Blood transfusions involves transfusing whole blood or blood components into venous circulation. It’s usually given to replace blood lost during surgery or life-saving situations such as massive blood loss due to trauma. They are also given when a person’s body does not produce enough blood because of certain illness.

This  procedure is in accordance to ANSAP Nursing Standards on Intravenous Practice.

  1. Verify the physician’s written order and make a treatment card according to hospital policy
  2. Observe the 10 Rs when preparing and administering any blood or blood components
  3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Get patient histories regarding previous transfusion.
  4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719- National Blood Service Act of 1994).
  5. Request prescribed blood/blood components from blood bank to include blood typing and cross matching and blood result of transmissible Disease.
  6. Using a clean lined tray, get compatible blood from hospital blood bank.
  7. Wrap blood bag with clean towel and keep it at room temperature.
  8. Have a doctor and a nurse assess patient’s condition. Countercheck the compatible blood to be transfused against the crossmatching sheet noting the ABO grouping and RH, serial number of each blood unit, and expiry date with the blood bag label and other laboratory blood exams as required before transfusion.
  9. Get the baseline vital signs- BP, RR, and Temperature before transfusion. Refer to MD accordingly.
  10. Give pre-meds 30 minutes before transfusion as prescribed.
  11. Do hand hygiene before and after the procedure
  12. Prepare equipment needed for BT (IV injection tray, compatible BT set, IV catheter/ needle G 19/19, plaster, tourniquet, blood, blood components to be transfused, Plain NSS 500cc, IV set, needle gauge 18 (only if needed), IV hook, gloves, sterile 2×2 gauze or transplant dressing, etc.
  13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on another site, anchor catheter properly and regulate IV drops.
  14. Open compatible blood set aseptically and close the roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles (if any). Use needle g.18 or 19 for side drip (for adults) or g.22 for pedia (if blood is given to the Y-injection port, the gauge of the needle is disregarded).
  15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle, from BT administration ser and secure with adhesive tape.
  16. Close the roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on.
  17. Transfuse the blood via the injection port and regulate at 10-15gtts/min initially for the first 15 minutes of transfusion and refer immediately to the MD for any adverse reaction.
  18. Observe/Assess patient on an on-going basis for any untoward signs and symptoms such as flushed skin, chills, elevated temperature, itchiness, urticaria, and dyspnea. If any of these symptoms occur, stop the transfusion, open the IV line with Plain NSS and regulate accordingly, and report to the doctor immediately.
  19. Swirl the bag gently from time to time to mix the solid with the plasma N.B one B.T set should be used for 1-2 units of blood.
  20. When blood is consumed, close the roller clamp, of BT, and disconnect from IV lines then regulate the IVF of plain NSS as prescribed.
  21. Continue to observe and monitor patient post transfusion, for delayed reaction could still occur.
  22. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed and/or per institution’s policy.
  23. Discard blood bag and BT set and sharps according to Health Care Waste Management (DOH/DENR).
  24. Fill-out adverse reaction sheet as per institutional policy.
  25. Remind the doctor about the administration of Calcium Gluconate if patient has several units of blood transfusion (3-5 more units of blood).
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  1. Some added info: look out for these keywords in your pts.
    Itch/rash = allergic rxn
    Itch/rash + respiratory involvement = anaphylaxis
    Increase in temperature by 1 degree = febrile rxn
    Flank/back pain = hemolytic rxn

    In any case, remember SPINS:
    S = stop infusion
    P = pulses & vital signs should be monitored
    I = infuse NSS using a different line in a different site. More blood would be infused (causing more damage) if you use the same line.
    N = notify the doctor
    S = samples of the first voided urine as soon as adverse reaction was noted (to check for renal function) and blood samples (to find out what’s going on)