Nursing Mgt & Principles in Blood Transfusion 2.
Ensure that the IV catheter is 18 or 19 gauge
 -Proper refrigeration
 -proper typing and cross matching
 type O -universal donor
 type AB - universal recipient
 85% of people is Rh (+) positive
Concept
1. Aseptic we assemble all materials needed:
 filter set
 isotonic or PNSS or 0.9 NaCl to prevent hemolysis
 Hypotonic solution -swell or burst
 Hypertonic solution - will shrink or crenate
 needle gauge 18 - 19 or large bore needle to prevent
hemolysis.
2. Instruct another RN to re-check the following:
 patient's name
 blood typing and Rh
 cross matching
 expiration date
 serial number
3. Check blood unit for presence of bubbles, cloudiness,
dark in color and sediments - indicates bacterial
contamination.
 Don't dispose, return to blood bank.
4. Never warm blood products - may destroy vital factors in
blood.
 Warming is done if with warning device -only in
emergency! For multiple blood transfusions!!
 What blood still within 30 minutes on room temp.
only!
5. Blood transfusion should be completed <4 hours because
life that is exposed at room temp for more than 2 hours can
start to deteriorate.
6. Avoid axing for administering drug at BT line - leads to
hemolysis.
7. Regulate BT 10 - 15 gtts/min KVO or 100 cc/hr to prevent
circulatory overload.
8. Monitor VS before, during and after BT especially q15
mins (local board) for 1st hour.
 NCLEX - q 15 min. for 1st 15 min.
 majority of BT reaction occurs within 1 hour.
Nursing care
1. Assess history of allergy
3. Use 0.9% NaCl
4. Verify the blood
5. Take baseline vital signs
6. Start transfusion slowly (KEEP VEIN OPEN - 10 drops/min)
7. Stay with the client during the initial 15 minutes.
8. Maintain the transfusion rate
 FWB = 3 to 4 hours
 PRBC = 2 to 4 hours
 FFP, platelets, cryoprecipitate - fast drip
9. Monitor adverse reaction
10. Document the following:
a. Blood component and number
b. Infusion started and ended
c. Client reaction
Materials needed:
1. IV tray
2. Compatible BT set
3. IV catheter/needle gauge 18/19
4. Plaster
5. Tourniquet
6. Blood product
7. Plain NSS
8. IV stand
9. Gloves
Procedures and rationale
1. Verify doctors order and make a treatment card *to avoid
mistakes.
2. Explain procedure to the client *to encourage client
operation and decrease anxiety of clients.
3. Request blood/blood component from hospital blood
bank to include blood typing and cost matching *to prevent
untoward blood reaction.
4. Warm-blooded at room temperature by wrapping the
blood back with a towel. Blood should be transfused not
more than 20 min. from the time it arrives from the blood
bank *to prevent untoward look reaction.
5. Have a doctor and a nurse counter check the compatible
blood to be transfused:
 name and identification number
 client's blood group and Rh type
 donor's blood group and Rh type
 crossmatch compatibility
 blood unit and serial component
 expiration date of blood product
*To prevent any problem in relation to transfusion.
6. Get baseline vital signs before transfusion *to compare
any change in vital signs before entering BT.
7. Give premed 30 minutes before transfusion is and he is  dyspnea
ordered *to prevent minor allergic reactions.  palpitation and tachycardia
8. Wash hands and don gloves *to prevent contamination of  lumber/sterna/flank pain
microorganisms.  hypotension
9. Prepare equipment needed *to facilitate intervention.  flushed skin
10. Initiate an IV line with appropriate IV catheter with plain  (read) port wine urine.
NSS, and or catheter properly and regulate rate *to flush out
to big and keep IV open. Nursing management
11. Open compatible aseptically & spike blood carefully;  stop BT-remove and change the tubing
primed to being and remove bubbles *to prevent air  notify Dr.
embolism.  flush with plain NSS
12. Disinfect the Y injection and port of IV tubing and
 administer isotonic fluid solution to counteract shock
inserted the needle from the BT administration sent and
 send blood units of blood bank for re-examination
secured with adhesive tapes.
 obtain urine and blood sample and send to lab for
13. Close IV fluid of plain NSS or regulates you KVO while
re-examination
transfusion is going on.
 monitor vital signs and allergic reaction
14. Transfuse the blood (4 hours) by injection port at 10-15
gtts. initially for 15 min. then regulate at ordered rate
Allergic reactions-rashes and itchiness, dyspnea,
*transfusion reaction occurs during the 1st 10 to 15 min. of
bronchospasm due to sensitivity in foreign proteins in
transfusion.
plasma.
15. Observe for any untoward s/s (flushed skin, chills,
elevated temperature, itchiness, urticaria and dyspnea). If
Signs and symptoms
any occurs, STOP the transfusion, open IV line with NSS and
 fever/chills
report to the physician *transfusion reaction occurs during
 Urticaria/pruritus
the 1st 10 to 15 min. of transfusion.
16. Swirl the bad ones in a hang *to mix the solid and liquid  dyspnea
element of the blood, RBC which tends to settle at the  laryngospasm/bronchospasm
bottom of the solution while the plasma rises to the top as  bronchial wheezing
the blood bag hangs.
17. If blood is consumed, close roller clamp of BT set then Nursing management
disconnect from IV line then regulate IVF as ordered.  stop BT
18. Carry out post BT orders such as re-check Hgb and Hct  notify Dr.
bleeding time, serial platelet count, etc.  flush with PNSS
19. Document observation and intervention done.  administer antihistamine - diphenhydramine HCL
(Benadryl). Give bedtime.
Blood transfusion reactions  Side effect – adult – drowsiness.
H- hemolytic reaction  If (+) hypotension - anaphylactic shock administer-
A- allergic reaction epinephrine
P- pyrogenic reaction  send the blood unit to blood bank
C- circulatory overload  obtain you reading and blood samples – send to lab
A- air embolism  monitor vital signs and input and output
T- thrombocytopenia  administer antihistamine as ordered for allergic
C- citrate intoxication - expired blood - hyper K reaction,
H- hyperkalemia  if (+) to hypotension - indicate anaphylactic
shock
Hemolytic reaction-donor blood is incompatible with the  administer epinephrine
recipient's blood, most feel, may present chills, diaphoresis  administer antipyretic and antibiotic for pyogenic
and back pains. reaction and TSB.

Signs and symptoms Pyogenic reaction-fever and chills due to sensitivity to

 Headache leukocyte or placement in addition – most common.
 dizziness
 Signs and symptoms
 fever/chills 2. Which of the following should a nurse to if blood
 tachycardia transfusion reaction occurs?
 headache A. notify physician
 palpitations B. continue IV transfusion
 dyspnea C. stop infusion immediately
 diaphoresis D. assess client

Nursing management 3. The IV method of medication is the most dangerous

 stop BT routes of administration because:
 notify Dr. A. the vein can only take a small amount of fluid at a time
 flush with PNSS B. the vein may harden and become non-functional
C. blood clots may become a serious problem
 administer antipyretics, antibiotics
D. the drug is placed directly into the bloodstream and its
 send blood unit to blood bank
action is immediate
 obtain urine and blood samples – send to lab
 Monitor VS and IO
4. As an IVT nurse, what are the sites that you need to avoid
 tepid sponge bath - offer hypothermic blanket
in inserting IV catheter except:
A. straight vein and dilated
Circulatory overload
B. veins below previous IV or phlebetic sites
C. infiltration sclerosed or thrombosed veins
Signs and symptoms
D. areas of skin inflammation, bruising or breakdown
 dyspnea
 orthopnea
 rales or crackles
 tachycardia and hypertension

Nursing management
 stop BT in place the client up right with fast
dependent
 notify physician. Don't flush due to patient has
circulatory overload.
 Administer diuretics.

Priority cases
1st = hemolytic reaction -due to hypotension-attend
to destruction of Hgb - O2 brain damage
2nd = circulatory overload
3rd = allergic reaction
4th = pyrogenic

SAMPLE BOARD QUESTIONS:

1. A patient who is a Jehovah's Witness is scheduled to have

a bowel resection for colon cancer. When planning care for
the patient, the nurse should be aware that:
A. the patient will most likely refuse any blood transfusion
B. the resected colon and surrounding tissue will be officially
buried
C. surgery must be delayed due to the priest would visit
D. holy Communion should be given on the day of the
surgery