Chapter 8: IV Therapy
8.11 Transfusion of Blood and Blood Products
Critical Thinking Exercises: Questions, Answers, and Sources / References
- How long can blood or blood products be at room air temperature before being considered at risk for infusion?
Answer: 4 hours
2. You are about to initiate an infusion of packed red blood cells. What patient teaching is important to include about possible signs and symptoms of reaction?
Answer: it is important to discuss general potential S&S and ask the patient to report any changes to how they feel. General S&S with potential concern include:
- Fever
- Light headedness
- Shivering
- anxiety
- Back or chest pain
- Nausea/vomiting
- Shortness of breath (dyspnea)
- Bleeding/pain at IV site
- Rash ≥ 25% of body
- Urticaria (itching)
The following chart represents different types of transfusion reactions and their accompanying signs & symptoms. For more information about what the nurse should do in response to an actual or potential reaction including prevention refer to your agency guidelines. A summary is also included in Anderson, R. (2018). Clinical Procedures for Safer Patient Care – Thompson Rivers University Edition. Adapted from Clinical Procedures for Safer Patient Care by G. R. Doyle and J. A. McCutcheon. Chapter 8.11 Transfusion of Blood and Blood Products. https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/8-11-transfusion-of-blood-and-blood-products/
| Type of Reaction | S&S |
| Allergic |
Mild: antibodies against donor plasma proteins. Flushing, itching, urticaria (hives) Anaphylactic: antibodies to donor plasma. anxiety, urticarial, dyspnea, wheezing, severe hypotension, shock, cardiac arrest |
| Febrile Non Hemolytic | Greater than (>) 1 degree above the temp when the transfusion was initiated
Chills, headache, flushing, anxiety, muscle pain |
| Acute hemolytic | Chills, fever, low back pain, tachycardia, tachypnea, hypotension, hemoglobinemia / uria, circulatory shock, cardiac arrest, death |
| Circulatory overload | Dyspnea, cough, crackles, distended neck veins, hypertension |
| Sepsis | Rapid onset chills, fever, severe hypotension, circulatory shock |
Sources: Canadian Blood Services. (2017c). Clinical guide to transfusions. Blood components. https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-components
Potter, P., Perry, A., Stockert, P. , Hall, A. (2019). Canadian Fundamentals of Nursing. Sixth Edition. B. Astle & W. Duggleby (Eds). Milton, Ont: ELSEVIER
- When preparing to administer a blood product the nurse notes a discrepancy between the spelling of the patient’s name on the prescriber’s order and the transfusion medical services (TMS) documents. The nurse should first:
| Distractor | Answer | More information |
| Get a 2nd health care provider to confirm it is the correct patient | Incorrect | The nurse must stop and investigate. Another health care provider won’t be able to provide guidance about a misspelled name |
| Stop and investigate | Correct | At any time if there is a discrepancy, the nurse must stop and investigate to prevent an error with blood administration |
| Proceed cautiously with the transfusion | Incorrect | The nurse cannot proceed until all discrepancies are sorted out |
| Call the prescriber | Incorrect | It is not likely that the prescriber can resolve a misspelled name. The nurse should call transfusion medical services (TMS) / blood bank |
Sources:
Alberta Health Services. (2015a). Transfusion of blood and blood components. Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-59.pdf.
Alberta Health Services. (2015b) (2017) . Transfusion of blood and blood components—Acute adult. Retrieved from https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-adult-acute-procedure-ps-59-01.pdf.
Canadian Blood Services (2017a). Blood administration. Retrieved from https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.
Interior Health. (2018). Transfusion practices manual. Retrieved from http://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
Vancouver Coastal Health. (2008). Administration of blood components and blood products. Vancouver, BC: Vancouver Health Authority.
2. The nurse is administering a transfusion of packed red blood cells. Which of the following are appropriate nursing actions? (Select all that apply)
| Distractor | Answer | More information |
| Preassessment should include vital signs | Correct | A baseline set of vitals serves as a reference point in the event of a potential reaction |
| Preassessment should include observing for rash | Correct | Rash is one symptom of an allergic reaction. If present before the transfusion, it might be difficult to assess for this potential reaction |
| The nurse should remain with the patient for the first 20 minutes of the transfusion | Incorrect | While not a bad thing, protocols suggest to remain with the patient for the first 5 minutes of the transfusion. Before leaving the patient, teach about what signs to report immediately |
| The nurse should aim to have the transfusion done quickly | Incorrect | Transfusions of packed RBCs are initiated at 50-100 cc/hr (check agency policy) with the goal of completion within 2 hours or according to the prescribers’ order |
| The nurse should call for delivery of the blood product as soon as the order is received | Incorrect | The nurse should call for delivery of the product when it can be infused. Blood products that can’t be infused within 30 minutes of arrival should be returned to the TMS |
| The nurse can use a regular IV administration set if Blood tubing is not available | Incorrect | Blood tubing must have a filter to filter out clots, debris, and coagulated protein |
| The nurse can continue to give scheduled IV meds through the same site as the transfusion | Incorrect | Meds are not compatible with blood. If necessary, a separate site should be used for medications needed during a transfusion |
Sources:
Alberta Health Services. (2015a). Transfusion of blood and blood components. https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-policy-ps-59.pdf.
Alberta Health Services. (2015b) (2017) . Transfusion of blood and blood components—Acute adult. https://extranet.ahsnet.ca/teams/policydocuments/1/clp-prov-transfusion-blood-product-adult-acute-procedure-ps-59-01.pdf.
Canadian Blood Services (2017a). Blood administration. https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.
Interior Health. (2018). Transfusion practices manual. http://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
Vancouver Coastal Health. (2008). Administration of blood components and blood products. Vancouver, BC: Vancouver Health Authority.
3. An infusion of packed red blood cells is indicated for:
a. Hypotension (incorrect: hypotension requires volume and not necessarily RBCs)
b. Anemia (Correct)
c. Hypertension (incorrect)
d. hives (incorrect)
Sources:
Canadian Blood Services (2017a). Blood administration. https://professionaleducation.blood.ca/en/transfusion/clinical-guide/blood-administration.
Interior Health. (2018). Transfusion practices manual. http://insidenet.interiorhealth.ca/Clinical/transfusionccr/Pages/manual.aspx.
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed). St. Louis, MO: Elsevier-Mosby.
