Safety

• Use only 0.9% normal saline solution, which is compatible with blood products, to administer blood. No other solutions are to be administered or piggybacked with blood. Solutions that contain dextrose cause coagulation of blood.
• If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing attached directly to the venous access device, and notify the health care provider immediately. Do not infuse saline through the existing tubing because it will cause the blood in the tubing to enter the patient.
• Do not let a unit of blood hang for more than 4 hours because of the danger of bacterial growth. Administration sets should be changed at the completion of each unit or every 4 hours to reduce bacterial contamination.
• Never store blood in an agency refrigerator. Never inject medication into the same IV line with a blood component. Never use the same IV line to administer medication and blood since preservatives in the medication could cause hemolysis or clotting of the blood. Maintain a separate access line if IV solutions or medications are to be administered.

Equipment

(Roll cursor over items to see labels)

Y-type blood administration set (in-line filter)

IV pump (if not already in use)

Prescribed blood product

250-mL bag normal saline IV solution

Clean gloves

Tape

Thermometer

Stethoscope

Pulse oximeter

Delegation

The skill of initiating blood transfusion therapy may not be delegated to nursing assistive personnel (NAP). Delegation of related skills to licensed practical nurses (LPNs) is specified by each state’s Nurse Practice Act.

After the blood transfusion has been started and the patient’s stability has been confirmed, a patient may be monitored by NAP. Such monitoring does not relieve the registered nurse (RN) of the responsibility for continuing to assess the patient during the transfusion. Be sure to inform NAP of the following:

• Specify the frequency with which vital signs should be monitored.
• Review the information that should be reported to you immediately, including complaints of shortness of breath, hives, or chills.
• Discuss how to obtain blood components from the blood bank according to your agency’s policy.

Preparation

Verify the health care provider’s orders for the specific blood or blood product, the date, the time at which the transfusion is to begin, its duration, and any pretransfusion or posttransfusion medications to be administered.

• Obtain the patient’s transfusion history, and note any known allergies and previous transfusion reactions. Verify that type and cross-match have been completed within the past 72 hours.
• Verify that the patient’s IV cannula is patent and without complications, such as infiltration or phlebitis.
• Check that the patient has properly completed and signed the transfusion consent form, and assess his or her understanding of the procedure and its rationale.
• Assess laboratory values. Obtain and record the patient’s pretransfusion baseline vital signs. If the patient is febrile, notify the health care provider before initiating the transfusion.
• Assess the patient’s need for IV fluids or medications during the blood transfusion.

Follow-up

• Observe the IV site and status of the infusion each time vital signs are taken.
• Observe for any changes in vital signs and any signs of transfusion reactions such as chills, flushing, itching, dyspnea, or rash.
• Observe the patient, and assess laboratory values to determine the patient’s response to administration of the blood component.

Documentation

• Record pretransfusion medications, vital signs, location and condition of IV site, and patient education.
• Record the type and volume of blood component, blood unit/donor/recipient identification, compatibility, and expiration date according to agency policy, along with the patient’s response to therapy. Document on the transfusion record the nurses’ notes, medication administration record, flowsheet, and/or intake and output sheet, depending on your agency’s policy.
• Record the volume of normal saline and blood component infused.
• Report immediately to the health care provider any signs and symptoms of a transfusion reaction.
• Record the amount of blood received by autotransfusion and the patient’s response to therapy.
• Report to the health care provider any intratransfusion or posttransfusion deterioration in the patient’s cardiac, pulmonary, and/or renal status.
• Record the patient’s vital signs before, during, and after the transfusion.