A physician orders a blood transfusion for an anemic patient. Before transfusing the patient, the nurse should:


•To ensure compatibility between the patient and the donor blood, the patient's blood needs to be screened for typing and crossmatching.

•Typing and crossmatching is required before blood will be released for transfusion, so this should be done first. Having a second RN verify cross match and identification is generally standard for most hospitals.

•Obtaining baseline vital signs is best practice for monitoring patient response to the transfusion. Patients generally do not know their hospital number, but you should verify their name and birthday.

•Normal saline is the only fluid compatible with blood transfusions.

•The recipient's blood type is determined (i.e., their ABO type and RhD status) and a crossmatch is done. To perform a crossmatch, a small amount of the recipient's serum is mixed with a small amount of the donor RBCs. If the transfusion would be incompatible, the donor RBCs will be agglutinated by antibodies in the recipient's serum when examined by microscope.

•Always verify the order, conduct and document a thorough physical assessment of the patient (including vital signs) to help identify later changes. Baseline vitals including temperature and respirations will be taken just prior to administration of blood product and every 15–30 minutes during administration. Assess the IV access site for patency; catheter should ideally be size 18 gauge or larger. Confirm that informed consent was given and teach the patient about the signs and symptoms of a reaction.

•Before starting the transfusion, two RNs (this policy may vary) must confirm the following on the blood, paperwork, and the blood ID band at the bedside: blood ABO and Rh type, unit expiration date, blood unit unique identifier (or barcode), and patient's name and DOB confirmed with the patient ID band.

•Begin the transfusion slowly, at a rate of 2 mL/minute for the first 15 minutes (100 mL/hour). Stay with the patient for the first 15 minutes and assess vital signs at 15 minutes and again at 30 minutes. Most severe reactions occur in the first 15 minutes or 50 mL of the transfusion. Watch for pain near the insertion site, backache, fever, chills, itching, hives, dyspnea, or unusual complaints from the patient. From the time a unit of blood is spiked, the infusion should take a maximum of 4 hours. Each unit of plasma or platelets should be administered over 30-60 minutes maximum.

•If a reaction is suspected, stop the blood immediately, replace the tubing, and run 0.9% normal saline. Report this to the health care provider AND the blood bank immediately. The entire unit with tubing still connected is usually retrieved by the blood bank.

Visit our website for other NCLEX topics now!