SUFFOLK COUNTY COMMUNITY COLLEGE
NR33 Lab
Blood Transfusions Worksheet
Instructions: All worksheets should be reviewed prior to the lab. You will be required to demonstrate your
preparation by participating in the discussion which includes completing the worksheet and performing the
skills demonstrated by the instructor. Procedure checklist should be reviewed in the clinical skills book.
Blood Transfusions: is the IV administration of whole blood or a component such as plasma, packed cells,
platelets, clotting factors, albumin and cryoprecipitate.
Indications for use:
 correct severe anemia
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replace blood volume
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Blood groups and types:
 A
 B
 AB
 O
Rh factor:
 Rh positive
 Rh negative
Before administering any blood a type and crossmatch must be done.
Two kinds of transfused blood
 homologous
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autologus
Types of Transfusion: the patient’s condition determines which type of transfusion is needed.
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Whole Blood:
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Packed Red Blood Cells: Volume: 250cc
Infusion Time: 2-3 hours
Indications for use: To increase oxygen (02) carrying capacity in anemic patients
without a need for volume expansion.
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Modified Blood Products:
Leukocyte poor RBC: Volume: 250cc
Indications for use: Prevent recurrence of febrile reaction, utucaria and
Volume: 500cc
Infusion Time: 3-4 hours
Indication for use: Massive hemorrhage, hypovolemic shock.
anaphylactic reactions.
Platelet Concentrations: Volume: One Unit (50-70cc) (from one unit of fresh whole blood)
Indications for use: To control or prevent bleeding associated with platelet
deficiencies. Ten or more units may be required at one time.
Because platelets contain few RBC’s, ABO compatibility is not required,
multiple donors may be used.
Fresh Frozen Plasma: (FFP) Volume: 200-250cc
Indications for use: Plasma contains albumin, globulin, antibodies and clotting
factors. It is given to increase the level of clotting factors.
Volume: 5-20cc
Indications for use: Contains clotting factors: VIII, XIII and fibrinogen.
The RN must check, verify and inspect to prevent the patient from receiving the wrong blood product.
You want to prevent a fatal hemolytic reaction.
The nurse checks for:
 consent form
 name, ID#, DOB
 order
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The nurse verifies for:
 2nd nurse verifies the same information according to facility guidelines
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List the data the nurse must check for on the requisition form and the blood unit:
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Compare these 2 labels. Are they the same?
What should the nurse do if the labels are not correct?
Mary S. Smiley
DOB 02/02/22
MR#2536460
Dr. S Bonneraco
Mary S. Smiley
DOB 02/02/22
MR#25364160
Dr. S Bonneraco
Unit #31945A
Exp.10/10/06
B
Rh positive
Unit #31945A
Exp.10/10/06
AB
Rh positive
Procedures for Blood Transfusion: (refer to blood bank slip)
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Verify physician order, obtain consent, and explain procedure to patient.
Notify blood bank (Type and Crossmatch [TXM])
Take vital signs and ascertain patency of I.V. with at least a 20g. or larger angio catheter
Hang IV of Normal Saline to run KVO (Note: only 0.9% N.S. [normal saline] is infused with blood).
Must transfuse using blood transfusion tubing
Obtain blood from blood bank.
With a second nurse check transfusion slips , blood bag and patient ID
Prime unit of blood, check the patient’s I.D. band with the # on the blood.
Begin infusion slowly (25-50mL of blood) for first 5-15 minutes (rate 100mL/hr. Stay with the patient.
Most reactions occur in the first 15minutes.
Observe patient frequently throughout the transfusion
Document
When transfusion is completed:
 Flush the tubing with the IV of 0.9% NS, close clamp on completed unit of blood
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Reassess the patient, including vital signs
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Blood Transfusion Reactions: can occur immediately or up to 96 hours after.
 Stop transfusion immediately
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Change the tubing, infuse normal saline
Assess patient, including vital signs
Notify MD
Obtain urine and blood samples
Prepare for further treatment
Complete reports (see blood reaction form)
The nurse started a transfusion 30 minutes ago. The blood is not infusing. The nurse should:
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The nurse hung a unit of packed cells 30 minutes ago. The patient now complains of a back ache.
List the actions the nurse should take in order of priority.
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Review transfusion reaction chart (see chart)
The nurse is responsible for assessment of a possible transfusion reaction. List 10 interventions the nurse
should perform before, during and after the transfusion?
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Verifies MD order
Demonstration/Practice: Case scenario: administering a blood transfusion and documentation
Rev.atm 07/06
TRANSFUSION REACTION
REACTION
HEMOLYTIC
FEBRILE
ALLERGIC
BACTERIAL
CIRCULATORY
OVERLOAD
AIR EMBOLISM
CLINICAL OBSERVATION
Chills, fever, low back pain, chest
pain, hypotension, nausea,
vomiting, and bleeding
abnormalities, headache, shock.
From mild chills and fever to
extreme symptoms. Starts about
one hour after start of I.V.
Persists 8-10 hours.
TREATMENT
Stop transfusion. Notify M.D.
Administer 02, Adrenaline, fluids
as ordered. Collect blood and urine
samples for lab. Record I&O.
Observe for diuresis or oliguria.
Stop transfusion. Notify M.D.
Administer Antipyretics as
ordered.
Urticaria, rash, pruritis. In rare
cases, asthma, pulmonary edema,
facial or glottal edema. Nausea or
vomiting.
Stop transfusion. Notify M.D.
Administer antihistamine or, for
more serious reaction, epinephrine
or steroids as ordered.
Chills, fever, hypotension.
Vomiting and bloody diarrhea.
Dry flushed skin, abdominal and
extremity pain.
Stop transfusion. Notify M.D.
Treat with antibiotics and steroids
as ordered.
Engorged neck veins. Chest
constriction, dyspnea, dry cough,
rales at base of lungs, pulmonary
edema.
Stop or slow transfusion. Notify
M.D. Place patient in sitting
position. Administer diuretics,
rotating tourniquets if ordered.
Cyanosis, Dyspnea, Shock,
Cardiac Arrest
Stop transfusion. Notify M.D.
Turn patient on his left side with
his head down. Treat for shock.
NOTE: ALWAYS NOTIFY BLOOD BANK IF PATIENT HAS A TRANSFUSION REACTION.
PREVENTION
Minimize Risk by:
-Double-check patient I.D. and
blood type
-Remain with patient 1st 20 min.
-Begin transfusion slowly
Minimize Risk by:
-Keeping patient warm and
covered.
-Use saline washed RBC & P.C.
*Never add antihistamines to
blood.
Minimize Risk by:
-Determine if patient had prior
reaction to transfusions.
-Administer antihistamines
pre-transfusion as ordered.
Minimize Risk by:
-Use air free-touch free methods
to draw and deliver blood.
-Change filter and tubing between
transfusions.
Minimize Risk by:
-Use packed cells instead of
whole blood.
-Infuse split units for high risk
patients.
Minimize Risk by:
-Expel air from tubing before
transfusion.
-Do not allow blood bag to run dry.