3.3: Applying the Nursing Process
The procedural steps for blood product administration while applying the nursing process are described in Table 3.3 with associated rationale.
| Assessment | Rationale |
|---|---|
| Verify written informed consent has been received for the procedure. Check the form to ensure it is properly completed and signed and assess client understanding of the procedure. | Infusion of blood is an invasive procedure with inherent risks and requires specific informed consent. Patient understanding of the procedure and its rationale must be assessed by the nurse prior to its initiation. |
| Verify provider order for the blood product to be administered. Note any pre- or post-transfusion medications that have been prescribed. | A prescription from a health care provider is necessary before transfusing any blood product. Verifying the order and associated medications ensures they are appropriately administered. |
| Obtain client allergies, previous transfusion history, and transfusion reactions. | Gathering this data helps prevent transfusion reactions. If the client has had previous transfusion reactions, measures can be taken to help prevent another one from occurring. |
| Assess the recent laboratory values and results related to the blood product being transfused. | Ensure the type and screen has been completed. Assessment of other laboratory values provides a baseline comparison when evaluating the patient’s response to the transfusion or in the event of a complication. |
| Analyze recent vital signs and notify the provider of any concerns. For example, if the client has a fever, clarify the order with the provider before obtaining the blood product from the blood bank. | If the client has any vital signs that are out of range and require clarification from the provider, this clarification should be addressed before obtaining the blood product because it typically must be initiated within 20-30 minutes of retrieval and cannot be returned. |
| Perform a respiratory assessment, skin assessment, and pain assessment. | Establish a baseline to use to trend future assessments and recognize changes in the event a transfusion reaction occurs. |
| Planning | |
| Review the indication for the transfusion with clinical supportive data. | The nurse develops a plan of care and formulates expected outcomes of the procedure based on the indication for the transfusion. |
| Determine expected outcomes for the client receiving a blood product transfusion. Expected outcomes of the transfusion are based on the indications for the transfusion. | Examples of expected outcomes for a PRBC transfusion include improved activity tolerance and improved hemoglobin and hematocrit to target range. |
| Determine if pre- or post-medication is needed for this specific client. | Diphenhydramine and acetaminophen are commonly prescribed for clients with a previous history of reactions. Anticipate that a client with a history of heart failure who will be receiving multiple units of blood may require furosemide to prevent fluid overload. |
| Implementation | |
| Start or verify venous access. Use short peripheral catheters (20G to 24G) based on vein size and patient preference or 18G to 20G if rapid transfusion is required. Verify the integrity and patency of IV catheters already in place. The distal lumen of a central venous access device may also be used to administer blood. Consider establishing a second peripheral venous access site for administration of other medications while blood is transfusing. |
Correct catheter use ensures appropriate size, gauge, and viable intravenous access for the blood product.
A second venous access site may be required for administration of other fluids, medications, or other substances while blood is transfusing because they cannot be administered using the same line. |
| Retrieve appropriate Y-infusion tubing set specific to blood product administration (for example, a microaggregate filter for leukocyte-reduced RBC) and 0.9% normal saline IV fluid. Inspect the tubing and filter. | Only IV normal saline is compatible with simultaneous blood product administration. Lactated ringers, dextrose, hyperalimentation (artificial nutrients supplied intravenously), and other intravenous solutions with medications are not compatible with blood products. A microaggregate filter is a blood filter with a pore size of 20–40 µm that removes 75–90% of white cells. Inspection of the tubing and the filter ensures it is suitable for the specific blood product prescribed. |
| Obtain blood or blood product from facility blood bank (follow agency policy). | Blood should not remain in the client care area for more than 30 minutes before the transfusion begins, so the nurse must be prepared to begin the transfusion shortly after the blood is delivered. |
| Perform the following checks with a second nurse or agency-defined trained health professional: compare the blood unit to the order, verify the client’s identity, verify the client’s blood type and Rh factor against the type of blood that will be infused, check the expiration of the blood component, and compare the client’s number against the blood product number. The nurses should also visually inspect the blood for any unusual color, precipitate, clumping, and any other unusual signs. | Checks by two nurses prevent transfusion reactions through proper client identification, verification of the prescription, and blood product compatibility. Note: The Joint Commission classifies a blood incompatibility error as a sentinel event (i.e., an event that is an unexpected occurrence resulting in death or serious physical or psychological injury, or the risk thereof). [2] |
| Obtain and document pre-transfusion vital signs and a baseline physical assessment. If the client is febrile (i.e., above 37.8° C or 100.4° F), notify the provider before starting the transfusion. | Baseline data and hemodynamic status must be established immediately before the transfusion begins so that manifestations of a transfusion reaction can be quickly recognized. For example, if a client develops fluid overload, a baseline assessment, including lung sounds, can be used for comparison with new findings. |
| Initiate the blood transfusion. The nurse must remain with and monitor the client for at least 15 minutes as the transfusion begins at a slow rate of 2 mL/min (i.e., 120 mL/hour). Ask the client to report unusual sensations (i.e., chills, hives, itching, shortness of breath, and chest pain). Note: All blood products must be completely administered in less than four hours. Administration sets are changed based on agency policy, commonly at the completion of every unit or every four hours. | Most transfusion reactions occur within the first 15 minutes of starting the transfusion. Blood products should not hang for more than four hours, and administration sets should be changed at the completion of each unit or every four hours to reduce bacterial contamination. |
| After 15 minutes, obtain another set of vitals. Determine an appropriate rate of transfusion based on agency policy and client considerations. | Most transfusion reactions occur within the first 15 minutes of starting the transfusion. The rate of infusion can be adjusted after the initial 15 minutes based on patient tolerance. For example, a client with an active hemorrhage requires a fast rate whereas an elderly, symptomatic anemic patient with a history of heart failure requires a slower rate. |
| If signs of a transfusion reaction occur, stop the transfusion and perform appropriate steps based on the agency’s transfusion reaction policy and protocol. Assess the patient and obtain vital signs. Start normal saline with new primed tubing attached directly to the venous access device and notify the health care provider immediately. Do not infuse saline through the existing tubing because it will cause the blood in the tubing to enter the patient. Do not discard the blood product or tubing; prepare it for lab analysis according to agency policy. | These steps prevent increased risks to the client. New tubing ensures that none of the blood product will further infuse into the client. Agency policy typically requires additional steps such as labs drawn, urine collection, and forms to be filled out and sent to lab. |
| Frequently monitor and assess the IV site and surrounding area. | Early detection of IV site complications improves patient outcomes. |
Delegation Tips:
Each state’s Nurse Practice Act specifies if the skill of blood product transfusion can be delegated to a licensed vocational/practical nurse (LVN/PN) and if unlicensed assistive personnel (UAP) may collect vital signs after the first 15 minutes of the transfusion and the client’s stability has been confirmed. During the delegation process, the registered nurse (RN) should specify the frequency in which the client should be monitored and vital signs collected, as well as the parameters for vital signs and symptoms that should be immediately reported. Examples of parameters include an increased temperature, decreased pulse oximetry reading, shortness of breath, chest pain, hives, or chills. The RN retains responsibility and accountability for monitoring the client’s status during the transfusion. Read more information about delegation in the “Delegation and Supervision” chapter in Open RN Nursing Management & Professional Concepts .
Post-Procedure
| Evaluation | |
| Evaluate and document client response and tolerance of the infusion, comparing current status to baseline data, such as physical assessment, vital signs, and lab results. Assess IV site to ensure integrity and patency after the infusion. | Evaluation determines if the goals of the transfusion therapy were achieved or if late onset transfusion complications are developing. Note: Some laboratory results may not reflect anticipated targets for several hours after the transfusion is completed. |
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- Blood and blood product transfusion. (2022). Lippincott procedures. http://procedures.lww.com ↵
- World Health Organization. (2022). Blood products . https://www.who.int/health-topics/blood-products#tab=tab_ ↵