Administering a Blood Transfusion

Goal: The patient receives the correct blood type and remains free of injury due to transfusion complications and/or reactions.

1. Verify the medical order for transfusion of a blood product. Verify the completion of informed consent documentation in the medical record. Verify any medical order for pretransfusion medication. If ordered, administer medication at least 30 minutes before initiating transfusion.

2. Gather all equipment and bring to bedside.

3. Perform hand hygiene and put on PPE, if indicated.

4. Identify the patient.

5. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Ask the patient about previous experience with transfusion and any reactions. Advise patient to report any chills, itching, rash, or unusual symptoms.

6. Prime blood administration set with the normal saline IV fluid. Refer to Skill 15-2.

7. Put on gloves. If patient does not have a venous access in place, initiate peripheral venous access. (Refer to Skill 15-1.) Connect the administration set to the venous access device via the extension tubing. (Refer to Skill 15-1.) Infuse the normal saline per facility policy.

8. Obtain blood product from blood bank according to agency policy. Scan for bar codes on blood products if required.

9. Two nurses compare and validate the following information with the medical record, patient identification band, and the

label of the blood product:
• Medical order for transfusion of blood product
• Informed consent
• Patient identification number
• Patient name
• Blood group and type
• Expiration date
• Inspection of blood product for clots

10. Obtain baseline set of vital signs before beginning transfusion.

11. Put on gloves. If using an electronic infusion device, put the device on “hold.” Close the roller clamp closest to the drip chamber on the saline side of the administration set. Close the roller clamp on the administration set below the infusion device. Alternately, if using infusing via gravity, close the roller clamp on the administration set.

12. Close the roller clamp closest to the drip chamber on the blood product side of the administration set. Remove the protective cap from the access port on the blood container. Remove the cap from the access spike on the administration set. Using a pushing and twisting motion, insert the spike into the access port on the blood container, taking care not to contaminate the spike. Hang blood container on the IV pole. Open the roller clamp on the blood side of the administration
set. Squeeze drip chamber until the in-line filter is saturated. Remove gloves.

13. Start administration slowly (no more than 25 to 50 mL for the first 15 minutes). Stay with the patient for the first 5 to 15 minutes of transfusion. Open the roller clamp on the administration set below the infusion device. Set the rate of flow and begin the transfusion. Alternately, start the flow of solution by releasing the clamp on the tubing and counting the drops. Adjust until the correct drop rate is achieved. Assess the flow of the blood and function of the infusion device. Inspect the insertion site for signs of infiltration.

14. Observe patient for flushing, dyspnea, itching, hives or rash, or any unusual comments.

15. After the observation period (5 to 15 minutes) increase the infusion rate to the calculated rate to complete the infusion within the prescribed time frame, no more than 4 hours.

16. Reassess vital signs after 15 minutes. Obtain vital signs thereafter according to facility policy and nursing assessment.

17. Maintain the prescribed flow rate as ordered or as deemed appropriate based on the patient’s overall condition, keeping in mind the outer limits for safe administration. Ongoing monitoring is crucial throughout the entire duration of the blood transfusion for early identification of any adverse reactions.

18. During transfusion, assess frequently for transfusion reaction. Stop blood transfusion if you suspect a reaction. Quickly replace the blood tubing with a new administration set primed with normal saline for IV infusion. Initiate an infusion of normal saline for IV at an open rate, usually 40 mL/hour. Obtain vital signs. Notify physician and blood bank.

19. When transfusion is complete, close roller clamp on blood side of the administration set and open the roller clamp on the normal saline side of the administration set. Initiate infusion of normal saline. When all of blood has infused into the patient, clamp the administration set. Obtain vital signs. Put on gloves. Cap access site or resume previous IV infusion. (Refer to Skill 15-1 and Skill 15-5.) Dispose of blood-transfusion equipment or return to blood bank, according to facility policy.

20. Remove equipment. Ensure patient’s comfort. Remove gloves. Lower bed, if not in lowest position.

21. Remove additional PPE, if used. Perform hand hygiene.