoglobin at
least 1 gram (Simmons, 2003).
• Change usually seen 4-6 hours after transfusion

26. Questions

27. 1
• A client receiving PRBCs begins to vomit. The nurse takes the
client’s blood pressure and it is 90/50 from a baseline of 125/78
mm/Hg. The client’s temperature is 100.8° F orally from a baseline
of 99.2°F orally. The nurse determines that the client may be
experiencing which complication of blood transfusions?
– Septicemia
– Hyperkalemia
– Circulatory overload
– Delayed transfusion reaction

28. 2
• The nurse enters a client’s room to assess the client who began
receiving a blood transfusion 45 minutes earlier. She notes that the
client is flushed and dyspneic. On assessment, the nurse
auscultates the presence of crackles in the lung bases. The nurse
determines that this client most likely is experiencing which
complication?
– Bacteremia
– Hypovolemia
– Fluid overload
– Transfusion reaction

29. 3
• The nurse determines that the client is having a
transfusion reaction. After the nurse stops the
transfusion, which action should be immediately taken
next?
– Remove the IV line
– Run normal saline to keep the vein open
– Run a solution of 5% dextrose
– Obtain a culture of the tip of the catheter device
removed from the client

30. 4
• PRBCs have been ordered for a client with a low
hemoglobin and hematocrit. The nurse takes that clients
temperature before hanging the blood transfusion and
records 100.6°F orally. Which of the following is the
appropriate nursing action?
– Begin the transfusion as prescribed
– Delay hanging the blood and notify the MD
– Administer an antihistamine and begin the transfusion
– Administer two tablets of Tylenol and begin the
transfusion

31. 5
• The nurse is picking up a unit of PRBCs at the hospital
blood bank. After putting the pen down, the nurse
glances at the clock which reads 1:00. The nurse
calculates that the infusion must be started by:
– 1:30
– 2:00
– 2:30
– 3:00

32. 6
• The nurse has just obtained a unit of blood from the
blood bank to transfuse into a client as ordered. Before
preparing the transfusion, the nurse next looks for which
of the following members of the health care team to
assist in checking the unit of blood?
– Phlebotomist
– Medical student
– Registered nurse
– Blood bank technician

33. 7
• The nurse has obtained a unit of PRBCs from the blood
bank and has checked the bag properly with another
nurse. Before beginning the transfusion the nurse should
first:
– Assess vital signs
– Assess skin color
– Assess urine output
– Get the latest hematocrit level

34. 8
• The nurse has just received an order to transfuse a unit
of PRBCs for an assigned client. Approximately how
long will the nurse need to stay with the client to ensure
that a transfusion reaction is not occurring?
– 5 minutes
– 15 minutes
– 30 minutes
– 45 minutes

35. 9
• A unit of PRBCs has been prescribed for a client with low hemoglobin and
hematocrit levels. The nurse notifies the blood bank of the order and a
blood specimen is drawn from the client for typing and crossmatching. The
nurse receives a telephone call from the blood bank and is informed that the
unit of blood is ready for administration. Number the actions in order of
priority that the nurse should take to administer the blood:
– Hang the bag of blood
– Obtain the unit of blood from the blood bank
– Ensure that an informed consent has been signed
– Verify the physician’s order for the blood transfusion
– Insert an 18-19 gauge IV catheter into the client
– Ask a licensed nurse to assist in confirming blood compatibility and verifying client ID

36. References
• Houck, D. & Whiteford, J. (2007). Improving patient outcomes: Transfusion with infusion pump for peripherally
inserted central catheters and other vascular access devices. Journal of Infusion Nursing, 30(6), 341-344.
• Lewis, S.M., Heitkemper, M.M., & Dirsken, S.R. (2004). Medical surgical nursing: Assessment and management of
clinical problems. St. Louis: Mosby.
• Simmons, P. (2003). A primer for nurses who administer blood products. Medical surgical nursing, June 2003.