Blood Transfusion Blood transfusions is the introduction of whole blood or components of the blood into the venous circulations.

. Equipments: Blood or blood component product Blood administration set Container of 0.9% NaCl solution IV pole Venipuncture set- usually a 19 or 18 gauged needle is used Tourniquet Alcohol swabs Tape Gloves

Procedure: 1. Verify the doctors order. Should be checked by 2 registered nurses. 2. Check if consent has been signed. 3. Obtain and document baseline vital signs: BP, Temperature, RR, PR, any previous reaction to a blood transfusion, specific signs to the clients pathology and reason for the transfusion 4. Prepare the client o Explain the procedure and its purpose o Instruct to report any sudden chills, nausea, itching, rash, dyspnea or other unusual symptoms. o Request for the blood product depending on hospital protocol. o If the client has an IV solution, check if the infusion set, the solution and the needle is compatible with blood transfusion. A blood set with a blood filter, gauge 18 or 20 needle & a 0.9% NaCl is recommended. Any other or medications is incompatible. o If there is no existing IV line suitable for blood transfusion, start venipuncture using gauge 18 or 20 IV cannula.

o Consult with the primary physician for the need for a double intravenous line if the existing IV line is not suitable for blood transfusion. 5. Prepare the equipments 6. Obtain the correct blood product ordered for the client. Check the: o Blood type o Rh group o The blood donor number o Expiration date o Abnormal color, dark color, cloudiness o ABC clumping o Gas bubbles o Extraneous materials 7. Type and cross match the blood, 2 RNs should verify the following on the cross match result: o Clients name and Identification number o The serial number on the blood bag label. o The ABO group & Rh on the blood bag label. 8. Verify the clients identity- ask the client to state his/her full name. check arm band if present. 2 RNs are also required for verification. 9. Recheck the physicians order for any pre blood transfusion medications/instructions. 10. Wash hands. 11. Setting up the equipment and establishing the blood transfusion: Administering blood using a Y set: o After inserting a G18/G20 IV line using a y set, attach 0.9% NaCl solution to one of the two spikes and prime the tubings. Connect the blood product to the spike only after patent IV line is established. o Wash hands. o Put on gloves. o Prepare the blood bag.

o Blood products should be transfused within 30 minutes after exposure to room temperature. RBC hemolysis begins after 2 hours of exposure to room temperature. Hemolysis of RBC could cause release of potassium into the blood stream which can result of hyperkalemia. Prolonging the exposure to room temperature could also increase the risk of bacterial growth in the blood product. o Warming the blood product to room temperature is done by wrapping it with clean towel or using the hospital blood warmer if available. o Invert the blood bag gently several times to mix the cells. Rough handling can damage the cells. o Connect the blood product to the other end of the tubing. The clamp near the spike and the clamp below the drip chamber should be closed prior to the insertion. o Open the clamp near the spike first and then allow the blood product to drip into the saline filled drip chamber. Once drip chamber is 1/3 full, open the clamp below the drip chamber. 12. Regulate flow rate slowly to about 5ml/min or 20gtts/min for the first 15 mins. 13. Stay with client and observe him/her closely for 15-30 minutes. 14. Obtain and document vital signs every 15 minutes after infusion has started. Take note of any adverse reaction. Ask the client if she/he feels anything unusual. 15. If transfusion reaction occurs, close the transfusion immediately, run 0.9 NaCl at 10gtts/min and do quick assessment and intervention and immediately report to the attending physician. 16. If no untoward effects are observed, regulate the flow rate according to blood product protocols. o Most adults can tolerate receiving up to 1 unit in 1-2 hours. o For elderly, infusion should be slower, 1 unit should be transfused over 34 hours or depending on the hospital and blood product protocols. o Do not transfuse a unit of blood for more than 4 hours. 17. Invert the bag every once in a while to mix solid and liquid elements.

18. Wash hands. 19. Obtain and document vital signs every 30 minutes for 1 hour until transfusion is complete. Continue monitoring every hour for the next 3 hours after the infusion. 20. Ask the client to report any signs and symptoms for post transfusion reaction. 21. If more than 1 unit of blood is required, use a new blood administration set for every unit of blood that follows. 22. Follow up post blood transfusion orders such as requesting blood examinations to determine effectiveness of the transfusion. Like repeat CBC 6 hours post BT. 23. Document all relevant data.

Termination of the blood transfusion 1. Check the doctors order and the chart if transfusion is already completed. 2. Wash hands and wear clean gloves. 3. If no more transfusion follows, terminate the blood line similar to that termination an IV line. 4. If the primary IV is to be continued, flush the maintenance line with the saline solution. Discontinue the blood tubing system from the primary system and then regulate to the prescribed rate. 5. Discard blood bag and blood transfusion set per hospital protocol. 6. Remove gloves and then wash hands. Again monitor vital signs for any delayed or untoward reactions. 7. Document any relevant data.