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Nursing Lab 3

SKILL PERFORMANCE CHECKLIST

Administering a Blood Transfusion


S U NP Comments
1. Identify the patient __ __ __ ___________
Check physician’s order for type of transfusion __ __ __ ___________
2. Check with patient or chart for any history of: __ __ __ ___________
 Allergies
 Previous blood transfusions
 Consent for blood transfusion/blood products
 Patient’s blood type
 Reason for blood transfusion
3. Check patient for understanding of procedure and reason for blood __ __ __ ___________
transfusion
4. Discuss with patient signs and symptoms to report (ie. rash, __ __ __ ___________
itchiness, chills)
5. Perform hand hygiene, put on clean gloves __ __ __ ___________
6. Set up blood transfusion administration set (if IV not already __ __ __ ___________
started). Ensure Normal Saline as mainline IV
7. Ensure IV started with #18 or #20 gauge catheter (nothing smaller) __ __ __ ___________
for blood transfusion
8. Check IV site for any complications (infiltration, phlebitis, systemic __ __ __ ___________
infection)
9. Obtain blood product for transfusion from blood bank just prior to __ __ __ ___________
transfusion
10. Confirm the following with another Nurse prior to hanging blood __ __ __ ___________
product (checking blood product label with patient information)
 Pt name
 Pt ID number
 Blood group and type
 Expiration date
 Blood inspected for clots
If any discrepancy exists blood should not be given!
11. Obtain baseline vital signs prior to starting transfusion __ __ __ ___________
12. Start transfusion very slowly (no more than 25-50 mL in first 15 __ __ __ ___________
minutes)
13. Stay with the patient for the first 15 minutes and recheck vital signs, __ __ __ ___________
assessing for any signs of transfusion reaction
14. Infuse remainder of transfusion as per MD orders, over no more __ __ __ ___________
than 4 hours ( risk of bacterial contamination)

15. If transfusion reaction is suspected nurse must: __ __ __ ___________


 stop infusion immediately
 piggyback N/S into the line (closest port to patient) or
change IV tubing to N/S only
 Call physician immediately
 Remain with patient, check vital signs q 5 min, observe for
signs and symptoms
 Prepare to administer meds (antihistamines, vasopressors,
S U NP Comments
steroids etc) as ordered
 Prepare to perform CPR if needed
 Obtain urine sample and send it to the lab (to determine
presence of hemoglobin)
 Save blood container, tubing, labels and transfusion record,
return them to the lab
16. Upon completion of transfusion document procedure and return __ __ __ ___________
blood product bag to blood bank.

Sources:

Potter, P.A., & Perry, A. E. (2010) Canadian Fundamentals of Nursing (4th ed.). Toronto: Mosby
Elsevier.

Lynn, P, & LeBon, M. (2008) Skills Checklists to Accompany Taylor’s Clinical Nursing Skills (2 nd ed.)
Philadelphia: Wolters Kluwer Lippencott Williams & Wilkins.

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