Blood Transfusion
High-Alert ProceduresThe steps
- Verify order, consent, and type & screen are current
- Baseline vitals within 30 min before hanging
- Two-RN verification at the bedside: patient ID, blood product, unit number, ABO/Rh, expiration
- Prime with NORMAL SALINE only — nothing else touches the line
- Start slow (~2 mL/min) and STAY with the patient for the first 15 minutes
- Re-check vitals at 15 min, then per policy; complete within 4 hours of leaving the fridge
🛡 Never skip
The first 15 minutes is when acute hemolytic reactions declare themselves Reaction signs: fever/chills, back pain, dark urine, hypotension, dyspnea, feeling of doom REACTION? STOP the blood, keep the line open with NS via NEW tubing, stay with patient, call provider and blood bank, recheck IDs, save the bag and tubing
Common mistakes
- Hanging blood with dextrose or LR (hemolyzes cells)
- Leaving during the first 15 minutes
- Treating a mild temperature bump as 'probably nothing' — report per policy, every time
Source: Lippincott Nursing Procedures, 9th ed.Reference only — verify against your facility's policy.
