Transfusing Blood and Blood Products
Points to Remember
- Blood and Blood products are to be administered by the RN
- Only NS may be used in conjunction with administering blood and blood products
- Product instructions will be on the packet stating the maximum number of units that can be administered through a single filter.
- Do not infuse any medication into the client via the blood IV tubing.
- All blood products require a filter.
- Most of the time, blood will be given via a pump.
- Be sure to complete all vital signs and transfusion records. You will need a set of baseline vital signs before administering the blood.
- You may have a separate flow sheet for administering blood products. See your facilities policy and procedure manual.
- Each client must have a type and screen and crossmatch in the lab prior to obtaining a blood product. Each type and screen is only good for 72 hours.
- Verification occurs in the blood bank and on the floor. A designated person in the blood bank verifies with the RN, and the RN verifies with another RN at the bedside. See your hospital’s policy and procedure manual for specific details; however, the following verifications must be made: the client’s name, date of birth, blood bank number, unit number, expiration date of unit of blood or blood product, blood type and group, primary healthcare provider’s order.
- Check blood product for any signs of abnormalities.
- You will need a primary healthcare provider’s order to administer blood or blood products.
- Signed consent form from the client (or the next of kin if the client is unable to sign the form). It is the primary healthcare provider’s responsibility to have the consent form signed and to explain to the client and/or family the need and possible side effects.
- Initially begin infusion slowly and observe client closely especially for the first 15 minutes of the infusion. If no reaction is observed, infusion rate may be increased. The rate will depend on the condition of the client. You will not want to infuse the blood quickly if you have a client that is elderly, has any type of heart or kidney condition or someone very young.
- Infusion of the blood should be started within 30 minutes of receiving the blood from the blood bank.
- All blood from each unit must be completed within a 4 hour time frame. If the unit of blood is not completed in a 4 hour time frame the blood must be discarded.
- Dispose of blood tubing and blood or blood product bag according to hospital policy.
- Be sure to flush lines after transfusing blood or blood product with 0.9% normal saline.
- Document administration of blood transfusion according to hospital policy.
Signs of Transfusion Reaction
- Chest pain
- Hives or skin rash
- Hypotension/Hypertension
- Fever
- Chills
- Anxiety
- Wheezing
- Headache or muscle pain with fever
- Flushing
- Back pain
- Dizziness
- Itching
- Urticaria
- Tachycardia
- Tachypnea
- Dyspnea
- GI symptoms: nausea and vomiting
If an adverse reaction occurs you should:
- Discontinue the transfusion IMMEDIATELY.
- Remove blood and blood tubing set.
- Check your facility’s policies and procedure manual. You may have to return the blood and tubing to the blood bank.
- Start normal saline with new primed tubing at keep vein open rate.
- Check and document vital signs. Stay with client.
- Notify primary healthcare provider and monitor client closely for anaphylaxis.
- Notify lab/ blood bank of transfusion reaction.
Potter and Perry, Clinical Nursing Skills and Techniques, 2010 Infusion Nursing Standards of Practice, 2011.