1. Suite 260 – 3480 Gilmore Way
Burnaby BC V5G 4Y1
Tel: 778.373.3100
College of Licensed Practical Nurses Fax: 778.373.3102
Toll Free in BC: 1.877.373.2201
of British Columbia Email: info@clpnbc.org
www.clpnbc.org
ensuring safe, competent, and ethical nursing practice
PRACTICE GUIDELINE: BLOOD & BLOOD PRODUCT TRANSFUSION THERAPY
As regulated professionals, individual LPNs undertake only those roles, functions, and activities for which they have
demonstrated the required competencies. The responsibility and accountability for determining those competencies
rests with the nurse and the nurse’s employer.
Definition: Blood/blood product transfusion therapy is a therapeutic nursing intervention which involves the preparation,
administration, monitoring, evaluation, and documentation of these products.
Professional Practice
An LPN maintains standards of professional nursing practice, professional conduct, and safety in the practice setting during
blood/blood product transfusion therapy, as indicated by:
 Being aware of health authority, facility, agency and/or departmental policies, protocols, and guidelines regarding:
o roles and responsibilities for transfusion of designated products
o safe infusion rates and maximum duration of each infusion for each product
o frequency of client monitoring (i.e. vital signs)
o correct use of infusion devices for blood/blood product transfusions
o frequency of bag, tubing, intravenous site changes, and correct disposal of used equipment
o expected documentation of client monitoring and evaluation of blood/blood product transfusion
 Assessing one’s own knowledge, skill, judgment, and ability to safely and competently monitor and evaluate
blood/blood product transfusion therapy.
 Researching unfamiliar blood/blood product transfusion prior to administration.
 Being aware of the cause and treatment of each of the six types of blood/blood product transfusion reactions.
Ethical Practice
An LPN understands and adheres to the ethical obligations and requirements of the profession for blood/blood product
transfusion therapy, as indicated by:
 Demonstrating respect for the right of choice and personal freedoms held by clients and acknowledging that clients
are integral partners in the decision-making process.
 In the event of an error:
o checking the client immediately by assessing all parameters and documenting accordingly
o contacting respective practitioners and completing forms according to health authority, facility, agency, and/or
departmental policies and protocols
o critically self-reflecting on one’s own practice and events to prevent future errors
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2. Legal Practice
An LPN understands and adheres to the legal obligations and requirements of the profession during blood/blood product
transfusion therapy, as indicated by:
 Providing blood/blood product transfusion therapy in a manner that enables the LPN to function in compliance with
the scope of practice for LPNs, as set out in the Nurses (Licensed Practical) Regulation under the Health Professions
Act, and the CLPNBC Standards of Practice and Code of Ethics.
 Completing all required checks and co-signing for blood/blood products according to health authority, facility, agency,
and/or departmental policies and protocols with another nurse. These checks include:
o physician’s order
o blood-transfusion record and information
o signed informed client consent
o client identification (client’s full name, date of birth, and medical record number on client’s identification band)
o blood bag identifiers (ABO group and Rh, blood expiration date)
o requisition and/or documentation accompanying the blood/blood product from the laboratory
o cross-checking and matching information on the component bag with information on the compatibility label,
including:
 unit number
 component blood grouping
 patient blood group
 Reporting and immediately correcting irregularities with blood/blood product transfusion therapy.
Foundations of Practice
An LPN draws upon knowledge of human biological sciences, pharmacology, and health-promotion and prevention strategies
while formulating and implementing the nursing care plan, as indicated by:
 Understanding the indication for the ordered blood/blood product for a particular client. For example, client diagnosis,
medications, lab values, and current signs and symptoms.
 Being aware of client’s previous blood/blood product transfusions and reactions.
 Ensuring correct intravenous catheter gauge for transfusion.
 Obtaining the ordered product from blood bank/laboratory immediately prior to the transfusion:
o packed red blood cells
o fresh frozen plasma
o albumin
o cryoprecipitate
o platelets
o packed white blood cells
o plasma expanders
 Selecting, setting up, and programming the appropriate infusion equipment.
 Calculating the drop factor if infusing via gravity, or the correct millilitres/hr if infusing via electronic pump.
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3.  Validating signed client consent for transfusion of blood/blood products.
 Assessing and maintaining the integrity of the intravenous infusion line.
 Monitoring the client closely during all stages (phases) of the transfusion for signs of reaction.
 Providing ongoing monitoring of the client as directed by health authority, facility, agency, and/or departmental
policies and protocols during the transfusion.
 Recognizing and immediately reporting a suspected non-therapeutic effect; stopping blood/blood product transfusion;
starting alternate flush solution; notifying the appropriate health-care professional as directed by health authority,
facility, agency, and/or departmental policies and protocol; continuing to monitor the client; assessing relevant
parameters; and documenting accordingly.
 Recognizing and responding to immediate and delayed complications of transfusion therapy, such as:
o allergic reaction
o anaphylaxis
o circulatory overload
o hemolytic reaction
o sepsis
o transfusion-related acute lung injury (T.R.A.L.I.)
Collaborative Practice
An LPN collaborates with clients, families, and members of the health-care team to promote best client outcomes during
blood/blood product transfusion therapy, as indicated by:
 Teaching the client about the indications and possible side effects of the ordered blood/blood product transfusion.
 Communicating with other members of the health-care team about abnormal assessment findings during the
blood/blood product transfusion.
 Withholding the blood/blood product transfusion therapy and following up with the prescriber in a timely manner in the
event that an order is unclear, inappropriate, or misunderstood.
Key Strategies/Actions for Ensuring Safe and Competent Practice
On an individual basis, nurses can practise safely by implementing the following strategies:
 Ensuring adequate references, resources, and supports, such as information available from Canadian Blood
Services, are readily available and utilized.
 Seeking assistance in response to recognition of personal limitations in the safe monitoring and evaluation of
blood/blood product transfusion.
 Advocating for systemic changes that improve the safety of blood/blood product transfusion therapy.
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4. References
Canadian Blood Services. (2007). Clinical Guide to Transfusion. Ottawa. Available at: http://www.transfusionmedicine.ca/
College of Licensed Practical Nurses of British Columbia. (2009). Baseline Competencies for Licensed Practical Nurses’
Professional Practice. Burnaby.
College of Licensed Practical Nurses of British Columbia. (2010). Medication Administration (Practice Guideline). Burnaby.
College of Licensed Practical Nurses of British Columbia, (2010). Peripheral Infusion Therapy (Practice Guideline). Burnaby.
College of Licensed Practical Nurses of British Columbia. (2010). Professional Standards of Practice for Licensed Practical
Nurses. Burnaby.
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