reviewer

1. INITIATING,MAINTAINING ANDTERMINATING
A BLOOD TRANSFUSIONUSING A Y-SET
DefinitionofBlood Transfusion
 A bloodtransfusionisthe transferof
bloodor bloodproductsfromone
person(donor) intoanotherperson's
bloodstream(recipient).
 Thisis usuallydone asa life saving
procedure toreplace bloodcellsor
bloodproductslostthroughsevere
bleeding,duringsurgerywhenblood
lossoccurs or to increase the blood
count inan anemicpatient
BLOOD GROUPS
 Human bloodiscommonlyclassified
intofourmain groups
• Type A
• Type B
• Type AB
• Type O
> The surface of an individual’sredbloodcells
containsa numberof proteinsknownas
antigenand consideredasunique for each
person
 Antigenspromote agglutinationor
clumpingof bloodcells,theyare also
knownas agglutinogens
 The A antigenispresentonthe RBCs of
people withbloodgroupA
 The B antigenispresentinpeoplewith
bloodgroupB
 Both A and B antigensare foundonthe
RBC on the RBC surface inpeople with
groupAB blood.
 Neitherantigenispresentinpeople
withgroupO blood
 People withbloodgroupA have B
antibodies(agglutinins);A antibodies
are presentinpeople withbloodgroup
B and people bloodgroupOhave
antibodiestobothA and B antigens
• Type O -Type O bloodisthe universal
bloodtype andis the onlybloodtype
that can be transfusedtopatientswith
otherbloodtype
BLOOD TYPING AND CROSSMATCHING
 To avoidtransfusionincompatible red
bloodcells,bothblooddonorand
recipientare typedandtheirblood
crossmatched
 Bloodtypingisdone to determinethe
ABO bloodgroupandRh factor (
RHESUS) status.
 Thistestis alsoperformedonpregnant
womenandneonatestoassessfor
possible intrauterine exposure of either
to an incompatiblebloodtype
 Crossmatchingisalsonecessary
because bloodtypingonlydetermines
the presence of the majorABO andRH
antigens.
SELECTION OF BLOOD DONORS:
 Selectionisrigorous
 Criteriahave beenestablishedto
protectthe donor frompossible ill
effectsof donationandtoprotectthe
recipientfromexposure todiseases
transmittedthroughthe blood
Donorsare eliminatedbyahistoryof:
 Hepatitis
 HIV infection
 Heart disease,mostcancers
 Severe asthma

2.  Bleedingdisorders
 Convulsion
 Historyof malaria
 Highor lowbloodpressure
 Pregnant
 Takingcertaindrugs
 6. ClottingFactorsand Cryoprecipitate
> Usedfor clientswithclottingfactor
deficiencies.Eachprovidesdifferent
factors involvedinthe clottingpathway;
cyoprecipitate alsocontainsfibrinogen
REACTION:CAUSE
HemolyticReaction:
Incompatibilitybetweenclient’sbloodand
donor’sblood
CLINICAL SIGNS
> Chills,fever,headache,backache dyspnea,
cyanosis,chestpain,tachycardia,hypotension
NURSING INTERVENTION
1. Discontinue the transfusion
immediately.
REACTION:CAUSE
Febrile reaction:sensitivityof the client’sblood
to white bloodcells,plateletsorplasma
proteins
CLINICAL SIGNS
> Fever,chills,warm, flushedskin;headache,
anxiety,muscle pain
NURSING INTERVENTION
2. Maintainvascular accesswithnormal saline,
or accordingto agency protocol
3. Notifythe primarycare provider
immediately.
Monitorvital signs.
Sendthe remainingblood,bag,filtertubing,a
sample of the client’sbloodandaurine sample
to the laboratory
4. Documentthe findingsandactionstakenon
the client’schart.
1. Discontinue the transfusion
immediately
2. Give antipyreticsasordered.
3. Notifythe primarycare giver
immediately
4. Keepthe veinopenwithanormal saline
solution

3. REACTION:CAUSE
Allergicreaction(mild);sensitivityto
infusedplasmaproteins
Allergicreaction(severe);
Antibody-antigenreaction
CLINICAL SIGNS
Flushing,itching,urticaria,bronchialwheezing
Dyspnea,chestpain,circulatorycollapse,
cardiac arrest
NURSING INTERVENTION
1. Stopor slowthe transfusiondepending
on agencyprotocol
2. Notifythe primarycare provider
3. Administermedication( antihistamine)
as ordered
1.Stop the infusion.
2.Keepthe veinopenfornormal saline.
3.Notifythe primarycare provider.
4. Monitor vital signs. Administer
cardiopulmonaryresuscitationif needed
5. Administermedicationsandor/oxygenas
ordered
REACTION:CAUSE
CirculatoryOverload
Sepsis;contaminatedblood
administered
CLINICAL SIGNS
Cough,dyspnea,crackles(rales),distendedneck
veins,tachycardia,hypertension
Highfever,chills,vomiting,diarrhea,
hypotension
NURSING INTERVENTION
1. Place the clientupright,withfeet
dependent.
2. Stopor slow the infusion.
3. Notifythe Primarycare provider
4. Administerdiureticsasordered.
1.Stop the infusion.
2.Keepthe veinopenwithanormal saline
infusion.
3.Notifythe primarycare provider.
4.AdministerIV fluids,antibiotics
5.Obtaina bloodspecimenfromthe clientfor
culture.
6.Sendthe remainingbloodandtubingtothe
laboratory
ADMINISTERING BLOOD
Special precautions:
1. Once transfusionisordered,obtainthe
bloodfromthe bloodbankjustbefore
startingthe transfusion.
2. Administerbloodwithin4hours.
3. Use #18 to #20 gauge IV needle or
catheter
4. A Y-type bloodtransfusionsetwith an
inline or addon filterisused
5. One arm of the administrationset
connectsto the blood;normal saline
(0.9% NaCl) isattachedto the otherarm
of the Y-type set.
6. Checkthe client’svital signs15minutes
before the infusion.
Assessment:

4. 1. Verify/Check the doctor’sorqualified
practitioner’sorderforthe transfusion.
Rationale:
 Bloodmustbe orderedbya physician
or qualifiedpractitioner
 To ensure thatthe rightorderis carried
out at the right time forthe right
patient
2. Client’slevel of consciousnessandlevelof
knowledge andunderstanding
Rationale: To determine the client’sabilityto
followinstructionsandpromote cooperation
duringthe procedure
3. If the clienthasalreadysignedthe consent
form.
Rationale: Providesastructure fora patientto
make an informedchoice regardingthe
indications,risks,possiblealternativesand
benefitsof abloodtransfusion
4. Client’spotential riskstobleedingdisorders.
Rationale: To avoidlocal ecchymosesand
hemorrhagiccomplications.
5. Disease orinjuryto extremity
Rationale: Patientswithvasculardisease or
dehydrationmayhave limitedvenousaccess.
6.Checkthe client’svital signs.
Rationale:
 To serve as a baseline dataforfurther
medical managementforboththe
doctor’sand nurse.
 Allows detectionof areactionbyany
change in vital signsduringthe
transfusion.
7.Healthworker’sandclient’sallergytolatex.
Rationale: To helpthe nurse toselecttype of
materialsandto preventallergicreactions.
8. Availability,sterilityandintegrityof the
neededmaterials
Rationale: To save the nurse’stime andenergy
and to preventinfection.
PROCEDURE IMPLEMENTATION
1.Obtainthe bloodproductfrom the bloodbank
within30 minutesof initiation.
Rationale: Preventsbacterial growthand
destructionof redbloodcells
2.Wash handsand wearcleanglovesandother
Personal ProtectiveEquipment.
Rationale: To protectthe nurse and clientby
reducingthe transmissionof bacteriaand
microorganisms.
3.Identifythe clientwithanothernurse taking
notesof the following:
a.Client’sname,blood,group,Rhtype
b.Cross-matchcompatibility
c.Donor’sbloodgroupand Rh type
d.Unitand hospital number/casenumber
e.Expirationdate andtime onbloodbag
f.Type of bloodproductcomparedwith
physician’sorqualifiedpractitioner’sorder
g.Presence of clotsinthe blood.
Note:This should be done at the client’sbed
side.
Rationale: Strictverificationprocedureswill
reduce the riskof administeringbloodproduct
to the wrongpatient.If there isan error during
thisprocedure,notifythe bloodbankanddo
not administerthe product.

5. 4.Gather the necessarymaterialsandarrange at
the client’sbedside table.
Rationale:
>Savestime andeffort.
>Avoidsleavingthe clientunattendedto
retrieve missingmaterials.
>Promotesclient’ssafety.
a.Hypotray to holdthe materials
b. Bloodproduct
Close the doorand draw the curtaindivider.
Rationale: To promote client’sprivacy.
6.Raise the bedto its’comfortable level and
lowerthe siderailswhere youwill workandput
away call light.
Rationale:
>Helpsthe nurse to workat ease.
>Preventsstrainatthe nurse’sback.
7.Do hand rub andwear cleangloves.
Rationale: Preventscontaminationand
transmissionof microorganism.
8.Openbloodadministrationkit,invertthe
bloodbag gentlyseveral timestomix the cell
withinthe plasmaandmove rollerclampto
“off”position.
Rationale: Closedrollerclampsprevent
accidental spillingof blood.
9.Spike bloodunitwiththe plasticspike
Rationale: Itwill attach the tubingtobloodunit.
10.Hang the bloodunitonthe IV stand/pole 3ft
(1meter) above the client.
Rationale: To ensure there isenoughpressure
to keepthe bloodrunningata constant rate.
11.Squeeze dripchamberandallow the filterto
fill withblood.
Rationale: A correctlyfilleddripchamber
enablesanaccurate drip count.
12.Openrollerclampand allow tubingtofill
withbloodtothe hub.
Rationale: Preventsairfrombeingforcedinto
the vein
13.Prime anotherIV tubingwithnormal saline
and piggybackitto the bloodadministrationset
witha needle andsecure all connectionswith
tape.
Rationale: The bloodproductshouldnotbe
piggybackedintothe normal saline line toavoid
forcingbloodcellsthroughbotha needle anda
venouscatheter.
14.Attach tubingto venouscatheterusing
sterile precautionsandopenrollerclamp.
Rationale: Allowsthe bloodproducttobe
infusedintothe client’svein
15.Infuse the bloodat the followingrate:2-5
ml/minaccordingtothe physician’sorqualified
practitioner’sorder.
Rationale: Packedredbloodcellsusuallyrun
over1 ½ to 2 hours,whole bloodover2-3
hours.
16. Stay withthe clientforfirst15 to 30
minutes,monitoringvital signsevery5minutes
for 15 minutes,then every 15 minutesfor1
hour thenhourlyuntil 1hour afterthe infusion
iscompleted.
Rationale: If a reactionoccurs, itgenerally
happensduringthe first15 to 30 minutes.
Changesto vital signscanwarn of a transfusion
reaction.
17.Afterbloodhas infused,allow the tubingto
clearwithnormal saline.

6. Rationale: The clientwill receive all of the blood
that isleftinthe tubing.
Termination/Removal of Blood Tranfusion:
1. Planning:
1.Checkthe doctor’s order.
 Rationale:Toensure thatthe right
orderis carriedout at the righttime for
the right patient
2.Gather the neededmaterials:
Rationale:
>Savestime andeffort.
>Avoidsleavingthe clientunattendedto
retrieve missingmaterials.
Procedure:
1.Identifythe patient,introduce self and explain
the procedure.
Rationale:
>To preventerrorsinperformingprocedureson
the wrong patient
>To preventclient’sanxietyandgainclient’s
trust andcooperation
2.Put the hypotray on the client’sbedside table
3.Close the dooror draw the curtains
Rationale: To promote client’sprivacy.
4.Raise the bed,lowerthe siderailswhere you
will workandput awaythe call light
Rationale:
>Helpsthe nurse to workat ease.
>Preventsstrainatthe nurse’sback.
5. Do handrub and wearcleangloves
Rationale: Preventscontaminationand
transmissionof microorganism.
6. Close the rollerclamp.
Rationale:Closedrollerclampsprevent
accidental spillingof blood.
7. Gentlyrub the plasteronthe client’sskin
usingcottonball withalcohol,liftthe plaster
one by one.Discardthe usedcotton ballsona
waste receptacle.
Raionale:To minimizeskinirritationduring
removal of plaster.
8. Remove the needle bypressingitwithapiece
of sterile gauze,avoidtouchingthe surface that
comesincontact withthe IV site,andgently
pull off the needle withyourdominanthand.
Put the needle ontopof the hypotray with
lining.
Rationale: Applyingpressure dressingcan
minimize painandpossible bleedingfromthe IV
site duringandafterremoval of the needle
9.Secure the gauze with3 stripsof plaster.
Rationale: To secure the dressingsinplace.
10. Lowerthe bed,raise the siderailsandplace
the call lightwithinclient’sreach.
Rationale: To promote client’scomfort,safety
and privacy/
11. Gather the nonreusable materialsand
discardproperly,rearrange the reusable onesto
itsproperplaces.Usedneedlesshouldbe
placedinneedle receptacles.
Rationale:
 To maintainthe orderlinessand
cleanlinessof the area.
12.Bring back the emptybloodbag,BT set and
needles tothe bloodbank.
Rationale: Thisisbasedon the hospital’spolicy
regardingthe properdisposal of useditems.

7. 13. Remove gloves,discardproperlyandwash
hands.
Rationale:Topreventthe spreadof micro
organism.
14.Evaluate client’sresponsetothe procedure
15.Documentthe procedure onthe client’s
chart as well asotherpertinentdata.
Rationale
>Timelydocumentationhelpstoensure patient
safety.
>Providesrecordof the client’scare andserves
as a baseline forfurthermanagement.
Include inthe Documentation:
• Time infusionstarted
• Vital signs
• Bloodtype
• Bloodunitserial number
• Site of venipuncture
• Needle gauge
• Drip rate
• Patientassessmentfindingsand
tolerance toprocedure