JCAHO Essential
Education Information on Blood Transfusion Reactions
'
¿After the transfusion:
Monitor the patient for signs of adverse
reactions.
Some transfusion reactions may not occur for up to
weeks after the transfusion. You should continue to monitor the patient for
signs such as urticaria, fever, or fatigue, especially if associated with a
decreasing hemoglobin.
Document the patient’s response to the
transfusion.
Place the
medical record’s copy of the blood bag tag in the patient’s chart. Either the
physician or the nurse needs to make a progress note entry that describes the
patient’s response to the transfusion. This note should include what outcomes
were achieved, such as increased hemoglobin and change in physical assessment.
Complete the transfusion reaction work-up, if
appropriate.
1. Complete the transfusion reaction
section of the blood bag tag indicating the patient's vital signs and symptoms.
2. Place the top copy of the blood bag tag in
the patient's medical record and return the remaining two copies along with the
bag of blood or blood product with the administration set and any attached IV
solutions to the Blood Bank.
3. A red top tube and a purple top tube of blood should be obtained, labeled
as "Post-Transfusion Reaction" and sent to the Blood Bank. The Blood Bank
physician will notify the nursing unit if additional transfusion reactions are
required.
4. Document the following in the patient's medical record:
.Time transfusion discontinued
.First initial, last name and classification of person starting the
infusion and the two people verifying the blood or blood product.
