TRAINING DESIGN
Title: Blood Transfusion
Description of Learners: Fifty Clinical Nurses from Mariano Marcos Memorial Hospital & Medical Center
General Objective: After 1 hour and 30 minutes of imparting knowledge through lecture discussion and demonstration, the fifty clinical nurses from
Mariano Marcos Memorial Hospital & Medical Center will be able to:
Learning
Objectives
Content
Explain at least 3 Introduction to Blood Transfusion
blood products for IV fluids can be effective in restoring intravascular (blood)
transfusion.
volume; however, they do not affect the oxygen-carrying
capacity of the blood. When red or white blood cells, platelets,
or blood proteins are lost because of hemorrhage or disease, it
may be necessary to replace these components to restore the
bloods ability to transport oxygen and carbon dioxide, clot, fight
infection, and keep extracellular fluid within the intravascular
compartment. A blood transfusion is the introduction of whole
blood or blood components into venous circulation.
Purposes
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To restore blood volume after severe hemorrhage
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To restore the oxygen-carrying capacity of the blood
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To provide plasma factors, such as antihemophilic factor
TeachingLearning
Activities
LectureDiscussion
Time Frame
Instructional
Resources
Methods of
Evaluation
40 minutes
Laptop
LCD projector
Power point
Presentation
Question and
Answer
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(AHF) or factor VIII, or platelet concentrates, which prevent
or treat bleeding.
To treat severe anemia.
Blood Products for Transfusion
1. Whole blood. Not commonly used except for extreme cases
of acute hemorrhage. Replaces blood volume and all blood
products: RBCs, plasma, plasma proteins, tresh platelets, and
other clotting factors.
2. Packed red blood cells (PRBCs). Used to increase the oxygencarrying capacity of blood in anemias, surgery, and disorders
with slow bleeding. One unit of PRBCs has the same amount of
oxygen-carrying BCs as a unit of whole blood. One unit raises
hematocrit by approximately 2% to 3%.
3. Autologous RBCs. Used for blood replacement following
planned elective surgery. Client donates blood for autologous
transfusion 4-5 weeks prior to surgery.
4. Platelets. Replaces platelets in clients with bleeding disorders
or platelet deficiency. Fresh platelets are most effective. Each
unit should increase the average adult client's platelet count by
about 5,000 platelets/ microliter.
5. Fresh frozen plasma. Provides clotting actors. Does not need
to be typed and crossmatched (contains no RBCs).
6. Albumin and plasma protein fraction. Blood volume
expander; provides plasma proteins
7. Clotting factors and cryoprecipitate. Used for clients with
clotting factor deficiencies. Each provides different factors
involved in the clotting pathway; cryoprecipitate also contains
fibrinogen.
Steps in Performing Blood Transfusion
1. Prior to performing the procedure, introduce self and
verify the client's identity using agency protocol. Explain to
the client what you are going to do, why it is necessary,
and how he or she can participate. Instruct the client to
report promptly any sudden chills, nausea, itching, rash,
dyspnea, back pain, or other unusual symptoms.
2. Provide for client privacy and prepare the client.
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Assist the client to a comfortable position, either sitting or
lying. Expose the IV site but provide for client privacy.
3. Perform hand hygiene and observe other appropriate
infection prevention procedures.
4. Prepare the infusion equipment.
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Ensure that the blood filter inside the drip chamber is
suitable for the blood components to be transfused. Attach
the blood tubing to the blood filter, if necessary.
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Apply gloves.
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Close all the clamps on the Y-set: the main flow rate clamp
and both Y-line clamps.
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Insert the piercing pin (spike) into the saline solution.
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5.
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6.
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7.
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Hang the container on the IV pole about 1 m (39 in.) above
the venipuncture site.
Prime the tubing.
Open the upper clamp on the normal saline tubing, and
squeeze the drip chamber until it covers the filter and one
third of the drip chamber above the filter.
Tap the filter chamber to expel any residual air in the filter.
Open the main flow rate clamp, and prime the tubing with
saline.
Close both clamps.
Start the saline solution.
If an IV solution incompatible with blood is infusing, stop
the infusion and discard the solution and tubing according
to agency policy.
Attach the blood tubing primed with normal saline to the
IV catheter.
Open the saline and main flow rate clamps and adjust the
flow rate. Use only the main flow rate clamp to adjust the
rate.
Allow a small amount of solution to infuse to make sure
there are no problems with the flow or with the
venipuncture site.
Obtain the correct blood component for the client.
Check the primary care provider's order with the
requisition.
Check the requisition form and the blood bag label with a
laboratory technician or according to agency policy.
Specifically, check the client's name, identification number,
blood type (A, B, AB, or O) and Rh group, the blood donor
number, and the expiration date of the blood. Observe the
blood for abnormal color, RBC clumping, gas bubbles, and
extraneous material. Return outdated or abnormal blood
to the blood bank.
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With another nurse (most agencies require an RN), verify
the following before initiating the transfusion:
a. Order: Check the blood or component against the primary
care provider's written order.
b. Transfusion consent form: Ensure the form is completed per
facility policy.
c. Client identification: The name and identification number on
the client's identification band must be identical to the name
and number attached to the, unit of blood.
d. Unit identification: The unit identification number on the
blood container, the transfusion form, and the tag attached to
the unit must agree.
e. Blood type: The ABO group and Rh type on the primary label
of the donor unit must agree with those recorded on the
transfusion form.
f. Expiration: The expiration date and time of the donor unit
should be verified as acceptable.
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g. Compatibility: The interpretation of compatibility testing
must be recorded on the transfusion form and on the tag
attached to the unit.
h. Appearance: There should be no discoloration, foaming,
bubbles, cloudiness, clots, or clumps, or loss of integrity of the
container.
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If any of the information does not match exactly, notify the
charge nurse and the blood bank. Do not administer blood
until discrepancies are corrected or clarified.
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Sign the appropriate form with the other nurse according
to agency policy.
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Make sure that the blood is left at room temperature for
no more than 30 minutes before starting the transfusion.
Agencies may designate different times at which the blood
must be returned to the blood bank if it has not been
started.
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If the start of the transfusion is unexpectedly delayed,
return the blood to the blood bank after 30 minutes. Do
not store blood in the unit refrigerator.
8. Prepare the blood bag.
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Invert the blood bag gently several times to mix the cells
with the plasma.
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Expose the port on the blood bag by pulling back the tabs.
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Insert the remaining Y-set spike into the blood bag.
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Suspend the blood bag.
9.
Establish the blood transfusion.
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Close the upper clamp below the IV saline solution
container.
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Open the upper clamp below the blood bag. The blood will
run into the saline-filled drip chamber. If necessary,
squeeze the drip chamber to reestablish the liquid level
with the drip chamber one third full. (Tap the filter to expel
any residual air within the filter.)
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Readjust the flow rate with the main clamp.
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Remove and discard gloves.
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Perform hand hygiene.
10. Observe the client closely for the first 15 minutes.
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Phillips and Gorski (2014) report that the AABB
recommends that "transfusions of RBCs be started at 1-2
mL/min for the first 15 minutes of the transfusion" (p.
732).
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Note adverse reactions, such as chills, nausea, vomiting,
skin rash, dyspnea, back pain, or tachycardia.
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Remind the client to call a nurse immediately if any
unusual symptoms are felt during the transfusion such as
chills, nausea, itching, rash, dyspnea, or back pain.
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If any of these, reactions occur, report these to the nurse in
charge, and take appropriate nursing action.
11. Document relevant data.
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Record starting the blood, including vital signs, type of
blood, blood unit number, sequence number (.g. #1 of
three ordered units), site of the venipuncture, size of the
catheter, and drip rate.
12. Monitor the client.
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Fifteen minutes after initiating the transfusion (or
according to agency policy), check the vital signs. If there
are no signs of a reaction, establish the required flow rate.
Most adults can tolerate receiving one unit of blood in 1.5
to 2 hours. Do not transfuse a unit of blood for longer than
4 hours.
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Assess the client, including vital signs, per agency policy. If
the client has a reaction and the blood is discontinued,
send the blood bag and tubing to the laboratory for
investigation of the blood.
13. Terminate the transfusion.
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Apply clean gloves.
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If no infusion is to follow, clamp the blood tubing. Check
agency protocol to determine if the blood component bag
needs to be returned or if the blood bag and tubing can be
disposed of in a biohazard container. The IV line can be
discontinued or capped with an adapter or a new infusion
line and solution container may be added. If another
tansfusion is to follow, clamp the blood tubing and open
the saline infusion arm. Check agency protocol. A new
blood administration set is to be used with each
component (Philips & Gorski, 2014, p. 733).
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If the primary IV is to be continued, flush the maintenance
line with saline solution. Disconnect the blood tubing
system and reestablish the IV infusion using new tubing.
Adjust the drip to the desired rate. Often a normal saline or
other solution is kept running in case of delayed reaction to
the blood.
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Measure vital signs.
14. Follow agency protocol for appropriate disposition of the
used supplies.
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Discard the administration set according to agency
practice.
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Dispose of blood bags and administration sets.
a. On the requisition attached to the blood unit, fill in the time
the transfusion was completed and the amount transfused.
b. Attach one copy of the requisition to the client's record and
another to the empty blood bag if required by agency policy.
c. Agency policy generally involves returning the bag to the
blood bank for reference in case of subsequent or delayed
adverse reaction.
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Remove and discard gloves.
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Perform hand hygiene.
15. Document relevant data.
Record completion of the transfusion, the amount of blood
absorbed, the blood unit number, and the vital signs. If the
primary IV infusion was continued, record connecting it. Also
record the transfusion on the IV flow sheet and intake and
output record.
Verbalize
Blood Transfusion Reactions
understanding on ● Transfusion-associated Circulatory Overload. It is
at least 3 blood
characterized by respiratory distress secondary to
transfusion
cardiogenic pulmonary edema. This reaction is most
reactions.
common in patients already in a fluid-overloaded state,
such as congestive heart failure or acute renal failure.
Diagnosis is based on symptom onset within 6 to 12 hours
of receiving a transfusion, clinical evidence of fluid
overload, pulmonary edema, elevated brain natriuretic
peptide, and response to diuretics. Preventive efforts and
treatment include limiting the number of transfusions to
the lowest amount necessary, transfusing over the slowest
possible time, and administering diuretics before or
between transfusions.
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Allergic Reaction. It often manifests as urticaria and
pruritis and occurs in less than 1% of transfusions. More
severe symptoms, such as bronchospasm, wheezing, and
anaphylaxis, are rare. Allergic reactions may be seen in
patients who are IgA deficient, as exposure to IgA in donor
products can cause a severe anaphylactoid reaction. This
can be avoided by washing the plasma from the cells prior
LectureDiscussion
10 minutes
Laptop
LCD projector
Power point
Presentation
Simple Recall
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to transfusion. Mild symptoms, such as pruritis and
urticaria can be treated with antihistamines. More severe
symptoms can be treated with bronchodilators, steroids,
and epinephrine.
Fatal Hemolysis. This is extremely rare, occurring only in 1
out of nearly 2 million transfusions. It results from ABO
incompatibility, and the recipient’s antibodies recognize
and induce hemolysis in the donor’s transfused cells.
Patients will develop an acute onset of fevers and chills,
low back pain, flushing, dyspnea as well as becoming
tachycardic and going into shock. Treatment is to stop the
transfusion, leave the IV in place, intravenous fluids with
normal saline, and keep urine output greater than 100
mL/hour, diuretics may also be needed. Cardiorespiratory
support may be provided as appropriate. A hemolytic
workup should also be performed, including sending the
donor blood and tubing and post-transfusion labs from the
recipient to the blood bank.
Infections. These are potential complications. However,
the risk of infections has decreased due to the screening of
potential donors, so hepatitis C and human
immunodeficiency virus risk are less than 1 in a million.
Bacterial infection can also occur, but does so rarely, about
once in every 250,000 units of red cells transfused.
Febrile Reactions. If this occurs, the transfusion should be
halted, and the patient evaluated, as a hemolytic reaction
can initially appear similar and consider performing a
hemolytic or infectious workup. The treatment is with
acetaminophen and, if needed, diphenhydramine for
symptomatic control. After treatment and exclusion of
other causes, the transfusion can be resumed at a slower
rate.
Show all the steps Materials
in
blood ● Unit of whole blood, packed RBCs, or other component
transfusion.
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Blood administration set
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IV pump, if needed
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250 mL normal saline for infusion
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IV pole
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Venipuncture set containing a #14- to #22-gauge catheter
(if one is not already in place)
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Alcohol swabs
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Tape
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Clean gloves
Preparation
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If the client has an IV solution infusing, check whether the
IV catheter and solution are appropriate to administer
blood. The IV catheter size ranges between #14 and #22
gauge, and the solution must be normal saline. Dextrose
(which causes lysis of RBCs), Ringer's solution, medications
LectureDemonstration
40 minutes
Laptop
LCD projector
Power point
Presentation
Skill
Performance
Checklist
using the
rating scale:
5Outstanding
4 - Very
Satisfactory
3Satisfactory
2 - Needs
Improvement
Return
Demonstration
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and other additives, and hyperalimentation solutions are
incompatible.
If the client does not have an IV solution infusing, check
agency policies. In some agencies an infusion must be
running before the blood is obtained from the blood bank.
In this case, perform a venipuncture on a suitable vein and
start an IV infusion of normal saline.
Steps
1. Prior to performing the procedure, introduce self and verify
the client's identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how he or
she can participate. Instruct the client to report promptly any
sudden chills, nausea, itching, rash, dyspnea, back pain, or other
unusual symptoms.
2. Provide for client privacy and prepare the client.
3. Perform hand hygiene and observe other appropriate
infection prevention procedures.
4. Prepare the infusion equipment.
5. Prime the tubing.
6. Start the saline solution.
7. Obtain the correct blood component for the client.
a. Order: Check the blood or component against the primary
care provider's written order.
b. Transfusion consent form: Ensure the form is completed per
1 - Not
Observed
facility policy.
c. Client identification: The name and identification number on
the client's identification band must be identical to the name
and number attached to the, unit of blood.
d. Unit identification: The unit identification number on the
blood container, the transfusion form, and the tag attached to
the unit must agree.
e. Blood type: The ABO group and Rh type on the primary label
of the donor unit must agree with those recorded on the
transfusion form.
f. Expiration: The expiration date and time of the donor unit
should be verified as acceptable.
g. Compatibility: The interpretation of compatibility testing
must be recorded on the transfusion form and on the tag
attached to the unit.
h. Appearance: There should be no discoloration, foaming,
bubbles, cloudiness, clots, or clumps, or loss of integrity of the
container.
8. Prepare the blood bag.
9. Establish the blood transfusion.
10. Observe the client closely for the first 15 minutes.
11. Document relevant data.
12. Monitor the client.
13. Terminate the transfusion.
14. Follow agency protocol for appropriate disposition of the
used supplies.
15. Document relevant data.
References:
Berman, A., Synder, S. J., & Frandsen, G. (2018). Kozer & Erb’s Fundamentals of Nursing 10th Edition Volume 2.
Lotterman,
S.,
&
Sharma,
S.
(2023,
June
20).
Blood
Transfusion.
Nih.gov;
https://www.ncbi.nlm.nih.gov/books/NBK499824/
StatPearls
Publishing.