administering blood transfusion

identify client, order for transfusion, client allergies, and previous transfusion reaction

Provide education to client regarding reasons for ordered transfusion, transfusion complications

Obtain consent, ensure Type and cross match completed, and blood bank arm band on the client

Ensure patent IV #18g.

Obtain Vital signs

Identify proper blood products infusion set, prime blood products infusion set with 0.9% NS to include back priming of Y connection

Request blood products from blood bank (ordered throught IMED) and complete transfusion criteria form

• Complete bedside identification with 2 RN or and RN and LPN
• - Client name
• - DOB
• - Blood type
• - Blood tag
• - Client admission armband
• - unit number on the blood transfusion form and blood bag tag match the blood bag number
• - the blood bag number must remain on the blood bag until the transfusion is terminated
• - both nurses sign the blood transfusion sheet
• - if any discrepancy, return blood to blood bank immediately within 10 minutes
• - You MUST START THE BLOOD TRANSFUSION WITHIN 10 MINUTES OF RECEIVING BLOOD FROM BLOOD BANK

Obtain vital signs and document on transfusion sheet

• Start blood transfusion at a slow rate (25-50ml per hour), remaining with client for the first 15 minutes
• - rate can be adjusted after the first 15 minutes
• - blood products must be infused within 4 hours
• if not infused with 4 hours, products must be discarded

• client education-
• - tell client to immediately report the occurence of transfusion reaction symptoms.

Obtain vital signs as indicated on transfusion sheet

assess patient frequently

Upon completion of tranfusion, clamp off blood and infuse NS

• Complete blood transfusion record- leave no blanks
• - place original on chart
• - send copy marked "blood bank" to blood bank

Continue to monitor client for S/S of adverse reaction

• transfusion is immediately stopped an MD and blood bank notified if any other the following occur
• - urticaria (a transient condition of the skin, usually caused by an allergic reaction, characterized by pale or reddened irregular, elevated patches and severe itching; hives)
• - chills
• - fever- 2 degree change from baseline
• - nausea
• - backache/ flank pain
• - dyspnea (difficult or labored breathing)
• - hypotension
• - apprehension, anxiety, feelings of impending doom

• In the event of transfusion reaction
• - Stop transfusion immediately, maintaining patent IV with new IV tubing infusiion NS
• - Notify MD
• - Notify blood bank
• - Complete transfusion reaction consultation form
• - obtain urine specimen
• - hand carry blood bag, urine specimen and complete form to blood bank.