Blood transfusion is a critical procedure that carries significant risk. Adhering to strict validation protocols and patient monitoring standards is key to maintaining safety.
Pre-Transfusion Checklist
- Verify the doctor's order and obtain signed informed consent.
- Double-verify patient identity, blood type, and unit number with another registered nurse.
- Assess baseline vital signs immediately before starting the transfusion.
- Use a dedicated Y-tubing set with an in-line filter, primed with 0.9% Normal Saline only.
Monitoring & Transfusion Rate
Start the transfusion slowly (no more than 2 mL/min or 50 mL/hour for the first 15 minutes). The nurse must stay with the patient for the first 15 minutes to monitor for acute reactions.
Managing Transfusion Reactions
If a reaction (fever, chills, dyspnea, back pain, hives) is suspected:
- 1. STOP the transfusion immediately.
- 2. Disconnect the blood tubing and connect new tubing with 0.9% Normal Saline to keep the vein open.
- 3. Notify the physician and the blood bank.
- 4. Document vitals and return the blood bag and tubing to the laboratory.
