06/11/2025
Here’s a comprehensive guide for nurses on how to safely administer a blood transfusion, adapted from multiple clinical sources. Always follow your hospital’s policy and local guidelines — these are general best-practice steps.
⸻
1. Preparation & Pre-transfusion checks
• Verify the physician orders: confirm indication, product ordered, volume, rate. 
• Ensure informed consent has been obtained from the patient (or legal representative) and documented. 
• Educate the patient: explain purpose of transfusion, estimated time, need to monitor and report symptoms (e.g., chills, itching, shortness of breath). 
• Establish appropriate IV access: for adults typically 18-20 gauge (for rapid transfusion maybe 16-18). 
• Obtain baseline vital signs (temperature, blood pressure, pulse, respiratory rate, oxygen saturation) and document. 
• Gather equipment: blood administration set (Y-tubing with filter), 0.9% normal saline, gloves, steady IV patent line. 
⸻
2. Verification of blood product
• At the blood bank and again at the bedside with another trained nurse (two-nurse check):
• Patient identity (e.g., name, MRN, DOB) matches wristband and order. 
• Blood product: unit number, ABO/Rh, expiration date, product type, special requirements (e.g., leukocyte-reduced) match order. 
• Inspect bag for integrity: no leaks, clots, unusual colour, bubbles. 
• Only normal saline (0.9% NaCl) is to be used as the IV fluid compatible with blood products; other fluids may cause hemolysis or incompatibility. 
⸻
3. Initiating the transfusion
• Prime the blood administration tubing with normal saline, then attach to the blood bag. Maintain aseptic technique when connecting to patient’s IV. 
• Start transfusion within 30 minutes of the blood unit leaving the blood bank (depending on facility). 
• For the first 15 minutes: infuse slowly (e.g., ~120 mL/hr or lower depending on patient condition); remain with the patient and monitor for any signs of reaction. 
• After initial period and if no adverse reaction: increase to prescribed rate as per physician order and facility policy. 
⸻
4. Monitoring during and after transfusion
• Vital signs:
• Immediately before start
• At ~15 minutes after start
• Then hourly (or per facility policy) until completion. 
• Continually assess patient for transfusion reaction signs: fever, chills, itching, hives, shortness of breath, back pain, dark urine, hypotension, tachycardia, etc. 
• Transfusion must be completed within 4 hours once the unit is out of the controlled storage environment (for most red cell units). Exceeding this increases risk of bacterial proliferation. 
⸻
5. If a reaction occurs
• Immediately stop the transfusion.
• Keep the IV line open with normal saline via new tubing (if directed).
• Notify the physician/blood bank per hospital protocol.
• Retain the blood bag, tubing, and send samples (patient’s blood & urine) as indicated. Document everything. 
⸻
6. Post-transfusion tasks
• After the transfusion ends: flush IV line with normal saline (if needed) to clear residual cells from tubing. 
• Dispose of blood bag and tubing according to biohazard policy. 
• Document in patient record: product type, unit number, start & end times, volume transfused, patient’s vital signs and condition, any adverse events. 
• Continue to monitor patient for delayed reactions (which may occur hours later) and observe for effectiveness of transfusion (e.g., increase in hemoglobin, improvement of symptoms). 
⸻
7. Special considerations
• Only trained staff (nurses who have had competency training) should perform transfusions. 
• Use appropriate tubing/filters depending on the blood product (e.g., leukocyte-reduced RBC may use microaggregate filters 20-40 µm). 
• For rapid transfusion needs (massive bleeding), use larger gauge IV and rapid infusion devices as per protocol. 
• In pediatric or neonatal patients, rate, volume and monitoring may differ — refer to pediatric protocols.
• Cultural/contextual: In the Philippines (and other settings) nurses also check institutional protocols such as 10 “R’s” of blood transfusion, alertness to local regulations (e.g., National Blood Service Act of 1994 in Philippines) and donor-blood screening laws. 
