Administering Blood and Blood Products

Administering Blood and Blood Products

Equipment
■ Clean nonsterile gloves.
■ Blood product.
■ 250 mL normal saline IV solution.
■ Blood administration set with a 200-micrometer filter and Luer-Lok
connection (if there is no filter on the tubing, you must attach one).
■ Be Smart! Although nurses commonly use a 20-gauge catheter, for
routine transfusion, a 22- or 24-gauge can be used. You would need
an 18- or 20-gauge catheter to transfuse large amounts of blood
rapidly.
■ Be Smart! When choosing an IV catheter for transfusion, the
primary consideration should be the size of the patient’s veins
and not an arbitrary catheter size.
■ IV pole.
■ Watch with a second hand or digital readout.
■ Thermometer.
■ BP cuff with sphygmomanometer.
■ Stethoscope.

Assessment
■ Confirm the patient’s need for blood products by assessing VS, urine output, and laboratory studies.
■ Be Safe! Check the history for previous transfusions and reactions. Verify the patient’s blood type.
■ Assess that the existing IV catheter is patent and the proper size for blood product administration.
■ Assess the IV insertion site for signs of infiltration, phlebitis, infection, or inflammation.
■ Assess for allergy to tape.

Post-Procedure Reassessment
■ Be Safe! Monitor for signs of fluid overload and for signs and symptoms of transfusion reaction.
■ Check laboratory studies, such as complete blood count, to help evaluate the effectiveness of therapy and identify transfusion reaction.

Key Points
■ Verify that informed consent has been obtained.
■ Verify the prescriber’s order, noting the indication, and rate of infusion.
■ Administer any prescribed pretransfusion medications.
■ Obtain a blood administration set and 250 mL of IV normal saline solution.
■ Obtain the blood product from the blood bank according to your institution’s policy.
■ With another qualified staff member, and using two identifiers, verify the patient and blood product identification (e.g., birth date, hospital ID number, blood type).
■ Be Safe! Contact the blood bank immediately if there are discrepancies, and do not administer the blood product.
■ Document on the blood bank form the date and time the transfusion is begun.
■ Check that all clamps are closed on the blood administration set; label the tubing.
■ Hang the normal saline and prime the tubing.
■ Gently invert the blood product container several times.
■ Spike the blood product and hang the blood on the IV pole.
■ Obtain a set of VS.
■ Scrub the port with an alcohol or CHG-alcohol antiseptic swab for at least 15 seconds
■ Attach the administration set tubing to the IV catheter.
■ Slowly open the roller clamp closest to the blood product.
■ Be Safe! Infuse the first 50 mL slowly and remain with the patient for the first 5 minutes.
■ Measure VS at 5 minutes, 15 minutes, and 30 minutes; then hourly.
■ Observe for and ask the patient to report symptoms of transfusion reaction.
■ When the blood has transfused, flush the line with the saline solution.
■ Disconnect the tubing from the IV catheter, and dispose of the blood product container and tubing per agency policy.
■ If a second unit of blood is to be transfused, the same administration set may be used.
■ Administer any post-transfusion medications prescribed.

Documentation
■ Chart the date, time, and reason the transfusion was started.
■ Document transfusion VS according to institution policy (many institutions have a special form for this).
■ Record the amount of blood transfused on the I&O record.
■ Chart any complications and the interventions taken.