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Learning Objectives

By the end of this section, you will be able to:

• Discuss the physiology of the antigen response with blood types
• Identify examples of blood products
• Explain the legal and ethical implications of administering blood products
• Describe the pertinent nursing assessments included in the care of a patient receiving a blood transfusion

A blood transfusion is a medical procedure involving the transfer of blood or its components from one individual (donor) to another individual (recipient). Blood transfusions have been performed for centuries (Figure 16.7). The first recorded transfusion was attempted in 1628, shortly after an English physician discovered the process by which blood circulates through the body (AABB, n.d.). Unfortunately, many early blood transfusions failed; practitioners were not aware of the differences of blood types. Once scientists identified the ABO system of blood types, in the early 20th century, transfusions became much safer because providers could ensure that patients receive only compatible blood.

Figure 16.7 This illustration from a 19th-century English medical journal shows a man giving blood to a sick woman via a direct transfusion. (credit: “Immediate transfusion in” by J. H. Aveling/Wellcome Images, CC BY 4.0)

Blood transfusion protocols must adhere to stringent specifications to guarantee patient safety, including compatibility testing, proper storage, observance of expiration dates, and close supervision during administration. Transfusions may be administered based on clinical indications as well as tailored to a patient’s unique medical conditions. Advances in blood component separation and processing techniques continue to enhance both the safety and efficacy of these processes.

Blood Typing and Antigen Response

ABO blood typing is a laboratory procedure used to ascertain an individual’s blood type based on the different antigens (proteins) on the surface of the RBCs. The ABO system classifies these antigens into four main blood types: A, B, AB, and O. This test is essential in blood transfusion procedures to ensure compatibility between donor’s and recipient’s blood types. Blood typing is critical because if incompatible blood is given, the immune system treats the donor cells as if they were foreign invaders and attacks them accordingly. Mismatching of blood products has profound physiological effects if not done so correctly; a catastrophic effect of a severe immune response could have dire consequences, even death.

Table 16.6 lists the types of blood products that are compatible with each blood type (Poh et.al., 2021). Note that recipients with type AB blood can receive blood from any donors, and donors with type O blood can give blood to recipients of any blood type.

Blood Product	Recipient Blood Type	Donor Blood Type	Rh Compatibility
Red blood cells	A B AB O	A, O B, O AB, A, B, O O	Rh-negative patients must receive Rh-negative RBCs. Rh-positive patients must receive Rh-positive RBCs.
Plasma	A B AB O	A, O B, O AB, A, B, O O	Not applicable
Platelets	The same blood type is preferable but not necessary.		Rh compatibility is preferable but not necessary.
Cryoprecipitate (clotting proteins)	The same blood type is preferable but not necessary.		Not applicable

Table 16.6 Blood Products by Type

Examples of Blood Products

Recall that blood is composed of fluid (plasma, which contains clotting factors, electrolytes, and nutrients) and the three major formed elements (RBCs, WBCs, and platelets). These components can be separated and given as treatment for specific medical deficiencies. Table 16.7 outlines the major blood products for each component (American Red Cross, 2021).

Blood Product	Component	Indications	Storage
Packed red blood cells	RBCs, some plasma, and platelets as whole blood	For anemia resulting from blood loss, surgery, trauma, or medical conditions such as sickle cell disease	Typically stored refrigerated; have a shelf life of ~42 days
Fresh frozen plasma (FFP)	Plasma that contains clotting factors, proteins, and electrolytes	Corrects coagulation deficiencies, such as those caused by liver disease, massive transfusions, or clotting factor deficiencies	Frozen within 8 hours of collection and typically stored for up to 1 year
Platelets	Concentrated platelets with less plasma	For conditions with low platelet counts, such as leukemia, chemotherapy-induced thrombocytopenia, or platelet function disorders	Stored at room temperature with a shorter shelf life compared with other blood products (up to 5 days)
Cryoprecipitate	Derived from FFP; contains high concentrations of clotting factors, including fibrinogen	To treat bleeding disorders, particularly those related to fibrinogen deficiencies, such as in cases of trauma, surgery, or liver disease	Frozen within 8 hours of collection and typically stored for up to 1 year
Albumin	Albumin, which is a protein-rich component of plasma	Used to treat hypovolemia, burns, or conditions for which plasma volume expansion is required	Stored at room temperature; has a longer shelf life compared with other blood products; provided in a glass bottle
Granulocyte transfusions	Granulocytes, which are a type of WBC	For severe infections or neutropenia in which the patient is not responding to antibiotics	Have a short shelf life; typically administered shortly after collection

Table 16.7 Blood Products and Components

Nurses need to understand the rationale for administering each blood product and the rationale for type and crossmatch. Transfusion reactions must be avoided, so donated blood must be compatible with the blood of the patient who is receiving the transfusion (Andiç, 2022). More specifically, the donated RBCs must lack the same ABO and Rh D antigens that the patient’s RBCs lack (Andiç, 2022). For example, a patient with blood group B can receive blood from a donor with blood group B, because they lack the A antigen, or they can receive from blood group O because donors with blood group O lack all ABO blood group antigens (Andiç, 2022). Proper blood administration protocols must be followed exactly to avoid the devastating aftermath of mismatch transfusions.

If a patient has a low platelet level but is at risk for fluid volume overload, administering a smaller volume of 50 mL of cryoprecipitate is better than administering a full unit of whole blood (which is approximately 240 milliliters). If a patient’s blood pressure, Hb, and Hct values are low and the laboratory values of platelets are within the normal range, then the volume of whole blood is the better choice. If the Hb, Hct, and vital signs are stable and a provider orders a unit of blood for transfusion, the nurse may need to call the provider and clarify the order.

Read the Electronic Health Record

Laboratory Values after PRBCs

The nurse is caring for a patient who reports feeling weak and tired all the time. The patient has a history of right-sided congestive heart failure, atrial fibrillation, and anemia. The nurse notes atrial fibrillation on the telemetry monitor. The provider ordered two units of PRBCs, each unit to be infused over 4 hours. Laboratory values show the following:

Laboratory Values	Normal Range	Result
Hct	37–52	↓ Hct: 22.4%
Hb	12–18	↓ Hgb: 6.9 g/dL
Blood urea nitrogen	4–10	↑ 21 mg/dL
WBCs	5–10	↑ 10,000/μL
Platelets	150–400	300,000/μL
Creatinine	0.6–1.2	↑ 1.8 mg/dL
Potassium	3.5–5.0	3.7 mEq/L
Sodium	135–145	137 mEq/L

Table 16.8 EHR

1.

What information on the electronic health record concerns you?

2.

Are any of these findings expected?

3.

Is there any information you should question?

Legal and Ethical Implications

Nurses should be aware of the following legal and ethical considerations regarding blood transfusion. These considerations ensure the standards of care are followed and care takes place safely, responsibly, and with due regard for individuals’ rights and well-being.

• Informed consent: Prior to administering blood transfusion services, health-care providers must obtain informed consent from either the patient or the patient’s legal representative. Informed consent ensures that patients understand all potential risks, benefits, and alternatives associated with any procedure or health-care service offered to them. Respect for patients’ autonomy and right to make informed health-care decisions are vital elements of ethical standards of care. Health-care providers must communicate clearly and transparently, providing accurate information for patients to make educated decisions based on facts (INS, 2024). The role of the nurse is to advocate for the patient and witness the consent, ensuring the information was provided in a manner the patient fully understands before the consent form is signed.
• Testing and screening: Blood donors must undergo stringent screening and testing protocols to guarantee safe blood donation practices. Legal regulations govern testing procedures to safeguard transfusion patients against infectious disease transmission through transfusions. Assuring blood product safety also reflects the ethical obligation to shield patients from potential harm. Rigorous testing is essential to safeguarding the health-care system and limiting disease transmission.
• Blood donation policies: Legal frameworks dictate who can donate blood and under what conditions. These regulations may include age and health requirements as well as restrictions based on recent travel or high-risk behaviors. From an ethical perspective, blood donation policies attempt to strike an appropriate balance between meeting an adequate blood supply while protecting donor and recipient well-being. Fairness in donation policies is vitally important in upholding public trust.
• Privacy and confidentiality: Information related to blood transfusions is protected under privacy legislation, offering legal certainty regarding data handling practices. Health-care providers must abide by stringent confidentiality standards. Respecting patient privacy is an ethical imperative and helps develop trust between health-care providers and patients. Protecting sensitive health information is critical for maintaining individuals’ dignity and confidentiality. Legal frameworks may recognize religious or cultural exemptions to certain medical procedures, including transfusions. Health-care providers must navigate these exemptions while upholding patient safety.
• Reporting adverse events or complications: This may be legally mandated, but there are ethical considerations as well. Transparent reporting of adverse events creates an atmosphere of accountability and learning that makes possible continuous improvement of blood transfusion practices to protect patient safety and mitigate risks.
• Resource allocation: A network of local, state, and national guidelines regulates the dispersal of blood products. Ethical considerations begin with the limited supply of blood products. How should providers determine who receives a product if the demand exceeds the supply? How much should products cost, and what role, if any, should cost play in determining whose needs are met?

Cultural Context

Cultural and Religious Beliefs Regarding Transfusions

Ethical nurses consider the cultural diversity and religious beliefs of their patients when providing health care. Some religious groups do not accept blood transfusions. For example, Jehovah’s Witnesses believe the Bible prohibits consumption of blood (Pavlikova & van Dijk, 2022). From their perspective, most believe receiving a blood transfusion, even in life-threatening cases, would violate this prohibition (Pavlikova & van Dijk, 2022). Providers must be prepared to offer alternative interventions that do not use blood products. For example, a bolus normal saline fluid may be used to maintain blood pressure, and the hormone epoetin may help stimulate natural bone marrow production of RBCs.

Nursing Care of the Patient Receiving Blood Products

Though an everyday nursing procedure, administering blood transfusions requires close monitoring to ensure patient safety and well-being. The following are key nursing interventions for blood transfusions:

• Patient assessment: Assess the patient’s baseline vital signs such as temperature, heart rate, blood pressure, and respiratory rate before starting the transfusion process. This information will enable you to quickly notice any deviations that indicate a potential reaction to the transfusion. Document any signs or symptoms of anemia or other conditions necessitating transfusion. The nurse ensures all appropriate informed consent forms are comprehensively completed by the patient or their legal representative prior to the transfusion procedure. The nurse should also educate the patient and their caregivers about the blood transfusion processes, including the purpose, risks, and benefits, to ensure an optimal experience during the blood transfusion.
• Blood product verification: Institutional policies require two registered nurses to implement the verification. The nurses should confirm the patient demographics, medical record number, signed consent form, the blood product type, the registered number that is applied to the product, and the product expiration time and date.
• IV access: Establish IV access and ensure patency before retrieving the blood product. The specialized filtered tubing made for blood products is called Y tubing. It allows a unit of the blood product to be hung on one side of the tubing and normal saline to be on the second side of the Y. Typical IV gauges used for routine or nonurgent transfusions are 20–22 gauge for adults, whereas 16–18 gauge or central venous catheters are preferred for rapid administration (Lotterman & Sharma, 2023). Access assessment is critical because blood products must be administered within a certain time once arriving on the patient’s floor.
• Patient monitoring: Before, during, and after the transfusion, the patient should be monitored carefully. Assessments typically occur within the first 15 minutes after the transfusion, then hourly and at the completion of the transfusion (Lotterman & Sharma, 2023). Delivery of the blood differs between patients, depending on the perfusion requirements and how well the patient can handle volumes. Patients with a history of heart failure may require a slower transfusion due to an impaired heart ventricle that cannot tolerate fast infusions. In contrast, patients with active hemorrhage may receive blood products more rapidly, as prescribed.

Real RN Stories

Nurse: Nancy, BSN
Years in Practice: Forty-five
Clinical Setting: Surgical step-down unit
Geographic Location: Washington, DC

I have been a nurse for a long time! I remember giving blood in the 1980s before HIV was identified. Before the blood-transmitted virus was identified, our blood transfusion delivery was much less strict. The testing and safety measures for any unit of donated blood were less stringent. It has been interesting to watch the evolution of a much more detailed process for blood donations and administration. Although it takes the nurse much longer to prepare and administer a single unit of PRBCs, it is satisfying to know the blood we are giving a recipient has been strictly screened for a myriad of potential problems. Blood is life, but giving the wrong blood can be death!

Recognizing and Analyzing Cues

The most critical cues for a nurse to be aware of during a transfusion is for a transfusion reaction within the first 15 minutes of transfusion (Bates & Owusu-Ofori, 2020). Table 16.9 lists important cues by body systems.

System	Cues
Neurologic	Dizziness, anxiety, localized pain Disorientation if the reaction develops into shock
Integumentary	Flushing, itching, hives, chills Edema if the reaction is due to fluid volume overload
Respiratory	Wheezing, shortness of breath, dyspnea
Cardiac	Tachycardia, hypotension, shock
Gastrointestinal	Nausea, abdominal pain
Genitourinary	Dark or blood-tinged urine, hematuria, lower back pain
Renal	Hematuria, hemoglobinuria

Table 16.9 Most Common Transfusion Reaction Cues by Body System

There are different types of reactions to a blood transfusion. Treatment varies depending on the cause (Cleveland Clinic, n.d.).

• A febrile nonhemolytic reaction: This is the most prevalent reaction type. It usually manifests through an increase of 1° in temperature over baseline. When this happens, patients typically receive acetaminophen for treatment before returning for further transfusion if deemed safe by their medical provider.
• An allergic reaction: This happens when there is an allergy to one or more proteins present in donor blood. Symptoms may range from mild irritation to serious anaphylaxis (which is rare). Most often, this reaction will not require disrupting transfusion, because diphenhydramine may provide sufficient relief.
• An acute hemolytic reaction: This reaction, typically due to an administrative mistake, is caused by an ABO mismatch between donor and recipient. The patient may complain of low back pain, itching, or increased body temperature. It can lead to serious symptoms, including low blood pressure and shock, hemoglobinuria, nausea, vomiting, pain, chills, and fever. The patient can show extreme distress, including hypotension from shock as well as nausea, vomiting, chills, fever, and hemoglobinuria (the breakdown of Hb in the urine).
• A delayed hemolytic reaction: Most transfusion reactions happen within 15 minutes of transfusion. If the reaction happens after 15 minutes, it is considered delayed. Delayed hemolytic reactions manifest with similar clinical symptoms as other transfusions.
• A septic reaction: Septic reactions arise when blood products, particularly platelets, are improperly stored and become contaminated. Shortly after the transfusion, patients may exhibit signs of severe infection, including high fever, chills, hypotension, and tachycardia, as well as nausea, vomiting, dyspnea, and even cardiovascular collapse. Septic transactions usually happen within hours or soon after blood transfusion has taken place.
• A transfusion-related acute lung injury (TRALI): Transfusion reactions can often result in acute respiratory distress syndrome due to an immune response between donor antibodies and antigens in a recipient, which triggers mediator release, resulting in pulmonary edema and causing rapid tissue swelling. Signs and symptoms manifest during or shortly after transfusion; they include respiratory distress symptoms such as shortness of breath. On physical assessment, the patient may have rales in the lung fields.
• A transfusion-associated circulatory overload (TACO): This reaction happens when fluid volumes exceed expectations. Symptoms include shortness of breath and coarse lung sounds. This condition could also include possible widespread edema. Patients with background heart failure may receive a dose of diuretics, such as furosemide, to mitigate this reaction.

Link to Learning

A further explanation of the differences between TACO and TRALI is given in this video.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

When administering a blood transfusion, nurses use clinical judgment and critical thinking to identify a transfusion reaction. Prioritizing actions is critical to avoid serious complications. For example, knowing the patient’s baseline vital signs and clinical status are key to be able to compare baseline values with any changes throughout the transfusion. Immediately stopping the blood transfusion when a reaction is occurring is important. Knowing the steps to take to stop a transfusion reaction helps the nurse generate solutions and act quickly:

• Stop the transfusion.
• Disconnect the blood tubing and flush the patient’s IV with normal saline.
• Prime new IV tubing with normal saline and infuse at a lowered rate to keep the vein open (typically 20 mL/h).
• Notify the provider.
• Monitor the patient’s vital signs and remain with the patient.
• Prepare to obtain blood and urine specimens from the patient to send to the laboratory.
• Send the used blood bag and IV tubing to the blood bank for further testing.

Evaluation of Nursing Care for the Patient Receiving Blood Products

Evaluating nursing care for patients receiving blood products is essential to ensure both safety and effectiveness during a transfusion. Evaluation involves gauging a patient’s response to the transfusion, observing for any possible complications, and quickly responding to any issues as soon as they arise. The following are key questions to ask during evaluation:

• Did the patient’s vital signs remain stable during administration of blood products? Did they normalize after the transfusion?
• Did the patient’s blood Hb, Hct, platelets, and RBC levels return to target norms?
• Does the patient report improvement in fatigue?
• Did the patient tolerate the blood transfusion without any incidence of transfusion reaction?

By conducting systematic nursing care evaluations before, during, and after blood transfusions, nurses can identify any problems, respond quickly to complications that arise, and promote patient safety and well-being. Continuous quality improvement efforts further optimize this process and the patient outcome.