Blood Transfusion Flow Sheet

BLOOD TRANSFUSION FLOW SHEET

Patient DATE: ______BLOOD COMPONENT: ______Allergies: DONOR #: ______

1. Order to give blood on chart: ☐Yes ☐No 7. NS hung with blood filter: Time ______2. Patient name band on and correct: ☐Yes ☐No 8. Transfusion started: Time: ______☐ ☐ 3. Crossmatch Identification Bracelet on: ☐Yes ☐No 9. Warming coil used? Yes NO ☐ ☐ 4. Blood Transfusion Consent signed: ☐Yes ☐No 10. Hx of previous transfusion Yes No ☐ ☐ 5. Lab called – Blood is ready: Yes No Reaction: ______6. Condition of IV site: ☐Intact ☐Restarted

CIRCLE IF PATIENT HAS HAD IN LAST 24 HOURS:

FEVER CHILLS NAUSEA DYSPNEA HEADACHE CYANOSIS BACKACHE URTICARIA

CHEST PAIN RASH MENTAL CONFUSION OTHER: ______

Infusion Assessment (See Chart below for Normal Time Temp. Pulse Resp. B/P Rate Assessment)

☐ Normal Assessment

☐ Abnormal, See Comments ☐ Normal Assessment

☐ Abnormal, See Comments

247 Nuero Alert, oriented x 3. Behavior appropriate to situation. PERRLA. Active ROM to all extremities with symmetry of strength. No parasthesia. Verbalization clear and understandable. Swallowing without coughing or choking on liquids or solids CV Regular, apical pulse. Neck veins flat at 45 degrees. Peripheral pulses palpable. No edema or calf tenderness. CRT < 3 sec. Peripheral pulses palpable. Resp Respirations 10-20/min. at rest, quiet and regular. Breath sounds clear and equal bilaterally to auscultation. Sputum clear. GU Able to empty bladder without dysuria. Bladder not distended after voiding. Urine clear-yellow to amber.

COMMENTINTERVENTION Signature TIME

POST-TRANSFUSION ASSESSMENT: ______

______

Empty Blood Bag Returned to Lab: ☐Yes ☐No Time: ______

DID SYMPTOMS OF A TRANSFUSION REACTION OCCUR: ☐YES ☐NO IF YES, Complete the following:

FEVER CHILLS NAUSEA DYSPNEA HEADACHE CYANOSIS BACKACHE URTICARIA

248 CHEST PAIN RASH MENTAL CONFUSION OTHER: ______

Time transfusion stopped: ______Physician Notified: ☐Yes ☐No TIME: ______

Time Lab Notified: ______Urine Specimen Sent to Lab: ☐Yes ☐No Time: ______

Transfusion Reaction completed on Blood Bank Record: ☐Yes ☐No Time: ______

N:Syllabus/Skills/1216/Blood Transfusion Flow Sheet Reviewed 05/15