Blood transfusion nursing responsibilities from consent to the first 15 minutes

Before the blood arrives: order, consent and baseline

Verify the provider's order for the component and amount. Unless it is an emergency, confirm written informed consent is in the record. Check that a compatibility sample was taken within the time frame agency policy allows, and ask about previous transfusion reactions. Make sure the client has suitable venous access before the unit is collected.

Take baseline vital signs shortly before starting, per agency policy, and assess breath sounds, skin and relevant laboratory values. Note conditions that raise risk, such as fever, heart failure or kidney disease, and ask about symptoms the client already has, so they are not later mistaken for a reaction. Review any prescribed premedications.

The two-person bedside check

Identification errors at the bedside can lead to an incompatible transfusion. Collect the unit only when ready, because policy sets a short window between leaving the blood bank and starting the transfusion. At the bedside, two qualified staff match the client's wristband name and identification number to the blood bag label and the order.

Confirm the blood type and unit number match the compatibility record, check the expiry date, and inspect the bag for leaks, clots or unusual colour. Return any expired or abnormal unit to transfusion services. Ask the client to state their name and date of birth when able. Do not proceed if any detail does not match.

Fluids, tubing and the early-minute watch

Prime the blood administration set, which contains a filter, with 0.9% sodium chloride. 0.9% sodium chloride is the standard fluid to run with blood; dextrose solutions, lactated Ringer's and medications must not go through the same line unless facility policy approves a specific product. Inspect the filter and tubing, trace the line from client to bag, and label it.

Start slowly, as agency policy directs, and remain with the client during the first 15 minutes, when many reactions appear. Ask the client to report chills, itching, hives, shortness of breath, chest or back pain. Repeat vital signs per policy, then increase to the prescribed rate if there is no reaction. Each unit must finish within the time limit agency policy sets.

Recognising and responding to a reaction

Reactions can present as fever, chills, flushing, hives, itching, dyspnoea, back or flank pain, hypotension, tachycardia or dark urine. Stop the transfusion immediately. Keep the vein open with 0.9% saline through new primed tubing attached at the access device, not through the blood-filled line. Assess the client, take vital signs, and notify the provider and transfusion services.

Consider this hypothetical scenario. Ten minutes into a red cell transfusion, a client reports chills and low back pain. Options include slowing the rate and rechecking in fifteen minutes, giving a prescribed antipyretic and continuing, or stopping the transfusion and maintaining access with saline through new tubing. Stopping is correct; slowing or continuing exposes the client to more incompatible blood.

Completing the transfusion and documenting

Continue observation for the rest of the infusion, watching especially for fluid overload in clients with heart failure or older age, which presents with dyspnoea, cough, crackles and rising blood pressure. When the unit is complete, flush the line with saline and take vital signs per policy. Change administration sets as agency policy directs.

Document consent, the bedside verification and both checkers, unit number, start and end times, volume given, vital signs at each interval and the client's response. After a suspected reaction, send the bag, tubing and any requested blood or urine samples to transfusion services according to the reaction protocol, and record every action taken.

Sources and further reading

Open RN Nursing Advanced Skills: Checklist for administration of blood products. Order and consent verification, baseline vital signs, two-person bedside check, filtered set primed with normal saline, slow start, staying for the first 15 minutes, completion time limit.

Open RN Nursing Advanced Skills: Applying the Nursing Process to blood administration. Only normal saline is compatible, symptoms to report, stopping the transfusion and starting saline with new primed tubing at the access device.

MedlinePlus Medical Encyclopedia: Hemolytic transfusion reaction. Symptoms of haemolytic reaction (back pain, bloody urine, chills, fever, flank pain, flushing) and timing during or right after transfusion.