Blood Product Administration

Blood transfusion is a potentially life-saving intervention that carries significant risks. The NCLEX heavily tests your knowledge of safe transfusion practices and recognition of transfusion reactions.

Blood Products

Pre-Transfusion Requirements

Before Blood Leaves Blood Bank:

1. Order verified
2. Type and crossmatch completed
3. Patient consent obtained
4. Baseline vital signs documented
5. Patent IV access confirmed (18-20 gauge)

The Two-Person Verification

Both nurses at the bedside verify:

Both nurses sign documentation before transfusion begins.

Blood Type Compatibility

ABO Compatibility:

Rh Compatibility:

• Rh negative patients should receive Rh negative blood
• Rh positive patients can receive either

Administration Protocol

Equipment:

• Blood administration set with in-line filter
• IV pump (if approved for blood)
• 0.9% Normal Saline (only compatible solution)
• 18-20 gauge IV catheter (larger for rapid transfusion)

Procedure:

1. Prime tubing with Normal Saline
2. Start transfusion slowly: 2 mL/min for first 15 minutes
3. Stay with patient for first 15 minutes
4. Take vital signs: baseline, 15 min, 30 min, end of transfusion
5. Complete transfusion within 4 hours of leaving blood bank
6. Document per facility policy

Rate Guidelines:

• PRBCs: Usually over 2-4 hours
• Platelets: Usually over 15-30 minutes
• FFP: Usually over 30 minutes to 2 hours
• Adjust based on patient tolerance

Transfusion Reactions

Acute Hemolytic Reaction (Most Severe)

Cause: ABO incompatibility - immune destruction of transfused cells

Onset: Within minutes to hours

Intervention:

1. STOP transfusion immediately
2. Keep IV line open with NEW tubing and saline
3. Stay with patient
4. Notify provider and blood bank STAT
5. Send blood bag and tubing to lab
6. Draw blood samples as ordered
7. Monitor urine output (renal failure risk)
8. Prepare for emergency intervention

Febrile Non-Hemolytic Reaction (Most Common)

Cause: Antibodies against donor WBCs

Signs: Temperature rise > 1°C (1.8°F), chills, mild dyspnea

Intervention:

1. Stop transfusion
2. Notify provider
3. Rule out hemolytic reaction
4. Antipyretics as ordered
5. May be able to resume with leukocyte-reduced blood

Allergic Reaction

Cause: Sensitivity to donor plasma proteins

Mild Signs: Urticaria (hives), itching, flushing

Intervention for Mild Reaction:

1. Stop transfusion temporarily
2. Notify provider
3. Administer antihistamine (diphenhydramine) as ordered
4. May resume if symptoms resolve

Anaphylactic Reaction (Severe):

• Bronchospasm, stridor
• Angioedema
• Hypotension, shock

Intervention:

1. Stop transfusion permanently
2. Maintain airway
3. Epinephrine as ordered
4. Full resuscitation if needed

Transfusion-Related Acute Lung Injury (TRALI)

Cause: Donor antibodies attack recipient lung tissue

Signs: Within 6 hours of transfusion

• Acute respiratory distress
• Pulmonary edema (non-cardiogenic)
• Hypoxia
• Fever

Intervention:

1. Stop transfusion
2. Supportive respiratory care
3. May require mechanical ventilation

Circulatory Overload (TACO)

Risk Factors: Elderly, heart failure, renal failure

Signs:

• Dyspnea, orthopnea
• Jugular vein distension
• Crackles in lungs
• Hypertension

Prevention: Slow infusion rate, may give furosemide between units

Quick Response Guide

Documentation Requirements

• Consent obtained
• Pre-transfusion vital signs
• Two-nurse verification (both signatures)
• Time transfusion started
• Vital signs at 15 min, 30 min, end
• Volume transfused
• Any reactions and interventions
• Post-transfusion assessment

On the Exam

• Know the verification process
• Only Normal Saline with blood
• Complete within 4 hours
• Recognize hemolytic reaction signs
• First action for any reaction: STOP the transfusion