This document provides information about administering blood transfusions, including pre-transfusion assessment of the patient's history and vitals, potential complications of transfusions, and nursing management of transfusion reactions. It discusses common complications like febrile nonhemolytic reactions, acute hemolytic reactions, allergic reactions, circulatory overload, and bacterial contamination. It also addresses risks of transmitting diseases and complications of long-term transfusion therapy.

1. INTRODUCTION
Administration of blood and blood components requires knowledge of correct
administration techniques and possible complications. It is very important to be familiar
with the agency’s policies and procedures for transfusion therapy.
Pre transfusionAssessment
PATIENT HISTORY
Patient history is an important component of the pretransfusion assessment to
determine the history of previous transfusions as well as previous reactions to
transfusion. The history should include the type of reaction, its manifestations, the
interventions required, and whether any preventive interventions
were used in subsequent transfusions. It is important to assess the number of
pregnancies a woman has had, because an increased number can increase her risk for
reaction due to antibodies developed from exposure to fetal circulation. Other
concurrent health problems should also be noted, with careful attention to cardiac,
pulmonary, and vascular disease.
PHYSICAL ASSESSMENT
A systematic physical assessment and measurement of baseline vital signs are
important before transfusing any blood product. The respiratory system should be
assessed, including careful auscultation of the lungs and for use of accessory muscles.
Cardiac system assessment should include careful inspection for any edema as well as
other signs of cardiac failure (eg, jugular venous distention). The skin should be
observed for rashes, petechiae, and ecchymoses. The sclera should be examined for
icterus. In the event of a possible transfusion reaction, a comparison of findings can
help differentiate between types of reactions.
Patient Teaching
Reviewing the signs and symptoms of a potential transfusion reaction is crucial for
patients who have not received a transfusion before. Even for those patients who have
received prior transfusions, a brief review of signs and symptoms of potential
transfusion reactions is advised. Signs and symptoms of a possible reaction include
fever, chills, respiratory distress, low back pain, nausea, pain at the intravenous site, or
anything “unusual.” Although a thorough review is very important, it is also important to
reassure the patient that the blood is carefully tested against the patient’s own blood
(cross-matched) to diminish the likelihood of any untoward reaction. Such assurance
can be extremely beneficial in allaying anxiety. Similarly, it can be useful to mention
again the very low possibility of contracting HIV from the transfusion; this fear persists
among many people.
Transfusion Complications
Any patient who receives a blood transfusion may develop complications from that
transfusion. When explaining the reasons for the transfusion, it is important to include
the risks and benefits and what to expect during and after the transfusion. Patients must
be informed that the supply of blood is not completely risk-free although it has been
tested carefully. Nursing management is directed toward preventing complications,
promptly recognizing complications if they develop, and promptly initiating measures to
control any complications that occur. The following sections describe the most common
or potentially severe transfusion-related complications.

2. FEBRILE, NONHEMOLYTIC REACTION
The nonhemolytic reaction, caused by antibodies to donor WBCs that are still present in
the unit of blood or blood component, is the most common type of transfusion reaction,
accounting for more than 90% of reactions. It occurs more frequently in patients who
have had previous transfusions (exposure to multiple antigens from previous blood
products) and in Rh-negative women who have borne Rh-positive children (exposure to
an Rhpositive fetus raises antibody levels in the mother). These reactions occur in 1%
of PRBC transfusions and 20% of platelet transfusions. More than 10% of patients with
a chronic transfusion requirement develop this type of reaction. The diagnosis of a
febrile, nonhemolytic reaction is made by excluding other potential causes, such as a
hemolytic reaction or bacterial contamination of the blood product. The signs and
symptoms of a febrile, nonhemolytic transfusion reaction are chills (absent to severe)
followed by fever (more than 1 elevation). The fever typically begins within 2 hours
after the transfusion is begun. Although not life-threatening, the fever and particularly
the chills and muscle stiffness can be frightening to the patient. These reactions can be
diminished, even prevented, by further depleting the blood component of donor WBCs;
this is accomplished by a leukocyte reduction filter. The blood product may be filtered
during processing, which achieves better results but is more expensive, or during the
actual transfusion by adding the filter to the blood administration tubing. Antipyretics can
be given to prevent fever, but routine premedication is not advised because it can mask
the beginning of a more serious transfusion reaction.
ACUTE HEMOLYTIC REACTION
The most dangerous, and potentially life threatening, type of transfusion reaction occurs
when the donor blood is incompatible with that of the recipient. Antibodies already
present in the recipient’s plasma rapidly combine with antigens on donor RBCs, and the
RBCs are hemolyzed (destroyed) in the circulation (intravascular hemolysis). The most
rapid hemolysis occurs in ABO incompatibility. This reaction can occur after transfusion
of as little as 10 Ml of RBCs. Rh incompatibility often causes a less severe reaction. The
most common causes of acute hemolytic reaction are errors in blood component
labeling and patient identification that result in the administration of an ABO-
incompatible transfusion. Symptoms consist of fever, chills, low back pain, nausea,
chest tightness, dyspnea, and anxiety. As the RBCs are destroyed, the hemoglobin is
released from the cells and excreted by the kidneys; therefore, hemoglobin is present in
the urine (hemoglobinuria). Hypotension, bronchospasm, and vascular collapse may
result. Diminished renal perfusion results in acute renal failure, and DIC may also occur.
Perspectives of Recipients of Blood Transfusions
ALLERGIC REACTION
Some patients may develop urticaria (hives) or generalized itching during a transfusion.
The cause of these reactions is thought to be a sensitivity reaction to a plasma protein
within the blood component being transfused. Symptoms of an allergic reaction are
urticaria, itching, and flushing. The reactions are usually mild and respond to
antihistamines. If the symptoms resolve after administration of an antihistamine (eg,
diphenhydramine [eg, Benadryl]), the transfusion may be resumed. Rarely, the allergic
reaction is severe, with bronchospasm, laryngeal edema, and shock. These reactions
are managed with epinephrine, corticosteroids, and pressor support, if necessary.

3. CIRCULATORY OVERLOAD
If too much blood infuses too quickly, hyper volemia can occur. This condition can be
aggravated in patients who already have increased circulatory volume (eg, those with
heart failure). PRBCs are safer to use than whole blood. If the administration rate is
sufficiently slow, circulatory overload may be prevented. For patients who are at risk for,
or already in, circulatory overload, diuretics are administered after the transfusion or
between units of PRBCs. Patients receiving fresh frozen plasma or even platelets may
also develop circulatory overload. The infusion rate of these blood components must
also be titrated to the patient’s tolerance. Signs of circulatory overload include dyspnea,
orthopnea, tachycardia, and sudden anxiety. Neck vein distention, crackles at the base
of the lungs, and a rise in blood pressure can also occur. If the transfusion is continued,
pulmonary edema can develop, as manifested by severe dyspnea and coughing of pink,
frothy sputum
BACTERIAL CONTAMINATION
The incidence of bacterial contamination of blood components is very low; however,
administration of contaminated products puts the patient at great risk. Contamination
can occur at any point during procurement or processing. Many bacteria cannot survive
in the cold temperatures used to store PRBCs (platelets are at greater risk for
contamination because they are stored at room temperature), but some organisms can
survive cold temperatures. Preventive measures include meticulous care in the
procurement and processing of blood components. When PRBCs or whole blood is
transfused, it should be administered within a 4-hour period, because warm room
temperatures promote bacterial growth. A contaminated unit of blood product may
appear normal, or it may have an abnormal color. The signs of bacterial contamination
are fever, chills, and hypotension.
DELAYED HEMOLYTIC REACTION
Delayed hemolytic reactions usually occur within 14 days after transfusion, when the
level of antibody has been increased to the extent that a reaction can occur. The
hemolysis of the RBCs is extra vascular, via the RES, and occurs gradually. Signs and
symptoms of a delayed hemolytic reaction are fever, anemia, increased bilirubin level,
decreased or absent haptoglobin, and possibly jaundice.
DISEASES TRANSMITTED BY BLOOD TRANSFUSION
Despite the advances in donor screening and blood testing, certain diseases can still be
transmitted by transfusion of blood components.
Hepatitis (Viral Hepatitis B, C)
• Greater risk from pooled blood products and blood of paid donors than from volunteer
donors
• Screening test detects most hepatitis B and C
• Transmittal risk estimated at 1:10,000
AIDS (HIV and HTLV)
• Donated blood screened for antibodies to HIV
• Transmittal risk estimated at 1:670,000
• People with high-risk behaviors (multiple sex partners, anal sex, intravenous/injection
drug use) and people with signs and symptoms that suggest AIDS should not donate
blood

4. Cytomegalovirus (CMV)
• Transmittal risk greater for premature newborns with CMV antibody-negative mothers
and for immune compromised
recipients who are CMV-negative (eg, those with acute leukemia, organ or tissue
transplant recipients).
• Blood products rendered “leukocyte-reduced” help reduce transmission of virus.
Graft-Versus-Host Disease (GVHD)
• Occurs only in severely immune compromised recipients (eg, Hodgkin’s disease, bone
marrow transplantation).
• Transfused lymphocytes engraft in recipient and attack host lymphocytes or body
tissues; signs and symptoms are fever, diffuse reddened skin rash, nausea, vomiting,
diarrhea.
• Preventive measures include irradiating blood products to inactivate donor
lymphocytes (no known radiation risks to
transfusion recipient) and processing donor blood with leukocyte reduction filters.
Creutzfeldt - Jakob disease (CJD)
• Rare, fatal disease causing irreversible brain damage
• No evidence of transmittal by transfusion, but hemophiliacs and others are concerned
that transmittal is possible
• All blood donors must be screened for positive family history of CJD.
• Potential donors who spent 6 months or more in the United Kingdom (or Europe) from
1980 to 1996 cannot donate blood; blood products from a donor who develops CJD are
recalled.
COMPLICATIONS OF LONG-TERM TRANSFUSION THERAPY
The complications that have been described represent a real risk for any patient any
time a unit of blood is administered. However, patients with long-term transfusion
therapy (eg, those with MDS, thalassemia, sickle cell anemia) are at greater risk for
infection transmission and for becoming more sensitized to donor antigens, simply
because they are exposed to more units of blood and, consequently, more donors. Iron
overload is a complication unique to those individuals with long-term PRBC
transfusions.
NURSING MANAGEMENT FOR
TRANSFUSION REACTIONS
If a transfusion reaction is suspected, the transfusion must be immediately stopped and
the physician notified. A thorough patient assessment is crucial, because many
complications have similar signs and symptoms. The following steps are taken to
determine the type and severity of the reaction:
• Stop the transfusion. Maintain the intravenous line with normal saline solution through
new intravenous tubing, administered at a slow rate.
• Assess the patient carefully. Compare the vital signs with those from the baseline
assessment. Assess the patient’s respiratory status carefully. Note the presence of
adventitious breath sounds, use of accessory muscles, extent of dyspnea (if any), and
changes in mental status, including anxiety and confusion. Note any chills, diaphoresis,
complaints of back pain, urticaria, and jugular vein distention.

5. • Notify the physician of the assessment findings, and implement any orders obtained.
Continue to monitor the patient’s vital signs and respiratory, cardiovascular, and renal
status.
• Notify the blood bank that a suspected transfusion reaction has occurred.
• Send the blood container and tubing to the blood bank for repeat typing and culture.
The identifying tags and numbers are verified. If a hemolytic transfusion reaction or
bacterial infection is suspected,
the nurse should do the following:
• Obtain appropriate blood specimens from the patient.
• Collect a urine sample as soon as possible for a hemoglobin determination.
• Document the reaction, according to the institution’s policy.
Transfusion of packed RBC
Preprocedure
1. Confirm that the transfusion has been prescribed.
2. Check that patient’s blood has been typed and cross-matched.
3. Verify that patient has signed a written consent form per institution policy.
4. Explain the procedure to the patient. Instruct patient in signs and symptoms of
transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills).
5. Take patient’s temperature, pulse, respiration, and blood pressure to establish a
baseline for comparing vital signs during transfusion.
6. Use hand hysgeine and wear gloves in accordance with Standard Precautions.
7. Use a 20-gauge or larger needle for placement in a large vein. Use special tubing
that contains a blood filter to screen out fibrin clots and other particulate matter. Do not
vent the blood container.
Procedure
1. Obtain the PRBCs from the blood bank after the intravenous line is started.
(Institution policy may limit release to only 1 unit at a time.)
2. Double-check the labels with another nurse or physician to make sure that the ABO
group and Rh type agree with the compatibility record. Check to see that the number
and type on the donor blood label and on the patient’s chart are correct. Check the
patient’s identification by asking the patient’s name and checking the identification
wristband.
3. Check the blood for gas bubbles and any unusual color or cloudiness. (Gas bubbles
may indicate bacterial growth. Abnormal color or cloudiness may be a sign of
hemolysis.)
4. Make sure PRBC transfusion is initiated within 30 min after removal of the PRBCs
from the blood bank refrigerator.
5. For first 15 minutes, run the transfusion slowly—no faster than 5 mL/min. Observe
the patient carefully for adverse effects. If no adverse effects occur during the first 15
min, increase the flow rate unless the patient is at high risk for circulatory overload.

6. 6. Monitor closely for 15–30 min to detect signs of reaction. Monitor vital signs at regular
intervals per institution policy; compare results with baseline measurements. Increase
frequency of measurements based on patient’s condition. Observe the patient
frequently throughout the transfusion for any signs of adverse reaction, including
restlessness, hives, nausea, vomiting, torso or back pain, shortness of breath, flushing,
hematuria, fever, or chills. Should any adverse reaction occur, stop infusion
immediately, notify physician, and follow the agency’s transfusion reaction standard.
7. Note that administration time does not exceed 4 hr because of the increased risk for
bacterial proliferation.
8. Be alert for signs of adverse reactions: circulatory overload, sepsis, febrile reaction,
allergic reaction, and acute hemolytic reaction.
9. Change blood tubing after every 2 units transfused, to decrease chance of bacterial
contamination.
Post procedure
1. Obtain vital signs and compare with baseline measurements.
2. Dispose of used materials properly.
3. Document procedure in patient’s medical record, including patient assessment
findings and tolerance to procedure.
4. Monitor patient for response to and effectiveness of the procedure
Transfusion of platelets or fresh frozen plasma
Pre procedure
1. Confirm that the transfusion has been prescribed.
2. Verify that patient has signed a written consent form per institution policy.
3. Explain the procedure to the patient. Instruct patient in signs and symptoms of
transfusion reaction (itching, hives, swelling, shortness of breath, fever, chills).
4. Take patient’s temperature, pulse, respiration, and blood pressure to establish a
baseline for comparing vital signs during transfusion.
5. Wash hands and wear gloves in accordance with Standard Precautions.
6. Use a 22-gauge or larger needle for placement in a large vein, if possible. Use
appropriate tubing per institution policy (platelets often require different tubing from that
used for other blood products).
Procedure
1. Obtain the platelets or FFP from the blood bank (only after the intravenous line is
started.)
2. Double-check the labels with another nurse or physician to make sure that the ABO
group matches the compatibility record (not usually necessary for platelets; here only if
compatible platelets are ordered). Check to see that the number and type on the donor
blood label and on the patient’s chart are correct. Check the patient’s identification by
asking the patient’s name and checking the identification wristband.

7. 3. Check the blood product for any unusual color or clumps (excessive redness
indicates contamination with larger amounts of red blood cells).
4. Make sure platelets or FFP units are administered immediately after they are
obtained.
5. Infuse each unit as fast as patient can tolerate to diminish platelet clumping during
administration. Observe the patient carefully for adverse effects, including circulatory
overload. Decrease rate of infusion if necessary.
6. Observe the patient closely throughout the transfusion for any signs of adverse
reaction, including restlessness, hives, nausea, vomiting, torso or back pain, shortness
of breath, flushing, hematuria, fever, or chills. Should any adverse reaction occur, stop
infusion immediately, notify physician, and follow the agency’s transfusion reaction
standard.
7. Monitor vital signs at end of transfusion per institution policy; compare results with
baseline measurements.
8. Flush line with saline after transfusion to remove blood component from tubing.
Post procedure
1. Obtain vital signs and compare with baseline measurements.
2. Dispose of used materials properly.
3. Document procedure in patient’s medical record, including patient assessment
findings and tolerance to procedure.
4. Monitor patient for response to and effectiveness of procedure. A platelet count may
be ordered 1 hr after platelet transfusion to facilitate this evaluation.