Blood transfusion NCLEX review for nurses. As a nurse you must know how to transfuse blood and what type of transfusion reactions can happen during a blood transfusion.
Don’t forget to take the blood transfusion nclex quiz after reading this review.
Lecture on Blood Transfusion Procedure
Blood Transfusion NCLEX Review
What is a blood transfusion? It’s where the nurse transfuses a patient with new red blood cells via a venous access. Most transfused red blood cells are from donated red blood cells.
WHY would a patient need a blood transfusion? Because the patient is low on RBCs (erythrocytes)
A few reasons why a patient may be low on red blood cells?
- Anemia (body not producing enough red blood cells or the body is destroying them): in cases of renal failure, cancers, liver failure etc.
- Excessive blood loss (surgery or trauma)
What is the Importance of RBCs?
Our body can’t function without them very well! When a patient is low on RBCs the may experience:
- Pale looking skin color
- Feel weak
- Experience shortness of breath with activity
- Tachycardia (heart has to work harder to replenish the organs with oxygen) etc.
Red blood cells, with the help of the protein hemoglobin, carries oxygen it receives from the lungs throughout our body and helps remove the CO2 that has collected in our body, which will go to the lungs to be exhaled.
When are patients usually transfused? It depends on what is going on with the patient….patient’s health history, their current signs and symptoms etc., but recent guidelines by the American Association of Blood Banks recommends transfusing blood when hbg (hemoglobin) levels fall 7-8 g/dL (“Guidelines Define Hemoglobin Levels for Transfusion”, 2012).
What are normal Hbg Levels? Varies depending on gender:
- Men: 14 to 18 g/dL
- Women: 12 to 16 g/dL
Nurse’s Responsibilities with Blood Transfusions
Transfusing blood is VERY common in the hospital setting! Most hospitals only allow registered nurses to transfuse blood. As a new graduate be sure to access your hospital’s protocol for transfusing blood and be familiar with their rules.
A lot of prep work is done before a patient is transfused with packed red blood cells to prevent a transfusion reaction. One of the most common reasons for a transfusion reaction is a clerical error. So, the prep work is very important!
You receive an order: “Transfuse patient with 2 units of PRBCs.”….one unit is transfused at a time.
First, the patient will be typed and crossmatched. This will require you draw blood and place a blood band on the patient. NOTE: It is very important everything is written correctly. If any errors occur this increases the risk of a transfusion reaction.
Then send the blood to the lab who will type the patient and crossmatch it with a donor. Then the prescribed amount of units will be ordered. The blood bank will notify you when the blood is ready.
As the nurse, you must be familiar the ABO blood types and compatibility along with Rh factors (Rh+ can receive both positive and negative factor blood, while Rh- can only receive negative factor blood). Be sure to watch my blood typing lecture on this topic.
Quick review: O type: universal donor, AB type: universal recipient
Obtain Informed Consent:
Assess your patient’s allergies and their understanding about a blood transfusion (the purpose of the transfusion, how it is performed and what signs and symptoms they must report to the nurse if they experience during them during the transfusion).
Also, this is a great time to ask them if they’ve ever had a blood transfusion before and if they tolerated it well.
Let the physician know if the patient had a transfusion reaction before or has received many blood transfusions in the past. The physician may need to order the patient to be premeditated before the transfusion. WHY? If a patient has received many blood transfusions in the past they create antibodies that can lead to a febrile non-hemolytic transfusion reaction (most common type of transfusion reaction…more information about this below).
Premedications used: Benadryl (diphenhydramine) and Tylenol (acetaminophen)….if ordered orally give 30 minutes before transfusion. In addition, if the patient is at risk for circulatory overload (like patients with heart failure etc.) a loop diuretic (ex: Lasix/Furosemide) may be ordered before, after, or in between units.
Need IV access: follow hospital’s protocol
18 gauge or larger: WHY? To prevent damage to the transfusing RBCs…the RBCs will lysis if the cannula is too small.
NOTE: If the patient will need IV medications at other times while the blood is transfusing, the patient will need another IV access site….so keep that in mind. The IV line transfusing the blood is just for the blood administration during that time……NO other medications or fluids!
Special Y-Tubing that has an in-line filter
Bag of 0.9% normal saline (NO other fluids can be given with blood or hung with it EVER….other fluids like dextrose fluid can cause clumping of the blood cells). The normal saline is used to prime the line and flush it afterwards.
Other supplies to dispose: red biohazard bag (the blood bag and tubing NEVER goes in the regular trash).
Follow hospital protocol for how often to change the y-tubing. Some say to change y-tubing sets after each unit…while others say that the set must be changed after 4 hours (remember each unit must be given within 2-4 hours from the time it leaves the fridge….so if you are giving 2 units you may go over the 4 hour limit if you run it slowly).
Transfusing the blood!
When lab notifies you that the blood is ready, you will let them know when you are ready for it. Either you will collect the blood yourself or someone will bring it to you. You must start the transfusion within 30 minutes of receiving the unit of blood (one unit is given at a time). Notify the blood bank to send the blood when you are ready for it…..30 minutes goes by fast as a nurse!
Blood warmers can be used when giving large amounts of blood quickly and for patients who may have a hypothermic response….use a special warmer for warming blood, don’t warm it up in the microwave.
Before starting the transfusion, a verification process is done! You will verify everything is correct with another registered nurse (will do this with each unit of blood): hospitals vary on who you do this verification process with…..needs to be licensed personnel though (most require two RNs to do this).
- Verify the order
- Patient’s Identification and Blood Bank’s Information
- Patient’s blood type and donor’s type and RH factor….compatible?
- Expiration Date (look at the blood make sure it doesn’t have any clots or abnormal substances in the blood or it’s damaged)
- EVERYTHING MUST MATCH!!!! If there is a discrepancy, notify the blood bank immediately…don’t start the transfusion.
BASELINE VITAL SIGNS: blood pressure, heart rate, temperature, and respirations
-If temperature greater than 100’F notify MD.
Again, explain to the patient about what is about to happen and inform the patient to notify you immediately if they start to experience the following:
- Sweating, chills, chest pain, shortness of breath, headache, back pain, nausea, vomiting, itching
Start the blood transfusion SLOWLY on an infusion pump: 2 mL/min for the first 15 minutes and STAY at the patient’s bedside for the first 15 minutes. If the blood is tolerated after 15 minutes, rate can be increased. Most blood bags are 250 to 300 cc and remember they must transfuse within no more than 4 hours.
WHY? Most transfusion reactions occurs within this timeframe and you want to give the least amount of blood to minimize that reaction if the patient is going to have one.
Obtain VS per protocol (most transfusion bags come with a piece of paper where you record the vital signs and it will go in the patient’s chart but again this depends on your hospital system):
You will obtain vital signs at:
- 5 minutes from the start of the 5 minutes
- 15 minutes
- 30 minutes
- 1 hourly until done
- 1 hour after the transfusion
Watch for: various types of transfusion reactions (immune system interacts with the donor’s blood): allergic, hemolytic, febrile, GVHD (graft-versus-host-disease) along with other complications like circulatory overload (especially in patient who are susceptible to this like cardiac and renal patients)
Elevated temperature 1 degree Celsius or 1.8’ f or more from baseline
Aching (back, chest or head)
Oliguric (low urine output or no urine output anuria)… hemoglobinuria: free hemoglobin in the urine (purplish color)
Flush the line with normal saline and dispose of it properly when the blood is done transfusing. Then obtain vital signs 1 hour after transfusion.
Review of Transfusion Reactions
Hemolytic: immune system is killing the donors RBCs. The antibodies in the recipient’s blood match the antigens on the donor’s blood cells….mistyped!!
*lead to DIC (disseminated intravascular coagulation) and renal failure…death: fever, chills, anxiety, back pain, chest pain, hemoglobinuria, increased heart rate, low blood pressure
Allergic: recipient’s immune system reacts to the proteins found in the donor….can progress to anaphylaxis.
*hives, rashes, respiratory issues: wheezes, oral swelling…anaphylaxis reaction
Febrile (non-hemolytic): The recipient’s WBCs are reacting with the donor’s WBCs. This causes the body to build antibodies. You can see an increase in temperature 1’C or 1.8’F from baseline.
Most common, especially if patient has received blood in the past, because their body has created antibodies.
*chills, headache, increased heart rate, fever
GvHD …graft-versus-host-disease: (rare but deadly and occurs days to weeks after the transfusion): the donor’s T lymphocytes cause an immune response in the recipient by engrafting in the marrow of the recipient and attacking the recipient’s tissues.
These T-cells are usually killed by the recipient’s body but not in this case (suppressed immune system).
*fever, rash all over the body (feet and hands as well), GI issues diarrhea, nausea, liver inflammation
Other complications…not immune related:
- Septicemia: blood is contaminated (very important to start transfuse promptly after receiving blood and that it is done transfusing within 4 hours)
- Blood is contaminated with a disease (not as common due to strict screening guidelines): Hep B, C, HIV etc.
- Circulatory overload
- High iron risk: frequent blood transfusions in the past
What to do if a transfusion reaction happens?
STOP TRANSFUSION and note the time mentally when the patient started showing signs and symptoms of a reaction.
Disconnect blood tubing from IV site and replace with NEW IV tubing set-up at the IV site and keep vein open with normal saline 0.9% (limits any more blood from the transfusion entering the patient’s blood).
Notify prescribing physician and blood bank (do all this while staying with the patient…get help from other staff)
Monitoring vital signs every 5 minutes!
Based on patient’s reaction and their signs and symptoms you will be ordered to give them various medications: corticosteroids (suppress immune system), fluids (flush the kidneys of the hemoglobin), antihistamines (decreases immune response), antipyretics (decreases temperature), vasopressors (increases blood flow to kidneys or opens airway…allergic reaction…epinephrine) or diuretics
Labs will be ordered for blood work (clotting levels…DIC?, electrolytes, blood levels, renal function etc.) along with a urine collection for hemoglobinuria
Keep and bag up blood bag and tubing and other needed documentation and send it to the blood bank (they will let you know what you need to send….don’t throw anything away…it will be tested and analyzed for what went wrong).
Document! Include time it was noted, the actions you took, and currently how the patient is doing.
Basics | Blood Safety | CDC. Cdc.gov. Retrieved 13 March 2018, from https://www.cdc.gov/bloodsafety/basics.html
Guidelines Define Hemoglobin Levels for Transfusion. (2012). Medscape. Retrieved 14 March 2018, from https://www.medscape.com/viewarticle/760919