Blood Transfusions

Patient Identification

Double-check the ID band before starting a blood transfusion.

Verify Blood Products

Ensure the correct blood products are prepared for transfusion.

Informed Consent

Obtain consent from the patient before proceeding with the transfusion.

Preparation

Gather equipment, explain the procedure, and ensure a proper environment.

Baseline Assessment

Check vital signs and identify any abnormal findings prior to transfusion.

Insert IV Line

Set up the IV line for the blood transfusion.

Initiate Transfusion

Start the blood transfusion after all preliminary steps are completed.

Monitor Vitals

Measure and record the patient's vital signs every 15 minutes initially during the transfusion.

Post-Assessment

Observe the patient for any reactions after the transfusion.

Dispose of Equipment

Properly dispose of all equipment used during the transfusion process.

Document Everything

Keep a detailed record of the transfusion process, including any reactions.

Use 20G IV

A 20-gauge IV catheter should be used, or an 18-gauge if rapid infusion is needed.

0.9% NaCl

The only compatible solution to use for flushing during blood transfusion.

Filter all blood

Use a filter to catch clots and cell fragments during transfusion.

4 hrs of hanging

Blood must be used within four hours of being hung for transfusion.

30 mins of removing from blood bank

Blood products must be used within 30 minutes of being taken from the blood bank.

Stored blood lasts 72 hrs

Blood can be stored for up to 72 hours.

Only RN can start the transfusion

Only a registered nurse is permitted to initiate a blood transfusion.

What’s a Transfusion Reaction?

A severe immune response to mismatched or contaminated blood products.

Signs of Hemolytic Reaction

Back pain, chills, fever, tachycardia, low BP, dark urine.

Signs of Allergic Reaction

Hives, swelling, vomiting, elevated HR, shortness of breath.

Signs of Febrile Reaction

Flushing, chills, elevated temperature, headache, elevated HR.

STOP the transfusion immediately

The first intervention when a transfusion reaction occurs.

Keep IV open with 0.9% NaCl

Continue IV access with saline after stopping the transfusion.

Notify HCP & Blood Bank

Contact healthcare provider and blood bank in case of a reaction.

Change IV tubing down to the site

Replace the IV tubing if a reaction occurs.

Don’t leave patient alone

Stay with the patient and assess their airway, breathing, and circulation.

Document and monitor reactions closely

Record any reactions and vital signs post-transfusion.

H

Hemolytic Reaction — High risk, fast action needed.

A

Allergic Reaction — Similar to food allergies, rash + swelling.

F

Febrile Reaction — Mild fever + chills, still needs reporting.

Memory Tip for Hemolytic Reaction

BLOOD BAD—watch for back pain, dark urine, fever.

Memory Tip for Allergic Reaction

HIVES—monitor for hives, swelling, elevated heart rate.

Memory Tip for Febrile Reaction

FEVER—includes flushing, chills, heightened body temp.

ABC Checklist for Reactions (A)

Assess Compatibility + Airway.

ABC Checklist for Reactions (B)

Bring emergency supplies.

ABC Checklist for Reactions (C)

Check vitals & appearance during and after the transfusion.

What is the main purpose of patient identification before a transfusion?

To ensure the correct patient receives the matching blood product.

What should be done if a transfusion reaction is suspected?

Stop the transfusion and maintain IV access with saline.

What does 0.9% NaCl refer to in blood transfusions?

It is the only solution allowed for maintenance during transfusion.

What are signs of Tachycardia during a transfusion?

An increased heart rate that can indicate a transfusion reaction.

What type of IV catheter is recommended for blood transfusions?

A 20-gauge IV catheter or 18-gauge for rapid infusions.

What does the acronym RN stand for?

Registered Nurse, who must be present during the initial 15 minutes of a transfusion.

What is a Febrile Reaction?

A mild transfusion reaction characterized by fever and chills.

What is the recommended action if a patient has dark urine after a transfusion?

This could indicate a hemolytic reaction; immediately report and assess!

What symptoms indicate an Allergic Reaction?

Hives, vomiting, elevated heart rate, shortness of breath.

What are the main types of transfusion reactions?

Hemolytic, Allergic, and Febrile reactions.

Why is it important to monitor vitals post-transfusion?

To detect any adverse reactions early.

What do you do if the blood product is not used within 30 minutes of removal from blood bank?

It should be returned to the blood bank.

What must be done with blood products within 4 hours of hanging?

They must be transfused to the patient.

Why is it important to use a filter during transfusion?

To trap clots and cell fragments that may cause complications.

How should abnormal findings be recorded during a transfusion?

Document all observations, including changes in vital signs.

What is a key intervention after stopping a transfusion?

Keep the IV line open with saline.

What are the signs of hypotension during a transfusion?

Decreased blood pressure that may signal a reaction.

What is the action for tachycardia during a transfusion?

Assess the patient and confirm symptoms of a reaction.

What does systemic response to transfusion mean?

A widespread reaction throughout the body from a transfusion.

Why should the nurse stay with the patient for the first 15 minutes?

To monitor for potential transfusion reactions that typically occur early.

What type of tubing should be used for blood transfusions?

Special Y tubing with an inline filter.

What equipment is necessary for a blood transfusion?

Sterile IV equipment, blood product, saline solution, and monitoring tools.

Why is obtaining informed consent important before a transfusion?

To ensure the patient is aware of potential risks and agrees to the procedure.

What role does the Blood Bank play during a transfusion?

They verify blood compatibility and assist with any reactions.

During a transfusion, what should be done in the event of fever and chills?

Consider a febrile reaction; assess the patient and report findings.

What equipment should be disposed of properly after a transfusion?

All tubing and blood product containers used during the process.

What should be checked immediately if a patient shows signs of a reaction?

Assess vital signs and ensure compatibility of blood products.

What is the definition of back pain as a symptom during transfusion?

It may indicate a hemolytic reaction; assess promptly.

Why is it critical to document transfusion reactions?

For legal, clinical, and patient safety reasons.

What does dark urine indicate after a transfusion?

Possible hemolytic reaction and requires immediate action.

What does vital sign monitoring entail during a transfusion?

Checking heart rate, blood pressure, temperature, and oxygen levels.

What action does an elevated body temperature suggest during a transfusion?

Possible febrile reaction necessitating further assessment.

Why shouldn't dextrose or Lactated Ringer's solution be used during transfusion?

They are not compatible with blood transfusion products.

What is the ideal environment for performing a blood transfusion?

A quiet, controlled environment to minimize stress and errors.

What tools can help in monitoring for reactions during transfusion?

Electronic monitoring devices and manual observations.

What role does careful preparation play before a transfusion?

It minimizes the risk of complications and ensures patient safety.

What must be assessed during the baseline assessment before a transfusion?

Vital signs and abnormal findings to establish a reference point.

Why is the use of special Y tubing essential?

To ensure safe transfusion with filtering to prevent adverse events.

What is the consequence of failing to correctly identify the patient?

It may lead to a transfusion reaction due to mismatched blood.

How does anxiety manifest in patients undergoing a transfusion?

Nervousness or distress about the procedure's potential complications.

What is the significance of chills during a transfusion?

They may indicate an immune response or adverse reaction.

What should you do if blood is not compatible during a transfusion?

Stop the transfusion immediately and maintain IV access.

How can tachycardia affect patient safety during transfusions?

It may indicate a serious allergic or hemolytic reaction.

What types of blood products might be involved in transfusions?

Whole blood, RBCs, plasma, and platelets.

What does the acronym ABC represent in the context of transfusion reactions?

Assess Compatibility, Bring emergency supplies, Check vitals.

What might indicate a need to increase the transfusion rate?

If no adverse reactions occur after the initial 15 minutes.

What are the methods used to monitor vital signs during a transfusion?

Regular checks with a stethoscope, clock, and patient observation.

What is the initial response to a suspected transfusion reaction?

Stop the transfusion and keep IV access with 0.9% NaCl.

What condition is a febrile reaction commonly associated with?

Elevated body temperature during or after a transfusion.

What does monitoring the patient Q15min involve?

Checking blood pressure and heart rate regularly at 15-minute intervals.

What must the health care provider be notified of during a reaction?

Any changes in the patient's condition or reaction symptoms.

What should always be maintained during a transfusion?

The IV line must remain open with the appropriate solution.

When is it essential for the RN to document the transfusion process?

Immediately after any reactions or complications arise.

What primary concerns require immediate attention during a reaction?

Patient’s airway, breathing, circulation, and overall stability.

What is the importance of explaining the procedure to the patient?

To ensure their understanding and cooperation during the transfusion.

What indicates a possible adverse reaction during monitoring?

Sudden changes in vital signs or adverse symptoms.

What should be done upon observing symptoms of an allergic reaction?

Stop the transfusion and assess the patient for further intervention.

Why is it critical to assess the patient's baseline vitals before transfusion?

To identify changes that may occur during the transfusion process.

What indicates a response to transfusion when monitoring for reactions?

Changes in vital signs, symptoms reported by the patient, or observable reactions.

What fluid should never be used to flush during a transfusion?

Dextrose or Lactated Ringer's solution, as they are incompatible.

What is the purpose of using an inline filter during transfusion?

To catch any potential clots or cellular debris in the blood.

What information is critical to relay in documentation after a transfusion?

Time of transfusion, type of blood product, and patient reactions observed.

What actions constitute a transfusion reaction?

Any severe immune response to transfused blood, requiring immediate attention.