DEFINITION:

All intravenous administration of a component of blood or whole blood.

This can be categorized into 3 types:
 Homologous Transfusion - standard transfusion which random donors are used for
transfusion to other individuals.
 Autologous Transfusion - blood products donated by the patient for his own use.
 Direct Transfusion - blood products donated by an individual for transfusion to a
specified Recipient

PURPOSES:
 To increase blood volume after surgery, trauma/hemorrhage.
 To increase the number of RBC in patient with severe chronic anemia.
 To provide platelets for those with low platelet counts due to treatment and
chemotherapy.
 To provide clotting factors in plasma for patients with hemophilia or DIC (Disseminated
Intravascular Coagulopathy)).
 To replace plasma proteins such as albumin.
 To provide antibodies (IMMUNOTRANSFUSION) to those who are sick and having
lowered immunity by giving blood or plasma taken from person who have just
recovered from the same disease.
 To replace the blood with hemolytic agents with fresh blood (exchange blood
transfusion) as in case of erythroblastosis fetalis in hemolytic anemia etc.
 To combat infection in patients with leukopenia.
 To improve the leukocyte count of blood in agranulocytosis.
 Patient with cardiovascular failure, to increase blood volume and RBC while avoiding
cardiovascular overload.
EQUIPMENTS/SUPPLIES:
 Blood administration set, IV set
 Blood / Blood components
 NSS 500cc
 Antiseptic solution, tourniquet
 Disposable gloves, blue pads, alcohol swabs
 IV pole, small sharp container
 IV 3000 transparent dressing, cannula g. 16, 18, 20, 22
 Pressure pump (if needed)
 Infusion pump (optional)
 Armboard (if needed)

POLICIES:
 No blood should be transfused without proper typing, cross matching and screening.
 Prior to blood drawing for blood typing and cross matching, 1 phlebotomist and 1 nurse
or 2 nurses should verify patient’s identity.
 The doctor should countercheck and sign in the cross matching report Form M2028
 Obtain doctor’s order and client or family member consent, and explain about the needs
for blood transfusion.
 Blood received from blood bank should be started within 30 minutes which is at room
temperature, if not, return to blood bank with the filled up form blood returned to
blood bank information sheet M2043.
 Two (2) nurses or 1 nurse and 1 physician should verify the patient’s identity prior to the
administration of blood.
 Administration time should not exceed 4 hours because of the increase risk of bacterial
proliferation.
 Vital signs should be taken and monitored every 5 minutes for the first 15 minutes then
every 15 minutes for 30 minutes then hourly until the transfusion is finished.
 Identification label from the blood bag should not be removed until the transfusion is
completed.
 Blood components should not be mixed/primed with any solutions other than Normal
Saline.
 Used blood bag with the tubing should be saved for a period of 24 hours after
transfusion.
  If the patient is to receive more than 1 unit of blood, a new transfusion set should be
used per
 transfusion.
 Follow infection control measures.
o Perform hand-washing techniques before initiating blood transfusion.
o All blood units for transfusion should be screened appropriately to reduce the
risk of transmitting infectious diseases.
o All blood products should be assumed to be infectious and should be handled
with gloves.
 For any transfusion reaction identified, immediately discontinue the transfusion. Inform
the attending physician and fill-up an incident report.

PREPARATIONS:
 Assess:
o Manifestations of hypervolemia
o Status of infusion site
o Any unusual symptoms
o Vital signs for baseline data
 Determine:
o That a signed consent form was obtained
o Any known allergies or previous adverse reactions to blood
 Assemble equipment and supplies:
o Prepare the client.
o Instruct the client to report promptly any sudden chills, nausea, itching, rash,
dyspnea, back pain, or other unusual symptoms.
o If the client has an intravenous solution infusing, check whether the needle and
solution are appropriate to administer blood.

PROCEDURES:
 Check the doctor’s order and obtain client or family member’s consent for blood
transfusion.
 Identify correct patient by calling the patient full name and checking the ID band.
 Assess the patient’s condition, vital signs as baseline and any history of previous blood
transfusion reaction.
 Explain to the patient/relatives the procedure, approximate duration and desired
outcome of the transfusion.
 Wash hands, put on gloves.
 Prepare infusion site, select a large vein.
 If cannula is not present, prepare the site for venipuncture, insert cannula and start NSS
@ KVO rate.
 Remove gloves and wash hands.
 Obtain correct blood component for the client from blood bank and check for the
following:
 Check the physician’s order with the requisition.
 Check the requisition form and the blood bag label with a laboratory technician.
 Observe the blood for abnormal color, RBC clumping, gas bubbles, and extraneous
material.
 Return outdated or abnormal blood to the blood bank.
 With another nurse, compare the laboratory blood record with:
o The client’s name and PIN
o The number on the blood bag label
o The ABO group and Rh type on the blood bag label
o If any of the information does not match exactly, notify the charge nurse and the
blood bank.
o Do not administer blood until discrepancies are corrected or clarified.
o Sign the appropriate form with the other nurse
o Call the doctor to countercheck the blood and have him sign in the cross
matching report Form M2028.
o Assess the patient’s physical condition.
o Verify the client’s identity.
o Ask the client’s full name.
o Check the client’s ID band.
 Set up the infusion equipment.
o Ensure that the blood filter inside the drip chamber is suitable for whole blood or
the blood components to be transfused.
o Attach the blood tubing to the blood filter, if necessary.
o Put on gloves.
o Close all the clamps on the Y-set: the main flow rate clamp and both Y-line
clamps.
o Using a twisting motion, insert the piercing pin (spike) into a container of 0.9
percent saline solution.
o Hang the container on the IV pole about 1 m (36 in) above the planned
venipuncture site.
 Prime the tubing.
 o Open the upper clamp on the normal saline tubing, and squeeze the drip
chamber until it covers the filter and one-third of the drip chamber above the
filter.
o Tap the filter chamber to expel any residual air in the filter.
o Remove the adapter cover at the tip of the blood administration set.
o Open the main flow rate clamp, and rime the tubing with saline.
o Close both clamps.

 Prepare the blood bag.

o Invert the blood bag gently several times to mix the cells with the plasma.
o Expose the port on the blood bag by pulling back the tabs.
o Insert the remaining Y-set spike into the blood bag.
o Suspend the blood bag.
o Close the upper clamp below the IV saline solution on the Y-set.
o Open the clamp on the blood arm of the Y-set, and prime the tubing.

 Establish the blood transfusion.

o The blood will run into the saline filled drip chamber. If necessary, squeeze the
drip chamber to reestablish the liquid level with drip chamber one-third full.
o Readjust the flow rate with the main clamp.

 Observe the client closely for the first 5–10 minutes.

o Run the blood slowly for the first 15 minutes at 20 drops per minute.
o Note adverse reactions, such as chilling, nausea, vomiting, skin rash, or
tachycardia.
o Remind the client to call a nurse immediately if any unusual symptoms are felt
during the transfusion.
o If any of these reactions occur, report these to the nurse in charge, and take
appropriate nursing action.

 Document relevant data. Record:

o Starting the blood
o Vital signs
o Type of blood
o Blood unit number
o Sequence number
o Site of the venipuncture
 o Size of the needle
o Drip rate

 Observe for any transfusion reactions as follows.

o Circulatory Overload: dyspnea, cyanosis, sudden anxiety orthopnea, cough,
tachypnea, increased central venous pressure, crackles at the base of the lungs
and neck vein distention.
o Septic Reaction: Chills, fever vomiting, diarrhea, marked decreased in blood
pressure and shock.
o Anaphylactic (life threatening reaction): Urticaria, nausea and vomiting, chest
pain, anxiety, wheezing, hypotension and cardiac arrest.
o Hemolytic Reaction – the most dangerous type of transfusion reaction occurs
when the donor is incompatible with that of the recipient.
o Acute Hemolytic: Fever, chills, hypotension, nausea and vomiting, flushing,
tachycardia, tachypnea, anxiety, hemoglobinemia, hemoglobinuria, coagulation
disorder and renal failure.
o Delayed Hemolytic :Continued anemia, hemoglubinuria
o Febrile Nonhemolytic : Fever (>1oC), flushing, chills, headache, anxiety, muscle
pain.
o Graft-versus-host-disease - Normal donor lymphocytes reproduce in a recipient
who immunocompromised (e.g. patient’s receiving high dose of
chemotheraphy): Fever, skin rash, diarrhea, infection, liver dysfunction,
manifested by jaundice, bone marrow depression.

 Monitor the client.

o Fifteen minutes after initiating the transfusion, check the vital signs of the
client.
o If there are no signs of a reaction, establish the required flow rate.
o Do not transfuse a unit of blood for longer than 4 hours.

 Assess the client, including vital signs, every 30 minutes or more often, depending on
the health status, until 1 hour post-transfusion.
 If the client has a reaction and the blood is discontinued, send the blood bag to the
laboratory for investigation of the blood.
 If there is transfusion reaction:
o Stop transfusion immediately by keep IV line open with a saline solution in case
IV medication should be needed rapidly.
o Notify the physician.
o Monitor vital signs every 15 minutes.
o Send blood samples and collect urine sample for testing per doctor’s order.
o Return blood bag and tubing to blood bank with Blood Returned Blood Bank
Information Sheet (Form M2043) properly filled-up.
o Administer medication per doctor’s order.
o Fill-up the incident report for intensive investigation.

 After transfusion, flush with NSS 20-250 ml.

 Terminate the transfusion.
o Don clean gloves.
o If no infusion is to follow, clamp the blood tubing and remove the needle.
o 3.24.3If another transfusion is to follow, clamp the blood tubing and open the
saline infusion arm.
o If the primary IV is to be continued, flush the maintenance line with saline
solution.
o Disconnect the blood tubing system and reestablish the intravenous infusion
using new tubing.
o Save the used blood bag for 24 hours.
o Adjust the drip to the desired rate.
o Needles should be placed in a labeled, puncture-resistant container designed for
such disposal. Blood bags and administration sets should be bagged and labeled
before being sent for decontamination and processing.
o Monitor vital signs again.
o After care of equipment.
o Wash hands and remove gloves.

 Document the following:

o Completion of the transfusion
o Amount of blood absorbed
o The blood unit number
o Vital signs
o If the primary intravenous infusion was continued, record connecting it.
o Also record the transfusion on the IV flow sheet and Intake and Output record.
 o Charge the procedure and supplies used

SPECIAL CONSIDERATIONS:
 Make sure platelets/fresh frozen plasma are administered immediately when
obtained, and follow doctor’s order for the rate and maximum duration.
 Nurses must be aware of the appropriate measures to be done in case of any
untoward reaction occur. After transfusion, it should be flushed with 20-250 ml
of NSS.
 Metric volume measured set is the one being used as blood transfusion set in
Newborn.
 For newborn cases that need fresh frozen plasma transfusion, it is being
delivered via perfusion pump and regulated per doctor’s order.
Contraindications
o Platelet Transfusion:
 Disseminated intravascular disorder.
 Idiopathic thrombocytopenic purpura disorders causing rapid platelet
destruction.
o Albumin Transfusion :Severe anemia because of risk of cellular dehydration. (Should be
administered cautiously in cardiac and pulmonary disease because of the risk of
congestive heart failure from circulatory overload)
o Gamma Globulin Transfusion: Known hypersensitivity to it or an anti immunoglobulin
antibody (IgA).