6217328 Blood Transfusion

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This copy of the procedures from the 7th edition of the Nursing Standards on Intravenous Practice by ANSAPwas 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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BLOOD TRANSFUSION

1. Verify doctors written prescription and

make a treatment card according tohospital policy.

2. Observe ten (10) Rs when preparing and administering any blood or bloodcomponents.

3. Explain the procedure/rationale forgiving blood transfusion toreassure patient and significant

others and secure consent. Getpatients history regarding previoustransfusion.

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 includeblood 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 patientscondition. Countercheck the compatible blood tobe transfused against the X-matching sheetnoting ABO grouping and Rh, serial no. of eachblood unit, and expiry date with the blood baglabel and other laboratory blood exam asrequired before transfusion (Hgb and Hct).

9. Get the baseline vital signs BP, RR,temperature before transfusion. Refer toMD accordingly.


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

11. Do hand hygiene before and after theprocedure.

12. Prepare equipment needed for BT:

IV injection tray, IV catheter/needle G18/19, plaster, tourniquet, gloves

compatible BT setG 18 needle (only if needed)

blood component to be transfused


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14. Open compatible blood set aseptically and close roller clamp. Spike bloodbag carefully; fill the drip chamber at least half full; prime tubing andremove air bubbles (if any). Use needle G 18 or 19 for side drip (foradults) 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 BTadministration set and secure with adhesivetape.

16. Close roller clamp of IV fluid of Plain NSSand regulate to KVO while transfusion isgoing on.

17. Transfuse the blood via the injection portand regulate at 10-15 gtts initially for 15minutes and then at the prescribed rate(usually based on the patients condition).

18. Observe patient for 10-15minutes for any immediatereaction.

19. Observe patient on an on-going basis for anyuntoward signs andsymptoms such as flushedskin, chills, elevatedtemperature, itchiness,urticaria and dyspnea. Ifany of these symptomsoccurs stop thetransfusion, open the rollerclamp of the IV line withPlain NSS, and report todoctor immediately.

20. Swirl the bag hourly to mix the solid with the plasma. N.B. one BT setshould be used for 1-2 units of blood.

21. When blood is consumed, close the roller clamp of BT, and disconnectfrom IV lines then regulate the IVF of plain NSS as prescribed.


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6217328 Blood Transfusion