What Is a Blood Transfusion?
A blood transfusion is the administration of blood or blood components (most commonly packed red blood cells – PRBCs) through venous access to a patient who has low red blood cell levels.
Purpose:
To restore oxygen-carrying capacity and improve tissue perfusion.
Why Do Patients Need Blood Transfusions?
1. Blood Loss
Surgery
Trauma
Gastrointestinal bleeding
Internal hemorrhage
2. Decreased RBC Production
Severe anemia
Renal failure (↓ erythropoietin)
Bone marrow disorders
Cancer / chemotherapy
Why Are Red Blood Cells Important?
Red blood cells (RBCs), via hemoglobin, perform two critical functions:
✔ Carry oxygen (O₂) from lungs → tissues
✔ Remove carbon dioxide (CO₂) from tissues → lungs
Signs & Symptoms of Low Hemoglobin
Pallor
Fatigue / weakness
Shortness of breath
Tachycardia
Dizziness
Hemoglobin Values
| Patient | Normal Range |
|---|---|
| Male | 14–18 g/dL |
| Female | 12–16 g/dL |
Transfusion Threshold (general guideline):
≈ 7–8 g/dL (depends on patient condition & protocols)
Nurse’s Role in Blood Transfusion
Blood transfusion is a high-risk procedure requiring strict adherence to policy.
1. Preparation Phase
Type & Crossmatch
Correct patient identification is critical
Prevents hemolytic reactions
Clerical errors = most common cause of reactions
Verify Blood Compatibility
Universal Donor: O negative
Universal Recipient: AB positive
Obtain Informed Consent
Nurse responsibilities:
✔ Explain procedure
✔ Assess understanding
✔ Ask about:
Previous transfusions
History of reactions
Allergies
Premedication (if ordered)
May include:
Acetaminophen (Tylenol)
Diphenhydramine (Benadryl)
Used for patients with prior febrile/allergic reactions.
Assess Fluid Status
High-risk patients:
Congestive heart failure (CHF)
Renal failure
Fluid overload
Possible order:
Loop diuretic (e.g., furosemide/Lasix)
Ensure IV Access
Preferred:
✔ 18-gauge or larger
Why?
Prevent RBC damage (hemolysis)
Allows proper flow
Consider:
✔ Second IV site for medications
Gather Supplies
Y-tubing with inline filter
0.9% Normal Saline (NS)
Infusion pump
Biohazard disposal bag
Important Rule
🚨 ONLY 0.9% Normal Saline with Blood
❌ No dextrose (causes RBC clumping)
❌ No medications
2. Blood Administration Phase
Timing Rules
✔ Start within 20–30 minutes of receiving blood
✔ Complete within 2–4 hours
✔ NEVER exceed 4 hours
Reason:
Risk of bacterial growth → sepsis
Blood Warmers
Used when:
Rapid / massive transfusion
Hypothermia risk
Two-Nurse Verification
Check together:
✔ Physician order
✔ Patient ID
✔ Blood unit number
✔ ABO & Rh compatibility
✔ Expiration date
✔ Blood appearance (no clots/leaks)
Baseline Vital Signs
Temperature
Blood pressure
Heart rate
Respirations
🚨 Report fever before starting
Educate Patient
Report immediately:
Chills
Itching / rash
Chest or back pain
Shortness of breath
Nausea
Starting the Transfusion
✔ Begin slowly (~2 mL/min)
✔ Stay with patient first 15 minutes
Why?
Most reactions occur early.
Vital Sign Monitoring (varies by policy)
Common practice:
Baseline
5 minutes
15 minutes
30 minutes
Hourly
Post-transfusion
Transfusion Reactions
Mnemonic: “REACTION”
| Letter | Symptom |
|---|---|
| R | Rash |
| E | Elevated temperature |
| A | Ache (back/chest/head) |
| C | Chills |
| T | Tachycardia |
| I | Increased respirations |
| O | Oliguria |
| N | Nausea |
Types of Reactions
1. Hemolytic (Most Dangerous)
Cause:
ABO incompatibility
Signs:
Fever
Chills
Back pain
Chest pain
Hypotension
Hemoglobinuria
Complications:
🚨 DIC
🚨 Renal failure
🚨 Death
2. Allergic
Cause:
Reaction to donor plasma proteins
Signs:
Hives
Rash
Itching
Wheezing
Possible anaphylaxis
3. Febrile Non-Hemolytic (Most Common)
Cause:
Recipient antibodies vs donor WBCs
Signs:
Fever
Chills
Headache
Prevention:
Premedication (if indicated)
4. GVHD (Rare but Fatal)
Onset:
Days to weeks later
Signs:
Fever
Widespread rash
Diarrhea
Liver dysfunction
5. Circulatory Overload (TACO)
High-risk:
CHF
Renal failure
Signs:
Dyspnea
Crackles
Hypertension
JVD
6. Septic Reaction
Cause:
Contaminated blood
Signs:
High fever
Chills
Hypotension
If a Transfusion Reaction Occurs
Immediate Actions
✔ STOP transfusion
✔ Keep vein open with new tubing + NS
✔ Stay with patient
✔ Monitor vitals frequently
✔ Notify provider & blood bank
Do NOT Discard
✔ Blood bag
✔ Tubing
Send to blood bank for investigation.
Possible Treatments (Provider Orders)
Antihistamines
Antipyretics
Corticosteroids
IV fluids
Vasopressors
Diuretics
Labs May Include
CBC
Renal function
Electrolytes
Coagulation studies
Urinalysis (hemoglobinuria)
Documentation
Record:
✔ Time of reaction
✔ Symptoms
✔ Interventions
✔ Provider notifications
✔ Patient response
Post-Transfusion Care:
✔ Flush line with NS
✔ Dispose per biohazard policy
✔ Obtain post-transfusion vitals
✔ Reassess patient
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