Blood Administration
Nursing
This self-directed learning module contains information
you are expected to know to protect yourself, our
patients, and our guests.
Target Audience: Nursing (RN’s)
Contents
Instructions ........................................................ 2
Learning Objectives ........................................... 2
Module Content ................................................. 3
Job Aid .............................................................. 12
Posttest ............................................................. 13
Page 1 of 14
Blood Administration
Introduction
The material in this module is an introduction to important general information. After
completing this module, contact your supervisor to obtain additional information specific to
your department.

Read this module.

If you have any questions about the material, ask your supervisor.

Complete the online post test for this module.

The Job Aid on page 12 may be used as a quick reference guide.

Completion of this module will be recorded under My Learning in PeopleLink.
Learning Objectives:
When you finish this module, you will be able to:





Identify 3 types of blood products
Identify 1 indication for each blood product
Describe the proper procedure for the administration of blood products at CMCLincoln
Identify steps to ensure product and patient verification
Identify signs and symptoms of suspected transfusion reaction
Page 2 of 14
Blood Administration
Introduction
A variety of medical conditions result in the need for a patient to receive a blood
and/or blood product transfusion.
Nursing care for these patients is centered on knowledge of the various blood
products. Awareness of the signs and symptoms of early and late transfusion
reactions is crucial.
This module reviews essential nursing considerations of blood administration
including the pre-assessment, equipment needed, blood product administration
information, and review of potential post-transfusion reactions.
Types of Blood Products
The patient’s physician will evaluate which blood product is best for the treatment of
the underlying medical or surgical condition.
Whole Blood

Replenishes both the volume and the oxygen-carrying capacity of the
circulatory system and promotes coagulation.

Used to treat acute, massive blood loss.

Contains approximately 500ml of volume.
Packed Red Blood Cells

Restore the oxygen-carrying capacity of the blood with less volume.

Used when decreased hemoglobin and hematocrit levels accompany a normal
blood volume.

Often used to replace blood loss in surgery.

Contains approximately 250ml of volume.
Platelets

Used to treat a patient that has a decreased platelet count (thrombocytopenia)
due to either a decreased platelet production or increased platelet destruction.

Used to treat acute leukemia and bone marrow aplasia.

Contains approximately 50 ml per unit.
Page 3 of 14
Blood Administration
Fresh Frozen Plasma

A product in which plasma is separated from RBCs.

Plasma is rich in coagulation factors V, VIII, and IX.

Used to expand plasma volume, treat post-operative hemorrhage/shock or to
correct and undetermined coagulation factor deficiency.

Contains 200 to 250 ml of volume.
Safe Blood Administration
Blood Administration Filters
The use of a standard blood administration set is required for the administration of all
blood and blood components. This standard blood administration set has a built in
filter designed to remove debris and clots.
Each standard blood administration set can be used for the transfusion of up to 2
units of PRBC or for a maximum of 4 hours total hang time.
Blood Administration Tips
You should always review the blood administration policy before administering blood
products.
Stay alert for signs and symptoms of a blood transfusion reaction.
Step One
Verify physician’s order for the words administer or transfuse blood product.
Unfortunately, transfusion errors have occurred when the physician order reads to
“type and cross 2 units of PRBCs” versus an order to “administer 2 units of PRBCs”.
The first order (type and cross) is to prepare the product (should the transfusion be
needed at a future time), and not to administer the product. The second order
(administer/transfuse) is to actually administer the blood product. It is important for
the nurse to differentiate between these two types of orders.
Page 4 of 14
Blood Administration
Step Two
Administer pre-medications, if ordered, to minimize potential for mild allergic
transfusion reaction.
Step Three
Make sure there is a signed informed consent form before the therapy is
initiated. Allow time in advance of the transfusion for the patient to understand what
is said and to have time to make an informed choice. The RN should notify the
physician if the patient or responsible party has questions or is unwilling to provide
consent.
Step Four
Ensure patent IV access of 20-gauge or larger catheter. (A 22-gauge may be
used as the minimal size but note that there is increased risk of hemolysis. Infusion
rate should be no greater than 100 ml/hr.) Prime the transfusion tubing using aseptic
technique with 0.9% sodium chloride solution only.
Step Five
Obtain the patient’s vital signs (including blood pressure, heart rate, respiratory
rate, and temperature) before beginning the transfusion. Obtaining an accurate
temperature is important since febrile reactions are the most common reaction to
blood transfusions. If the patient has a temperature greater than 100 degrees
Fahrenheit, notify the MD before proceeding.
Step Six
Obtain blood product from blood bank. The blood bank personnel and employee
picking up the blood product will verify patient and type of blood product ordered by
providing the following information in writing to the lab (may use patient labels):

Patient Name

Medical Record Number

Account Number

Blood Bank Unique ID Number
Page 5 of 14
Blood Administration
**Blood may be delivered from the Blood Bank through the pneumatic tube system
using the following steps:

Send Blood Release Form to Blood Bank for each product needed via the tube
system. Blood product should arrive at requesting location within 15 minutes of
sending the request form.

Blood received through the tube system should be retrieved out of the system
by an RN only.

When the blood products arrive via the tube system via secured delivery, the RN
should retrieve using the secure code and should sign the Blood Release Form
and send the form back to the Blood Bank signifying receipt of the blood
products.

Nursing personnel receiving the blood product from Blood Bank should deliver
promptly to the transfusionist. Note: May only transport one unit at a time.
Exception: More than one unit may be used with dedicated cooler. Refer to
Blood Bank Policy Manual.
Blood products must be initiated within 30 minutes of receipt from blood bank. If
there is an unexpected delay with the initiation of the transfusion, return the blood to
the blood bank immediately for refrigeration. Blood products can not be stored in the
refrigerator on your unit.
Step Seven
Perform visual check of the blood product. Assess the blood product for any
abnormalities in color, RBC clumping, gas bubbles, or extraneous material. Assess
the expiration date. Return abnormal or outdated blood product to the blood bank.
Step Eight
Perform a bedside patient identification and blood product verification by two
licensed nurses (one must be an RN). One of which must be the individual
transfusing the blood.
Compare the patient’s hospital bracelet and blood bank bracelet with the
Transfusion Record attached to the blood bag label. Verify the following information:

Patient’s full name

Patient’s medical record number

Unique blood bank armband number

Blood/Blood product information
Page 6 of 14
Blood Administration

Donor Unit Number

ABO

Rh

Expiration Date

Physician Order
**If the patient’s blood ID band is not present or needs to be removed, only lab
personnel can remove and reapply the armband.
Upon completion of the bedside verification, document the check in Cerner. Do not
administer any blood product if there is a patient related discrepancy.
Step Nine
Instruct patient and patient family of signs and symptoms of blood transfusion
reactions and document the education on the Education Teaching Record.
Blood and blood products must be administered within 4 hours from the time
the product is dispensed by the blood bank because the risk of contamination and
sepsis increase after that.
Step Ten
Obtain and document vital signs (BP, T, P, R are required and oxygen saturation
if indicated) as follows:

Baseline vital signs are obtained within 30 minutes prior to starting the
transfusion.

15 minutes after starting the transfusion.

One hour from the start of the transfusion.

Then every hour.

At the end of the transfusion.

30-60 minutes after the transfusion is stopped.
Transfusion Reactions
Blood transfusion reactions occur when the recipient’s immune system launches a
response against a component of the transfused product.
Page 7 of 14
Blood Administration
Types of Transfusion Reactions

Allergic:
o Mild reaction: Skin changes such as wheals, urticaria,
macular or maculopapular erythema
o Moderate reaction: Respiratory changes such as
wheezing especially on expiration, laryngeal edema
o Severe reaction: Anaphylactic/signs of shock.

Febrile, non-hemolytic:
o Temperature elevation > 1.8 degrees F
during the transfusion and up to 1 hour post transfusion,
headache, flushing, anxiety, vomiting and muscle pain.

Hemolytic, Acute:
o Back pain, tightness in chest, pain and/or burning at site of infusion,
chills, rigors, hypotension, flushing, tachycardia.

Hemolytic, Delayed:
o Patient may develop symptoms from 24 hours to 21 days post transfusion
that would include milder symptoms of acute hemolytic reactions such as
chills, rigors, back/flank pain, hypotension, jaundice.

Circulatory overload:
o pulmonary congestion, moderate to severe respiratory distress,
hypertension, tachycardia.

Transfusion related acute lung injury (TRALI):
o acute onset of ALI within 6 hours of infusion; hypoxemia, oxygen
saturation less than 90% on room air, respiratory distress.

Bacterial Contamination:
o Severe chilling, high fever, dry flushing, nausea, vomiting,
hemoglobinemia, bleeding, and sudden severe hypotension.
Suspected Reaction
1. Stop the transfusion immediately, as soon as the transfusion reaction is
suspected.
2. Notify physician and blood bank immediately.
3. Do not discard the blood or blood tubing as the blood bank will require these for
testing.
4. Follow policy guidelines for transfusion reaction.
Page 8 of 14
Blood Administration
5. Complete an Investigation of Suspected Transfusion Reaction Report and send
a copy to the blood bank with blood component and tubing in plastic/specimen
bag. Notify Risk Management.
6. Monitor vital signs and oxygen saturation based on patient’s condition until
within normal limits or within patient baseline and condition has stabilized, or
according to physician order.
7. Document the event in the medical record.
Post Blood/Blood Component Transfusion Process
When blood/blood component has been infused, document the completion of
the transfusion to include:

Date and Time

Completed or Discontinued

Whether or not a reaction had occurred

Amount transfused
Place blood tag from the unit of blood/blood component in the medical record as
required by the facility.
If another unit of blood is to be given and is not readily available, keep/maintain
patency of the IV until next unit is available.
Confirm that outpatients or patients who will be leaving the hospital on the day of
transfusion have received written instructions regarding delayed transfusion
reactions.
Discard the empty/completed blood/blood component bag in the biohazard waste
upon completion.
Return the blood/blood component bag and tubing to the Blood Bank in the event of a
suspected blood transfusion reaction (excludes mild allergic reaction).
Special Considerations
Volume Overload
Occurs when blood is administered faster than the circulation can accommodate.

Monitor high risk patients closely
o For example: Congestive Heart Failure or Renal Failure patients.
o May need to infuse blood more slowly (must not be longer than 4 hours).
Page 9 of 14
Blood Administration
o Adjust transfusion volume and flow rate based on patient size and clinical
status. (May need to infuse blood over full 4 hours).
o Administer diuretics prophylactically after/between units of blood if
ordered.
Signs and Symptoms

Cough, dyspnea, crackles, headache, hypertension, tachycardia, and distended
neck veins
Treatment

Place patient in Fowlers position

Notify physician immediately

Diuretics, oxygen, and morphine as ordered

Adjust rate of blood as ordered
TRALI (Transfusion Related Acute Lung Injury)

A potential life threatening complication of blood transfusion

One of the leading causes of transfusion related fatalities in the US

Occurs in one out of every 5,000 transfusions with a mortality rate of 6-9%
Causes

Occurs when WBC antibodies in the donor blood reacts with the recipient’s
WBC’s causing a change in the lung tissue that allows fluid to enter.

Donors implicated in TRALI reactions are women with more than 2 children or
donors who have had multiple transfusions.

The most common transfused blood product implicated in cases of death due to
TRALI has been fresh frozen plasma.

Can also occur in recipients of PRBC’s due to the residual plasma present in the
unit.
Clinical Presentation

In most cases it presents within 2 hours of the transfusion but may be up to 4 to
6 hours following the administration of a plasma containing blood component.

Patient manifests physical symptoms of rapid onset respiratory failure.
Page 10 of 14
Blood Administration

Chest X-ray shows severe pulmonary edema, without cardiac enlargement or
involvement of the vessels.
Signs and Symptoms

Fever, hypotension, tachycardia, chills, cyanosis, non-productive cough, and
dyspnea
Treatment

Primarily supportive measures. Most patients require mechanical ventilation.

TRALI is associated with microvascular damage not fluid overload, so diuretics
are not recommended.
Refusal of Blood Transfusion

Patients have the right to refuse blood without compromising other medical
treatment options

If the family refuses a blood transfusion on an incompetent patient, a court
order must be obtained to transfuse the patient

Notify physician of patient’s decision
Conclusion
Administration of blood and blood products is a common nursing task; however, it
carries with it certain risks.
Knowledge about blood products and adherence to the organization’s policy and
procedure for blood administration is critical. Recognition of reactions and rapid
treatment is crucial for the safe administration of blood products.
Page 11 of 14
Blood Administration
JOB AID

Verify order for transfusion of blood product.

Verify that you have a signed informed consent form and that the patient has
been given information regarding transfusion.

Verify that patient has a patent IV access of 20g or larger (22g minimal if
necessary).

Obtain equipment needed for transfusion.

Obtain pre-transfusion vital signs including blood pressure, heart rate,
respiratory rate, and temperature.

Obtain blood product from Blood Bank.

Begin administration within 30 minutes of the time blood was obtained from the
blood bank.

Perform the final check for patient identification and blood product verification
at the bedside by two licensed individuals (one must be an RN).

Monitor for signs and symptoms of a reaction.

Management of Transfusion Reactions
o Stop transfusion immediately
o Notify physician and blood bank
o Send entire blood bag, blood set, and tubing to the lab
o Follow policy guidelines for transfusion reaction
o Complete Investigation of Suspected Transfusion Reaction Report and
notify Risk Management
o Monitor patient vital signs and condition
o Document event in medical record
Page 12 of 14
Blood Administration
Posttest
Name: _____________________________________________
Date: ______________________________________________
1. Transfusion of PRBCs restores the oxygen carrying capacity of the blood with less
volume.
a. True
b. False
2. An order to type and cross-match is an order to give blood.
a. True
b. False
3. Patients have the right to refuse a blood transfusion.
a. True
b. False
4. Where must the verification of the blood product with two licensed nurses take place?
a. at the Nursing station
b. in the blood bank
c. at the patient’s bedside
d. in the hallway outside the patient’s room
5. Blood products must be initiated within ____ minutes of receipt from blood bank.
a. 5 minutes
b. 10 minutes
c. 60 minutes
d. 30 minutes
6. Which of the following measures may be used to prevent volume overload in the CHF
patient receiving blood:
a. Infuse blood more slowly.
b. Administer diuretics between and after units of blood.
c. Monitor patient for signs of dyspnea, crackles, tachycardia, or distended neck veins.
d. All of the above.
Page 13 of 14
Blood Administration
7. The most common transfused blood product implicated in cases of death due to TRALI
has been fresh frozen plasma.
a. True
b. False
8. Which of the following is a signs of transfusion reaction?
a. increased temperature
b. decreased blood pressure
c. substernal chest pain
d. all of the above
9. If you suspect a blood transfusion reaction, the FIRST thing you should do would be:
a. Call the MD
b. Call the Blood Bank
c. Stop the Transfusion
d. Obtain vital signs
10. What is the maximum amount of time that blood or blood products can be administered
in after being dispensed from the blood bank?
a. 6 hours
b. 4 hours
c. 2 hours
d. 8 hours
Page 14 of 14