Nursing How To’s: Blood transfusion therapy

Aimee is observing the staff nurse as she prepares to administer a blood transfusion. She watches as the nurse checks the doctor’s order first then heads to the patient’s room probably to explain the procedure to the client and the folks. It has always amazed her how meticulous nurses are when it comes to administering medications or even when transfusing blood products. With them going from one place to another, it makes her wonder what sort of procedures the nurse must first follow before finally hooking the blood product to the patient’s IV line.

What exactly are the steps that nurses need to follow when administering blood products? And what are some things that the nurse must consider?

Nurse’s role in blood transfusion therapy

  1. Verify doctor’s order. Inform the client and explain the purpose of the procedure.
  2. Check for cross matching and typing. To ensure compatibility
  3. Obtain and record baseline vital signs
  4. Practice strict asepsis
  5. At least 2 licensed nurses should check the label of the blood transfusion. Check the following:
    • Serial number
    • Blood component
    • Blood type
    • Rh factor
    • Expiration date
    • Screening test (VDRL, HBsAg, malarial smear) – this is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.
  6. Warm blood at room temperature before transfusion to prevent chills.
  7. Identify client properly. Two Nurses check the client’s identification.
  8. Use needle gauge 18 to 19 to allow easy flow of blood.
  9. Use BT set with special micron mesh filter to prevent administration of blood clots and particles.
  10. Start infusion slowly at 10 gtts/min. Remain at bedside for 15 to 30 minutes. Adverse reaction usually occurs during the first 15 to 20 minutes.
  11. Monitor vital signs. Altered vital signs indicate adverse reaction (increase in temp, increase in respiratory rate)
  12. Do not mix medications with blood transfusion to prevent adverse effects. Do not incorporate medication into the blood transfusion. Do not use blood transfusion lines for IV push of medication.
  13. Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose based IV fluids cause hemolysis.
  14. Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
  15. Observe for potential complications. Notify physician.



Liane Clores, RN MAN

Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.

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