Verify doctor’s order. Inform the client and explain the purpose of the procedure.
Check for cross matching and grouping to ensure compatibility
Obtain and record baseline vital signs
Practice strict asepsis
At least 2 registered nurses should check the label of the blood transfusion. Check the following:
- Serial/Batch number
- Blood component
- Blood type
- Rh factor
- Expiration date
- Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood- carried diseases and therefore, safe for transfusion.
Warm blood at room temperature before transfusion to prevent chills.
Identify client properly. Two Nurses check the client’s identification.
Use needle gauge 18 to 19(cannula) to allow easy flow of blood.
Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)
Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.
Administer 0.9% NaCl before; during or after BT. Never administer BT with dextrose. Dextrose based IV fluids cause hemolysis.
Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
Observe for potential complications. Notify physician.