How nurses give blood safely and spot transfusion reactions
NCLEX-RN topic: Blood and blood products
- Two nurses check identity, ABO/Rh, unit number and expiration at the bedside.
- Run only 0.9% sodium chloride with blood; never add medications.
- Start slowly and stay with the client for the first 15 minutes.
- Start within 30 minutes of pickup; finish within 4 hours.
- Any reaction: stop the transfusion first, then run saline through new tubing.
Key facts
- A compatibility sample is usually drawn within 72 hours before the transfusion, and written consent is required unless it is an emergency.
- Only 0.9% sodium chloride may run with blood; never add medications to the blood line.
- Start the transfusion within 30 minutes of picking up the unit and finish it within 4 hours.
Show all 7 key factsShow fewer
- Begin slowly, about 2 mL/min (120 mL/hr), and stay with the client for the first 15 minutes, when most severe reactions appear.
- A pre-transfusion temperature above 100.4°F (37.8°C) is reported to the provider before the unit is obtained.
- Acute hemolytic reactions (ABO/Rh mismatch) start within about 15 minutes with fever, chills, flank or back pain, tachycardia and hypotension.
- TACO causes crackles, dyspnea, jugular vein distension and high blood pressure from too much volume or too fast a rate.
Quick check1 question · 2 more at the end
A client with symptomatic anemia is prescribed 1 unit of packed red blood cells. Consent is signed and the crossmatch is complete. Before the nurse calls for the unit, the client's temperature is 101.0°F (38.3°C); it was 98.6°F (37.0°C) four hours ago. What is the best action by the nurse?
Correct answer: D.
A pre-transfusion temperature above 100.4°F (37.8°C) is reported to the provider before the blood is picked up. A new fever would hide the main early sign of a transfusion reaction, and once a unit leaves the blood bank it must be started within about 30 minutes and can't be returned. Clarifying first is the safe choice when data change before a high-risk procedure.
A Starting with a new fever means a reaction fever couldn't be told apart from the baseline fever, and the provider hasn't been told about the change.
B Blood is never stored in a unit refrigerator; it must start within about 30 minutes of leaving the blood bank.
C Acetaminophen has not been prescribed, and treating the fever without telling the provider skips the needed clarification.
D Correct: a febrile client is reported to the provider before the unit is obtained, because blood can't go back to the bank once it is picked up.
Full lesson
Each part starts with its main idea. Open a part when you want the details.
The short answer: Before a transfusion, confirm consent, the order, a recent type and crossmatch, baseline vital signs and IV access, then do a two-person bedside check of client identity, ABO/Rh, unit number and expiration. Start slowly, stay for the first 15 minutes and finish within 4 hours. If a reaction appears, stop the transfusion first.
1 What must be checked before a transfusion starts?Most of the safety work in a transfusion happens before the first drop runs in. 1 min
Most of the safety work in a transfusion happens before the first drop runs in. The nurse is the last link in a chain designed to stop the wrong blood from reaching the wrong client.
- Consent and order: written informed consent is in the chart (unless it is an emergency), and the provider's order names the product and any premedications.
- Lab work: a type and screen or type and crossmatch sample has been drawn, usually within the past 72 hours.
- Baseline: vital signs, lung sounds, skin and allergy or prior-reaction history. A temperature above 100.4°F (37.8°C) is reported to the provider before the unit is picked up, because blood can't be returned once it leaves the bank.
- Access and tubing: a working IV (20G to 24G for routine transfusion, 18G to 20G for rapid), blood tubing with a filter, and 0.9% sodium chloride. Lactated Ringer's, dextrose and medications are not compatible with blood.
- Two-person bedside check: compare the client's name and ID number with the bag, the unit number, ABO group and Rh type, the expiration date, and the bag's appearance.
2 Which blood types can a client receive?Red cells must not carry an antigen the client has antibodies against. 1 min
Red cells must not carry an antigen the client has antibodies against. Type O negative is the universal red cell donor, and AB positive can receive red cells of any ABO and Rh type.
| Client's type | Red cells they can receive |
|---|---|
| A | A or O |
| B | B or O |
| AB | A, B, AB or O |
| O | O only |
| Rh-positive | Rh-positive or Rh-negative |
| Rh-negative | Rh-negative only |
3 How is the transfusion started and monitored?The first 15 minutes are the most dangerous, so the nurse stays at the bedside. 1 min
The first 15 minutes are the most dangerous, so the nurse stays at the bedside. Begin within 30 minutes of picking up the unit, at a slow rate of about 2 mL/min (120 mL/hr). Ask the client to report chills, itching, hives, shortness of breath or chest pain.
After 15 minutes without a reaction, recheck vital signs and increase to the prescribed rate. Every unit must finish within 4 hours. Never inject medications into the blood line, never store a unit in the unit refrigerator, and never heat blood in a microwave or warm water.
4 How do you tell transfusion reactions apart?Timing, blood pressure and the main symptom separate most reactions. 1 min
Timing, blood pressure and the main symptom separate most reactions. Fever, chills, hives and itching are the most common signs overall.
| Reaction | Typical timing | Key signs |
|---|---|---|
| Acute hemolytic (ABO/Rh mismatch) | Within about 15 minutes | Fever, chills, flank or low back pain, tachycardia, hypotension, pain along the vein |
| Febrile non-hemolytic | 30 minutes in to 6 hours after | Temperature up more than 1°C from baseline, chills, headache, flushing |
| Mild allergic | During or up to 24 hours after | Itching, redness, hives |
| Anaphylactic | Within 5 to 15 minutes | Wheezing, shortness of breath, hypotension |
| TACO (circulatory overload) | During or 1 to 2 hours after | Crackles, dyspnea, jugular vein distension, hypertension |
5 What the nurse doesWhen any reaction appears, stopping the transfusion is always the first move. 1 min
When any reaction appears, stopping the transfusion is always the first move. Then:
- Disconnect the blood tubing and run 0.9% sodium chloride through new primed tubing attached at the IV hub. Flushing the old line would push the remaining blood into the client.
- Assess the client and take vital signs.
- Notify the provider and the blood bank.
- Keep the bag and tubing and send them to the lab with blood and urine samples per policy.
- Give prescribed treatments: an antihistamine for allergic signs, epinephrine for anaphylaxis, or a diuretic with the head of the bed raised for TACO.
Common mistakes
The traps students fall into most. Read these before you practice.
Watch out: At the first sign of a reaction, stop the transfusion, not just slow it down.
Watch out: Run saline through new primed tubing at the IV hub, not through the old blood tubing, which would push more blood into the client.
Watch out: Send the blood bag and tubing to the lab per policy, not to the trash.
Watch out: TACO raises blood pressure, while acute hemolytic and anaphylactic reactions tend to drop it.
Watch out: Type O negative is the universal red cell donor; type AB positive is the universal red cell recipient.
How to remember it
Remember the rule "check twice, sit fifteen, finish in four" for every unit of blood. Two people check at the bedside, you stay for the first 15 minutes, and the unit is done within 4 hours.
Self-check:
- List five things the two nurses compare at the bedside.
- Name the reaction with crackles and a rising blood pressure.
- Explain why saline goes through new tubing after a reaction.