Nursing Care during a Blood Transfusion

One of the most common reasons for a transfusion of packed red blood cells (pRBC) is anemia. This can be due to an acute hemorrhage or chronic bleeding, renal failure, or some cancers.

Despite years of research, scientists have been unable to replicate human blood products in a lab. Donor blood is required for any blood transfusion therapy.

Red Blood Cells contain hemoglobin which carry oxygen during inhalation from the lungs to the tissues and removes carbon dioxide by returning it to the lungs for exhalation.

When a patient has a low red blood cell count (anemia) they do not have adequate carriers of oxygen and will show symptoms such as fatigue, dizziness, shortness of breath, diaphoresis, nausea, increased heart rate, and a pale (white as a sheet) complexion.According to the American Association of Blood Banks, a patient should be transfused with pRBC's when their HGB reaches 7-8g/dL and/or if they have symptomatic anemia in the presence of active bleeding.

As the nurse carrying out the doctor's order for a blood transfusion you are responsible to prep the patient and ensure appropriate history, lab work, documentation, and supplies are available prior to the transfusion. These crucial steps of prepping your patient for their blood transfusion helps prevent transfusion reactions.

Initiating Transfusion Prep work:

Step #1: Obtain current Type and Cross-Match
  • Obtained through veinipuncture blood sample
  • Sample lasts up to 72 hours from time resulted
  • Send your blood sample to the blood bank as soon as you suspect your patient may be at risk of needing a blood transfusion (pre-op, intrapartum labor patients, chronic anemic patients, etc.)
  • Ensure correct date/timing/labeling on blood sample to prevent reaction from mismatched blood
  • Type and cross-matching can take one to several hours
  • Blood bank will match and prepare needed units based on the blood sample you provided
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Step #2:  Obtain Informed Consent/Pertinent Health History
  • Discuss procedure with patient and what they can expect
  • Confirm allergies and health history
  • Ensure MD has acquired signature consent for administration of blood products from patient and form is readily available.
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Special Considerations

Has your patient received blood transfusions in the past? How many?
            If a person has a history of blood transfusion therapy there is a chance their body has built up antibodies against donor blood.  This puts a patient at risk for a FEBRILE transfusion reaction.
          Incidentally, the more transfusions a patient has the more antibodies circulating in their blood.  This puts them at higher risk for a febrile transfusion reaction.  While the most common transfusion reaction, a febrile transfusion reaction is not fatal.
          Notify the doctor of any prior history of blood transfusion therapy.  If appropriate, the doctor will order acetaminophen and benedryl to reduce the chances of a febrile transfusion response. These medications can reduce or eliminate the symptoms of a febrile transfusion reaction, such as fever or itching.
          When pre-medicating by mouth it is acceptable to administer these medicines thirty minutes prior to the transfusion.
Does your patient have circulatory issues? Fluid overload?
          Patients with congestive heart failure or renal failure, for example, may be at risk for fluid overload if blood products are given rapidly. As the nurse, you should discuss any fluid restrictions with the ordering doctor prior to administration of the blood transfusion.
          Depending on a patient's clinical picture, a doctor may prescribe a loop diuretic (i.e. lasix) to be given prior, during, or in between units of blood to prevent circulatory overload.  This will help to diurese extra intravascular fluid volume while still allowing the patient to benefit from the added RBC's.
          In addition to a diuretic, the doctor may order the transfusion to be infused at the slowest rate (no longer than four hours) to prevent a rapid increase in fluid volume for circulatory compromised patients.
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Step #3: Obtain large bore IV Access
  • 18G or larger IV access
    • RBC's have to be able to pass through the cathetar without causing cell lysis (RBC damage or death) the larger the cathetar the less likely damage will occur to the RBC's passing through
  • Each unit of pRBC's will be transfused over 2-4 hours
  • Obtain a second IV access if the patient requires additional IV medication therapy, such as antibiotics.
  • Normal Saline is the only solution that can be transfused with blood products
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Step #4: Assemble Supplies
  • Special Y tubing with an in-line filter
    • Depending on hospital policy, each unit of blood will require it's own Y tubing set up. Used Y tubing is to be discarded within four hours of initiation time in appropriate red biohazard containers
  • 0.9% NaCl (Normal Saline) solution
    • only approved solution used to prime Y tubing and flush Y tubing after transfusion.
    • solutions with dextrose can cause RBC's to clump and solutions with medications can cause cell lysis during administration
  • blood warmer
    • special device used to warm blood to prevent hypothermia during rapid, large transfusions
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Step #5: Obtain baseline Vital Signs
  • Heart rate, Blood Pressure, Temperature, Pulse Oximeter, Respiratory Rate should be assessed immediately prior to administration of blood transfusion
  • Temperature >100° F notify the Doctor before transfusion
  • Lung sounds and accurate urine output should also be documented
Step #6: Obtain blood from blood bank
  • Once the blood bank notifies you that your patient's blood is ready you must send for it from the blood bank.
  • pRBC's can only be hung ONE UNIT AT A TIME, if your patient has orders for 2 units pRBC's you will send for the second unit only after the first unit has completed transfusing.
  • From the time the blood has been released for your patient you, as the nurse, have 20-30 minutes to initiate the transfusion and a total of 2-4 hours to complete the transfusion

Initiating Blood Transfusion:

One unit of pRBC's can be infused at a time and must be completely transfused no more than four hours from the time the blood was released from the blood bank. Transfusing blood products within two to four hours helps to prevent bacterial growth and the risk for the patient developing septicemia.
Step #1: Verification of Blood Product
  • 2 RN verification at the bedside
    • Physician's orderpatient's identification vs blood bank documentation
    • (Patient's name, date of birth, medical record number)
    • Patient's blood type vs. donor's blood type, Rh factor compatibility
    • Blood expiration date
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Remember:

If the 2 RN verification shows any inconsistency, as the nurse, you must immediately return the blood back to the blood bank.  Both the blood bank and the ordering provider must be promptly notified.
Step #2:  Educate the patient S/S Transfusion Reaction
  • Explain to patient the signs and symptoms of a transfusion reaction and to notify the RN if any symptoms occur at anytime during the transfusion
    • Rash, itching, elevated temperature, chest/back/headache, chills, sweats, increased heart rate, increased respiratory rate, decreased urine output, blood in urine, nausea, vomiting
Step #3:  Assess & Document patient's status prior to infusion
  • Baseline vital signs (HR, RR, Temp, SPO2, BP), lung sounds, urine output, color
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Step #4:  Start the Blood Transfusion

  • Prime Y Tubing with Normal Saline, have blood set up on an infusion pump
  • RUN BLOOD SLOWLY FOR FIRST 15 MINUTES (2mL/min or 120cc/hr)
    • Minimize the amount of blood patient receives while you assess for signs of transfusion reaction
  • STAY WITH THE PATIENT FOR THE FIRST 15 MINUTES
    • Period of time when the most transfusion reactions occur
  • Increase rate of transfusion after 15 minutes if patient is stable and does not show s/s of transfusion reaction
    • REMEMBER ** Blood must be completed within a total of 2-4 hours!! **
  • Assess & document vital signs (according to hospital protocol) typically after 15 minutes into transfusion, hourly until transfusion is completed, and at completion of transfusion

During the Transfusion Monitor For:

⇒Transfusion Reactions:

Defined as the patient's IMMUNE SYSTEM reacting to the DONOR'S BLOOD.  There are five types of transfusion reactions:
  1. Hemolytic
  2. Allergic
  3. Febrile
  4. GVHD (Graft vs. Host Disease)
  5. TRALI (Transfusion Related Acute Lung Injury)
WHAT TO DO IF YOU SUSPECT A TRANSFUSION REACTION:
→STOP THE TRANSFUSION IMMEDIATELY!!
→DISCONNECT BLOOD TUBING FROM PATIENT!!
→STAY WITH THE PATIENT & ASSESS STATUS!!
→MONITOR VS EVERY 5 MINUTES!!
→NOTIFY THE DOCTOR & BLOOD BANK!!
→ANTICIPATE FURTHER DOCTOR'S ORDERS!!
→DOCUMENT!!

⇒ Circulatory Overload

Assess lung sounds, respiratory rate, assessment of breathing difficulty, edema, and urine output in patients at risk of circulatory overload.
i.e. Congestive Heart Failure or patients in renal failure that may not tolerate increased vascular volume.

⇒ Septicemia

Caused by contaminated blood or blood that was not completed within the 2-4 hour time frame.  Monitor increase in temperature, symptoms such as, chills, sweats, red streaking on the veins, change in level of consciousness.

Completion of the Transfusion:

⇒  Flush Y tubing with Normal Saline
⇒  Dispose of used Y tubing in RED BIOHAZARD BIN
⇒  Obtain post-transfusion vital signs & document patient status
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There are many clinical indicators for patient's requiring blood or blood component therapy via a transfusion. Read my post on Blood & Blood Component Therapy to learn why a patient may need a transfusion and the different therapies offered.

Click the links below for more!  Thanks for reading!

4 thoughts on “Nursing Care during a Blood Transfusion”

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