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BLOOD TRANSFUSION

1. Verify doctors written prescription and make a treatment card according to hospital policy.

2. Observe ten (10) Rs when preparing and administering any blood or blood components. 3. Explain the procedure/rationale for giving blood transfusion to reassure patient and significant others and secure consent. Get patients history regarding previous transfusion. 4. Explain the importance of the benefits on Voluntary Blood Donation (RA 7719 National Blood Service Act of 1994). 5. Request prescribed blood/blood components from blood bank to include blood typing and X-matching and blood result of transmissible disease. 6. Using a clean lined tray, get compatible blood from hospital blood bank. 7. Wrap blood bag with clean towel and keep it at room temperature. 8. Have a doctor and a nurse assess patients condition. Countercheck the compatible blood to be transfused against the X-matching sheet noting ABO grouping and Rh, serial no. of each blood unit, and expiry date with the blood bag label and other laboratory blood exam as required before transfusion (Hgb and Hct). 9. Get the baseline vital signs BP, RR, temperature before transfusion. Refer to MD accordingly.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP was reproduced for educational purposes of Filipino student nurses and registered nurses who need to review and study the procedures prior to actual IVT training and practicum.

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10. Give pre-med 30 minutes before transfusion as prescribed.

11. Do hand hygiene before and after the procedure.

12. Prepare equipment needed for BT:

IV injection tray, IV catheter/needle G 18/19, plaster, tourniquet, gloves

compatible BT set G 18 needle (only if needed)

blood component to be transfused

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP was reproduced for educational purposes of Filipino student nurses and registered nurses who need to review and study the procedures prior to actual IVT training and practicum.

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Plain NSS 500 cc, IV set

sterile 2x2 gauze or transparent dressing

IV hook and stand

13. If main IVF is with dextrose 5% initiate an IV line with appropriate IV catheter with Plain NSS on another site, anchor catheter properly and regulate IV drops.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP was reproduced for educational purposes of Filipino student nurses and registered nurses who need to review and study the procedures prior to actual IVT training and practicum.

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14. Open compatible blood set aseptically and close roller clamp. Spike blood bag carefully; fill the drip chamber at least half full; prime tubing and remove air bubbles (if any). Use needle G 18 or 19 for side drip (for adults) or of 22 for pedia (if blood is given through the Y-injection port, the gauge of needle is disregarded). 15. Disinfect the Y-injection port of IV tubing (Plain NSS) and insert the needle from BT administration set and secure with adhesive tape. 16. Close roller clamp of IV fluid of Plain NSS and regulate to KVO while transfusion is going on. 17. Transfuse the blood via the injection port and regulate at 10-15 gtts initially for 15 minutes and then at the prescribed rate (usually based on the patients condition). 18. Observe patient for 10-15 minutes for any immediate reaction. 19. Observe patient on an ongoing basis for any untoward signs and symptoms such as flushed skin, chills, elevated temperature, itchiness, urticaria and dyspnea. If any of these symptoms occurs stop the transfusion, open the roller clamp of the IV line with Plain NSS, and report to doctor immediately. 20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT set should be used for 1-2 units of blood. 21. When blood is consumed, close the roller clamp of BT, and disconnect from IV lines then regulate the IVF of plain NSS as prescribed.

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP was reproduced for educational purposes of Filipino student nurses and registered nurses who need to review and study the procedures prior to actual IVT training and practicum.

Downloaded from IVTeam Phils Hub | ivthub.blogspot.com

22. Continue to observe and monitor patient post transfusion for delayed reaction could still occur. 23. Re-check Hgb and Hct, bleeding time, serial platelet count within specified hours as prescribed &/or per institutions policy. 24. Discard blood bag and BT set and sharps according to Health Care Waste Management (DOH/DENR). 25. Document the procedure, pertinent observations and nursing intervention and endorse accordingly.

26. Remind the doctor about the administration of Ca gluconate if patient had several units of blood transfusion (3-6 or more units of blood).

This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAP was reproduced for educational purposes of Filipino student nurses and registered nurses who need to review and study the procedures prior to actual IVT training and practicum.