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 | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
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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