DEPARTMENTAL POLICY AND PROCEDURE (DPP)

DEPARTMENT: NICU
TITLE/DESCRIPTION
POLICY NUMBERBLOOD TRANSFUSION THERAPY DPP-NIC-010-V5
EFFECTIVE DATE REVISION DUE
11-11- 11-09-1443H DPP-NIC-010-V4 Page 1 of 5
1440HReplaces
Numberno. of pages
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR NICU MEDICAL, NURSING STAFF AND
BLOOD BANK

PURPOSE
1. To restore intravascular volume after hemorrhage.
2. To restore the oxygen-carrying capacity of blood by replacing red blood cells.
3. To replace clotting factor and correction of anemia.
DEFINITION
Blood transfusion therapy is the intravenous administration of whole blood or blood component
for therapeutic purposes.
RESPONSIBILITIES
.NICU Medical, Nursing staff and Blood bank
POLICY
1. Blood transfusion therapy must have a physician’s written order.
2. Standard precautions are to be followed when handling blood product.
3. Blood for transfusion must be cross matched to the recipients' blood type.
4. Blood transfusion must be checked at patient’s bedside by two registered nurses or a
registered nurse and a physician before infusion.
4.1. Name of patient
4.2. Chart number
4.3. Serial Number on the Blood bag level
4.4. Expiration date
4.5. Blood Group compatibility
4.6. Serology – free results
5. Baseline vital signs should be taken and recorded.
6. A standard blood filter must be used. Do not use the standard IV tubing set.
7. Nurse should observe patient closely for the first 5 to 15 minutes after the blood
transfusion is initiated.
8. The blood transfusion is to begin slowly and should be completed within 2 to 4 hours.

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9. Blood transfusion should be stopped and physician should be notified immediately if
signs of blood transfusion reaction occur.
10. Close observation of patient throughout the procedure for signs and symptoms of blood
DEPARTMENTAL POLICY AND PROCEDURE (DPP)
DEPARTMENT: NICU
TITLE/DESCRIPTION POLICY NUMBER
BLOOD TRANSFUSION THERAPY DPP-NIC-010-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
11-11-1440H 11-09-1443H DPP-NIC-010-V4 Page 2 of 5
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR NICU MEDICAL, NURSING STAFF AND
BLOOD BANK
reaction such as fever, allergy, and anaphylactic reaction. Have emergency medication
always available.
11. Medication should never be injected into an IV line with the blood component because of
the risk of contaminating the blood product with bacteria.
PROCEDURES
1. Verify a written order for Blood 1. A written order requesting the blood
Transfusion transfusion therapy must be made by a
physician prior to implementation of this
procedure.

2. Assess the patient for the following: 2.2 Verify patency of cannula.
2.1. History of blood reaction
2.2. Check blood return for venous
access.
3. Check that transfusion consent has been 3. Patient consent must be obtained.
properly completed.

4. Explain procedure to patient and family if 4. To allay anxiety and obtain

present. cooperation from patient

5. Pre-medicate the patient as per doctor, 15 5. To prevent and/or alleviate infusion

to 30 minutes before transfusion. reaction

6. Obtain blood product by registered nurse

from blood bank.

7. Check the blood product by two Staff Nurses 7. This is to make sure blood is given
on the following: correctly to the right patient.
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 8.1 Name of patient
. 8.2 Chart number
DEPARTMENTAL POLICY AND PROCEDURE (DPP)
DEPARTMENT: NICU
TITLE/DESCRIPTION POLICY NUMBER
BLOOD TRANSFUSION THERAPY DPP-NIC-010-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
11-11-1440H 11-09-1443H DPP-NIC-010-V4 Page 3 of 5
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR NICU MEDICAL, NURSING STAFF AND BLOOD
BANK

8.3 Serial Number of blood

8.4 Expiration date
8.5 Blood Group compatibility.
All information must match on the document
and patient.
8. Wash hands and wear disposable gloves. 8. Reduce transmission of microorganism.
Prevent exposure to patient’s blood and
body fluid.
9. Prime the blood administration set with 9. Blood products are only compatible
Normal Saline, ensure that it flush through with Normal Saline. Flushing prevents
the IV tubing to clear air bubbles. infusion of air and potential air embolism.

10. Invert blood component bag gently 2 to 3 10. Equally distribute cell throughout
times. preservatives solution.

11. Spike the product bag using aseptic technique 11. Opening of clamp will prime the
with clamp close. Squeeze drip chamber, tubing with Normal Saline. Priming the
allowing saline to cover the filter. tubing remove air from the system.
12. Open the IV clamp and allow the blood to
completely cover the filter.

13. Close the clamp on the Normal Saline and 13. Prevent back flow of blood into the
open the clamp on the blood. Allow the blood Normal Saline.
to completely cover the filter.

14. If no signs of reaction for the first 15 mins., 14. Maintaining the prescribed rate of flow
regulate the flow rate according to Physician’s decreases risk of fluid volume excess
order at least 2 to 4 hours ( drop factor for blood while restoring vascular volume.

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 DEPARTMENTAL POLICY AND PROCEDURE (DPP)
DEPARTMENT: NICU
TITLE/DESCRIPTION POLICY NUMBER
BLOOD TRANSFUSION THERAPY DPP-NIC-010-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
11-11-1440H 11-09-1443H DPP-NIC-010-V4 Page 4 of 5
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR NICU MEDICAL, NURSING STAFF AND
BLOOD BANK

transfusion is 10 drops/ml).

15. Monitor vital signs 15 minutes after the blood 15. Frequent monitoring of vital signs will
transfusion has started. help the nurse to alert quickly to any
transfusion reaction.
16. Observe for chills, flushing, dyspnea, rash or
other signs of transfusion reaction.

17. Stop blood transfusion immediately, and 17. Prompt intervention may minimize
inform doctor of any adverse hemolytic reaction. potential for serious complications

18. Flush the IV tubing with Normal Saline and 18. Infuse IV saline solution to keep IV
discard the blood bag, when transfusion is line patent for supportive measures in
completed. case of a delayed transfusion reaction

19. Document the completion of procedure in

nurses notes amount of blood infused, vital signs
and the response of the patient.
1. EQUIPMENTSStandard blood administration set with filter (170 micron filter)
2. Normal Saline and Blood products as prescribed
3. Alcohol 70%
4. Plaster
5. I.V.stand
6. Tourniquet
7. Venous canula size 20 or 18 for adults or 22 for pediatric
8. Emergency drugs e.g. Antihistamine, Epinephrine, Benadryl, Hydrocortisone
DEPARTMENTAL POLICY AND PROCEDURE (DPP)
DEPARTMENT: NICU
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TITLE/DESCRIPTION POLICY NUMBER
BLOOD TRANSFUSION THERAPY DPP-NIC-010-V5
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
11-11-1440H 11-09-1443H DPP-NIC-010-V4 Page 5 of 5
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR NICU MEDICAL, NURSING STAFF AND
BLOOD BANK

Suction and oxygen set up at patient’s bedside.CROSS REFERENCES

N/AREFERENCESDepartment of Nursing Administrative Policy. Unit level
orientation manuals, current standards of nursing practice, educational preparation and
licensure.
CBAHI Standards; MOH StandardsFORMS N/A

Approvals: Name Position Signature Date

Prepared by Hudiba Mattar Al
Head Nurse 25-07-1440H
Shammari
Reviewed by Dr. Mohamed Ahmed
Head of NICU 29-07-1440H
Abushawali
Reviewed by Fahad Khamis Al-
Nursing Director 03-08-1440H
Shammari
Reviewed by Quality
Dr. Emad Kotb Al-
Management 07-08-1440H
Din
Director
Approved by Dr. Mohd Shams Al-
Medical Director 09-08-1440H
Din
Approved by Mohd Mouhedi Al-
Hospital Director 08-09-1440H
Najdi

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