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Objectives
Definitions
Laboratory values
Blood transfusion
• Definitions
• Blood typing
• Blood products
• Nursing responsibilities
• Complications
• Summary
• References
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• To identify reference ranges of common laboratory values and to
interpret abnormal values
• To understand the pathophysiology and implications of blood typing,
specifically ABO and Rh compatibility
• To use knowledge of blood typing to prevent cross-match error and
subsequent complications
• To understand relevant nursing responsibilities before, during and after
blood transfusion
• To recognize causes, manifestations and management of various types
of blood transfusion reactions
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Complete Blood Count (CBC):
A serum laboratory test that
measures levels of blood
components. Includes:
• Red blood cell (RBC) count
and RBC features
• White blood cell (WBC)
count
• Hematocrit and
hemoglobin levels
• Platelet count
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DESCRIPTION
REFERENCE RANGE
BUN (Blood Urea
Nitrogen)
Concentration of urea in the
blood, which is regulated by
the rate at which the kidney
excretes urea
8.0-16.4 mmol/L
(8-25 mg/dL)
Creatinine
An end product of muscle and
protein metabolism that is
released at a constant rate and
is therefore a more reliable
indicator of kidney function
than BUN
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NAME
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50-110 mol/L
(0.7-1.3 mg/dL)
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DESCRIPTION
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NAME
REFERENCE RANGE
Function in hemostatic plug formation,
clot retraction, and coagulation factor
activation. Determines bleeding risk
150-400 x 10³/mm³
activated Partial
Thromboplastin Time
(aPTT)
Assessment of coagulation system
function by testing clotting time of plasma
with thromboplastin. Used to monitor the
effectiveness of heparin therapy
Normal: 25-40 sec
Therapeutic: 1.5-2.5
times the normal
Prothrombin Time (PT)
The amount of time it takes for a clot to
form
Normal: 11-12.5 sec
Therapeutic: 1.5-2x
International
Normalized Ratio (INR)
Standardization of the PT ratio, used to
monitor the effectiveness of warfarin
2 - 3 (standard)
3 - 4.5 (high dose)
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Platelets
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DESCRIPTION
REFERENCE RANGE
Hemoglobin
The main component of red
blood cells, act as a vehicle for
oxygen transportation
Male: 140-180 g/L
(14-18 g/dL)
Female: 120-160 g/L
(12-16 g/dL)
Hematocrit
Represents red blood cell mass,
useful in the detection of
anemia
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Male: 42-52%
Female: 37-47%
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DESCRIPTION
REFERENCE RANGE
White Blood Cells
Function as part of the immune system
to protect the body from infection
• Lower than normal values may
indicate depressed production or
recovery from infection; these
patients are vulnerable to new or
opportunistic infection
• Higher than normal values indicates
increased release from the bone
marrow as the body attempts to
fight off an infection
Total: 5.0-10 x 10⁹ / L
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NAME
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DESCRIPTION
REFERENCE RANGE
Glycosylated
Hemoglobin
(Hemoglobin A1C)
A reflection of the condition of
glucose control over the past 3
months; glycosylated
hemoglobin is blood glucose
bound to hemoglobin
<7% = good glycemic
control
Fasting Blood
Glucose
(FBG)
Main source of cellular energy
for the body and is essential for
brain and erythrocyte function.
FBG is used to assess diabetes
and hypoglycemia
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NAME
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3.9-5.5 mmol/L
(70-99 mg/dL)
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DESCRIPTION
Total
Cholesterol
Included in all body tissues, a major component
of LDL, nerve cells, and cell membranes
Lipoproteins
Vehicles for fat mobilization and transport,
may vary in composition. Classified as High
Density Lipoproteins (HDL) and Low-Density
Lipoproteins (LDL)
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NAME
Triglycerides
Synthesized in the liver and help to form
lipoproteins
REFERENCE RANGE
< 5.2 mmol/L
(< 200 mg/dL)
LDL: <3.5 mmol/L (< 100mg/dL)
HDL:
Men: > 1.0 mmol/L (40 mg/dL)
Women: >1.3 mmol/L (50 mg/dL)
< 1.7 mmol/L
(<150 mg/dL)
Note: Patients with increased
cholesterol, LDL and triglycerides and
decreased HDL are at a higher risk for
cardiovascular disease
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See also: NurseAchieve,
“Fluids and Electrolytes”
REFERENCE RANGE
ALTERATIONS
↑ in Addison’s disease, DKA, tissue
destruction, renal failure
↓ in Cushing’s syndrome, diarrhea,
diuretics, vomiting, pyloric obstruction
Sodium: maintains serum
osmolality and determines
fluid shift between spaces.
Kidneys retain or excrete
sodium in response to
vascular volume
↑ in dehydration, impaired renal
function, aldosteronism, corticosteroid
use
↓ in Addison’s disease, DKA, diuretics,
excessive loss from GI tract, excessive
perspiration
3.5-5.0 mmol/L
(3.5-5.0 mEq/L)
135-145 mmol/L
(135-145 mEq/L)
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Potassium: functions in cell
metabolism, cardiac and
neuromuscular function.
Excretion through the kidneys
is regulated by aldosterone
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Name AND DESCRIPTION
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Blood transfusion/blood replacement is the
administration of whole blood components,
or a plasma-derived product intravenously
for therapeutic purposes
Allogenic transfusion: Blood is donated from
another person. Compatibility of donor and
recipient, and prevention of disease
transmission must be carefully considered
Autologous transfusion: The patient’s own
blood is collected and reinfused for the
purpose of intravascular volume
replacement.
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Blood is classified by typing systems based on the presence of antigens on red blood cell surfaces
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ABO System: red blood cells may carry A or B antigens on their surfaces, which will cause
antibodies to react against antigens not found on the cells. Incompatible red blood cells
agglutinate (clump together) and cause a life-threatening hemolytic transfusion reaction.
Thus, correctly matching blood products to the patient’s blood type is extremely important.
Patients with both antigens are AB blood types, and those with neither are O blood types.
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Rh System: type D antigen is prevalent on red blood cell surfaces and elicits an immune
response. Presence of the antigen indicates a Rh-positive type; absence indicates a Rh
negative type. A transfusion reaction will occur on repeat exposures; a person with Rh
negative blood exposed to a large amount of Rh-positive blood will develop antibodies to this
antigen and react on subsequent exposure. Thus, a person with a negative RH typing should
receive only Rh-negative products (except in an emergency and without previous exposure),
while Rh-positive patients can receive both positive and negative blood products.
A (-)
B (+)
B (-)
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A (-)
B (+)
B (-)
AB (+)
AB (-)
O (+)
O (-)
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TRANSFUSION OPTIONS
A (+)
A (+)
O(-): universal donor
AB (+): universal recipient
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BLOOD TYPE
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AB (+)
AB (-)
O (+)
O (-)
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Fresh Frozen Plasma:
replaces plasma,
contains coagulation
factors, helps to
control bleeding
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Albumin: expands
blood volume, treats
hypoproteinemia
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Cryoprecipitate:
replaces fibrinogen
and coagulation
factors
Packed RBCs:
preferred method of
replacing RBC mass,
raises hemoglobin
and hematocrit
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Platelets: used for
thrombocytopenia
or prolonged
hemorrhage
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Whole blood: used to
replace RBC mass and
plasma volume, raise
hemoglobin and
hematocrit
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Prior to Transfusion
Nursing Alert!
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• Establish patency of the IV catheter and assess the site for Nursing responsibilities prior
complications
to blood transfusions apply
only to Registered Nurses.
• Ensure that 2 nurses independently verify the following:
Practical Nurses do not
• Blood product order, date, and time
initiate
the transfusion of
• Identify the patient by name and number
blood or blood products
• Assess blood compatibility
• Pre or post-transfusion medications to be administered
• Patient has signed the infusion consent
• History of transfusion or allergic reactions
• Assess baseline vital signs and laboratory values
• Inspect the blood for expiration, bubbling, and discoloration
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Nursing Alert!
During Transfusion
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Nursing responsibilities during
Initiation:
blood transfusions apply only to
• Perform hand hygiene, wear clean
Registered Nurses. Practical
gloves and maintain asepsis when
Nurses do not initiate transfusions
preparing the transfusion
of blood or blood products
• Blood products should be administered
with only normal saline
• Administer the blood product with a Ytubing filtered blood administration set
• The infusion should begin at a slow
rate of 2 mL/min
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During Transfusion
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After initiation:
• Remain with the patient during the first 15-30
minutes of the infusion to monitor for a
transfusion reaction. If no reaction occurs, the
infusion is set to the prescribed rate
• Continue to monitor vital signs: 15 minutes after
initiation and least every 30 minutes thereafter
• The blood should infuse for no more than
4 hours, otherwise blood begins to break down
Nursing Alert!
A patient must be assessed for
the first 15 minutes following
initiation of a blood transfusion
by only a Registered Nurse.
Afterwards a Practical Nurse can
be assigned to monitor the
patient and check vital signs
every 30 minutes.
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After Transfusion
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• The tubing should be flushed with normal saline and
the line and bag should be immediately discarded
• Documentation after transfusion should include:
• Type of product infused
• Product number
• Volume infused
Nursing Alert!
• Time of infusion
Only a Registered
• Adverse reactions
Nurse can discontinue
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or blood products
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Points for patient education:
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• Potential risks of blood transfusion
• Donor screening and testing for
blood safety
• Reporting of signs of reaction: warm
feeling, chills, itching, weakness,
difficulty breathing
• Discuss with the patient religious or
cultural considerations
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Acute hemolytic
Febrile, nonhemolytic
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Allergic transfusion
reactions (mild to severe)
Circulatory overload
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Infectious
transfusion
reaction (sepsis)
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Blood transfusion
reactions can be
mild to life
threatening. The
most common are:
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Acute hemolytic
transfusion reactions: occur
as a result of ABO or Rh
blood type incompatibility,
typically within the first 15
minutes of transfusion
Recipient’s antibodies
attach to antigens on
donor RBCs, causing
intravascular destruction
of transfused RBCs
Acute Hemolytic
Transfusion Reaction
Inflammatory
responses occur in
the blood vessel
wall and organs
Potentially results in
disseminated intravascular
coagulation (DIC) and
circulatory collapse
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Acute Hemolytic
Transfusion Reaction
Systemic:
• Fever, headache,
chills
MANIFESTATIONS
Cardio-respiratory:
• Tachycardia
• Chest pain
• Tachypnea, dyspnea
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Vascular:
• Hypotension
• Uncontrolled bleeding
Transfusion site:
• Heat
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Urinary:
• Hemoglobinuria
• Hyperbilirubinemia,
jaundice
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Acute Hemolytic
Transfusion Reaction
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EMERGENCY MANAGEMENT OF ACUTE HEMOLYTIC TRANSFUSION
REACTION
1. Stop the transfusion and remove the blood product and tubing
2. Maintain IV patency with saline solution
3. Notify the healthcare provider and blood bank
4. Monitor vital signs
5. Monitor urine output
6. Assess and treat for shock and other complications
7. Save and carefully examine the blood bag and tubing
8. Take blood and urine samples as required
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Febrile, Nonhemolytic
Transfusion Reaction
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Management:
1. Stop transfusion
2. Administer antipyretics
as prescribed
(acetaminophen- note
aspirin is contraindicated
in thrombocytopenia)
3. Monitor temperature
Manifestations:
• Fever
• Flushing
• Chills
• Headache
• Anxiety
• Muscle pain
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Febrile, Nonhemolytic Reactions occur as a result of sensitivity to donor leukocytes or other
blood components, it may occur to immunosuppressed patients or with repeated
transfusions. Although this is not typically a life-threatening condition, it does require prompt
recognition and intervention
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results from sensitivity to
foreign plasma proteins
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Mild Allergy
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Mild Allergic Transfusion
Reaction
Manifestations
local erythema, hives,
itching, pruritus
Management
1.
2.
3.
4.
Stop transfusion
Notify the healthcare provider and blood bank
Administer antihistamines as ordered
Monitor vital signs
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Severe or Anaphylactic
Transfusion Reaction
Severe Allergy or Anaphylaxis: sensitivity to a donor antigen, typically IgA. Results in
agglutination of RBCs, obstructed capillaries and blocked organ perfusion
(ID
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Emergency Management:
1. Stop transfusion
2. Maintain IV access
3. Notify healthcare provider and blood bank
4. Initiate CPR if necessary and monitor vital signs
5. Administer antihistamines, corticosteroids,
epinephrine, and antipyretics as prescribed
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Manifestations:
• Coughing, wheezing,
cyanosis, dyspnea,
respiratory distress
• Nausea and vomiting
• Hypotension
• Shock
• Cardiac arrest
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Infectious (Septic)
Transfusion Reaction
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Sepsis reaction: occurs as a result of the transfusion of infected blood components
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Manifestations (rapid onset)
• Tachycardia, hypotension
• Fever, chills
• Vomiting and diarrhea
• Shock
Management:
1. Stop transfusion
2. Remove blood product and tubing
3. Maintain IV access
4. Notify the healthcare provider and blood bank
5. Obtain blood cultures
6. IV fluids, antimicrobials, vasopressors, and
steroids may be prescribed
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Circulatory Overload
Transfusion Reaction
Circulatory overload occurs when a transfusion is of an excessive volume or rate. Can
progress to pulmonary edema. Increased risk in those with cardiovascular or kidney disease
Manifestations:
• Cough
• Dyspnea
• Pulmonary congestion
• Hypertension
• Tachycardia
• Bounding pulse
• Distended jugular veins
• Restlessness and confusion
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Interventions:
• Slow or stop infusion rate as ordered
• Elevate patient’s head and monitor for respiratory
distress
• Monitor intake and output
• Administer diuretics
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• Serum laboratory values have specific reference ranges that allow the nurse to
determine normal and abnormal body functioning, including kidney function,
coagulation, diabetic control, cholesterol, and immune system function
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• Blood transfusion is the administration of blood, blood components, and plasma
derived products including platelets, packed RBCs, cryoprecipitate, fresh frozen
plasma and albumin
• Blood is classified by typing systems, most commonly the ABO and Rh systems
• Nurses have specific responsibilities prior to transfusion that are essential in error
prevention
• The initial transfusion rate should be slow, and the registered nurse should remain
with the patient for 15 minutes following initiation to monitor for a transfusion
reaction
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• An acute hemolytic transfusion reaction occurs with the administration of ABO
incompatible blood, and results in life-threatening sequelae. Immediately stopping
the transfusion, treating for shock, and calling for help are essential nursing actions
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• Mild allergy and febrile, non-hemolytic reactions are less serious complications, but
also prompt intervention and must be monitored for
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• Severe allergy (anaphylaxis), septic reaction, or circulatory overload are also serious
potential complications of transfusion therapy, requiring prompt emergency
management
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1. Adams M, Holland L, Urban C. (2020). Pharmacology for Nurses: A Pathophysiologic Approach
(6th edition). Pearson.
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2. Bauldoff G, Gubrud P, Carno M. (2019). LeMone and Burke’s Medical-Surgical Nursing: Clinical
Reasoning in Patient Care. (7th edition). Pearson.
3. Harding MM, Kwong J, Roberts D, Hagler D, Reinisch C. (2020). Lewis’s Medical-Surgical
Nursing: Assessment and Management of Clinical Problems, (11th edition). Mosby.
4. Ignatavicius DD, Workman ML. (2016). Medical-Surgical Nursing: Patient-Centered
Collaborative Care. (8th edition). Saunders.
5.
Lewis SL, Bucher L, Heitkemper MM, Harding MM. (2018). Medical-Surgical Nursing in
Canada. (4th edition). Elsevier.
6.
Potter P, Perry A, Stockert P, Hall A. (2019). Canadian Fundamentals of Nursing. (5th edition).
Mosby.
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