Far Eastern University
Institute of Health Sciences and Nursing
Department of Nursing
AY 2023-2024
Performance Evaluation Tool
BLOOD TRANSFUSION
Name:________________________ Concept:________________ Score:_________
Section/Group No.:______________ Faculty:_________________ Date:__________
RATING QUANTITATIVE
SCALE DESCRIPTION
2 ACCEPTABLE Demonstrates expected procedures / behaviors correctly
1 MODERATELY Demonstrates expected procedure/behavior with minimal error
ACCEPTABLE
0 UNACCEPTABLE Missed procedure or procedure done but entirely incorrect
A. PREPARATION RATING REMARKS
1. Check the doctors order with the request. 0 1 2
2. Check patient’s name, serial number, blood type, Rh group, 0 1 2
the blood donor’s number and the expiration date of the
blood together with the head nurse.
3. Observe the blood for abnormal color, clumping, gas 0 1 2
bubbles and extraneous material.
4. Ensure that consent for blood transfusion was signed. 0 1 2
5. Determine if there is no known allergies or previous adverse 0 1 2
reactions to BT.
6. Introduce self to patient. 0 1 2
7. Verify patient’s name. 0 1 2
8. Inform patient of the procedure and its importance. 0 1 2
9. Perform handwashing. 0 1 2
10. Check baseline vital signs. 0 1 2
11. Assemble articles and equipment needed at the bedside. 0 1 2
12. Position patient accordingly. 0 1 2
B. INITIATING BLOOD TRANSFUSION
13. Don on gloves. 0 1 2
14. Close all the clamps. 0 1 2
15. Insert the piercing pin (spike) into a container of 0.9 percent 0 1 2
saline solution using a twisting motion.
16. Hang the IV container on the IV pole. 0 1 2
17. Squeeze the drip chamber of the normal saline until it covers 0 1 2
one-third of the drip chamber.
18. Expel any residual air in the tubing. 0 1 2
19. Start the saline solution. 0 1 2
20. Prepare the blood bag by inverting the blood bag gently 0 1 2
several times to mix the cells with the plasma.
21. Close the roller clamp of the filter set.
0 1 2
22. Attach a needle at the other end of the filter set.
0 1 2
23. Expose the part of the blood bag by pulling back the tabs. 0 1 2
24. Insert the spike of the filter set into the blood bag. 0 1 2
25. Open the clamp of the blood bag to prime the tubing then
0 1 2
closes the clamp.
26. Close the clamp on the IV saline solution. 0 1 2
27. Insert the needle of the blood bag to the Y- port of the saline 0 1 2
IV bottle then opens the clamp of the blood bag
28. Regulate the blood slowly for the first 10 minutes at 15 drops
0 1 2
per min.
29. Observe the patient closely for the first 15 minutes for any
0 1 2
reactions and take appropriate nursing action.
30. Readjust the flow rate of the blood transfusion after 10 min. 0 1 2
C. MAINTAINING A BLOOD TRANSFUSION
31. Monitor the patient’s vital signs every fifteen minutes for one 0 1 2
hour after initiating the transfusion.
32. Assess the patient including vital signs every 30 minutes for 0 1 2
the next three hours until blood transfusion is finished.
33. Alert senior nurse if there is any untoward reaction during the 0 1 2
transfusion.
D. TERMINATING A BLOOD TRANFUSION
34. Don on clean gloves. 0 1 2
35. Clamp the blood tubing and disconnects needle from the Y- 0 1 2
port.
36. Open the saline infusion clamp. 0 1 2
37. Adjust the saline drip to desired rate. 0 1 2
38. Check vital signs. 0 1 2
E. AFTER CARE
39. Put patient in a comfortable position. 0 1 2
40. Discard the blood administration set according to agency 0 1 2
policy.
41. Dispose needles in a labeled, puncture-resistant container. 0 1 2
42. Follow agency protocol for appropriate disposal of the blood 0 1 2
bag.
43. Remove gloves. 0 1 2
44. Discard gloves accordingly. 0 1 2
F. DOCUMENTATION
45. Document the procedure and all nursing assessment. 0 1 2
a. Reason for the transfusion
b. Whether consent was signed
c. Time when blood transfusion was initiated
d. Type of blood transfused, amount, blood type, Rh factor,
serial number, expiration date and rate of flow
e. Any medication given prior to transfusion
f. Baseline vital signs
g. Any untoward reaction during the transfusion
h. Time when transfusion was terminated
Total Score ________ ÷ 90 X 100 = ___________
__________________________ _________________________
Name and Signature of Student Name and Signature of Faculty
///revised as of Oct. 2023
