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CHAPTER 29 Blood Transfusions

involves misidentification of the patient or the unit of blood or

mislabeling the pretransfusion blood sample. Advances in technology help to decrease transfusion-related errors:
Bar-code technology helps prevent errors in the identification process between a patient and the compatible blood
unit.
Radiofrequency transponder microchips are used to standardize and document key steps in the blood collection and
confirm the recipientblood unit matching at a patients
bedside.
Advanced technologic laboratory screening procedures also
help to ensure safe transfusions with regard to bloodborne
pathogens:
Screening
identifies and thereby reduces pathogen
transmission.
Better assessment of blood and plasma cell integrity is available to avoid loss of blood component function.
Blood alternative therapies with pharmacologic developments such as colloids, crystalloids, erythropoietin, antifibrinolytics, and hematinics reduce the risks associated with
transfusing human blood.

PATIENT-CENTERED CARE
When administering blood products, you need to consider a
patients values and cultural beliefs about blood therapy. A persons
perception of his or her disease or health condition affects how
receptive he or she is to receiving blood. Blood transfusion is often
equated to severity of illness. Allay patient anxieties when possible.
Some religions do not allow blood transfusions. For example,

members of Jehovahs Witness do not allow blood transfusions or

organ donation if it involves blood exchange (Snyder etal., 2008).
It is helpful to consult a religious leader when caring for patients
in need of blood therapy. Be familiar with agency policies and
procedures to follow when patients refuse blood transfusion and
inform the health care provider of a patients decision.
Another aspect of patient-centered care is safety, specifically
the prevention of transfusion-related complications. Transfusionrelated reactions occur most commonly from clerical error. To
ensure safe patient outcomes, the National Quality Forum (NQF)
endorses a list of serious reportable events (SREs), which outlines
28 events that are preventable. Regarding transfusion therapy, any
patient death or serious disability associated with a hemolytic
reaction due to the administration of ABO/HLAincompatible
blood or blood products is considered a Care Management Event
and must be reported (NQF, 2011).

Safety Guidelines
1 Administration of blood and blood components requires meticulous attention to detail (e.g., preparation, administration, and
monitoring) to prevent life-threatening transfusion reactions
(Table 29-3).
2 Ensure that each blood unit is correctly labeled; check against
patients identification.
3 Review agency policy and procedure regarding administration
of blood or blood products.
4 Two nurses should verify correct unit and correct patient before
administration.

TABLE 29-3 Transfusion Reactions

Reaction

Mechanism

Onset

Signs and Symptoms

Prevention

Nursing Intervention

Febrile,
nonhemolytic
(most
common)

Accompanies less than

1% of transfusions;
possible sensitivity of
recipient to
leukocytes or
platelets in donors
blood

30min after
initiation to
6hrs after
completion
of
transfusion

Fever greater than 1C

above baseline,
flushing, chills,
headache, muscle
pain; occurs most
frequently in
immunosuppressed
patients

Use leukocyte-reduced
blood products in
patients who have
experienced febrile
nonhemolytic
reactions in the past.

Stop transfusion.
Administer antipyretics
as ordered. Monitor
temperature every
4hrs.

Acute hemolytic
transfusion
reaction

ABO, Rh
incompatibility;
causes intravascular
destruction of
transfused RBCs as
antibodies in
recipients plasma
attach to antigens on
donor RBCs.

Within 15
minutes of
transfusion
initiation

Severe pain in kidney

area and chest;
increased temperature
(up to 41C or 105F),
increased heart rate;
sensation of heat
and pain along vein
receiving blood; chills,
low back pain,
headache, nausea,
chest or back pain,
chest tightness,
dyspnea,
bronchospasm,
anxiety, hypotension,
vascular collapse,
disseminated
intravascular
coagulation, possibly
death

Carefully identify patient

and blood sample
obtained for blood
typing and
compatibility
screening. When
blood is released from
blood bank, match
with patient
information. Follow
agency verification
procedures at bedside
before transfusion.

Stop transfusion.
Remove blood product
and tubing. Maintain IV
access. Notify health
care provider. Monitor
vital signs at least every
15min. Administer
ordered therapy
to correct arterial
blood pressure and
coagulopathy. Insert
Foley catheter. Monitor
intake and output
hourly. Assess for
shock. Dialysis may be
required. Obtain blood
and urine samples and
send to laboratory with
unused portion of unit
of blood. Document
reaction according to
agency policy.

CHAPTER 29 Blood Transfusions

741

TABLE 29-3 Transfusion Reactionscontd

Reaction

Mechanism

Onset

Signs and Symptoms

Prevention

Nursing Intervention

Delayed
hemolytic
transfusion
reaction

Immune response
mounted by recipient
against non-ABO
donor antigens;
usually the result
of destruction of
transfused RBCs by
alloantibodies not
detected during
cross-match

2-14 days

Unexplained fever,
unexplained decrease
in Hgb/Hct, increased
bilirubin levels,
jaundice

Careful cross-matching
of donor and recipient
blood. Has potential
to be missed because
it may occur several
days after transfusion.

Monitor laboratory values

for anemia. (Recognition
is important because
subsequent transfusions
may cause an acute
hemolytic reaction.) If
detected, notify health
care provider and blood
bank. Most delayed
hemolytic reactions
require no treatment.

Allergic reaction
(mild-tomoderate)

Caused by recipient
allergy to a plasma
protein in donors
blood

During
transfusion
to 1hr after
transfusion

Local erythema, hives,

and urticaria, itching
or pruritus

May administer
antihistamines before
transfusion if
prescribed.

Stop transfusion. Notify

health care provider
and blood bank.
Administer
antihistamines as
ordered. Monitor
and document vital
signs every 15min.
Transfusion may be
restarted if fever,
dyspnea, and wheezing
are not present.

Allergic reaction
(severe)

Caused by recipient
allergy to a donor
antigen (usually IgA)
Agglutination of RBCs
obstructing capillaries
and blocking blood
flow, causing
symptoms to all
major organ systems

Within
5-15min of
initiation of
transfusion

Coughing, nausea,
vomiting, respiratory
distress, wheezing,
hypotension, loss
of consciousness,
possible cardiac arrest

Transfusion of salinewashed or leukocytedepleted RBCs.

This is a life-threatening
reaction. Stop
transfusion. Maintain IV
access. Notify health
care provider and blood
bank. Administer
antihistamines,
corticosteroids,
epinephrine, and
antipyretics as ordered.
Measure and document
vital signs until stable.
Initiate cardiopulmonary
resuscitation if
necessary.

Graft-versushost disease

Donor lymphocytes
are destroyed by
recipients immune
system. In
immunocompromised
patients the donor
lymphocytes are
identified as foreign;
however, patients
immune system is
not capable of
destroying, and in
turn patients
lymphocytes are
destroyed.

Days to weeks

Skin rash, fever,

jaundice caused by
liver dysfunction, bone
marrow suppression

Administer irradiated
blood and/or
leukocyte-depleted
RBC products as
prescribed.

Administer methotrexate
and corticosteroids as
ordered.

Continued

742

CHAPTER 29 Blood Transfusions

TABLE 29-3 Transfusion Reactionscontd

Reaction

Mechanism

Onset

Signs and Symptoms

Prevention

Nursing Intervention

Circulatory
overload

Occurs with
transfusion of
excessive volume or
excessively rapid
rate; can lead to
pulmonary edema.

Anytime
during or
within
1-2hrs after
transfusion

Dyspnea, cough,
crackles at lung
bases, tachypnea,
headache,
hypertension,
tachycardia, increased
central venous
pressure, distended
neck veins

Administer blood or
component at
prescribed rate,
usually no greater
than 2-4mL/kg/hr;
pay particular
attention to rate and
volume in older adults,
young children, and
patients with cardiac
and renal disorders.
Administer PRBCs
instead of whole
blood. Minimize
amount of saline
infused with
transfusion.

Slow or stop transfusion

as ordered. Elevate
patients head. Notify
health care provider.
Administer diuretics as
ordered.

Infectious
disease
transmission

Microorganism
contamination of
infused product

During
transfusion
to 2hrs after
transfusion
Complete
transfusion
within 4hrs

High fever, chills,

abdominal cramping,
vomiting, diarrhea,
profound hypotension,
flushed skin, back
pain

Proper care of blood or

blood product from
time of procurement
through end of
administration.

Stop transfusion.
Remove blood product
and tubing. Maintain IV
access. Notify health
care provider. Monitor
and document vital
signs. Obtain samples
for blood culture and
Gram stain from
recipient. Administer IV
fluids, broad-spectrum
antimicrobials,
vasopressors, and
steroids as ordered.

Iron overload

Iron from donated

blood binds to
protein and is not
eliminated

May occur
with multiple
transfusions
or chronic
transfusion
therapy

Cardiac dysfunction,
SOB, arrhythmias,
heart failure,
increased serum
transferrin, increased
liver enzymes,
jaundice

Chelation, phlebotomy,
monitor serum iron
levels.

Monitor patient for heart

failure, cardiac disorder,
liver disorder, serum
transferrin.

Data modified from Alexander M, et al.: Infusion nursing: an evidence-based approach, ed 3, St Louis, 2010, Mosby; and American Association of Blood Banks:
Standards for blood banks and transfusion services. ed 27, Bethesoa, Md, 2011, The Association.
HF, Heart failure; Hct, hematocrit; Hgb, hemoglobin; IV, intravenous; PRBCs, packed red blood cells; RBC, red blood cell; SOB, shortness of breath.

SKILL 29-1 Initiating Blood Therapy

NSO Blood Therapy Module / Lessons 1 & 2

Blood is administered for different clinical indications (Table

29-4). A patients medical condition determines which blood component is indicated. A health care providers order is required for
the administration of a blood product. A nurse is responsible for
understanding which components are appropriate in various situations. In addition, a nurse must ensure that a blood sample has
been collected and sent to the laboratory within 72 hours for
typing and compatibility screening. The blood sample collector
must be meticulous when labeling the patients identification information on the blood tube. This is the first step in the prevention
of error (Alexander etal., 2010; Gabriel, 2008).
Blood is stored in a refrigerated environment. In emergency
situations rapid transfusion of cold blood may lead to dysrhythmias
and a reduction of core temperature. Sometimes a blood-warmer
machine is used for large transfusions of greater than 50mL/kg/hr
or patients with cold agglutinins (Ackley etal., 2008) (Fig. 29-4).

Video Clip

Do not heat blood products in a microwave or with hot water

because this is dangerous and may destroy blood cells.

Delegation and Collaboration

The skill of initiating transfusion therapy cannot be delegated to

nursing assistive personnel (NAP). The skill of initiating transfusion therapy by a licensed practical nurse (LPN) varies by state
Practice Acts. After the transfusion has been started and the
patient is stable, monitoring of a patient by NAP does not relieve
a registered nurse (RN) of the responsibility to continue to assess
the patient during the transfusion. The nurse instructs the
NAP about:
Frequency of vital sign monitoring needed.
What to observe such as complaints of shortness of breath,
hives, and/or chills and reporting this information to the
nurse.