BLOOD TRANSFUSION FLOW SHEET



BLOOD TRANSFUSION FLOW SHEET

|Patient |DATE: ________________________________ |

| |BLOOD COMPONENT: __________________ |

|Allergies: |DONOR #: _____________________________ |

| | |

|Order to give blood on chart: ☐Yes ☐No |NS hung with blood filter: Time _______ |

|Patient name band on and correct: ☐Yes ☐No |Transfusion started: Time: _______ |

|Crossmatch Identification Bracelet on: ☐Yes ☐No |Warming coil used? ☐Yes ☐ NO |

|Blood Transfusion Consent signed: ☐Yes ☐No |10. Hx of previous transfusion ☐Yes ☐No |

|Lab called – Blood is ready: ☐Yes ☐No | |

|Condition of IV site: ☐Intact ☐Restarted |Reaction: ____________________________ |

| |

|CIRCLE IF PATIENT HAS HAD IN LAST 24 HOURS: |

| |

|FEVER CHILLS NAUSEA DYSPNEA HEADACHE CYANOSIS BACKACHE URTICARIA |

| |

|CHEST PAIN RASH MENTAL CONFUSION OTHER: _______________________________________ |

| | | | | | | | |

|Time |Temp. |Pulse |Resp. |B/P |Infusion | |

| | | | | |Rate |Assessment (See Chart below for Normal Assessment) |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| | | | | | |☐ Normal Assessment |

| | | | | | | |

| | | | | | |☐ Abnormal, See Comments |

| |

| |

|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 | | |

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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

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:CBCSyllabus/Transition/1118/Blood Transfusion Flow Sheet Reviewed12/16

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