Blood Administration
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Apply PPE
Prepare and prime the Y-type blood tubing with NS
Rotate blood bag gently back and forth a few times and spike the blood bag
Transfuse blood at a rate of 2ml/min for the first 15 minutes observing or signs of adverse
reaction (itching, hives, rash, flushing, dyspnea)
Stay with the client and record vital signs every 5-15 minutes or as directed by your
facility protocol.
If no adverse reactions are observed, increase the rate to the prescribed rate to be infused
within the time frame indicated- NO LONGER THAN 4 HOURS. Record vital signs
every 1-2 hours
Once all blood has been administered, flush with normal saline
Obtain another set of vital signs on the client and record
Discard blood administration equipment used or return to blood bank
Document
Complications
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Stop the transfusion and maintain IV access by infusing NS through new tubing at a slow
rate
Perform a physical assessment for any suspected reaction and compare previous vital
signs to current readings.
Notify the provider and continue to assess vital signs and change in conditions
Obtain blood ad urine samples for hemolytic and allergic reactions as soon as possible
Document transfusion reactions
Advise the client to inform HCP of the transfusion reaction
A type of protein the immune system produces to neutralize a threat of some kind, such as an
incompatible substance in the blood is called an: Antibody
A patient is about to receive a unit of packed RBC. The unit of blood has arrived and you're
about to initiate the transfusion. Which of the following procedures will help you protect the
patient against the possibility of a blood-group incompatibility? Comparing the ID numbers on
the blood unit with those on the order from and the wristband. Before administering blood or
blood products, the client's nurse and one other authorized individual are required to identify the client and
compare the label on the blood product to the prescription in the medical record and the client's armband.
These actions will verify that the correct client is receiving the correct blood and help prevent the possibility of a
blood-group incompatibility.
You started the transfusion of packed RBC about 1 hour ago. Your patient has suddenly
developed shaking chills, muscle stiffness, and a temperature of 104.4 F (38.6 C). He appears
flushed and reports a headache and "nervousness." Your patient has most likely developed which
type of transfusion reaction? Febrile nonhemolytic. This is the most common type of transfusion
reaction. The characteristic fever usually develops within 2 hr after the transfusion is started. Other classic
symptoms include chills, headache, flushing, anxiety, and muscle pain. This type of reaction is usually a result
of sensitization to the plasma, platelets, or white blood cells. Although this type of reaction is not lifethreatening, it can be frightening and uncomfortable for the client.
A patient about to receive a unit of packed RBC states, "This is my third unit of blood today. I
don't want to get some disease from all this blood." Which of the following would be your best
response? Donated blood is carefully screened for infectious diseases. The nurse might continue
to explain that the approach to blood safety in the U.S. includes stringent donor selection practices and the use
of screening tests for HIV, AIDS, hepatitis B and C, syphilis, and other infectious diseases. Infected blood and
blood products are safely discarded and are not used for transfusions.
When administering a transfusion of packed RBC, it's important to: Make sure the entire unit
is transfused within 4 hours. infusion times that exceed 4 hr increase the risk for bacterial proliferation.
Ideally, a unit of packed RBCs is infused within 2 hr. Clients who are at risk for fluid-volume excess will require
slower rates of infusion; however, the entire transfusion must not exceed 4 hr.
A patient who is anticipating total hip replacement is considering autologous transfusion. When
teaching this patient about autologous transfusion, it's important to emphasize that: It reduces
the risk of mismatched blood. Mismatched blood can cause an immune response to another person's
antigens. Because the client is their own donor in an autologous transfusion, there is no risk of exposure to
another person's antigens. A hemoglobin level of at least 11 g/dL is required for autologous donation. Blood
collected for autologous transfusion is tested for HIV and the hepatitis B virus. A client who has either of these
viruses is not eligible for autologous transfusion.
Prior to administering a blood transfusion, it's essential to explain to the patient that He must
immediately report any subjective symptoms like chills, nausea, or itching. Although the nurse
can identify objective signs of a transfusion reaction (changes in vital signs, flushing, cyanosis, coughing, and
to some extent, dyspnea), the nurse might not be able to tell if the client is experiencing subjective symptoms
(chills, nausea, chest pain, headache, backache, muscle pain). Subjective signs are important clues, and the
nurse must be aware of them.
Which is an essential nursing action prior to starting a blood transfusion: Ensure informed
consent has been obtained. It is the responsibility of the prescribing health care provider to answer the
client's questions about the need, risks, and benefits of a procedure. A nurse can witness the client's signature
indicating informed consent. This must be done prior to obtaining or administering the blood.
A platelet transfusion is indicated for a patient who: Has thrombocytopenia. A client who has
thrombocytopenia has a low platelet count. When platelet counts drop below 20,000/mm3, a transfusion of
platelets is generally indicated for the client.
You're caring for a patient with severe trauma whose blood type is A. A blood transfusion is
ordered STAT. You know that the patient can safely receive from blood group O because: Type
O blood contains no A antigens. Type O blood contains no antigens at all, which is why clients who have
type O blood are considered universal donors. Their blood can be transfused to anyone who has any ABOrelated blood type without putting them at risk for an ABO incompatibility. It is the specific antigens in the
transfused blood that can trigger hemolytic reactions. Because type O blood has no antigens, it is safe for this
client and for any other client.
A nurse is caring for a client who is receiving a blood transfusion and reports itching. The nurse
observes the areas of urticaria on the client’s skin. Which action should the nurse take? Stop the
blood transfusion. This client is exhibiting manifestations of a mild allergic reaction to the blood transfusion.
The nurse should stop the transfusion and follow facility protocol regarding transfusion reactions. The nurse
would also administer a prescribed antihistamine for this client