Definition
Administration of blood or blood components is a critical nursing procedure that requires precision, vigilance, and adherence to safety protocols to prevent life-threatening complications.
Types of Transfusion
- Blood plasma: Watery liquid, straw coloured extracellular matrix that contains dissolved substances.
- Packed red blood cells: They are prepared from whole blood by removing approximately 250 mL of plasma.
- Fresh frozen plasma (FFP): A blood product made from liquid portion of whole blood used to treat conditions of low blood clotting factors or other blood protein.
| TYPES OF BLOOD PRODUCTS USED FOR TRANSFUSION | ||||
| Blood products to be transfused | Indication | Contra indication | Transfusion time | Storage |
| Packed red blood cells (1 unit expected to increase levels of haemoglobin by 1 g/dL and haematocrit by 3%) | Acute sickle cell crisisAcute blood loss of >1,500 mLSymptomatic anemia | Volume replacement | Completed within 4 hours of removal from controlled temperature storage. | 1-6°C in temperature-controlled storage device. Transportation time does not exceed 24 hours. Shelf-life: 42 days from date of collection. |
| Platelets (1Unit expected to increase platelet count in adults by 30-60×103 per μL) | Thrombo- Cytopenia Platelet function defect | 1)Hepar-in-induced thrombocytopenia (HIT). 2)Thrombotic thrombocytopenic purpura (TTP) | Over time period of 30-60 minutes. | 20-24C. Shelf-life: 5 days from date of collection. Once opened expiry is 4 hours from the time of opening. |
| Plasma (Contains all coagulation factors) | Bleeding due to multiple clotting factor deficiencies. Inherited clotting factor deficiencies | Single coagulation factor deficiency Volume replacement alone | 30 minutes | 1-6°C for up to 5 days. Can be stored for up to 36 months at minus 25°C or below. Thawed units of FFP stored up to 24 hours at 4°C. |
Possible Complications
- Allergic reaction.
- Febrile reactions.
- Delayed or acute haemolytic transfusion reaction.
- Post – transfusion purpura.
Purposes
- To restore circulating blood volume in surgery and acute blood loss.
- To correct platelet and coagulation factor deficiencies.
- To correct anaemia.
- To treat acute sickle cell crisis.
Articles
- Blood transfusion set.
- Normal saline.
- Blood/blood components-sterile in appropriate container.
- Cannula No. 18/19 (adult).
- Alcohol/Iodine swabs (disinfectant).
- Sterile gauze.
- Tourniquet.
- Adhesive tape.
- Scissors.
- Roller bandage and splint (optional).
- Infusion stands.
- Disposal bag/kidney tray.
- Disposable gloves.
- Pressure bag (optional in case of severe bleeding).
- Specimen container.
Procedure
| Nursing Action | Rationale | |
| 1. | Before procedure Check physician’s orders, patient’s condition, and history of transfusion/ infusion reaction, reason for present transfusion, etc. | Obtains specific data and initiates patient education if required. |
| 2. | Identify patient. | Prevents errors and thus eliminates possibility of transfusion reactions. |
| 3. | Check availability of blood with the blood bank. | |
| 4. | Explain the procedure to the patient, need for transfusion, blood product to be given, approximate length of time, desired outcome, etc. Emphasize the need for patient to report unusual symptoms immediately Obtain informed consent from patient. | Provides reassurance and facilitates cooperation. Early identification of transfusion reactions aids in instituting prompt corrective measures. |
| 5. | Obtain blood from blood bank in accordance with agency policy. If transfusion cannot begin immediately, return product to blood bank. Blood which is out of refrigerator for more than 30 minutes, above 10°C cannot be re-issued. Never store blood in unauthorized area-like ward refrigerator. Blood must be stored in refrigerated unit at carefully controlled temperature (4°C). | Faulty techniques in storing blood products can cause haemolysis. |
| 6. | Encourage patient to empty bowel and bladder and assist to a comfortable position. Collect urine specimen. | Ensures comfort of the patient. Urine specimen collected before transfusion will serve as baseline data to identify transfusion reaction, if it occurs. |
| 7. | After procedure Ensure privacy. | |
| 8. | Wash and dry hands. | Prevents cross infection. |
| 9. | Check vital signs and record. | Obtains baseline data to compare with changes post-transfusion. Delay transfusion if temperature is more than 101.8°F. |
| 10. | Don disposable gloves. | Reduces risk of contracting infection. |
| 11. | Insert IV cannula (18 G/19 G), if not already present in a large peripheral vein and initiate infusion of normal saline solution using blood transfusion set. | Normal saline is the only crystalloid that is compatible with blood and priming of the blood set helps in reducing risk of haemolysis of blood in contact with tubing. Large bore cannula permits infusion of whole blood, reducing chances of haemolysis. |
| 12. | Inspect the blood product (By 2 nurses) for Identification numberBlood group and type Expiry date CompatibilityPatient’s name Abnormal colour, clots, excess air, etc. | Safe storage of blood is limited to 35 days before erythrocytes are damaged. Verifies that ABO group, Rh type, unit number, patient’s name, etc matches. This reduces chances of mismatched transfusion and transfusion reaction. |
| 13. | Warm blood, if needed, using special blood warmer or immerse partially in tepid water. | Cold blood can cause hypothermia and cardiac arrhythmias. |
| 14. | If blood product is found to be correct, stop the saline solution by closing roller clamp. Remove insertion spike from saline container and insert spike into blood container. | Priming of tubing is essential for preventing haemolysis. |
| 15. | Start infusion of blood product slowly, at the rate of 25-50 mL/hour for the first 15 minutes. Stay with patient for first 15 minutes. Check vital signs every 15 minutes for first 30 minutes, or as per agency policy. | Transfusion reaction typically occurs during this period. A slow volume can minimize the volume of RBCs transfused. Checking vital signs frequently helps in early identification of complications. |
| 16. | Increase infusion rate if no adverse reactions are noticed. The flow rate should be within safe limits. | Flow rate is determined by physician’s instruction and patient’s condition. |
| 17. | Assess the condition of patient every 30 minutes and if any adverse effect He is observed stop transfusion and start saline. Send urine sample, blood sample and remaining blood product in container with transfusion set, back to the blood bank. | Helps in identifying early transfusion reaction. Taking urine samples and blood samples helps in confirming transfusion reactions. |
| 18. | Complete transfusion and administer saline (as per physician’s order), if no adverse reaction is observed. | |
| 19. | Dispose blood product container and set in appropriate receptacle. | |
| 20. | Wash hands. | |
| 21. | Record the following: Product and volume transfused, identification number and blood group: Time of administration started and completed. Name and signature of nursing staff carrying out procedure, and patient’s condition. If agency policy requires, remove label from blood bag and paste it on patient’s record. | |
| 22. | Assist patient to comfortable position. |
Special Considerations
- Do not administer medication through the same line, where blood product is transfused. Start another IV line if medications are to be infused, because of possible incompatibility and bacterial contamination. Blood transfusion should be completed over a period of 4 hours from the time of initiation.
- Cover the blood bag with a towel when it hangs on the IV pole.
- Gently rotate the blood bag periodically to prevent clumping of cells.
- When rewarming blood by immersing in tap water, do not immerse the blood bag fully into the water as it may cause haemolysis.
- Rewarming of blood may be done by covering the blood bag with a blanket.
- Premeditations such as Antihistamines may be prescribed.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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