Ensuring Safe and Effective Blood Transfusion: A Step-by-Step Clinical Guide

Learn the step-by-step clinical procedure for performing a safe and effective blood transfusion. This guide covers preparation, patient monitoring, administration, and post-transfusion care to ensure best practices in nursing and medical settings.

PROCEDURE: Blood Transfusion

PURPOSE

To treat blood loss or to supply blood component your body can not make for itself

INDICATIONS

Anemia, Hypovolemic shock, Major surgical operation, severe burns victim, hereditary disorders etc.

PREPARATION

NURSE

Clean uniform (dress or gown).
Hair tied properly
Remove watch, jewelery, etc.
Wash hands.
Data-collection.
Identification of the patient.
Physical and psychological condition of the patient.
Assess and understand the patient's pathology.
Verify medical prescription.
Check the patient's blood group and Rh factor.

PATIENT

Respect patient privacy
Evaluate the patient's capacity to understand and collaborate
Inform and explain the patient/family: objective, procedure, of care.
Assess the puncture site for hygiene and integrity
Assure that clothing can be withdrawn easily.
Make sure that the test of compatibility has been completed accurately.

Material

Cleaned and disinfected trolley/tray.

Sterile cup/gallipot

Gauze / sterile pads.
Unit of blood, same blood group and type
Check the unit of blood (name of the patient, blood group and Rh factor of the donor and receiver, Bed number, blood aspect, expiry date).
Check the blood's temperature.
Transfusion set

Adapted catheter.
Tourniquet
Kidney dish.
Protective gloves.
Protection for bed.
Scissors.
Adhesive tape.
Bracket.
Container sharp objects.
Disinfectant (alcohol).
Splint.
Watch with second hand.
Label.
Material for taking vitals signs.

IMPLEMENTATION

Wash hands.
Check medical prescription.
Select the limb opposite from the dominant side (left for right-handed and right for left- handed persons).
Determine, with the patient, the position of the arm
Place protection under the limb to be punctured.
Inspect the patient's veins, looking for one near the surface
Take vital signs.
Prepare the transfusion set

* Move the drip regulator approximately 5 cm from the dropper.
* Close the drip regulator
Disinfect the cap of the bottle / nozzle of the bag.
Connect the transfusion se to the bottle / bag
Hang the bottle and tubing to the bracket.
Fill the dropper until the filter is entirely immersed with blood.
Open the drip regulator and prime the tube with blood.
Close the drip regulator and replace the cap on the end of the tube
Hang the transfusion set to the bracket.
Apply protective gloves.
Locate the vein, stimulating the circulation, if necessary.
Place the tourniquet at approximately 10 cm above the puncture site.
Massage along the vein in the direction of venous return
Select the vein.
For 1 minute widely disinfect the selected puncture site
Take the catheter packing and open it.
Visualize the vein and begin by stretching the skin downward below the anticipated
venipuncture site with the opposite hand to anchor the vein and limit vein movement
Penetrate in the vein, either from the top, or from the side.
Puncture the vein using direct or indirect entry:
Direct (one step, used for larger veins): Hold the over-the-needle assembly at 15 to 20 degrees above the site and enter the vein directly.
Indirect (two steps, used for smaller veins): hold the assembly 15 to 20 degrees above the site and 20 degrees lateral to the vein, insert the catheter into the skin, and then advance into the vein.
When the vein is punctured, blood should appear in the flash chamber: withdraw slightly the needle while slipping the catheter into the vein.
Put a small compress below the end of the needle.
Remove the needle by slightly pressing on the skin from the top of the catheter extremity.
Maintain the catheter holder in place.
Loosen the tourniquet and remove it.
Quickly connect the transfusion set to the catheter.
Open the drip regulator and adjust it to the prescribed rate of transfusion
Slip sterile gauze under the catheter pavilion.
Fix the catheter with adhesive tape
Adjust the flow according to the prescription.
Place the label (name of the patient, n° of bed, dates, hour of beginning, hour of end, flow rate )
Evaluate the reactions from the patient.
check vital signs after 15 minutes, monitoring for an adverse reaction
Check the vital signs every 30 minutes.
Carefully monitor the patient throughout the transfusion process!

COMPLETION

Patient

Position the patient comfortably and appropriately
Arrange personal effects of the patient and put them within reach.
Thank the patient for his or her collaboration.

Material

Eliminate waste and separate the sharp objects
Clean and arrange the material.
Nurse
Education/ Care-related guidance.
Document, sign and deliver verbal or written report of Care provided
Wash and disinfect hands.
Monitor the infusion

As nurses or midwives you have to monitor this patient until the transfusion end, when there is change in temperature or any allergy to the patient you have to stop transfusion immediately.