Blood primarily functions as a transporter of oxygen, nutrients, and waste products to and from different parts and organs of the body. A blood transfusion is a standard medical intervention that replaces blood lost due to the following reasons:
- Surgery
- Trauma or injury
- Severe bleeding or shock
- Diseases/conditions that decrease blood production
- Disease/conditions that increase blood destruction
In this article:
- Blood Components
- Complications
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Excess Fluid Volume
- Hyperthermia
- Impaired Gas Exchange
- Ineffective Breathing Pattern
Blood Components
Blood components that a patient may receive include:
- Red blood cells
- Platelets
- Cryoprecipitate
- Plasma
- Factor concentrates from plasma
Packed red blood cells (PRBCs) are the most common type of blood transfusion. PRBCs restore red blood cells and are often transfused when hemoglobin levels are low.
Platelets help blood clot and prevent bleeding. Patients may need platelet transfusions due to thrombocytopenia.
Plasma is the largest component of blood and acts as a transporter. Plasma can be separated from the blood and is yellowish in color. Fresh frozen plasma (FFP) is a common blood product given due to abnormal coagulation.
Complications
While administering blood transfusions is considered generally safe, complications and reactions can occur. Mild to severe complications can happen during the transfusion or several hours or even days after the procedure. The primary types of transfusion reactions include:
- Acute Hemolytic Reaction is a very serious transfusion reaction associated with ABO incompatibility that causes lysis or the destruction of blood cells. Its signs and symptoms include chest pain, bleeding, back pain, tachypnea, tachycardia, and hypertension. In severe cases, this can lead to shock and even death.
- Febrile Reaction causes transient fever, nausea and vomiting, chills, headaches, and chest pain, which is associated with the release of proteins by the white blood cells during blood storage.
- Allergic Reaction is associated with the sensitivity to proteins in transfusion. Its signs and symptoms include urticaria, watery eyes, itching, mild wheezing, and shortness of breath.
- Anaphylaxis is a severe form of allergic reaction and is life-threatening. Its symptoms include anxiety, hypotension, severe wheezing, cyanosis, and extensive urticaria.
- Bacterial Reaction occurs when there is bacterial contamination of the blood products being transfused. This can cause renal failure and shock. Its signs and symptoms include high fever and blood pressure fluctuations.
- Circulatory Overload occurs when there is decreased cardiac output or when fluids are transfused too quickly, overloading the circulatory system. Symptoms include anxiety, dyspnea, crackles, hypertension, tachycardia, and tachypnea.
Nursing Process
Administering blood transfusions is a common nursing intervention. Once blood products are ordered, it is vital to provide patient education about the transfusion process and the signs and symptoms that the patient should report once the transfusion starts.
Nurses are also responsible for double-checking the physician’s orders and comparing them to the actual blood product to ensure that the right blood components are being transfused. Most facilities require a two-nurse check of blood products. If there are any discrepancies, the transfusion should not be started.
In the event of a transfusion reaction, the transfusion is stopped immediately, and the healthcare provider is alerted for orders to manage symptoms.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to blood transfusions.
Review of Health History
1. Determine the patient’s indication for blood transfusion.
Assess the patient for any signs of bleeding or trauma. Symptoms may or may not be obvious. Signs of internal bleeding may include severe hypotension, pallor, a swollen abdomen, respiratory distress, and changes in consciousness.
2. Review records for a history of blood transfusions.
Check the patient’s records for a history of blood transfusions and its indication. A possible recurrence of the cause may have led to the current blood transfusion.
3. Assess for medical conditions related to bleeding.
Severe anemia, sickle cell disease, hemophilia, and certain cancers increase the need for frequent blood transfusions.
4. Identify the patient’s known allergies.
The patient may need pre- and post-transfusion medications to avoid allergic reactions if they have experienced them previously with blood transfusions.
5. Assess for previous transfusion reactions.
Transfusion reactions can occur during and after the transfusion (delayed reaction). Symptoms of transfusion reactions include:
- Breathing difficulties
- Chills
- Fever
- Urticaria
- Hypertension
6. Ask about the patient’s religion.
Jehovah’s Witnesses refuse to receive blood transfusions or blood products. It is the patient’s right to refuse treatment, though the nurse must educate on the risks of refusing necessary medical treatment.
7. Assess for any comorbidities or conditions that may be affected by blood transfusion.
Take caution when administering blood products to patients with comorbidities such as congestive heart failure or kidney disease, as the patient may experience fluid volume overload.
Physical Assessment
1. Obtain baseline vital signs.
Monitor temperature, respiratory rate, heart rate, and blood pressure prior to initiating the transfusion. The nurse should closely monitor the vital signs during the transfusion to identify a reaction or complication.
2. Perform a physical assessment.
To establish baseline data, focus on the CNS, respiratory, cardiovascular, and integumentary systems. Symptoms of pallor, dyspnea, tachycardia, hypotension, and lightheadedness should improve with blood transfusion.
3. Monitor after surgery or trauma.
The nurse should closely monitor any surgical incisions for obvious signs of bleeding. Pregnant patients will lose blood during childbirth or C-section delivery and are at risk for complications such as postpartum hemorrhage, which may require blood transfusions.
Diagnostic Procedures
1. Perform blood tests.
Typing and crossmatching are crucial before receiving a blood transfusion. Tests must be performed to ensure that a given blood product matches the patient’s blood type before administering the blood transfusion. The most common blood tests are:
- ABO and Rh Typing
- Antibody screening
- Crossmatch
2. Know the patient’s blood type.
ABO typing determines a patient’s blood type based on the presence or absence of specific antigens on the surface of red blood cells and classifies blood into four main types: A, B, AB, and O. Determining if the patient is Rh positive or negative is another aspect of blood typing.
3. Review the patient’s antibody screening.
An antibody screen is performed after blood typing. This test assesses the patient’s plasma and screens for antibodies that could react with the patient’s antigens.
4. Check for blood compatibility.
Crossmatching mixes a sample of the patient’s blood with the donor’s to assess compatibility. If clumping or hemolysis occurs, they are not compatible.
5. Monitor the complete blood count (CBC).
The nurse can monitor the patient’s CBC, which includes red blood cell levels, hemoglobin and hematocrit, and platelet levels post-transfusion to assess for effectiveness. In some instances, physician orders may indicate for the nurse to transfuse additional units of blood if the patient’s hemoglobin remains low.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient receiving a blood transfusion.
Pre-Procedure
1. Obtain informed consent from the patient.
Allow the patient to review and sign the informed consent form after the healthcare provider orders a transfusion.
Important: A signed informed consent indicates that the patient knows the benefits and hazards of blood transfusion. In some states, it is the physician’s responsibility to obtain consent. Check with your facility and state board of nursing.
2. Insert patent IV access.
Ensure there is patent venous access. Prepare the patient for the transfusion by inserting a large-bore IV access of at least 20G or larger.
3. Administer pre-medications if necessary.
If the patient is at risk for fluid volume overload, furosemide may be administered prior. Other medications like acetaminophen or diphenhydramine may also be administered to prevent fever or itching.
4. Verify the blood and the test results with another RN.
The nurse will perform several safety checks with another RN at the bedside to ensure the blood product is appropriate for the patient. Compare the blood bag label with the patient’s ID band. Check the following against the transfusion request form and blood bag:
- Patient identifiers (name, DOB, medical record number)
- Blood component to be transfused and special requirements and preparations (if necessary)
- Volume/number of units
- Blood type and compatibility
- Expiration date
5. Keep the vein open with normal saline.
The only fluid that is compatible with blood products is normal saline. Ensure no other fluids or medications are infused into the same IV site as the blood products.
6. Consider another IV access.
A second IV access should be inserted if the patient needs additional IV medication or IV fluids while receiving blood products.
7. Prepare devices if necessary.
Blood components can be transfused using infusion devices such as:
- Infusion pumps
- Blood warmers – to prevent hypothermia
- Rapid infusers
- Pressure infusion devices – for rapid blood transfusion
8. Prime the blood administration tubing.
All transfusions are performed using a standard blood administration kit (170-200 m integral mesh filter).
9. Obtain baseline vital signs before blood transfusion.
Take vital signs right before the transfusion, then again 15 minutes later, and then hourly until the transfusion is completed.
During the Procedure
1. Begin the transfusion slowly.
Start packed red blood cell (PRBC) infusions at a slower rate for the first 15 minutes, as most transfusion reactions happen within this timeframe. Refer to the facilities policy for a specified rate.
2. Remain with the patient at the start of the transfusion.
Observe the patient for the first 15 minutes upon starting the transfusion. Note any clinical indications of a transfusion reaction. If no reaction occurs, the nurse should increase the transfusion rate.
3. Transfuse within the recommended timeframe.
The blood transfusion should start within 30 minutes upon release from the blood bank. Each unit must be transfused within the following timeframe:
- PRBC: 2-4 hours
- Platelets and plasma: 30 minutes – 1 hour
4. Monitor for transfusion reaction.
The nurse will continue to monitor the patient and obtain vital signs:
- Hourly until the transfusion is complete
- At the completion of the transfusion
- Per facility protocol for the next 24 hours
5. Immediately act if a transfusion reaction is suspected.
Stop the infusion if a transfusion reaction occurs. Follow the protocol while managing symptoms. Document the necessary transfusion reaction form and incident report. Bring residual blood and all equipment to the blood bank for laboratory testing. Obtain blood and urine samples from the patient for further investigation.
6. Flush the IV line after use.
Keep the vein open with normal saline to prepare for additional units of blood or other medications.
7. Document the transfusion.
Complete all forms as specified by the facilities policies. Documentation includes the following:
- Transfusion record form
- Vital signs and reaction monitoring
- Observations during and at the completion of the transfusion
- Incidence of transfusion reaction (if any)
Post-Procedure
1. Continue to monitor for signs of transfusion reaction.
Inform the patient about transfusion symptoms. Continue to evaluate and monitor for any clinical signs of reactions within 24 hours after the transfusion.
2. Advise the patient when to seek immediate medical attention.
Advise the patient to seek medical attention if any of the following transfusion reaction signs occur:
- CNS: fever
- Respiratory: difficulty in breathing, wheezing
- Cardiovascular: palpitations, chest pain
- Gastrointestinal: nausea or vomiting
- Integumentary: rashes, hives, itchiness
- Other: severe back pain, bleeding, chills
3. Re-check the vital signs post-transfusion.
Patients receiving scheduled transfusions in an outpatient setting are often required to remain for one hour post-transfusion to monitor for a reaction. Ensure the patient’s vital signs are stable before discharging.
4. Schedule the patient for re-evaluation of blood tests.
In instances of frequent transfusions, re-evaluation of blood tests, such as a complete blood count, is necessary to monitor the effectiveness or need for another blood transfusion.
Nursing Care Plans
Once the nurse identifies nursing diagnoses related to blood transfusion, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples related to blood transfusion.
Decreased Cardiac Output
A rapid blood transfusion may lead to a transfusion reaction known as circulatory overload, overwhelming the heart and circulatory system.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Rapid transfusion
- Small body size
- Chronic cardiac conditions
- Rapid filling of blood in the ventricles
- Irregular cardiac muscle contraction
- Difficulty of the heart muscle to pump blood
As evidenced by:
- Tachycardia
- Hypertension
- S3 heart sound upon auscultation
- Sudden dyspnea
- Tachypnea
- Crackles upon auscultation
- Hypoxia
- Orthopnea
- Jugular vein distention
- Anxiety/restlessness
Expected outcomes:
- Patient will not report symptoms of anxiety, dyspnea, or heart palpitations.
- Patient will demonstrate a respiratory rate within normal limits and clear breath sounds upon auscultation.
Assessment:
1. Note any changes in the vital signs.
During a blood transfusion, note the following changes in vital signs:
- Tachycardia
- Hypertension
- Widened pulse pressure
Transfusion-associated circulatory overload (TACO) usually occurs near the end or within 6 hours of completion of blood transfusion.
2. Obtain blood tests.
Rapid blood transfusion can increase brain natriuretic peptide (BNP). The heart releases the hormone BNP in response to volume overload.
3. Determine risk factors.
Identify factors that may predispose the patient to TACO. This includes pediatric patients, elderly patients, and those with a history of cardiac or renal conditions.
Interventions:
1. Ensure patient safety.
Ensure the patient’s safety by cautiously regulating the blood transfusion rate. This will prevent circulatory overload and decreased cardiac output. Transfuse slowly (but still within the recommended transfusion timeframe) for patients with cardiovascular or kidney disease.
2. Premedicate with a diuretic.
Patients at risk for circulatory overload may need to be premedicated with a diuretic like furosemide. Additional doses of a diuretic may be necessary if symptoms persist.
3. Stop the infusion immediately if a reaction is identified.
If the patient reports any dyspnea or vital signs are unstable, stop the infusion immediately.
4. Apply oxygen.
After stopping the infusion, sit the patient upright and apply supplemental oxygen.
Excess Fluid Volume
Circulatory overload can occur during a blood transfusion procedure when blood products are administered at a rate greater than what the circulatory system can accommodate.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Blood transfusion reaction
As evidenced by:
- Crackles or rales on auscultation
- Jugular vein distention
- Elevated blood pressure
- Dyspnea or cough
- Adventitious breath sounds
- Pulmonary congestion
Expected outcomes:
- Patient will remain normovolemic as evidenced by clear lung sounds, normal blood pressure readings, and the absence of jugular vein distention.
Assessment:
1. Assess and monitor the patient’s intake and output.
Intake and output can indicate the patient’s fluid volume status. If output does not match what is being transfused, the patient may be experiencing fluid volume overload.
2. Assess and auscultate breath sounds.
Breath sounds such as crackles and rales combined with dyspnea can indicate circulatory overload.
3. Assess and monitor the patient’s vital signs.
Increased blood pressure and sinus tachycardia are early signs of fluid volume excess.
4. Consider the patient’s history.
A patient with a history of congestive heart failure or other cardiopulmonary condition will need to be monitored very carefully.
Interventions:
1. Administer diuretics as indicated.
Diuretics are usually indicated in cases of excess fluid volume following blood transfusions as it helps in the excretion of excess fluids in the body. For patients with a history of CHF, diuretics may be ordered prior to the transfusion to prevent fluid volume overload.
2. Regulate the rate of IV fluids or blood products as indicated.
Strict adherence to the rates of IV fluids is vital as it can help avoid excess fluid volume. Transfuse blood at the slowest possible rate to meet protocols but prevent fluid overload.
3. Provide supplemental oxygenation as needed.
Providing oxygenation will help facilitate breathing during circulatory overload.
4. Place the patient in a semi-Fowler’s position.
This position allows for the proper evaluation of jugular vein distention. It also offers ease of breathing for optimal chest and lung expansion.
5. Elevate edematous extremities if present.
Elevation of affected body parts can reduce edema by promoting an increased venous return to the heart.
Hyperthermia
Fever is the most common infusion reaction symptom and can be caused by hypersensitivity to donor blood cells or cytokines accumulating in stored blood products.
Nursing Diagnosis: Hyperthermia
Related to:
- Adverse reaction from a blood transfusion
As evidenced by:
- Increase in body temperature
- Flushed or warm skin
- Chills
- Lethargy
Expected outcomes:
- Patient will maintain body temperature within normal limits as evidenced by stable vital signs and the absence of chills.
Assessment:
1. Assess and monitor vital signs every 5 minutes.
Constant monitoring is essential in patients undergoing blood transfusions. Monitoring can help determine the need for intervention.
2. Assess for a previous transfusion reaction.
Some patients who receive frequent or routine blood transfusions may commonly present with an elevated temperature as a normal response to the white blood cells. The healthcare provider may have the nurse premedicate with a fever reducer.
Interventions:
1. Stop the transfusion and report adverse reactions to the physician.
When fever is exhibited during the transfusion, the procedure must be stopped and findings must be reported to the physician.
2. Obtain urinalysis or blood samples.
Hemolytic reactions can be investigated and confirmed through urine or blood tests. This can also help confirm the patient was correctly typed and crossmatched.
3. Administer antipyretics as indicated.
Antipyretics such as acetaminophen will aid in the reduction of the patient’s body temperature.
4. Make use of a cooling blanket as needed.
A cooling blanket will help reduce the patient’s elevated body temperature which may reach up to 104.0 F (40.0 C).
5. Administer IV fluids.
If not already infusing, 0.9% normal saline should be infused to keep the IV open and clear.
Impaired Gas Exchange
Gas exchange can be impaired by complications or adverse reactions of blood transfusion. These include:
- Transfusion-associated circulatory overload (TACO)
- Allergic reaction
- Anaphylaxis
- Transfusion-related acute lung injury (TRALI)
- Hemolysis
- Electrolyte abnormalities
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Impaired gas exchange process
- Inadequate supply of oxygenated blood
- Lack of blood supply to the lungs
- Pulmonary congestion
- Development of blood transfusion reactions
As evidenced by:
- Dyspnea
- Tachypnea
- Use of accessory muscles
- Headache or dizziness
- Change in level of consciousness
- Change in skin color (pale or cyanotic)
- Tachycardia
- Palpitations
- Prolonged capillary refill time
- Anxiety
- Restlessness
- Crackles on auscultation
- Hypoxia
- Orthopnea
Expected outcomes:
- Patient will demonstrate oxygen saturation and breathing pattern within normal limits.
- Patient will maintain the ability to breathe without difficulty in a relaxed supine position.
Assessment:
1. Assess respiratory status.
During a blood transfusion, closely monitor for any difficulty in breathing. Dyspnea and hypoxia develop due to insufficient cardiac output and backup of blood into the lungs. Orthopnea is a late finding from pulmonary congestion.
2. Auscultate the lung sounds.
Wheezing may be heard over the lungs due to bronchospasm in allergic reactions. Pulmonary congestion from volume overload causes decreased lung compliance and compressed airways, resulting in crackles.
3. Assess for changes in mentation.
Monitor the patient for changes in level of consciousness and the presence of restlessness or anxiety. These are signs of hypoxia and decreased brain perfusion.
4. Monitor pulse oximetry.
Closely monitor the patient’s oxygen saturation during a blood transfusion. A drop in oxygen saturation signals impaired gas exchange and decreased perfusion.
Interventions:
1. Position the patient properly.
Ensure that the patient is in an upright position. This position will maximize lung expansion and promote gas exchange.
2. Administer oxygen therapy.
Administer oxygen as ordered to prevent hypoxia and improve gas exchange.
3. Administer medications as ordered.
For mild symptoms, antihistamines can counteract blood transfusion-related allergic reactions. The following medications can open the airway for better gas exchange in patients with severe symptoms:
- Bronchodilators
- Epinephrine
- Corticosteroids
4. Anticipate the need for airway devices and mechanical ventilators.
If breathing difficulties persist, assist with inserting an artificial airway device (endotracheal or tracheostomy tube). A mechanical ventilator is attached to promote adequate gas exchange.
Ineffective Breathing Pattern
The most common signs and symptoms of blood transfusion reactions include fever, chills, urticaria, and itching which may resolve with little or no treatment. In some cases, severe side effects can occur including respiratory distress, hypotension, and hemoglobinuria.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Blood transfusion reaction
As evidenced by:
- Increased respiratory rate
- Tachypnea
- Labored breathing
- Cough
- Nasal flaring
- Hypoxia
- Altered tidal volume
- Bradypnea
- Cyanosis
Expected outcomes:
- Patient will maintain an effective breathing pattern as evidenced by the absence of cough or dyspnea.
- Patient’s respiratory rate will remain within normal limits during blood transfusion.
Assessment:
1. Assess respiratory rate and depth.
Subtle changes in the patient’s breathing pattern can indicate adverse reactions from a blood transfusion.
2. Monitor oxygen saturation.
Assess for decreasing Spo2 levels that signal respiratory distress.
Interventions:
1. Place the patient in Fowler’s position.
A sitting position allows the lungs to expand to their full potential. Proper positioning enables optimal breathing patterns.
2. Administer medications as indicated.
Medications will depend on the type of reaction and may include epinephrine, solumedrol, antihistamines, and vasopressors.
3. Administer supplemental oxygen as needed.
Supplemental oxygen can increase the oxygen in the blood and decrease symptoms of breathlessness.
4. Prepare for intubation.
Rarely, severe transfusion reactions that cannot be quickly and adequately managed may require emergency intubation.
5. Stay with the patient during episodes of acute respiratory distress.
Staying with the patient can help lessen the patient’s anxiety which can lessen oxygen demand as well.
References
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