1. Nelia B. Perez RN, MSN

2. Complications, Nursing
Interventions and Preventive
Measures of Blood Transfusion
Infiltration
Thrombophlebitis
Circulatory Overload
Air Embolism
Catheter embolism infection
Transfusion Reaction

3. Infiltration
– A substance (blood) that passes into the
tissues and forms an accumulation of the
blood to the skin
Manifestations:
– Blanching of skin
– Swelling, pain at site
– Cool to touch
– Decreased infusion rate

4. Nursing Interventions:
– Discontinue IV
– Restart in a new site
– Apply warm compress to increase fluid
absorption
Preventive Measures:
– Check the IV site before starting the transfusion
– Monitor the site during the transfusion
– Inspect the site thoroughly.
– Make sure that a main line is set before starting
the transfusion.

5. Thrombophlebitis
– Inflammation of a vein with formation of a
thrombus / clot
Manifestations:
– Redness, heat & swelling at site
– Possible pain
– Red line along course of vein

6. Nursing Interventions:
– Discontinue IV
– Restart in a new site
– Apply warm compress to site
Preventive Measures:
Measures
– Check the site before transfusion
– Monitor and inspect the site during and after
the transfusion
– Inquire and tell the patient to notify you if any
sudden awkward feeling is felt
– Check the integrity of the IV line and patency

7. Circulatory Overload
– Too rapid infusion of the blood causing
fluid volume overload to the patient
 Manifestations:
– Apprehension, shortness of breath
– Coughing, frothy sputum, crackles
– Engorged neck veins
– Increased central venous pressure and
jugular vein pressure
– Increased blood pressure and pulse

8.  Nursing Interventions:
– Stop the infusion / Slow down IV rate
– Inform the doctor at once.
– Monitor CVP through a separate line
– Maintain the I.V. infusion with normal saline solution
– Administer oxygen.
– Elevate the patient’s head.
 Preventive Measures:
– Always monitor the patient’s vital signs before, during
and after blood transfusion
– Transfuse blood slowly.
– Don’t transfuse more than 2 units of blood in 4 hours.
– Have oxygen readily available at the bedside of the
patient.

9. Air Embolism
– Obstruction of the circulation by air that has
gained entrance to veins usually caused by
empty IV lines and sets
– Blood given under air pressure following
severe blood loss
Manifestations:
– Dyspnea, cyanosis, hypotension, tachycardia
– Loss of consciousness
– Wheezing, chest pain

10. Nursing Interventions:
– Stop infusion immediately
– Clamp tubing
– Turn client to the left with his left down
– Administer oxygen
– Inform the doctor
Preventive Measures:
– Have a clamp accessible at the bedside
– Check the patient and site and line every now
and then
– Monitor the time of the transfusion.

11. Catheter Embolism Infection
Clogging of the catheter set causing
obstruction of a blood vessel by a clot or
particle that leads to development of
infection
Manifestations:
– Fever, shills, flushing, tachycardia

12. Nursing Interventions:
– Stop the transfusion at once.
– Replace the whole set.
– Inform the doctor.
– Open the main line

13.  Preventive Measures:
– Monitor patient’s vital signs.
– Use a blood set with filter and check the patency of
the whole set before transfusion.
– Assess patient for occurrence of signs and symptoms
of fever.
– Inspect the blood before the transfusion.
– Change the blood tubing and filter every 4 hours.
– Infuse each unit of blood over 2 to 4 hours; terminate
the infusion if the time period exceeds 4 hours.
– Maintain sterile technique when administering blood
products.

14. Transfusion Reaction
Includes Hemolytic, Allergic, Pyrogenic,
Anaphylactic
– Caused by ABO & Rh incompatibility,
allergic antigen
Manifestations:
– Fever, chills, headache, lumbar or sternal
pain, palpitations, tachycardia, urticaria,
laryngeal edema, bronchospasm,
– Flushing, heat along vein

15.  Nursing Interventions:
– Stop the IV at once.
– Continue main IV
– Inform the doctor
– Give medicines as prescribed
– Send blood and urine specimen for work-up
 Preventive Measures:
– Have a thorough assessment of the patient
before hand. Take note of the occurrence of any
allergies.
– Monitor patient’s vital signs.
– Always check the line, site, and set for the
validity and availability of the company…

16. Citrate Intoxication
– Large amounts of citrated blood in
patients with decreased liver function.
Manifestations:
– Neuromascular irritability
– Bleeding due to decreased calcium
– Cardiac arrhythmias
– Hypotension
– Muscle cramps
– Nausea and vomiting
– Seizures
– Tingling in the fingers

17.  Nursing Interventions:
– Monitor and treat hypocalcemia
– Encourage patient to eat foods rich in calcium
– Monitor how many blood bags already infused to
the patient.
– Monitor calcium and citrate level if with multiple
transfusions
 Preventive Measures:
– Remind the doctor about how many blood bags
already infused to the patient
– Avoid using citrated blood
– Monitor liver function
– Have calcium gluconate available in your unit.

18. WHAT TO DO IF TRANSFUSION
REACTION OCCURS…
When they do occur, it is usually
because of ABO incompatibility
between patient and donor during
transfusion of red cells.
Ensure that the intended recipient is
getting the intended unit at the time of
transfusion.

19.  Acute Transfusion Reactions signs and
symptoms will usually appear within the first 5-
15 minutes after the transfusion is started, but
can happen anytime during the transfusion.
 Types of Acute Transfusion Reactions:
– Acute hemolytic Transfusion Reaction
– Febrile nonhemolytic Transfusion Reaction
– Mild allergic (Urticarial)
– Anapylactic
– Transfusion Associated Circulatory Overload
– Transfusion – Related Acute Lung Injury
– Septic Transfusion Reaction

20.  Symptoms you might see during an acute
transfusion reaction include:
– Temperature increase of more than 1°C or 2°F
– Bloody urine
– Chills
– Hypotension
– Severe low back, flank, or chest pain
– Low or absent urine output
– Nausea and vomiting
– Dyspnea, wheezing
– Anxiety, "sense of impending doom"
– Diaphoresis
– Generalized bleeding, especially from punctures
and surgical wounds.

21.  Should any of these symptoms occur, discontinue the
unit immediately, hang normal saline (on a new
tubing) to maintain vascular access, and call for
assistance.
 Closely monitor the patient’s vital signs and
symptoms.
 Notify the physician and obtain further orders to
address the patient’s symptoms.
 Recheck the patient’s identifying information against
the transfusion record and blood bag.
 All bags, tubings, filters, and paperwork should be
retained and forwarded per hospital policy.

22. Importance of Giving Health
Education to Patients and Family
It can establish rapport to you and the
patient and family.
Tension will be lessen on their part and
anxiety will be alleviated.
To enlighten them the real concept of blood
transfusion therapy.
It serves as a channel and communication
between you and your patient.

23. The client’s major concern is likely to be
the safety of the transfusion, specifically the
risk of contracting AIDS.
Provide accurate information for the client,
and begin efforts to ensure a safe and
effective transfusion before the blood or
component is collected.

25. DOCUMENTING BLOOD
TRANSFUSIONS
 Date and time the transfusion was started and
completed
 Name of the health care professional who
verified the information of the patient and the
blood
 Catheter type and gauge
 Total amount of the transfusion
 Patient’s vital signs before and after the
transfusion

26.  Infusion device used
 Flow rate and if blood warming was used
 Vital signs obtain prior to, during, and after
the transfusion
 Name of the component, unit number
 Evidence of possible transfusion reaction.
– Document interventions done and to whom you
notified.
 Patient’s outcome.

27. Date Time
12/12/0 2:00 D = Patient reports nausea and chills
8 pm
= Cyanosis of the lips noted at 1:50 pm, with PRBCs transfusing
A = Infusion stopped. Approximately 100 mL infused.
= Tubing changed of 1,000 mL of D5NSS infusing at KVO rate in right arm.
= Notified Dr. X.
= BP:170/90, Pulse Rate: 104, Respiratory Rate: 25, Temperature: 36.0°C.
= Blood sample taken from PRBCs. Urine specimen also sent out to lab for
urinalysis.
= Gave patient diphenhydramine 50mg via IV as prescribed by the doctor.
= Two blankets placed on patient.
R = Patient reports he’s getting warmer and less nauseated.
= BP: 148/80; Pulse Rate: 80; Respiratory Rate: 20; Temperature: 36.8°C.
= Patient no longer complaining of nausea or chills.
---------------------------------------------------------------- Ram M. Mar, R.N.

28. TWELVE SIMPLE STEPS NECESSARY IN
CARING FOR A PATIENT RECEIVING BLOOD
TRANSFUSION
STEP 1: OBTAIN PATIENT’S TRANSFUSION HISTORY
STEP 2: SELECT A LARGE GAUGE NEEDLE OR
CATHETER
STEP 3: CONSIDER THE TUBING & FILTER’S PORE SIZE
STEP 4: FOLLOW PROTOCOL TO OBTAIN THE BLOOD
PRODUCT ACCORDING TO HOSPITAL POLICY
STEP 5: IDENTIFY THE BLOOD PRODUCT & THE
PATIENT
STEP 6: OBTAIN BASELINE VITAL SIGNS & RECORD

29. STEP 7: USE 0.9% NORMAL SALINE FOR
THE STARTER SOLUTION
STEP 8: START THE TRANSFUSION
SLOWLY
STEP 9: MAINTAIN THE PRESCRIBED
TRANSFUSION RATE
STEP 10: MONITOR PATIENT’S V/S &
DOCUMENT
STEP 11: OBSERVE FOR ANY ADVERSE
REACTION
STEP 12: COMPLETE THE NECESSARY
PAPERWORK

30. Computations of flow and
drip rates
Calculation of IV Flow Rates
 Calculation of cc/hr is essential in most IV therapy.
Volume
= cc/hr
# of hrs
E.g. 1 L over 8 hrs = 125 cc/hr
50 cc over 20 minutes = 150 cc/hr

31. Calculation of gtt/min (Long Method)
STEPS :
1. Need to know cc/hr to calculate
2. Gtt factor = gtt / ml
gtt factors : macrodrip 10, 15, 20 gtts/ml
microdrip 60 gtt/ml
EXAMPLE : LONG METHOD
Doctors Order : Run 1L D5W over 8 hours
Microdrip - 1000 ml ÷ 8 hours = 125 cc/hr
125 cc x 60 gtt/ml = 125 gtt/ml
60 min 1
10 gtt/ml set 125cc x 10 gtt/ml = 20 – 21 gtt/min
60 min 1
15 gtt/ml set 125cc x 15 gtt/ml = 31 gtt/min
60 min 1
20 gtt/ml set 125 cc x 20 gtt/ml = 41 – 42 gtt/min
60 min 1

32. SHORT METHOD
cc / hr ÷ 6 for 10 gtt / min
cc / hr ÷ 4 for 15 gtt / min
cc / hr ÷ 3 for 20 gtt / min
cc / hr = gtt / min for microdrip set

33. 10 Rights in Safe Drug Administration
• Right DRUG
• Right PATIENT
• Right DOSE
• Right ROUTE
• Right TIME
• Right DOCUMENTATION
• Right PATIENT’S HISTORY
• Right DRUG ALLERGIES
• Right DRUG-DRUG, DRUG-FOOD INTERACTION
• Right HEALTH EDUCATION