Blood Transfusion Nursing Diagnosis and Nursing Care Plan

Last updated on April 29th, 2023 at 11:17 pm

Blood Transfusion Nursing Care Plans Diagnosis and Interventions

Blood Transfusion NCLEX Review and Nursing Care Plans

Blood Transfusion (BT) is a medical procedure that involves the transfer of whole blood or blood components/products from one person to another.

If the body is deficient in one or more of the components that make up healthy blood, a transfusion can help supply what the body is missing.

Understand the basics behind this potentially life-saving procedure, as well as how nurses should manage and intervene before, during, and after the procedure.

Indications of Blood Transfusion

Blood Transfusions are generally given to people for several reasons, including anemia, complications during pregnancy and childbirth, severe trauma due to accidents, and surgical procedures.

The following are the key goals of this procedure:

  • To maintain adequate oxygen capacity of blood by giving red blood cells.
  • To maintain adequate tissue perfusion by restoring the blood volume.
  • To replace coagulation factors, platelets, and other plasma proteins.

Blood is frequently needed in circumstances such as blood loss secondary to bleeding and trauma, inadequate blood production brought about by chronic blood disorders such as thalassemia and leukemia, and excessive cell destruction.

Blood transfusions should only be used to treat a condition that would cause considerable morbidity or mortality that could not be avoided or controlled adequately with alternative methods.

Blood Components

A blood component is a part of the blood that has been separated from whole blood. It is made up of several parts, including the ones listed below:

  1. Whole blood cells. In general, whole blood cells are only indicated for patients who require both oxygen-carrying capacity enhancement and blood volume restoration when there is no time to get ready or acquire the particular blood components required.
  2. Packed Red Blood Cells (RBCs). Packed red blood cells should be transfused over 2 to 3 hours; if the patient cannot tolerate volume for more than 4 hours, the blood bank may need to divide a unit into smaller volumes, with proper refrigeration of remaining blood until needed. One unit of packed red cells should increase hemoglobin by about 1% and hematocrit by about 3%.
  3. Platelets/ As quickly as possible, platelets should be transfused (usually 4 units every 30 to 60 minutes). The recipient’s platelet count should increase by 6000 to 10,000/mm3 with each unit of platelets; however, alloimmunization from previous transfusions, hemorrhage, fever, infection, autoimmune destruction, and hypertension all result in poor incremental gains.
  4. Granulocytes. Granulocytes, which contains basophils, eosinophils, and neutrophils, can help a small group of infected, highly granulocytopenic individuals (less than 500/mm3) who are not responding to antibiotics and are likely to have a long period of limited granulocyte production.
  5. Plasma. Other colloids (e.g., albumin) or electrolyte solutions (e.g., Ringer’s lactate) are chosen if just volume expansion is necessary because plasma has a hepatitis risk equal to that of whole blood. In addition, because coagulation factors become unstable after thawing, fresh frozen plasma should be given as soon as possible.
  6. Albumin. In patients with hypoalbuminemia, albumin is used to increase blood volume and increase the supply of circulating albumin in patients in hypovolemic shock. Plasma oncotic pressure is largely caused by a big protein molecule.
  7. Cryoprecipitate. Hemophilia A, Von Willebrand’s disease, disseminated intravascular coagulation (DIC), and uremic hemorrhage can all be treated with cryoprecipitate.
  8. Factor IX concentrate. The use of Factor IX concentrate for the treatment of hemophilia B is recommended, but it has a high risk of hepatitis since it requires a large number of donors to be pooled.
  9. Factor VIII concentrate. The use of heat-treated product Factor VIII concentrate in the management of hemophilia A is advised since it reduces the risk of hepatitis and HIV transmission.
  10. Prothrombin complex. This blood component is being used in the case of congenital or acquired deficiency of prothrombin factors.

Prevention of Blood Transfusion Reactions

Blood transfusions are generally regarded to be safe, however there are some risks involved. Complications may appear right away, or they may take some time to appear.

The following are some of the most common blood transfusion adverse reactions or complications.

  1. Allergic reactions. It is a result of the donor antibody’s plasma protein reacting with the receiver antigen’s plasma protein. Flushing, hives, pruritus, laryngeal edema, and shortness of breath should all be watched out for by the nurse.
  2. Non-Hemolytic Fever. When having a blood transfusion, this is the most symptomatic adverse effect that the patient can have. A hypersensitive reaction to donor white cells, platelets, or plasma proteins is the cause of the fever. Flushing, headaches, chilles, fever, and anxiety are all common manifestations of this reaction.
  3. Septic Reaction. It is caused by a blood transfusion or a component that’s been contaminated with bacteria. Rapid onset of chills, vomiting, marked hypotension, and a high temperature should all be checked by the nurse.
  4. Circulatory Overload. It is caused by a high rate of blood supply that exceeds the capacity of the circulatory system. Increased venous pressure, dyspnea, crackles or rales, distended neck vein, cough, and elevated blood pressure should all be monitored by the nurse.
  5. Hemolytic reaction. Infusion of incompatible blood products is what causes it. Low back discomfort (initial sign), which is caused by the kidneys’ inflammatory response to incompatible blood, chills, feeling bloated, tachycardia, flushing, increased respiratory rate, low blood pressure, hemorrhage, vascular collapse, and acute renal failure should all be monitored by the nurse.

Assessment on Blood Transfusion Adverse Reactions and Complications

  1. Depending on the triggering cause, the clinical symptoms of blood transfusion complications may vary.
  2. The following are the signs and symptoms of a hemolytic transfusion reaction: fever, chills, low back pain, flank pain, headache, nausea, flushing, tachycardia (increased heart rate), tachypnea (increased pulmonary rate), hypotension (drop in blood pressure), and hemoglobinuria (cola-colored urine).
  3. In a delayed hemolytic reaction, the following clinical symptoms and laboratory results are present: fever, mild jaundice, gradual fall of haemoglobin, and positive Coombs’ test.
  4. The Febrile non-hemolytic reaction is characterized by temperature rise during or shortly after transfusion, chills, headache, flushing, and anxiety.
  5. The following are the signs and symptoms of a septic reaction: rapid onset of high fever and chills, vomiting, diarrhea, and marked hypotension.
  6. Allergic reactions from blood transfusion may exhibit hives, generalized pruritus, wheezing or anaphylaxis.
  7. The following are some signs and symptoms of circulatory overload: Dyspnea, cough, rales, and jugular vein distention.
  8. Depending on the condition, the symptoms of an infectious disease transmitted through transfusion may appear quickly or slowly.
  9. The following are some of the symptoms of Graft versus host disease (GvHD): skin changes (e.g. erythema, ulcerations, scaling), edema, hair loss, and hemolytic anemia.
  10. Massive blood transfusions cause a variety of reactions, each with its own set of symptoms.

Although it is very tough to prevent the above-mentioned adverse reactions and complications of blood transfusion, nurses should carefully undertake the following recommended nursing interventions to minimize their occurrence.

Transfusion reactions can be avoided by:

  • Double-checking blood product and patient identification prior to transfusion by collecting and labeling type and crossmatch samples to double-check blood product and patient identification before transfusing blood or blood components.
  • Before administering the blood product, inspect it for any gas bubbles, clothes, or unusual color.
  • Begin transfusion cautiously (1 to 2 mL/min) and keep a close watch on the patient, especially in the first 15 minutes, as severe reactions usually become apparent within 15 minutes after the start of transfusion.
  • To significantly reduce the risk of bacterial growth in warm room temperatures, transfuse blood within 4 hours and change blood tubing every 4 hours.
  • By carefully screening donors or completing pre-tests available to identify chosen infectious agents, infectious illness transmission can be avoided.
  • Prior to transfusion, ensure that blood products containing healthy White Blood Cells (i.e. whole blood, platelets, packed Red Blood Cells, and granulocytes) are irradiated; this affects the ability of donor lymphocytes to engraft and divide and prevents graft versus host disease (GvHD).
  • Warming the blood unit to 37 degrees Celsius before transfusion to avoid hypothermia.
  • Installing a microaggregate filter (20-40-um size) in the blood line to eliminate leukocytes and platelets aggregates from donor blood during transfusion.

Recognizing any reaction signs or symptom or adverse reactions:

  • Stop the transfusion as soon as possible and contact the primary health care provider.
  • Disconnect the transfusion set, but keep the 0.9 percent saline IV line open to allow for a prospective IV medication infusion.
  • Take the blood bag and tubing to the blood bank for a second culture and typing.
  • Take a second blood sample for plasma hemoglobin analysis, as well as a culture and retyping.
  • Take a urine sample as quickly as possible to determine the hemoglobin level.

Respond as necessary to manage the adverse reaction’s symptoms:

  • The goal of hemolytic reaction treatment is to prevent hypotension, dialysis, and renal failure caused by RBC hemolysis and hemoglobinuria.
  • Antipyretics are used to treat symptomatically nonhemolytic transfusion reactions; leukocyte-poor blood products may be considered for future transfusions.
  • Antibiotics, additional hydration, steroids, and vasopressors, as ordered by the primary care physician, must be used to treat septicemia in the event of a septic reactions.
  • If an allergic reaction occurs, treat it with antihistamines, steroids, or epinephrine, depending on the extent of the reaction. (Transfusion can sometimes continue, but at a slower rate, if hives are the sole symptom.)
  • Immediately treat circulatory overload by keeping the patient upright and dependent on their feet; diuretics, oxygen, and aminophylline may be administered.

Blood Transfusion Reaction Nursing Interventions

  • DISCONTINUE THE BLOOD TRANSFUSION if the patient has an adverse reaction.
  • Begin the IV line of 0.9 percent NaCl (Sodium Chloride)
  • To alleviate shortness of breath, place the client in Fowler’s position and deliver oxygen therapy.
  • The nurse stays with the client for up to 5 minutes at a time, noting signs and symptoms and checking vital signs.
  • Notify the primary healthcare physician as soon as possible.
  • As per the physician’s instructions or protocol, the nurse prepares to deliver antihistamines, vasopressors, fluids, and steroids in the event of an emergency.
  • The presence of hemoglobin as a result of RBC hemolysis should be determined by obtaining a urine sample and sending it to the laboratory.
  • The transfusion record, blood container, tubing, and affixed label are all saved and forwarded to the laboratory for analysis.

Nursing Diagnosis For Blood Transfusion

Blood Transfusion Nursing Care Plan 1

Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern related to blood transfusion as evidenced by increased respiratory rate, labored breathing, nasal flaring and cough.

Desired Outcome: The patient will maintain an effective breathing pattern, as evidenced by normal respiratory rate, relaxed breathing, and absence of cough.

Nursing Interventions for blood TransfusionRationale
Assess and record respiratory rate and depth as often as every 5 minutes while also observing the breathing patterns.Adults take between 10 and 20 breaths per minute on average. When the patient’s breathing patterns change, it’s critical to act quickly, as it might be an early sign of adverse reactions from blood transfusion.
Auscultate breath sounds as necessary.Breath sounds auscultation is used to detect decreased and adventitious breath sounds such as rales which is one of the symptoms of circulatory overload.
Place the patient to fowler’s, a position with proper body alignment for maximum breathing pattern.Sitting allows the patient’s lungs to expand and contract to their full potential.
Encourage the patient to use diaphragmatic breathing.Diaphragmatic breathing method relaxes the muscles and increases the patient’s oxygen level.
Administer antihistamines, respiratory medicines and oxygen according to the doctor’s instructions.Medications are used to open air passages by relaxing smooth muscles in the airways and causing bronchodilation. While oxygen is typically used to increase the supply of oxygen levels in blood.
Encourage the patient to mobilize their own secretions through effective coughing method.Effective coughing is used to maintain a clear airway.
During acute respiratory distress episodes, stay with the patient.By being with the patient, the nurse will be able to lessen the patient’s anxiety and hence the demand for oxygen.

Blood Transfusion Nursing Care Plan 2

Fluid Volume Excess

Nursing Diagnosis: Fluid Volume Excess related to blood transfusion reactions as evidenced by crackles breath sounds, jugular vein distention, changes in blood pressure, and oliguria.

Desired Outcome: The patient will be normovolemic as evidenced by urine output greater than or equal to 30 mL/hr, clear lung sounds, blood pressure with established limits, and absence of jugular distention.

Nursing Interventions for blood TransfusionRationale
Monitor the patient’s input and output thoroughly.The input and output of the patient is one of the indicators of his fluid volume status. Dehydration may also be the result of fluid shifting during blood transfusion even if overall fluid intake is adequate.
Monitor the vital signs and note any significance in Blood Pressure and Heart rate.Sinus tachycardia and increased Blood Pressure are apparent in early stages of fluid volume excess.
Administer diuretics as prescribed by the primary healthcare physician.Diuretics are usually ordered in case of fluid volume excess following a blood transfusion procedure, it aids in the excretion of excess body fluids.
Regulate the rate of IV fluids and medications strictly as prescribed and cooperate with the pharmacist on their increased concentration.Strict adherence to prescribed rates of IV fluids and medicines is necessary to avoid the aggravation of fluid volume excess. Concentration, on the other hand, decreases unnecessary fluids.
Put the patient in either a semi-Fowler’s position.The semi-Fowler’s position is also done to properly evaluate the jugular vein distention. It allows ease of breathing by expanding the chest.
Elevate edematous extremities if present and treat them with caution and care.Elevation of affected areas reduces edema by increasing venous return to the heart. While the edematous skin is more vulnerable to injury, therefore caution is highly advised.
Instruct the patient and family members regarding the appropriate fluid restrictions.Patients who will be co-managing fluids will need to know as much as possible about their condition to ensure compliance.

Blood Transfusion Nursing Care Plan 3

Altered Tissue Perfusion

Nursing Diagnosis: Altered Tissue Perfusion related to complications from blood transfusion

Desired Outcome: The patient will show no further deterioration and maintain maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range, normal Arterial Blood Gas (ABG), adequate urine production and absence of swelling.

Nursing Interventions for blood TransfusionRationale
Assess the patient for any signs of decreased tissue perfusion.The distinguishing qualities of Altered Tissue Perfusion Evaluation serve as a benchmark for comparison in the future.
As needed, submit the patient for diagnostic testing.A variety of tests may be described when altered tissue perfusion is suspected as complications of the blood transfusion.
Closely monitor the fluid balance of the patient. As directed, administer IV fluids.Intake of sufficient fluids helps to maintain proper filling pressures and maximizes the amount of cardiac output required for tissue perfusion.
Assist the patient with position changes.The likelihood of orthostatic BP fluctuations can be reduced by gently shifting the patient from supine to sitting/standing position.
Administer medications as prescribed by the primary healthcare physician.These medications facilitate adequate tissue perfusion of the patient.
As tolerated, place the patient in a semi-to Fowler’s high-position.Alveolar gas exchange is enhanced when the patient assumes the semi-to Fowler’s high-position.
Keep the patient warm.The extremities should be kept warm to sustain vasodilation and blood flow in patients with arterial insufficiency who complain of being continually cold.
Instruct the patient on how to identify signs and symptoms that should be reported to the nurse and explain all procedures and treatments accordingly.Treatment can be started right away if early detection of the patient will be encouraged.

Blood Transfusion Nursing Care Plan 4


Nursing Diagnosis: Hyperthermia related to adverse reactions from blood transfusion as evidenced by increase in body temperature, warm skin and chills.

Desired Outcome: The patient will maintain normal body temperature as evidenced by an acceptable range of vital signs, dry skin and absence of chills.

Nursing Interventions for blood TransfusionRationale
Monitor the vital signs of the patient every 5 minutes as possible.A healthcare provider can determine the need for intervention as well as the effectiveness of treatment by carefully observing the patient.
Provide Tepid Sponge Bath as necessary.Tepid Sponge Bath (TSB) aids in the body’s temperature reduction.
Administer antipyretics, as directed by the attending physician.Antipyretics will help in quickly reducing the body temperature of the patient.
Administer leukocyte-poor blood products for subsequent transfusions, as instructed by the attending physician.Leukocyte-poor blood products are known to minimize Febrile non-hemolytic blood transfusion reactions.
As necessary, adjust and monitor environmental conditions such as room temperature and bed sheets.The temperature of the room can be adjusted to close to the client’s normal body temperature, and the blankets and linens can be modified as needed to keep the client’s body temperature in check.
As indicated, provide a cooling blanket to the patient.Cooling blanket helps reduce elevated body temperature especially with temperatures of 39.5ᴼC – 40ᴼC.
Encourage the patient to drink more water.Water regulates body temperature and prevents the possible risk of dehydration.

Blood Transfusion Nursing Care Plan 5


Nursing Diagnosis: Hypothermia related to adverse reactions from blood transfusion procedure as evidenced by 33.5 degrees Celsius body temperature, cold clammy skin, shivering and slow weak pulse.

Desired Outcome: The patient will re-establish a normal body temperature between 36 degrees Celsius and 37.4 degrees Celsius.

Nursing Interventions for blood TransfusionRationale
Monitor the vital signs of the patient, taking note of the temperature, heart rate, rhythm and blood pressure.Aside from the temperature, hypothermia causes a drop in heart rate and blood pressure. Hypothermia of any kind, from mild to severe, raises the risk of ventricular fibrillation and other arrhythmias.
Adjust the temperature of the room or move the patient to a more comfortable location. Keep the patient and linens dry at all times.The body is gradually warmed using these methods. Ventricular fibrillation can be caused by rapid warming. Evaporative heat loss is aided by moisture.
Adapt the heat source to the patient’s physical reaction.The temperature of the body should not be increased by more than a few degrees every hour. As the patient’s core temperature rises, the blood pressure drops, causing vasodilation.
Provide extra covering (passive warming) such as garments and blankets.Rewarming through this method is done passively with warm blankets.
Warming pads, mattresses, or blankets, submersion in a warm bath, heated, moisturized oxygen, warmed intravenous fluids, or lavage fluids, are all examples of additional heat sources which can be provided to the patient, if applicable.The body temperature is raised and circulation is improved as a result of these procedures.
For patients who are alert, give them warm oral fluids.Warm fluids produce a heat source which can increase the body temperature of the patient.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon


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This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna Curran. RN, BSN, PHN

Anna Curran. RN-BC, BSN, PHN, CMSRN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.

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