Blood & Blood Transfusion Policy
Comprehensive Nursing Study Notes
Table of Contents
Introduction to Blood Transfusion
Blood transfusion is a life-saving medical procedure involving the transfer of blood or blood components from a donor to a recipient. As a nursing professional, understanding the complexities of blood transfusion policy is crucial for ensuring patient safety and optimal outcomes. This comprehensive guide covers all aspects of blood transfusion from a nursing perspective, emphasizing evidence-based practice and patient-centered care.
Key Learning Objectives:
- Understand blood physiology and compatibility principles
- Master pre-transfusion assessment and verification procedures
- Implement safe transfusion practices and monitoring protocols
- Recognize and manage transfusion reactions
- Apply legal and ethical considerations in transfusion medicine
Blood Anatomy & Physiology
Blood Components
Red Blood Cells (45%)
Oxygen transport, CO2 removal, contain hemoglobin
Plasma (55%)
Fluid component, proteins, electrolytes, nutrients
Platelets (<1%)
Clotting function, hemostasis
White Blood Cells (<1%)
Immune function, infection fighting
Normal Values
| Hemoglobin | 12-16 g/dL (F), 14-18 g/dL (M) |
| Hematocrit | 36-46% (F), 41-53% (M) |
| Platelets | 150,000-450,000/μL |
| Total Blood Volume | 7% of body weight |
Mnemonic: Blood Functions
“TORCH”
- Transport (oxygen, nutrients, waste)
- Oncotic pressure maintenance
- Regulation (pH, temperature)
- Clotting and hemostasis
- Homeostasis and immunity
Blood Types & Compatibility
ABO System
Type A
A antigens, anti-B antibodies
Can receive: A, O | Can donate to: A, AB
Type B
B antigens, anti-A antibodies
Can receive: B, O | Can donate to: B, AB
Type AB
A & B antigens, no antibodies
Universal recipient
Type O
No antigens, anti-A & anti-B antibodies
Universal donor
Rh System
Rh Positive (+)
Rh D antigen present
85% of population
Rh Negative (-)
Rh D antigen absent
15% of population
Critical Compatibility Rule
Rh-negative patients should receive Rh-negative blood to prevent sensitization, especially in women of childbearing age.
Mnemonic: Blood Compatibility
“A-B-O, Always Be Observant”
Type A: “A” can Accept from A and O
Type B: “B” can Borrow from B and O
Type AB: “AB” Accepts Both (universal recipient)
Type O: “O” Offers to all (universal donor)
Blood Products
Packed Red Blood Cells (PRBCs)
Volume: 250-300 mL
Storage: 1-6°C, 35-42 days
Indications: Anemia, blood loss
Infusion Rate: 1-2 mL/kg/hr
Expected Rise: Hgb 1g/dL, Hct 3%
Fresh Frozen Plasma (FFP)
Volume: 200-250 mL
Storage: -18°C, 12 months
Indications: Coagulopathy, factor deficiency
Infusion Rate: As fast as tolerated
Thaw Time: 30-45 minutes
Platelets
Volume: 50-70 mL/unit
Storage: 20-24°C, 5 days
Indications: Thrombocytopenia, bleeding
Infusion Rate: As fast as tolerated
Expected Rise: 30,000-60,000/μL
Cryoprecipitate
Volume: 10-15 mL/unit
Storage: -18°C, 12 months
Indications: Fibrinogen deficiency, DIC
Contains: Factor VIII, fibrinogen, vWF
Dosing: 1 unit/10 kg body weight
Albumin
Concentrations: 5%, 25%
Storage: Room temperature
Indications: Hypovolemia, hypoalbuminemia
Half-life: 15-20 days
Onset: Immediate volume expansion
Immunoglobulins
Types: IVIG, anti-D, specific antibodies
Storage: 2-8°C
Indications: Immunodeficiency, autoimmune
Infusion: Slow initial rate
Duration: 3-4 weeks effect
Transfusion Indications
PRBC Transfusion Decision Tree
Patient Assessment
Hemoglobin, symptoms, comorbidities
Hgb < 7 g/dL
Generally transfuse
Hgb 7-10 g/dL
Consider symptoms & risk factors
Hgb > 10 g/dL
Rarely indicated
Absolute Indications
- Acute blood loss >30% blood volume
- Hemoglobin <7 g/dL with symptoms
- Active bleeding with hemodynamic instability
- Severe anemia with cardiac symptoms
Relative Indications
- Hemoglobin 7-10 g/dL with risk factors
- Pre-operative optimization
- Chronic anemia with functional impairment
- Failed response to iron therapy
Special Populations
Pediatric
15 mL/kg for PRBC
10-15 mL/kg for FFP
Elderly
Consider cardiac status
Slower infusion rates
Cardiac Patients
Higher threshold (Hgb 8-10)
Monitor fluid status
Pre-transfusion Procedures
Physician Orders
- Type of blood product
- Number of units
- Rate of administration
- Special requirements (irradiated, CMV-negative)
- Pre-medication orders
Informed Consent
- Explain risks and benefits
- Discuss alternatives
- Address patient concerns
- Document consent process
- Respect religious/cultural beliefs
Pre-transfusion Checklist
Patient ID
Two identifiers minimum
Blood Sample
Type & crossmatch
Baseline Vitals
T, P, R, BP
IV Access
18-gauge or larger
Critical Safety Checks
Patient History
- • Previous transfusions
- • Transfusion reactions
- • Pregnancy history
- • Recent medications
Laboratory Requirements
- • ABO/Rh typing
- • Antibody screen
- • Crossmatch compatibility
- • Sample age <72 hours
Transfusion Process
Transfusion Workflow
Two-Person Verification
Patient Identification
- • Full name
- • Date of birth
- • Medical record number
- • Patient wristband
Blood Product Verification
- • Unit number
- • ABO/Rh type
- • Expiration date
- • Crossmatch compatibility
Infusion Guidelines
| Initial Rate | 1-2 mL/min for 15 minutes |
| Standard Rate | 2-4 hours per unit |
| Maximum Time | 4 hours per unit |
| Emergency Rate | Wide open with pressure |
| Filter | 170-260 micron standard |
Mnemonic: Verification Process
“RIGHT PERSON, RIGHT PRODUCT”
Recipient identification
Inspect blood product
General condition check
History review
Two-person verification
Product compatibility
Expiration date
Reaction history
Signatures required
Observe throughout
No interruptions during verification
Monitoring & Safety
First 15 Minutes
- • Stay with patient
- • Vital signs every 5 minutes
- • Watch for immediate reactions
- • Slow infusion rate (1-2 mL/min)
- • Document observations
During Transfusion
- • Vital signs every 30 minutes
- • Assess patient comfort
- • Monitor IV site
- • Check urine output
- • Observe skin color
Post-Transfusion
- • Final vital signs
- • Assess overall response
- • Monitor for delayed reactions
- • Complete documentation
- • Follow-up lab values
Vital Signs Monitoring Schedule
Red Flag Signs – STOP TRANSFUSION
Immediate Signs
- • Fever (>1°C rise)
- • Chills or rigors
- • Hypotension
- • Tachycardia
- • Difficulty breathing
Other Concerning Signs
- • Nausea/vomiting
- • Back or chest pain
- • Skin rash or flushing
- • Dark urine
- • Anxiety or sense of doom
Adverse Reactions
Acute Hemolytic
Cause: ABO incompatibility
Onset: Immediate
Signs: Fever, chills, back pain, hemoglobinuria
Action: STOP immediately, support BP, diuresis
Mortality: High if severe
Febrile Non-Hemolytic
Cause: Antibodies to WBC/platelets
Onset: During or within 4 hours
Signs: Fever >1°C, chills, malaise
Action: Stop, antipyretics, rule out hemolysis
Prevention: Leukoreduced products
Allergic
Cause: Proteins in donor plasma
Onset: Usually immediate
Signs: Urticaria, itching, mild dyspnea
Action: Stop, antihistamines, epinephrine if severe
Prevention: Washed RBCs
TACO
Cause: Volume overload
Onset: During or within 6 hours
Signs: Dyspnea, hypertension, JVD
Action: Stop, diuretics, O2 support
Prevention: Slow rate, monitor closely
TRALI
Cause: Donor antibodies to recipient neutrophils
Onset: Within 6 hours
Signs: Acute respiratory distress, fever
Action: Stop, ventilatory support
Key: Normal CVP (vs TACO)
Infectious
Cause: Contains pathogens
Onset: Days to months
Risk: Very low with modern screening
Examples: HIV, Hepatitis, CMV, bacteria
Prevention: Donor screening, testing
Transfusion Reaction Management
Suspect Reaction
Any abnormal sign/symptom
STOP TRANSFUSION
Keep IV line open with normal saline
Assess Patient
Vital signs, symptoms
Notify Physician
Report immediately
Blood Bank
Return unit, send samples
Mnemonic: Reaction Assessment
“STOP, THINK, ACT”
STOP
• Stop transfusion
• Stay with patient
• Support airway/breathing
THINK
• Type of reaction
• Hemolytic vs non-hemolytic
• Immediate vs delayed
ACT
• Alert physician
• Administer treatment
• Arrange for follow-up
Post-transfusion Care
Immediate Assessment (0-4 hours)
- Monitor vital signs every 30 minutes × 2 hours
- Assess for delayed reactions
- Check IV site for complications
- Monitor urine output and color
- Document patient tolerance
Laboratory Follow-up
- CBC 1-4 hours post-transfusion
- Assess hemoglobin response
- Platelet count if platelets given
- Coagulation studies if FFP given
- LDH, bilirubin if hemolysis suspected
Expected Responses
PRBC Transfusion
- • Hgb ↑ 1 g/dL per unit
- • Hct ↑ 3% per unit
- • Improved energy, less fatigue
- • Better exercise tolerance
Platelet Transfusion
- • Count ↑ 30,000-60,000/μL
- • Reduced bleeding tendency
- • Petechiae resolution
- • Improved clotting
FFP Transfusion
- • PT/INR improvement
- • aPTT normalization
- • Reduced bleeding
- • Volume expansion
Documentation Requirements
Patient Info
- • ID verification
- • Consent obtained
- • Baseline vitals
Product Details
- • Unit numbers
- • Blood type
- • Expiration dates
Timeline
- • Start/stop times
- • Vital sign times
- • Rate changes
Response
- • Patient tolerance
- • Any reactions
- • Final assessment
Legal & Ethical Considerations
Legal Requirements
- Informed Consent: Written consent for non-emergency transfusions
- Right to Refuse: Patients can decline transfusion
- Emergency Exception: Life-threatening situations
- Documentation: Complete records required
- Reporting: Adverse events must be reported
Ethical Principles
- Autonomy: Respect patient decision-making
- Beneficence: Act in patient’s best interest
- Non-maleficence: “Do no harm”
- Justice: Fair distribution of resources
- Veracity: Truthful communication
Special Situations
Jehovah’s Witnesses
- • Refuse whole blood and major components
- • May accept fractions (albumin, immunoglobulins)
- • Require clear documentation of refusal
- • Respect religious convictions
- • Explore alternatives (EPO, iron, autotransfusion)
Pediatric Considerations
- • Parent/guardian consent required
- • Court intervention for life-threatening refusal
- • Assent from mature minors
- • Best interest standard applies
- • Child protective services involvement if needed
Consent Process Components
Information Disclosure
- • Nature of procedure
- • Risks and benefits
- • Alternative treatments
- • Consequences of refusal
Comprehension
- • Patient understanding verified
- • Questions answered
- • Language barriers addressed
- • Capacity assessment
Voluntariness
- • Free from coercion
- • Adequate time to decide
- • Right to withdraw consent
- • Family influence considered
Nursing Implementation
Nursing Process Application
Assessment
- • Health history
- • Current status
- • Lab values
- • Risk factors
Diagnosis
- • Risk for injury
- • Anxiety
- • Fluid volume excess
- • Knowledge deficit
Planning
- • Safety goals
- • Patient outcomes
- • Intervention strategies
- • Resource allocation
Implementation
- • Safe practices
- • Patient monitoring
- • Education provision
- • Reaction management
Evaluation
- • Goal achievement
- • Patient response
- • Complications
- • Plan revision
Core Nursing Competencies
Clinical Skills
- • Patient identification techniques
- • IV access and maintenance
- • Vital sign monitoring
- • Reaction recognition and response
Communication
- • Patient education
- • Interdisciplinary collaboration
- • Family involvement
- • Documentation accuracy
Critical Thinking
- • Risk assessment
- • Priority setting
- • Problem solving
- • Evidence-based practice
Patient Education Topics
Pre-transfusion
- • Procedure explanation
- • Expected duration
- • Monitoring requirements
- • Signs to report
During transfusion
- • Comfort measures
- • Activity restrictions
- • Symptom reporting
- • Emotional support
Post-transfusion
- • Expected outcomes
- • Delayed reaction signs
- • Follow-up requirements
- • Lifestyle considerations
Nursing Interventions by Phase
| Phase | Priority Interventions | Monitoring Focus | Documentation |
|---|---|---|---|
| Pre-transfusion | Consent, ID verification, IV access, baseline vitals | Anxiety level, understanding, physical status | Consent, baseline assessment, patient teaching |
| Initial 15 min | Slow rate, stay with patient, frequent vitals | Signs of acute reactions, vital sign changes | Vital signs, patient tolerance, rate adjustments |
| During transfusion | Regular monitoring, comfort measures, IV maintenance | Ongoing tolerance, IV patency, symptoms | Vital signs, patient response, any interventions |
| Post-transfusion | Final assessment, line care, follow-up planning | Overall response, delayed reactions, lab results | Final assessment, patient outcomes, discharge planning |
Quality Assurance & Best Practices
Safety Culture
- • Error reporting without blame
- • Continuous learning environment
- • Team communication
- • Standardized procedures
- • Regular competency validation
Performance Metrics
- • Transfusion reaction rates
- • Identification error incidents
- • Compliance with protocols
- • Patient satisfaction scores
- • Staff competency rates
Education & Training
- • Initial competency training
- • Annual recertification
- • Simulation exercises
- • Case study reviews
- • Policy updates training
Best Practice Standards
The Joint Commission Requirements
- • Patient Safety Goals compliance
- • Two-patient identifier use
- • Timeout procedures
- • Medication reconciliation
- • Hand-off communication
AABB Standards
- • Blood bank accreditation
- • Quality management systems
- • Proficiency testing
- • Equipment validation
- • Personnel qualifications
Continuous Improvement Cycle
Assess
Current practices
Plan
Improvements
Implement
Changes
Evaluate
Outcomes
Final Mnemonic: Excellence in Transfusion
“SAFE TRANSFUSION”
Safety first priority
Accurate identification
Frequent monitoring
Education of patient/family
Two-person verification
Reaction recognition
Assessment continuous
Never rush the process
Standard precautions
Follow protocols strictly
Understand patient needs
Support emotional needs
Involve interdisciplinary team
Optimal outcomes focus
Nurse advocacy essential
Key Takeaways
Critical Success Factors:
- • Patient safety is paramount
- • Accurate identification prevents errors
- • Early recognition saves lives
- • Communication prevents complications
- • Documentation protects everyone
Nursing Excellence Requires:
- • Continuous learning and competency
- • Evidence-based practice application
- • Patient-centered care approach
- • Ethical decision-making skills
- • Collaborative team relationships
Blood & Blood Transfusion Policy – Nursing Study Notes
Comprehensive Educational Resource for Professional Practice