Blood Transfusions

Purpose Red blood cells may be administered to treat hemorrhage, symptomatic anemia, or sickle cell crisis, and will improve oxygen delivery to the tissues. Fresh frozen plasma can help reverse the effect of anticoagulants. Platelets transfusions may prevent bleeding with thrombocytopenia. Compatibility must be checked by two qualified personnel before a blood product is administered to prevent a life threatening transfusion reaction. Ask if patient has received a transfusion or organ or tissue transplant in the past and whether they had any reaction. Note the type of reaction. Check if the patient requires irradiated blood products due to immunosuppression.

Assessment★ Assess cultural and religious beliefs (

jehovah's witness). ★ Ensure you obtain informed consent.★ Assess vital signs, including, renal,

circulatory, respiratory status and lab work.

★ Assess the client's ability to tolerate the procedure.

★ Assess client's temperature. If there is a fever present the HCP may have you hold off on administering the blood product.

Risks ★ Risk for infections. ★ Risk for hemolytic reaction.★ Risk for sepsis.★ Risk for iron overload.★ Risk for disease transmission.★ Risk for circulatory overload.★ Risk for electrolyte imbalances.

Patient Teaching★ Explain procedure. ★ Instruct patient to report any sensation of

flushing, itching, shortness of breath, or back/flank pain immediately, as these may be signs of a transfusion reaction.

★ Explain feelings the client will feel. Explain you will maintain privacy.

★ Be supportive.

Supplies ★ 0.9% normal saline, 250 mL bag★ Blood administration set with in-line filter and a Y set for saline administration★ Clean gloves★ Blood product★ IV pump (most facilities), Blood warmer, if indicated

Procedure 1. Confirm HCP order, obtain consent.2. Confirm client ID and DOB.3. Provide privacy and introduce yourself .4. Perform hand hygiene .5. Insert peripheral IV access with an 18 or 19 gauge catheter

to ensure maximum flow of blood. 6. ALWAYS ensure patency of IV line prior to obtaining blood

from the lab.7. Obtain blood product from the blood bank quickly.8. Visually inspect the blood for clots, sediment, or bubbles.9. Obtain baseline vital signs. Pre-existing fever should be

reported to the provider prior to proceeding with transfusion.10. Two RNs (one of whom will administer the blood product,

though this policy may vary) must confirm the blood unit, lab paperwork, and the blood ID band at the bedside: blood unit ID number, blood and Rh type, unit expiration date, and patient’s name and DOB confirmed with the ID band.

11. Close ALL clamps on Y set tubing. Hang 0.9 % NS. 12. Prime Up: Spike the normal saline with one short end of the

Y tubing and open the clamps on both of the shorter Y ends set to prime them. The descending tubing clamp remains closed.

13. Prime Down: With NS clamp still open, now close the clamp on the other short end of the Y set and open main (descending tubing) clamp to prime the rest of tubing with NS. Close all clamps.

14. Gently agitate blood bag (suspends the blood cells). Pull back the tabs on blood bag ports to expose them.

15. Prime Blood: Main tubing and NS Y arm clamps remain closed. Spike the blood bag with the free short end of the Y tubing and open the corresponding clamp to allow blood to flow down and prime the filter with blood.

16. Ensure blood product is hanging above NS solution. 17. Load tubing into the infusion pump, if used.18. Prep injection port per facility policy, and connect the tubing

to patient.19. Open main clamp and begin infusion via pump or gravity.

Begin the transfusion slowly.

Documentation ★ Date and Time of procedure. ★ Why you preformed the procedure. ★ How many attempts, guage of the catheter.★ Insertion site, solution infused.★ Any signs of a hemolytic reaction. ★ Rate infused, client's response to the

procedure. Continually monitor vitals every 15 minutes for the first hour.

Note !★ Only isotonic electrolyte solutions are

approved for blood administration. Dextrose will hemolyze RBCs and the calcium in Lactated Ringers will cause clotting.

★ Do not heat blood in hot water or a microwave.

Complications ★ Transfusion Reaction: An immediate transfusion

reaction that manifests as, chills, hives, rash, diaphoresis, back pain, muscle aches, chest pain, rapid thready pulse, cyanosis, dyspnea, cough, wheezing, apprehension, headache, nausea, vomiting, diarrhea. If the client experiences a transfusion/hemolytic reaction the priority intervention is to STOP the transfusion IMMEDIATELY!

★ Septicemia: Rapid onset of chills and a high fever, vomiting, diarrhea, hypotension, and shock.

★ Circulatory overload: Caused by a transfusion that is too rapid. Manifestations include; Headache HTN, tachycardia, bounding pulse, distended neck veins.

★ Iron overload: A delayed transfusion reaction accompanied by, vomiting diarrhea, hypotension, altered blood labs.

★ Disease Transmission: A delayed reaction that occurs with contaminated blood. Symptom onset will be much later.

★ Hypocalcemia: Monitor for signs of hypocalcemia ( F&E study guides)citrate binds with calcium causing calcium excretion.

★ Hyperkalemia: Monitor for signs of hyperkalemia ( F&E study guides) can be from blood being too old.

★ Citrate toxicity: When citrate binds with magnesium it causes citrate toxicity. Citrate is the anticoagulant used in blood products.

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