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PROCEDURES AND SKILLS » BLOOD TRANSFUSION THERAPY
Blood Transfusion
Therapy
UPDATED ON APRIL 20, 2016 BY MATT VERA, BSN, R.N.
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Blood transfusion (BT) therapy involves
transfusing whole blood or blood components
(specific portion or fraction of blood lacking in
patient). Learn the concepts behind blood
transfusion therapy and the nursing
management and interventions before, during
and after the therapy.
1. Advantages
2. Principles
3. Blood Components
4. Objectives
5. Nursing Interventions
6. Complications
7. Assessment findings
8. Nursing Diagnosis
9. Planning and Implementation
10. Nursing Interventions
11. Evaluation
Advantages
1. Avoids the risk of sensitizing the
patients to other blood components.
2. Provides optimal therapeutic benefit
while reducing risk of volume overload.
3. Increases availability of needed blood
products to larger population.
Principles
Whole blood transfusion
Generally indicated only for patients who need
both increased oxygen-carrying capacity and
restoration of blood volume when there is no
time to prepare or obtain the specific blood
components needed.
Packed RBCs
Should be transfused over 2 to 3 hours; if
patient cannot tolerate volume over a
maximum of 4 hours, it may be necessary for
the blood bank to divide a unit into smaller
volumes, providing proper refrigeration of
remaining blood until needed. One unit of
packed red cells should raise hemoglobin
approximately 1%, hemactocrit 3%.
Platelets
Administer as rapidly as tolerated (usually 4
units every 30 to 60 minutes). Each unit of
platelets should raise the recipient’s platelet
count by 6000 to 10,000/mm3: however, poor
incremental increases occur with
alloimmunization from previous transfusions,
bleeding, fever, infection, autoimmune
destruction, and hypertension.
Granulocytes
May be beneficial in selected population of
infected, severely granulocytopenic patients
(less than 500/mm3) not responding to
antibiotic therapy and who are expected to
experienced prolonged suppressed
granulocyte production.
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Plasma
Because plasma carries a risk of hepatitis
equal to that of whole blood, if only volume
expansion is required, other colloids
(e.g., albumin) or electrolyte solutions (e.g.,
Ringer’s lactate) are preferred. Fresh frozen
plasma should be administered as rapidly as
tolerated because coagulation factors become
unstable after thawing.
Albumin
Indicated to expand to blood volume of
patients in hypovolemic shock and to elevate
level of circulating albumin in patients with
hypoalbuminemia. The large protein molecule
is a major contributor to plasma oncotic
pressure.
Cryoprecipitate
Indicated for treatment of hemophilia A, Von
Willebrand’s disease, disseminated
intravascular coagulation (DIC), and uremic
bleeding.
Factor IX concentrate
Indicated for treatment of hemophilia B;
carries a high risk of hepatitis because it
requires pooling from many donors.
Factor VIII concentrate
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Indicated for treatment of hemophilia A; heattreated product decreases the risk of hepatitis
and HIV transmission.
Prothrombin complex
Indicated in congenital or acquired
deficiencies of these factors.
Blood Components
Component
Additional Info
Packed RBCs
100% of erythrocyte,
100% of leukocytes,
and 20% of plasma
originally present in
one unit of whole
blood
Leukocyte-poor
packed RBCs
Indicated for
patients who have
experience previous
febrile no hemolytic
reactions
Platelets
either HLA (human
leukocyte antigen)
matched or
unmatched
Granulocytes
Contains basophils,
eosinophils, and
neutrophils
Fresh frozen plasma
Contains all
coagulation factors,
including factors V
and VIII
Single donor plasma
Contains all stable
coagulation factors
but reduced levels of
factors V and VIII;
the preferred
product for reversal
of Coumadininduced
anticoagulation.
Albumin
A plasma protein.
Cryoprecipitate
A plasma derivative
rich in factor VIII,
fibrinogen, factor
XIII, and fibronectin
Factor IX
concentrate
A concentrated form
of factor IX prepared
by pooling,
fractionating, and
freeze-drying large
volumes of plasma.
Factor VIII
concentrate
A concentrated form
of factor IX prepared
by pooling,
fractionating, and
freeze-drying large
volumes of plasma.
Prothrombin
complex
Contains
prothrombin and
factors VII, IX, X, and
some factor XI.
Objectives
1. To increase circulating blood volume
after surgery, trauma, or hemorrhage
2. To increase the number of RBCs and to
maintain hemoglobin levels in clients
with severe anemia
3. To provide selected cellular
components as replacements therapy
(e.g. clotting factors, platelets, albumin)
Nursing Interventions
1. Verify doctor’s order. Inform the client
and explain the purpose of the
procedure.
2. Check for cross matching and typing.
To ensure compatibility
3. Obtain and record baseline vital signs
4. Practice strict asepsis
5. At least 2 licensed nurse check the
label of the blood transfusion. Check
the following:
Serial number
Blood component
Blood type
Rh factor
Expiration date
Screening test (VDRL, HBsAg,
malarial smear) – this is to ensure
that the blood is free from bloodcarried diseases and therefore, safe
from transfusion.
6. Warm blood at room temperature
before transfusion to prevent chills.
7. Identify client properly. Two Nurses
check the client’s identification.
8. Use needle gauge 18 to 19 to allow
easy flow of blood.
9. Use BT set with special micron mesh
filter to prevent administration of blood
clots and particles.
10. Start infusion slowly at 10 gtts/min.
Remain at bedside for 15 to 30 minutes.
Adverse reaction usually occurs during
the first 15 to 20 minutes.
11. Monitor vital signs. Altered vital signs
indicate adverse reaction (increase in
temp, increase in respiratory rate)
12. Do not mix medications with blood
transfusion to prevent adverse effects.
Do not incorporate medication into the
blood transfusion. Do not use blood
transfusion lines for IV push of
medication.
13. Administer 0.9% NaCl before; during or
after BT. Never administer IV fluids with
dextrose. Dextrose based IV fluids
cause hemolysis.
14. Administer BT for 4 hours (whole blood,
packed RBC). For plasma, platelets,
cryoprecipitate, transfuse quickly (20
minutes) clotting factor can easily be
destroyed.
15. Observe for potential complications.
Notify physician.
Complications
1. Allergic Reaction – it is caused by
sensitivity to plasma protein of donor
antibody, which reacts with recipient antigen.
Assess for:
Flushing
Rash, hives
Pruritus
Laryngeal edema, difficulty of breathing
2. Febrile, Non-Hemolytic – it is caused by
hypersensitivity to donor white cells, platelets
or plasma proteins. This is the most
symptomatic complication of blood
transfusion
Assess for:
Sudden chills and fever
Flushing
Headache
Anxiety
3. Septic Reaction – it is caused by the
transfusion of blood or components
contaminated with bacteria.
Assess for:
Rapid onset of chills
Vomiting
Marked Hypotension
High fever
4. Circulatory Overload – it is caused by
administration of blood volume at a rate
greater than the circulatory system can
accommodate.
Assess for:
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Rise in venous pressure
Dyspnea
Crackles or rales
Distended neck vein
Cough
Elevated BP
5. Hemolytic reaction – it is caused by
infusion of incompatible blood products.
Assess for:
Low back pain (first sign). This is due to
inflammatory response of the kidneys
to incompatible blood.
Chills
Feeling of fullness
Tachycardia
Flushing
Tachypnea
Hypotension
Bleeding
Vascular collapse
Acute renal failure
Assessment findings
1. Clinical manifestations of transfusions
complications vary depending on the
precipitating factor.
2. Signs and symptoms of hemolytic
transfusion reaction include:
Fever
Chills
low back pain
flank pain
headache
nausea
flushing
tachycardia
tachypnea
hypotension
hemoglobinuria (cola-colored urine)
3. Clinical signs and laboratory findings in
delayed hemolytic reaction include:
fever
mild jaundice
gradual fall of hemoglobin
positive Coombs’ test
4. Febrile non-hemolytic reaction is
marked by:
Temperature rise during or shortly
after transfusion
Chills
headache
flushing
anxiety
5. Signs and symptoms of septic reaction
include;
Rapid onset of high fever and chills
vomiting
diarrhea
marked hypotension
6. Allergic reactions may produce:
hives
generalized pruritus
wheezing or anaphylaxis (rarely)
7. Signs and symptoms of circulatory
overload include:
Dyspnea
cough
rales
jugular vein distention
8. Manifestations of infectious disease
transmitted through transfusion may
develop rapidly or insidiously,
depending on the disease.
9. Characteristics of GVH disease include:
skin changes (e.g. erythema,
ulcerations, scaling)
edema
hair loss
hemolytic anemia
10. Reactions associated with massive
transfusion produce varying
manifestations
Nursing Diagnosis
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Ineffective breathing pattern
Decreased Cardiac Output
Fluid Volume Deficit
Fluid Volume Excess
Impaired Gas Exchange
Hyperthermia
Hypothermia
High Risk for Infection
High Risk for Injury
Pain
Impaired Skin Integrity
Altered Tissue Perfusion
Planning and
Implementation
Help prevent transfusion reaction by:
Meticulously verifying patient
identification beginning with type and
crossmatch sample collection and
labeling to double check blood product
and patient identification prior to
transfusion.
Inspecting the blood product for any
gas bubbles, clothing, or abnormal
color before administration.
Beginning transfusion slowly ( 1 to 2
mL/min) and observing the patient
closely, particularly during the first 15
minutes (severe reactions usually
manifest within 15 minutes after the
start of transfusion).
Transfusing blood within 4 hours, and
changing blood tubing every 4 hours to
minimize the risk of bacterial growth at
warm room temperatures.
Preventing infectious disease
transmission through careful donor
screening or performing pretest
available to identify selected infectious
agents.
Preventing GVH disease by ensuring
irradiation of blood products containing
viable WBC’s (i.e., whole blood,
platelets, packed RBC’s and
granulocytes) before transfusion;
irradiation alters ability of donor
lymphocytes to engraft and divide.
Preventing hypothermia by warming
blood unit to 37 C before transfusion.
Removing leukocytes and platelets
aggregates from donor blood by
installing a microaggregate filter (2040-um size) in the blood line to remove
these aggregates during transfusion.
On detecting any signs or symptoms of
reaction:
Stop the transfusion immediately, and
notify the physician.
Disconnect the transfusion set-but
keep the IV line open with 0.9% saline
to provide access for possible IV drug
infusion.
Send the blood bag and tubing to the
blood bank for repeat typing and
culture.
Draw another blood sample for plasma
hemoglobin, culture, and retyping.
Collect a urine sample as soon as
possible for hemoglobin determination.
Intervene as appropriate to address
symptoms of the specific reaction:
Treatment for hemolytic reaction is
directed at correcting hypotension,
DIC, and renal failure associated with
RBC hemolysis and hemoglobinuria.
Febrile, nonhemolytic transfusion
reactions are treated symptomatically
with antipyretics; leukocyte-poor blood
products may be recommended for
subsequent transfusions.
In septic reaction, treat septicemia with
antibiotics, increased hydration,
steroids and vasopressors as
prescribed.
Intervene for allergic reaction by
administering antihistamines, steroids
and epinephrine as indicated by the
severity of the reaction. (If hives are the
only manifestation, transfusion can
sometimes continue but at a slower
rate.)
For circulatory overload, immediate
treatment includes positioning the
patient upright with feet dependent;
diuretics, oxygen and aminophylline
may be prescribed.
Nursing Interventions
1. If blood transfusion reaction occurs:
STOP THE TRANSFUSION.
2. Start IV line (0.9% NaCl)
3. Place the client in Fowler’s position if
with Shortness of Breath and
administer O2 therapy.
4. The nurse remains with the client,
observing signs and symptoms and
monitoring vital signs as often as every
5 minutes.
5. Notify the physician immediately.
6. The nurse prepares to administer
emergency drugs such as
antihistamines, vasopressor, fluids, and
steroids as per physician’s order or
protocol.
7. Obtain a urine specimen and send to
the laboratory to determine presence of
hemoglobin as a result of RBC
hemolysis.
8. Blood container, tubing, attached label,
and transfusion record are saved and
returned to the laboratory for analysis.
Evaluation
1. The patient maintains normal breathing
pattern.
2. The patient demonstrates adequate
cardiac output.
3. The patient reports minimal or no
discomfort.
4. The patient maintains good fluid
balance.
5. The patient remains normothermic.
6. The patient remains free of infection.
7. The patient maintains good skin
integrity, with no lesions or pruritus.
8. The patient maintains or returns to
normal electrolyte and blood chemistry
values.
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Fundamentals of Nursing, Nursing
Procedures and Skills
blood transfusion
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