Blood Transfusion Nursing Care
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Direct answer
Safe transfusion is a choreography of verification and observation: physician order and informed consent, group and crossmatch, then a bedside check by two clinicians confirming patient identity, blood group, unit number, expiry and the crossmatch report against the bag's appearance. Blood primes only with normal saline, starts slowly for the first fifteen minutes with the nurse present, and completes within four hours. The commonest reaction is febrile non-haemolytic, the deadliest is acute haemolytic from an ABO mismatch — almost always a clerical error — and modern exams separate TRALI, the non-cardiogenic lung injury, from TACO, the circulatory overload.
What you must remember
- Components: packed red cells raise haemoglobin by about 1 g per dL per unit in an adult; fresh frozen plasma supplies clotting factors; platelet pools raise counts and are stored at 20 to 24°C with agitation, never refrigerated; cryoprecipitate supplies fibrinogen.
- Only normal saline (0.9%) runs with blood — dextrose haemolyses red cells, and no drug is ever added to a blood line.
- Transfuse the first 15 minutes slowly (about 2 mL per minute) staying with the patient; vitals are taken before, at 15 minutes, hourly during, and at completion.
- Acute haemolytic reaction: fever, chills, flank pain, hypotension, haemoglobinuria early in the unit — stop the blood, keep the vein open with saline, maintain urine output, send the unit and fresh samples back, and notify.
- Febrile non-haemolytic reaction is the commonest: fever with chills without haemolysis; the transfusion is paused to exclude a haemolytic cause, then may resume slowly with antipyretic cover.
- TRALI: acute dyspnoea, hypoxia and bilateral infiltrates within six hours, non-cardiogenic — stop, supportive respiratory care, report; TACO: overload in elderly, renal or cardiac patients — slow rates, diuretics, and it is prevented by splitting units.
- Massive transfusion brings citrate-induced hypocalcaemia (perioral tingling, prolonged QT), hypothermia and hyperkalaemia.
Working a reaction, step by step
Twenty minutes into her second unit of packed cells, a postpartum woman reports chills and loin pain, and her temperature climbs from 37 to 38.9°C with a pulse of 118. The nurse stops the transfusion first — not after, first — maintains the line with normal saline at the cannula, takes vital signs and stays with the patient while a colleague informs the doctor. The blood bag with its tubing, a fresh clotted sample and a urine sample for haemoglobinuria go to the laboratory, and the reaction is documented with times. The clinical reasoning then separates the possibilities: flank pain with hypotension this early pushes acute haemolysis to the top, so urine output is defended with fluids per orders and renal function is watched; had the picture been urticaria alone, an antihistamine with slowed resumption would follow; sudden breathlessness with bilateral crackles and low-grade fever would raise TRALI; and in the 70-year-old with heart failure receiving rapidly, wet lungs without fever point to TACO and furosemide. The transfusion is never restarted while the patient is symptomatic and unreviewed.
Where students slip
Candidates prime with dextrose in calculation-style questions — normal saline only is the fixed answer. The "first action" item is missed by those who call the doctor before stopping the blood; the sequence is stop, saline, stay, then inform. Storage slips: keeping a unit in the ward refrigerator or returning a warmed bag. The TRALI-TACO discrimination is the modern trap: TRALI gets respiratory support with fluid restriction, TACO gets diuresis and slower rates. Finally, the four-hour completion rule and the 30-minute rule about delayed hanging are quoted loosely; both numbers are exam facts.
Frequently asked questions
Which fluid is compatible with blood transfusion?
Normal saline 0.9% only; dextrose solutions haemolyse red cells and drugs are never added to the blood line.
Why must the nurse stay for the first fifteen minutes?
Because severe reactions — anaphylaxis and acute haemolysis — typically declare themselves early, and slow initial administration limits the volume infused if they do.
What is the first nursing action when a reaction is suspected?
Stop the transfusion immediately, keep the vein open with normal saline, assess and stay with the patient, then notify and return the unit with samples.
Which is the most common transfusion reaction?
Febrile non-haemolytic transfusion reaction, presenting with fever and chills from antibodies to donor leucocytes, once haemolysis has been excluded.
How do TRALI and TACO differ?
TRALI is non-cardiogenic lung injury with hypoxia and bilateral infiltrates within six hours treated supportively; TACO is volume overload in susceptible patients treated with diuresis and slower rates.
How long may one unit of packed cells hang?
It should be completed within four hours of starting, because warming beyond that invites bacterial proliferation.