Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

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Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 15-6

Administering a Blood Transfusion (Continued)

Comments

18.During transfusion, assess frequently for transfusion

reaction. Stop blood transfusion if you suspect a reaction.

Quickly replace the blood tubing with a new administra-

tion set primed with normal saline for IV infusion. Initi-

ate an infusion of normal saline for IV at an open rate,

usually 40 mL/hour. Obtain vital signs. Notify physician

and blood bank.

19. When transfusion is complete, close roller clamp on blood
    side of the administration set and open the roller clamp
    on the normal saline side of the administration set. Initiate
    infusion of normal saline. When all of blood has infused
    into the patient, clamp the administration set. Obtain vital
    signs. Put on gloves. Cap access site or resume previous IV
    infusion. (Refer to Skill 15-1 and Skill 15-5.) Dispose of
    blood-transfusion equipment or return to blood bank,
    according to facility policy.


20. Remove equipment. Ensure patient’s comfort. Remove
    gloves. Lower bed, if not in lowest position.


21. Remove additional PPE, if used. Perform hand hygiene.

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