NURSING SKILLS

BLOOD TRANSFUSION/ IV THERAPY

Lecturer: Mark Fredderick R. Abejo RN, MAN
______________________________________________

Blood Transfusion
Blood Compatibility

A
B
AB
O

Compatible
A/O
B/O
A / B / AB / O
O

Note:
Type AB Universal Recipient
Type O Universal Donor
Blood Products for Transfusion:
Product
Whole Blood

PRBC
Platelets

Fresh Frozen
Plasma

Albumin and
plasma protein
fraction
Clotting factor and
cryoprecipitate

Uses
Not commonly used except for
extreme cases of acute
hemorrhage.
Replaces blood volume and all
blood products
Used to increase the oxygencarrying capacity of blood
Replaces platelets in client with
bleeding disorder or platelet
deficiency
Expands blood volume and
provides clotting factor.
Note:
Does not need to be typed and
cross-matched, contains no
RBCs
Blood volume expander
Provide plasma proteins
Used for client with clotting
deficiencies
Cryoprecipitate also contains
fibrinogen

Incompatible
AB / B
AB / A
A / B / AB

Lecture Notes on Blood Transfusion Therapy & IV Therapy

Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

Purposes:
1. To administer required blood component by
the patient
2. To restore the blood volume
3. To improve oxygen-carrying capacity of the
blood.
Equipment:
- Unit of blood
- Normal saline ( PNSS)
- Blood transfusion set
- Venipuncture set containing needle gauge of #18 or
#19
- Alcohol and povidone-iodine swabs
- Tape
- Clean gloves

Nursing Intervention:
Verify doctors order. Inform client and explain the
purpose of the procedure.
Check for cross-matching and blood typing. To
ensure compatibility
Obtain and record baseline VS
Note: If patient has fever do not transfuse
Practice strict, ASEPSIS
At least 2 nurses check the label of the blood
transfusion, Check the following:
- Serial Number
- Blood component
- Blood type
- Rh factor
- Expiration date
- Screening test
Check the blood for gas bubbles and any unusual
color or cloudiness
Note: Gas bubbles indicate bacterial growth Unusual
color or cloudiness indicate
hemolysis
Warm blood at room temperature before
transfusion.
Identify client properly, two nurses check the
clients identification
Set up the infusion equipment, use BT set with
filter. To prevent administration of blood clots and
other particles.
Prepare the blood bag, expose the port on the blood
bag and insert the BT set, open the clamp let blood
flow to the tube up the needle.
To remove air in the tubing
Note:
Blood is transfuse as a side drip to PNSS. Direct
transfusion is done during emergency situation and as
ordered.

Blood Shelf Life

WBC
PRBC

Washed RBC

FFP
Cryoprecipitate
Platelets

Warm at
room
temperature
transfused
immediately
Transfused
within 1
hours
Use
immediately
upon
thawing

4 degree C

4 degree C

- 18 degree C
20 degree C

Lecture Notes on Blood Transfusion Therapy & IV Therapy

Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

BLOOD TRANSFUSION REACTION

Reaction

Cause

Clinical Signs

Nursing Intervention

Hemolytic Reaction

Incompatibility between
clients blood and the
donors blood

Chills, fever
Headache, backache
Dyspnea
Cyanosis
Chest pain
Tachycardia
Hypotension

Febrile Reaction

Sensitivity of the clients

blood to WBC, platelets
or plasma protein

Fever, Chills
Warm, flushed skin
Headache
Anxiety
Muscle pain

Sensitivity to infused
plasma proteins

Flushing
Itching
Urticaria
Brochial wheezing

STOP transfusion
Notify the physician
Administer antihistamine as
ordered

Severe

Antibody-antigen reaction

Dyspnea
Chest pain
Circulatory collapse
Cardiac arrest

Circulatory
Overload

Blood administered faster

than the circulation can
accommodate

Sepsis

Contaminated blood
administration

Cough
Dyspnea
Crackles
Distended neck veins
Tachycardia
Hypertension
High fever, chills
Vomiting
Diarrhea
Hypotension

STOP transfusion
KVO with PNSS
Notify the physician immediately
Monitor VS
Administer CPR as needed
Administer medication / oxygen as
needed
STOP or SLOW the transfusion
Place the client upright, with feet
dependent
Administer diuretics and oxygen as
needed
Notify physician
STOP transfusion
Send remaining blood to laboratory
Notify the physician
Obtain a blood specimen from the
client for culture
Administer IV fluids and
antibiotics
KVO with PNSS

Allergic Reaction
Mild

STOP transfusion
KVO with PNSS
Send remaining blood, a sample of
client blood and urine sample to the
laboratory.
Notify the physician
Monitor VS
Monitor I & O
STOP transfusion
Give antipyretics
Notify the physician
KVO with PNSS

Lecture Notes on Blood Transfusion Therapy & IV Therapy

Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

INTRAVENOUS INSERTION
( I.V Insertion )

Purposes:
To supply fluids when clients are unable to
take adequate volume of fluids by mouth.
To provide salts needed to maintain electrolyte
balance
To provide glucose, the main fuel for
metabolism
To provide water-soluble vitamins and
medications.
To establish a lifeline for rapidly needed
medications.
Equipment:
- Infusion set
- Solu set ( if needed )
- IV pole
- Adhesive tape
- Clean gloves
- Tourniquet
- Antiseptic swab or cotton with alcohol
- IV catheter
- Sterile gauze dressing
- Arm splint ( if needed )
- Towel or pad
- Infusion device or pump ( if required )

Steps / Procedure
Identify and inform
the client and explain
the procedure.
- A venipuncture can
cause discomfort, but

Rationale
To allay anxiety
Note:
Use dolls to explain to

there should be no
discomfort while
solution is flowing.
Wash hands and
perform appropriate
infection control
Open and prepare
the infusion set
- Remove tubing from
the package and
straighten it out.
- Slide the clamp just
below the drip chamber
and close it.
- Leave the ends of the
tubing covered with
plastic caps
Spike the solution/
IV fluids
- Remove the protective
cover of the container
of IV fluids.
- Remove the cap of the
spike and insert the
spike on the insertion
site of the container
Properly labeled the
solution:
- Name of Patient
- Kind of IVF
- Meds Incorporated
- No. of drops/min
- Date/Time Started
- Date/Time to be
consumed
Hang the solution on
the pole about 3 ft
above the clients
head
Partially fill the drip
chamber by
squeezing it gently
until half full
Prime the Tubing
Remove the
protective cap and
hold the tubing over
the container
Release the clamp
and let the fluid run
through the tubing

children

This will maintain the

sterility of the ends of
tubing.

Enable gravity to
overcome venous
pressure and facilitate
flow of the sol.

To prevent the
introduction of air to
the client

Lecture Notes on Blood Transfusion Therapy & IV Therapy

Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor

until all air are

remove

Note:
Air bubbles smaller
than 0.5 ml usually do
not cause problems in
the line.

Reclamp the tubing

and replace the
tubing cap.
If indicated was
hands again
Select Venipuncture Site
Guidelines in Vein Selection:
Use distal veins of the arm first
Use the clients nondominant arm as
possible.
Select a vein that is:
- easily palpated and feels soft and full
- naturally splinted by bone
- large enough to allow adequate circulation
Avoid using veins that are
- in areas of flexion
- highly visible
- damage by previous use
- distended, knotted or tortuous
- surgically compromised or injured
extremity
Dilate the chosen vein Distending the vein
- Place the extremity in a makes easier to insert
dependent position, lower the needle
than the clients heart
Gravity slow the
- Apply a tourniquet
venous return
firmy 6-8 inches above
the venipuncture site
To obstruct the
venous flow
Note:
If vein is not sufficiently
dilated;
a. Massage or stroke the
vein distal to the site, in
the direction of the heart.
b. Encourage the client to
clench and unclench the
fist.
c. Slightly tap the vein
with your fingertips
Put on clean gloves
and clean the site with Circular motion
alcohol / antiseptic sol. carries
in circular motion and microorganism away
from the site of entry
let it dry

Insert the catheter and initiate the infusion

If desired and permitted
by policy inject .05 ml of
1% lidocaine ID over the
puncture site. Allow 5-10
sec. to take effect
Use the nondominant
This stabilizes the
hand to pull the skin
vein
below the entry site
Holding the over-theneedle catheter at 15 to
30 degree angle bevel up,
insert through the skin
and into the vein.
Once blood appears in
the lumen of your needle,
advance the needle and
catheter approx. .5-1 cm
Holding the needle
portion steady, advance
the catheter until the hub
is at the venipuncture site
Release the tourniquet
Remove the protective
cap from the tubing and
hold it ready to attach to
the catheter
Attach the end of the
infusion tubing to the
catheter hub
Initiate the infusion
Tape the catheter
Dress and label the
venipuncture site and
tubing according to
agency policy
Ensure appropriate
infusion flow
Label the IV tubing
Document relevant data
and assessment

Lecture Notes on Blood Transfusion Therapy & IV Therapy

Prepared By: Mark Fredderick R Abejo R.N. MAN
Clinical Instructor