1. Blood Administration
Determine patient’s allergies and previous transfusion reactions
Check that consent is signed and on the chart
Blood consent will last for the duration of the patient’s
hospitalization
Instruct patient of signs and symptoms of a blood transfusion
reaction
The pink copy of the blood record or a copy of the order must be
taken to the lab to obtain blood

2. Blood Administration (continued)
Blood administration record is a triplicate form
1. Pink Copy: take to lab to obtain blood
2. Yellow copy (carbon): return to lab completed
3. White copy (original): place on chart under nurse’s notes {green}
tab
Vital signs are taken:
 Baseline [RN]
 15 minutes (from start of blood) [RN]
 30 minutes (from start of blood) [LPN or CSA]
 1, 2, and 3 hours (from start of blood) [LPN or CSA]
 Post transfusion [LPN or CSA]
 The “start of blood” is the time the blood hits the vein

3. Blood Administration (continued)
 Vital signs are taken q15
minutes during platelet
administration
 Clear pump before and
after any blood
administration
 Document INTAKE in CPSI
under appropriate box
 Change blood tubing after
two units or 4 hours –
whichever comes first
(maximum of 2 units per
administration set)

4. Blood Administration (continued)
Check crossmatch record with two nurses at bedside. This is a
NPSG
 ABO group & RH type
 Name & DOB
 Blood band number (at the bedside)
 Donor number/group/type
 Expiration date
 Check the order
 Check that permit is signed/on chart
Administer all blood products immediately (begin transfusion
in less than 30 minutes after obtaining from blood bank)

5. Blood Administration (continued)
 Never add ANY meds to blood products
 Infuse each unit over <4 hours
 Baseline vitals – before spiking blood
 18 GA needle preferred (may use 20 GA if
necessary)
 Prime/flush blood tubing with 0.9% Normal
Saline only
 Use blood administration set – micro filter in-
line
 Severe reactions most likely to occur during
the first 15 minutes and first 100 ml

6. Blood Administration (continued)
 It takes at least 30 ml to cause a blood reaction
 Blood is to be started at 120 ml/hr allowing 30 ml to infuse while
the nurse is at the bedside – change rate after first 15 minutes if
needed
 Transfuse a unit of packed red blood cells in about two hours not
exceeding 4 hours. Slower transfusions are for those patients
more susceptible to fluid overload
 The RN stays with the patient for first 15 minutes of each unit
 Most reactions are to additives, not blood
 It is not necessary to document the information from the blood
transfusion sheet (V/S, education) in CPSI
 Documentation of the start of the blood, volume infused, and any
reaction however, should be charted in CPSI

7. Blood Administration (continued)
Dispose of completed blood bag in biohazard (red) trash
Return completed blood bag to lab only if reaction suspected
If using a blood warmer (only if indicated)
• Set up prior to obtaining blood from blood bank
• Document blood warmer temperature before, during, and after
transfusion
• Do not use extension tubing below the warmer
• Clamp to IV pole less than 42 inches above the floor

8. Blood Administration (continued)
Do NOT warm unless risk of hypothermic response and then
only by specific blood warming equipment
In accordance with physician orders, a blood warmer may be
indicated in the following circumstances:
 Massive volume infusions
 Infusion rate greater than 300 ml/hr
 Exchange transfusion of newborn
 When cold agglutinin is present
 More than two blood units given consecutively
 When a patient’s body temperature is 35-38 C
 When blood is administered via a central line

9. Blood Administration (continued)
Types of reactions:
• Fever, defined as equal to or more than 1 C or 2 F above
baseline with or without chills
• Shaking chills (rigors) with or without fever
• Pain at infusion site or in chest, abdomen, flanks, back, or
joints
• Blood pressure changes, usually acute either hypertension
or hypotension
• Respiratory distress, including dyspnea, tachypnea, or
hypoxemia
• Skin changes, including flushing, urticaria, and localized or
general edema
Continued on next page…

10. Blood Administration (continued)
Types of reactions (continued)
• Nausea with or without vomiting
• Acute onset of sepsis including fever, severe
chills, hypotension, and high output cardiac failure
• Anaphylaxis
• Any of the above signs occurring within 6 hours of
transfusion should also be treated as a possible
transfusion reaction
• Patient death, only when accompanied by signs or
symptoms of a blood transfusion reaction, is reason to
initiate the transfusion reaction process

11. Blood Administration (continued)
If any of the previously mentioned symptoms are noted a blood
transfusion reaction is suspected and the following steps must be
taken immediately:
 Stop blood
 Connect saline with new tubing to infuse at KVO
 Initiation of a Suspected Transfusion Reaction Form
 Clerical check: Patient’s ID bracelet with Lab Transfusion copy
form
 Notify patient’s physician immediately
 She/he may want to continue the transfusion after
administration of antipyretics and/or antihistamines
 Transfusion reaction form must be filled out even if the
transfusion is resumed

12. Blood Administration (continued)
 Notify lab immediately to draw post reaction
specimen (Even if MD orders transfusion continued)
 Immediately collect a urine specimen
 Return the blood bag complete with tubing to
laboratory
 Order “SUSPECTED TRANSFUSION RCN I” in CPSI
If a patient refuses a transfusion, they sign a “Refusal
of Blood and Release from Consequences”
 The nurse then notifies the physician and
anesthesia if the patient is pre-operative

13. South Campus
 Upon receipt of order for blood products, WCMC – South
lab technicians draw patient specimens and deliver to
WCMC – North campus lab for crossmatch
 Upon completion of crossmatch, appropriate blood
products are packaged in a blood transport container with
ice. EXCEPTION – plateletpheresis is delivered at room
temperature in a special box designed for platelets only
 A temperature monitoring device is attached to the blood
product and a temperature monitoring form is initiated by
the blood band and placed in the transport container to be
completed by lab or the nursing supervisor on the south
campus

14. South Campus (continued)
 Following initial temperature check upon receipt to WCMC
– South, blood products are to remain in the transport
container unless being removed for the purpose of
administration
 Blood products are either used or returned within 24 hours
to the North Campus. Any unused blood products are
promptly returned to the North Campus
 Registered Nursing Associates obtain and administer
blood products to patients on the South Campus according
to the same procedure previously described