HANDOUT on NURSING MANAGEMENT FOR CLIENT RECEIVING BLOOD

TRANSFUSION
By: John Arbie T. Tattao, RN

• Blood Groups
A. Erythrocytes carry antigens, which determine the different blood groups.
B. Blood-typing systems are based on the many possible antigens, but the most
important are antigens of the ABO and Rh blood groups because they are most
likely to be involved I transfusion reactions.

1. ABO typing
• Antigens of system are labelled A and
• Absence of both antigens results in type O blood
• Presence of both antigens is type AB
• Presence of either A or B results in type A and type B respectively
• Nearly half the population is type O, the universal donor

 Antibodies are automatically formed against the ABO antigens not on

person’s own RBC’S; transfusion with mismatched or incompatible blood
results in a transfusion reaction

2. Rh typing
• Identifies presence or absence of Rh antigen (Rh positive or Rh negative).
• Anti-Rh antibodies not automatically formed in Rh-negative person, but if Rh-
positive blood is given, antibody formation starts and a second exposure to
Rh antigen will trigger a transfusion reaction.
Important for Rh-negative woman carrying Rh-positive baby; first
pregnancy not affected, but in a subsequent pregnancy with an Rh-
positive positive baby, mother’s antibodies attack baby’s RBCs.

Blood Transfusion and Component Therapy

BLOOD TRANSFUSION – the introduction of whole blood components of the blood
(plasma, serum, erythrocytes, or platelets) into the venous circulation.

Purposes:
a. To increase the circulating blood volume as in shock due to haemorrhage
b. To increase red cell volume of hemoglobin content of the blood as in anemia
c. To increase WBC content of the blood as in agranulocytosis and leucopenia
d. To increase the quantity of protein malnutrition, excessive loss of protein from
burns or vesicular skin diseases

A. Blood and blood products

1. Whole blood: provides all components
> 500 ml: 200 ml RBC and 300 ml Plasma
a. Large volume can cause difficulty: 12-24 hours for Hgb and hct to rise
b. For massive blood loss and exchange transfusion in neonates
c. Complications: volume overload, transmission of hepatitis or AIDS,
transfusion reaction, infusion of excess potassium and sodium, infusion of
anticoagulant (citrate) used to keep stored blood from clotting.
 2. Packed Red blood cells
> 350 – 400 ml: 200 – 250 ml RBC and 150 ml Plasma and additive
solution (saline, glucose, mannitol)
a. Provide twice the amount of Hgb as an equivalent amount of whole blood.
b. Indicated in cases of blood loss, pre and post-op clients, and those with
incipient congestive failure
c. Complications: transfusion reaction (less common than with whole blood
due to removal of plasma protein)

3. Fresh frozen plasma

> 200 – 250 ml: contains all coagulation factors and 250 mg of fibrinogen
a. Contains all coagulation factors including V and VIII
b. To expand plasma volume, treat post operative hemorrhage or shock and
correct coagulation factor deficiencies
c. Can be stored frozen for 12 months; takes 20 minutes to thaw
d. Hang immediately upon arrival to unit (Rationale: loses its coagulation
factors rapidly)

4. Platelets
> 30 – 60 ml: half of the number of platelets originally found in 1 unit
whole blood
a. Will raise recipient’s platelet count by 10,000/mm3
b. For thrombocytopenia, acute leukemia, to restore platelet count
preoperatively.
b. Pooled from 4-8 units of whole blood
c. Single-donor platelet transfusions may be necessary for clients who have
developed antibodies; compatibility testing may be necessary

5. Factor VIII fractions (cryoprecipitate): contains Factors VIII, fibrinogen, and

XIII
> Frozen 20 ml unit contains mostly coagulation factor VIII and 250 mg
fibrinogen
a. For hemophilia A

6. Volume expanders: albumin; percentage concentration varies (50-100

ml/unit)
> Serum albumin and Plasma Protein Fraction (PPF)
> 25% albumin in 50 ml and 100 ml units
> 5% albumin and PPF comes in 250 ml units
a. For hypovolemia and hypoproteinuria
b. Hyperosmolar solutions should not be used in dehydrated clients

7. Granulocytes
> Contains mostly granulocytes and RBC’s, plasma, and platelets
a. For severe gram negative infection or severe neutropenia, unresponsive
to routine forms of therapy in immunosuppressed patients

B. Nursing Interventions for patients receiving Blood Transfusion:

Nursing Responsibility Prior to Blood Transfusion
1. Verify doctor’s order and make a treatment card
Rationale: To avoid mistakes
2. Assess client for history of previous blood transfusions and any adverse
reactions.
3. Request blood/blood component from hospital blood bank to include blood
typing and cross matching
4. Ensure that the adult client has an 18- or 19- gauge IV catheter in place
Rationale: Large bore needle is indicated for BT since blood is viscous.
5. Initiate an IV line with appropriate IV catheter with 0.9% NaCL (PNSS).
Rationale: To flush out tubing and Keep IV open (KVO)
6. Ensure that the blood should be transfused not more than 20 minutes from
the time it arrives from the blood bank
Rationale: To prevent untoward blood reaction
7. Have a doctor and a nurse or at least two nurses countercheck the
compatible blood to be transfused:
a. Name and Identification number
b. Client’s blood group and Rh type
c. Donor’s blood group and Rh type
d. Cross-match compatibility
e. Blood unit and serial component
f. Expiration date of blood product
Rationale: To prevent any problem in relation to transfusion
8. Take baseline vital signs before initiating transfusion.
Rationale: To compare any change in vital signs before and during the BT
9. Give pre medications 30 minutes before transfusion if any is ordered
Rationale: To prevent minor allergic reaction

Nursing Responsibility during Blood Transfusion:

1. Start transfusion slowly (2 ml/minute)
2. Stay with the client during the first 15 minutes of the transfusion and take
vital signs frequently
Rationale: Transfusion reactions occurs during the first 10 – 15 minutes of
transfusion
3. Maintain the prescribed transfusion rate
a. Whole blood: approximately 3-4 hours
b. RBCs: approximately 2-4 hours
c. Fresh frozen plasma: as quickly as possible
d. Platelets: as quickly as possible
e. Cryoprecipitate: rapid infusion
d. Volume expanders: volume-dependent rate
4. Observe the patient for any untoward signs and symptoms (ICEFUD)
a. Itchiness
b. Chills
c. Elevated temperature
d. Flushed skin
e. Urticaria
f. Dyspnea
 If any occurs, institute (SPR) STOP transfusion, OPEN IV line
with PNSS, and REPORT to the physician
5. Swirl the bag once in a while
Rationale: To mix the solid and liquid elements of the blood. RBC tends to
settle at the bottom of the solution while the plasma rises to the top as the
blood bag hangs
6. If blood is consumed, close roller clamp of BT set then disconnect from IV line
then regulate the IVF as ordered

Nursing Responsibility after Blood Transfusion

1. Continuously monitor the patient for signs of blood transfusion reactions.
2. Carry out post BT order such as re-check Hgb and Hct level, bleeding
time,RBC and platelet count
3. Document observations and interventions done
a. Blood component unit number (apply sticker if available)
b. Date infusion starts and ends
c. Type of component and amount transfused
d. Client reaction and vital signs
e. Signature of transfusionist

C. Blood Transfusion Reactions (HAPCAT)

A. Hemolytic Reaction
1. Causes:
a. ABO incompatibility
b. Rh incompatibility
c. Use of dextrose solutions
2. Mechanism
a. Antibodies in recipient plasma react with antigen in donor cells.
Agglutinated cells block capillary blood flow to organs.
3. Occurrence:
a. Acute: first 5 min after completion of transfusion
b. Delayed: days to 2 weeks after
4. Signs and symptoms
a. Headache
b. Lumbar or sternal pain
c. Nausea and vomiting
d. Fever and chills
e. Flushing and heat along vein
f. Restlessness
g. Dysnea
h. Signs of shock; renal shutdown
i. DIC
5. Nursing Intervention
a. Stop transfusion (Standard Operating Procedure-SOP)
b. Continue saline IV
c. Notify Physician
d. Send blood unit and client blood sample to lab
e. Administer isotonic fluid solution as ordered. To prevent acute
tubular necrosis and counteract shock
 d. Watch for hemoglobinuria
e. Treat or prevent shock, DIC, and renal shutdown
f. Monitor Vital signs and intake and output

B. Allergic Reaction
1. Causes
a. Transfer of an antigen or antibody from donor to recipient
b. Allergic donors
2. Mechanism
a. Immune sensitivity to foreign serum protein
3. Occurrence
a. Within 30 min of start of transfusion
4. Signs and symptoms
a. Urticaria
b. Laryngeal edema
c. Wheezing
d. Dyspnea
e. Brochospasm
f. Headache
g. Anaphylaxis
5. Nursing Intervention
a. Stop transfusion
b. Flush with PNSS
c. Notify Physician
d. Administer antihistamine as ordered
 If (+) hypotension – signals anaphylactic shock – administer
epinephrine
e. Send blood unit to blood bank
f. Obtain urine and blood samples – send to lab
g. Treat life-threatening reactions
h. Monitor VS and I and O

C. Pyrogenic Reaction
1. Causes
a. Recipient possesses antibodies directed against WBCs
b. Bacterial contamination
c. Multitransfused clients
2. Mechanism
a. Leukocyte agglutination
b. Bacterial organisms
3. Occurrence
a. Within 15-90 min after initiation of transfusion
4. Signs and symptoms
a. Fever and chills
b. Flushing
c. Palpitations
d. Tachycardia
e. Occasional lumbar pain
 5. Nursing Intervention
a. Stop transfusion
b. Flush with PNSS
c. Notify Physician
d. Administer antipyretics, antibiotics as ordered
e. Treat temperature – Tepid sponge bath
f. Transfuse with leukocyte-poor blood or washed RBC

D. Circulatory overload
1. Cause
a. Too rapid infusion in susceptible clients
2. Mechanism: Fluid volume overload
3. Occurrence: During and after transfusion
4. Signs and symptoms
a. Dyspnea
b. Tachycardia
c. Orthopnea
d. Increased blood pressure
e. Cyanosis
f. Anxiety
5. Nursing Intervention
a. Slow infusion rate
b. Use packed cells instead of whole blood
c. Monitor CVP through a separate line

E. Air embolism
1. Cause: blood given under air pressure following severe blood loss
2. Mechanism: bolus of air blocks pulmonary artery outflow
3. Occurrence: anytime
4. Signs and symptoms
a. Dyspnea
b. Increased pulse
c. Wheezing
d. Chest pain
e. Decreased blood pressure
f. Apprehension
5. Nursing Intervention
a. Clamp tubing
b. Turn client on left side

F. Thrombocytopenia
1. Cause: Use of large amounts of banked blood
2. Mechanism: Platelets deteriorate rapidly in stored blood
3. Occurrence: When large amounts of blood given over 24 hr
4. Signs and symptoms
a. Abdominal bleeding
5. Nursing Interventions
a. Assess for signs of bleeding
b. Initiate bleeding precautions
c. Use fresh blood