A blood transfusion is a safe procedure that replaces blood lost to injury or

surgery. It can also help treat certain medical conditions.

According to the American Red Cross, there are four common types of
blood transfusions:

●​ Red blood cell transfusions: A person may receive a red blood cell
transfusion if they have experienced blood loss, if they have anemia
(such as iron deficiency anemia), or if they have a blood disorder.
●​ Platelet transfusions: A platelet transfusion can help those who have
lower platelet counts, such as from chemotherapy or a platelet
disorder.
●​ Plasma transfusions: Plasma contains proteins important for health.
A person may receive a plasma transfusion if they have experienced
severe burns, infections, or liver failure.
●​ Whole blood transfusion: A person may receive a whole blood
transfusion if they have experienced a severe traumatic hemorrhage
and require red blood cells, white blood cells, and platelets

1.​Verifies the written order for the transfusion.

Verify provider’s order (product, volume, rate )
Date/Time/type of blood
Secure and Transfuse 1 unit of whole blood of patient’s blood type,
properly screened and crossmatched.
Properly screened and crossmatched.
2.​Checks for signed consent for transfusion.
Obtains specific data and initiates patient education if required.
Patient should affix his/her signature to know if she agrees to the
procedure
For legal and documentation purposes.
Check availability of blood with the blood bank.

BLOOD REQUEST FORM:

Name
AP
Diagnosis
Blood type
Order
Blood component
Doctors signature
-sent to blood bank – to be processed. Take blood sample of patient for
blood typing and crossmatched
Charge nurse - usually sends doctors orders/requests and informs the
blood bank when to release the blood.

3.​Explains the procedure to the patient.

Explain the procedure to the patient, need for transfusion, blood product
to be given, approximate length of time, desired outcome, etc.
Emphasize the need for patient to report unusual symptoms
immediately
✅ I. Pre-Transfusion
●​ 🩺 Review transfusion history/allergies
●​ 🌡️ Record baseline vitals
●​ 🧪 Check labs (Hgb/Hct, ABO/Rh, compatibility)
●​ 💧 Assess fluid status
●​ 💉 Ensure IV line is patent (≥20G for PRBCs)
●​ 🚨 Prepare emergency meds/equipment

Equipment and Setup

 · Prepare Equipment: Ensure infusion pumps, blood warmers (if
needed), and IV access devices are ready.
· IV Access: Confirm that the intravenous line is patent and that the site
is clean.
· Transfusion Set: Prime the tubing and ensure all connections are
secure.
· Infusion Rate: Set the correct infusion rate as per the provider’s
order.

●​ 🗣️ Educate patient (what to expect and symptoms to report

-​ Prevents errors and thus eliminates possibility of transfusion
reactions.
-​ -Provides reassurance and facilitates cooperation.
-​ Early identification of transfusion reactions aids in instituting prompt
corrective measures.

4.​Informs the patient to report any signs of transfusion reaction. If

pre-medication has been ordered, administer it now.
Prepare the patient:
Encourage the patient to empty bowel and bladder and assist to a
comfortable position. Ensures comfort of the patient.

5.​Performs hand hygiene and put on clean gloves.

Prevents cross infection.

6.​Starts IVF with 0.9% Normal Saline Solution using an 18 or 19 gauge

catheter.
Normal saline must always be used when giving a blood
transfusion. If the client has an infusion of any other IV
solution, stop that infusion and flush the line with saline prior
to initiating the transfusion, or establish IV access through an
additional site. Solutions other than saline can cause damage
to the blood components.

Normal saline is the only crystalloid that is compatible with blood and
priming of the blood set helps in reducing risk of haemolysis of
blood in contact with tubing.

IV cannula G18 / 19 - Large bore cannula permits infusion

of whole blood, reducing chances of haemolysis.

7.​Keeps IV open by starting flow of normal saline.

KVO at 10cc/hr

8.​Obtains blood product from blood bank within 30 minutes of initiation.

Goes to the blood bank, brings medical blood transport bag

Obtain blood from blood bank in accordance with agency policy. If

transfusion cannot begin immediately, return the product to the blood
bank. Blood which is out of the refrigerator for more than 30 minutes,
above 10°C cannot be re-issued. Never store blood in an unauthorized
area-like ward refrigerator. Blood must be stored in a refrigerated unit at
carefully controlled temperature (4°C).
Once blood or a blood product is removed
from the blood bank refrigerator, it must be administered
within a limited amount of time (e.g., packed RBCs should
not hang for more than 4 hours after being removed from the
blood bank refrigerator)
Safe storage of blood is limited to 35 days before erythrocytes are
damaged. Verifies that ABO group, Rh type, unit number, patient’s name,
etc
matches. This reduces chances of mismatched transfusion and
transfusion reaction.

Faulty techniques in storing blood products can cause haemolysis.

9.​Verifies the blood product and the client with another nurse:
a.​Client’s name, blood group, Rh type
b.​Cross-match compatibility
c.​ Donor blood group and Rh type
d.​Serial number
e.​Expiration date and time on blood bag
f.​ Type of blood product compared with written order
g.​Presence of clots in blood

THE OTHER NURSE READS BACK THE DOCTOR’S ORDER AND

READ THE TAG OF THE BLOOD BAG

10.​ Obtains baseline vital signs.

Obtains baseline data to compare with changes post-transfusion. Delay
transfusion if temperature is more than 101.8°F.

11.​ Starts infusion:

The 30-minute rule states that red blood cell (RBC) units left out of
controlled temperature storage for more than 30 minutes should not be
returned to storage for reissue; the 4-hour rule states that transfusion of
RBC units should be completed within 4 hours of their removal from
controlled temperature storage
a.​Opens blood transfusion set and closes roller clamp.
b.​Spikes blood bag with a blood transfusion set and an 18 or 19 gauge
catheter. (large-bore needle)
c.​ Squeezes the drip chamber and allows the filter to fill with blood.
d.​Open the roller clamp and allow tubing to fill with blood.
Priming of tubing is essential for preventing haemolysis.
e.​Closed roller clamp.
 f.​ Attaches tubing with an 18 or 19 gauge catheter to the Y-port of the
tubing aseptically. Secure connections with tape.

g.​Start the transfusion slowly.

Start infusion of blood product slowly, at the rate of 25-50 mL/hour
for the first 15 minutes.
h.​Closes roller clamp of Normal Saline Solution.

i.​ Remove gloves.

12.​ Stays with the patient for the first 15-30 minutes of transfusion.
Transfusion reaction typically occurs during this period. A slow
volume can minimize the volume of RBCs transfused. Checking vital
signs frequently helps in early identification of complications.

13.​ Regulates the flow rate as prescribed (if no signs of transfusion

reaction).
-Increase infusion rate if no adverse reactions are noticed. The flow
rate should be within safe limits.
-Flow rate is determined by physician’s instruction and patient’s
condition.
14.​ Check vital signs at least every 15 minutes for the first hour.
Helps in identifying early transfusion reactions.
✅ III. During Transfusion
🐢 Start slowly for first 15 minutes
👩‍⚕️ Stay with patient during initial phase
📊 Monitor vital signs
​Before start
​15 minutes after initiation
​Hourly
​At completion
​
 👀 Watch for signs of reaction (fever, chills, SOB, rash, back pain)
Observe Patient Behavior: Watch for changes in mental status, new
onset chills, fever, itching, or pain at the infusion site.

📝 Document time, rate, vitals, and patient response

✅ IV. If Reaction Occurs
⛔ STOP the transfusion
💧 Maintain IV line with normal saline
📞 Notify provider and blood bank immediately
📈 Monitor/document vitals & symptoms
💊 Administer meds as ordered
📦 Return blood & tubing per facility protocol
Transfusion Reactions. Transfusion of ABO- or Rh- incompatible blood can
result in a hemolytic transfusion reaction,
which causes destruction of the transfused RBCs and subsequent
risk of kidney damage or failure. To avoid hemolytic transfusion
reactions, blood from the donor and from the recipient is tested for
compatibility. This is referred to as a type and crossmatch. Other
forms of transfusion reactions may also occur, including febrile or
allergic reactions, circulatory overload, and sepsis. Because the
risk of an adverse reaction is high when blood is transfused, clients
must be frequently and carefully assessed before and during trans
fusion. Many reactions become evident within 5 to 15 minutes of
initiating the transfusion, but reactions can develop any time dur
ing a transfusion; for this reason clients are most closely monitored
during the initial period of the transfusion. Stop the transfusion im
mediately if signs of a reaction develop. Keep the line open with
normal saline
15.​ After blood has infused, wear gloves to clamp off blood and to
remove bag and tubing.

✅ V. Post-Transfusion
●​ 🌡️ Reassess and document final vitals
●​ 🔍 Monitor for delayed reactions (fever, hematuria, jaundice)
●​ 💉 Inspect IV site
●​ 📝 Record end time, volume infused, and patient outcome
●​ 🗣️ Educate patient on delayed signs to report
●​ 📚 Communicate to healthcare team, update care plan

Patient Monitoring After Transfusion

· Reassess Vital Signs: Continue monitoring the patient’s vital signs
after the transfusion is completed.
· Evaluate for Delayed Reactions: Some transfusion reactions, such
as delayed hemolytic reactions, may occur hours later. Monitor for
signs such as fever, pain, or changes in urine color.
· Check IV Site: Inspect the insertion site for signs of infiltration or
phlebitis.

16.​ Begins Normal Saline Solution infusion.

17.​ Disposes bag and tubing.
18.​ Removes gloves and washes hands.am
19.​ Documents the procedure.

Documentation and Communication

· Record Completion Time: Document the end time of the transfusion.
· Document Patient Response: Record any adverse reactions,
interventions taken, and the patient’s overall response.
· Report to Healthcare Team: Communicate relevant information to the
provider and update the patient’s care plan.
· Ensure Follow-Up: Schedule any necessary follow-up labs or
assessments to evaluate the patient’s progress.