Administering Blood Products
1. Checks the physician's orders
2. Informs the client and explains the procedure. Verify the client's religion and refer accordingly.
3. Checks availability of blood in the blood bank.
4. Monitors and notes baseline vital signs. Refers for any abnormality especially the temperature.
6. Prepares the following: blood administration set, normal saline solution, g 19 butterfly needle/abbocatheter (if client has no ongoing IV line), IV stand, adhesive tape.
7. Assists during IV insertion (makes sure that main IV fluid is plain NSS).
8. Checks patency of the ongoing IV line.
9. Checks the cross-matching slip with the blood bag: client's name and bed number, blood type (A, B, AB, O), Rh factor, hepatitis and AIDS tests, blood products (PRBC, FWB, FFP), number of "u" or cc, expiration date, and serial number, and inspects the blood bag for clots and bubbles
10. Asks another nurse to countercheck.
11. Starts the transfusion by: Inserts administration set to the entry port of the blood bag.
12. Fills the drip chamber half with blood
13. Primes the tubing with blood
14. Stop the main IV line temporarily. (If main IV is not PNSS, flushes tubing with PNSS)
15. Connects the blood via the Y port of the main IV line and infuses as side drip
16. Secures BT line using an adhesive tape.
17. Regulates blood accordingly.
18. Note the time the infusion is started.
19. Stays with the patient during the first 15 minutes.
20. Monitors vital signs every 15 or 30 minutes during the first hour till stable (compared with baseline vital signs).
21. Resumption of IV Infusion after Blood Transfusion: Clamps BT set.
22. Detaches the BT set from the Y port.
23. Flushes tubing with PNSS.
24. Restarts/ regulates the main IV line at its previous rate
25. Discards blood bag, BT set, and needle observing universal precautions as per hospital protocol.
26. Termination of Blood Transfusion and IV Infusion: Clamps BT set.
27. Detaches the BT set from the Y port of the main IV line.
28. Removes abbocatheter and applied pressure dressing over the insertion site.
29. Discards the blood bag, BT set, and the abbocatheter observes universal precautions or sends it to the laboratory for analysis (in cases of BT reactions) as per hospital protocol.
30. Documents the following: start and end of infusion, blood product, serial number, blood type, number of "u" or cc transfused, vital signs before, during, and after transfusion, untoward reactions/responses of patient during and after transfusion, laboratory work-ups done as requested post-BT and medications given as ordered: pre- , mid-, or post-BT.
