BLOOD TRANSFUSIONS

Nursing Procedures and Policies

BEFORE THE TRANSFUSION

Remember to
Identify your patient Assess patients history with transfusions and previous reactions
Note concurrent health problems Obtain medical order for pretransfusion medication if necessary

Check that the patients blood has been typed and cross-matched
Check the ABO group and Rh type compatibility

BEFORE THE TRANSFUSION

Remember to
Begin IV line with normal saline Review the signs and symptoms of a transfusion reaction with the patient
Advise patient to report any chills, itching, hives, swelling, rash, shortness of breath, fever, low back pain, nausea, or anything unusual

Use blood within 30 minutes after its arrival from the blood bank Establish a baseline
Obtain vital signs Auscultate lungs Assess for JVD

BEFORE THE TRANSFUSION

2 nurses must verify the following with the medical record, patient ID band, and the blood product label:
Medical order for blood transfusion

Informed consent
Patient identification number Patient name Blood group and type

Expiration date
Inspection of blood product for clots or unusual color

FIRST 15 MINUTES OF TRANSFUSION

Begin running the transfusion slowly
10 gtts/min

Stay with patient

Observe patient for adverse effects

i.e. flushing, dyspnea, itching, hives, rash, or any unusual comments

At the end of15 minutes, reassess vital signs

AFTER THE FIRST 15 MINUTES OF TRANSFUSION

If no adverse effects occur
Increase the flow rate as ordered Assess frequently for any signs of adverse reaction
i.e. restlessness, hives, nausea, vomiting, torso or back pain, shortness of breath, flushing, hematuria, fever, chills, etc.

Infuse blood within 4 hours after its arrival from the blood bank to prevent risk for bacterial contamination Monitor vital signs at regular intervals

IF YOU SUSPECT A REACTION...

1. 2. STOP blood transfusion Quickly replace the blood tubing with new IV tubing primed with normal saline
Slowly administer normal saline for IV infusion at 40 mL/hour

3.

Carefully assess the patient

Obtain vital signs and compare with baseline Assess respiratory status Assess for changes in mental status Make note of adverse reactions

4.

Notify MD and blood bank

TRANSFUSION REACTIONS
Signs and Symptoms Hives Itching Urticaria Flushing Anaphylaxis Type of Reaction Allergic reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Administer antihistamine parenterally as necessary

Allergic reactions are the most common type of transfusion reaction

TRANSFUSION REACTIONS
Signs and Symptoms Fever Chills Headache Malaise Type of Reaction Febrile reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Treat symptoms

TRANSFUSION REACTIONS
Signs and Symptoms Immediate onset Flushing Fever Chills Headache Low back pain Apprehension Dyspnea Hypotension Shock Type of Reaction Hemolytic reaction Nursing Actions 1. Stop transfusion and maintain IV line with normal saline 2. Notify MD 3. Collect blood sample from site 4. Collect first voided urine sample 5. Treat shock if present 6. Send unit, tubing, and filter to lab

TRANSFUSION REACTIONS
Signs and Symptoms Dyspnea Orthopnea Tachycardia Sudden anxiety JVD Dry cough Crackles at the base of lungs Hypertension Pulmonary edema Type of Reaction Circulatory overload Nursing Actions 1. Slow or stop transfusion 2. Monitor vital signs 3. Notify MD 4. Elevate head of bed and lower feet

TRANSFUSION REACTIONS
Signs and Symptoms Fever Chills Hypertension Dry, flushed skin Abdominal pain Type of Reaction Bacterial reaction Nursing Actions 1. Stop transfusion 2. Collect blood culture from patient and return blood bag 3. Monitor vital signs 4. Notify MD 5. Administer antibiotics

AFTER THE TRANSFUSION

Obtain vital signs Dispose properly of used materials Document:
Blood transfusion Type of blood product Patients reaction throughout transfusion Vital signs Lungs sounds Patients subjective response Complications Transfusion volume

References
Blood transfusion bag [Online image]. (2009). Retrieved from http://americaninvetors.blogspot.com/ 2009/02/blood-transfusion.html Blood transfusions [Online image]. Retrieved from http://magazine.nursing.jhu.edu/2012/05/bloodtransfusion IV normal saline [Online image]. Retrieved October 20, 2013 from http://www.keyhostnet.com/ safetynett5/index.php?route=product/product&product_id=153 Nurses at the heart of transfusion safety [Online image]. (2011). Retrieved from http:// thebloodytruth.com/nursing-the-art-and-science-of-safe-transfusion Redding, D. J. (2006). 060427-M-0000C-001 [Online image]. Retrieved October 20, 2013 from http:// www.1stmlg.marines.mil/Photos/tabid/8621/igphoto/252242/Default.aspx Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths Textbook of Medical-Surgical Nursing (12th ed., pp. 967-972). China: Wolters Kluwer Health. Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of Nursing (7th ed., pp. 1458-1460, 1482-1485). Philadelphia, PA: Wolters Kluwer Health. [Untitled image of blood bag and patient]. Retrieved from http://www.daviddarling.info/ encyclopedia/B/blood_transfusion.html [Untitled image of sharps container]. Retrieved October 20, 2013 from https:// www.armstrongmedical.com/index.cfm/go/product.detail/sec/1/ssec/8/cat/5/scat/ 14/fam/2305