Blood Transfusion Nursing Diagnosis & Care Plan

Blood primarily functions as a main transporter of oxygen, nutrients, and waste products to and from the different parts and organs of the body. Blood and blood products may be transfused to a patient in a procedure referred to as blood transfusion. This potentially life-saving procedure helps replace blood lost due to injury or surgery, manage bleeding disorders, or treat other conditions.

Red blood cells, platelets, and plasma are the most common blood products patients receive.

Packed red blood cells (PRBCs) are considered “whole blood” and are the most common type of blood transfusion. PRBCs restore red blood cells and are often transfused when hemoglobin levels are low.

Platelets help form blood clots and prevent bleeding. Patients may need platelet transfusions due to thrombocytopenia.

Plasma is the largest component of blood and acts as a transporter. Plasma can be separated from the blood and is yellowish in color. Fresh frozen plasma (FFP) is a common blood product given due to abnormal coagulation.

While this procedure is considered generally safe, complications and reactions can occur. Mild to severe complications can happen while the transfusion is infusing or several hours or days after the procedure. The primary types of transfusion reactions include: 

  • Acute Hemolytic Reaction. The acute hemolytic reaction is a very serious transfusion reaction associated with ABO incompatibility that causes lysis or the destruction of blood cells. Its signs and symptoms include chest pain, bleeding, back pain, tachypnea, tachycardia, and hypertension. In severe cases, this can lead to shock and even death. 
  • Febrile Reaction. This reaction causes transient fever, nausea and vomiting, chills, headaches, and chest pain which is associated with the release of proteins by the white blood cells during blood storage. 
  • Allergic Reaction. This transfusion reaction is associated with the sensitivity to proteins in transfusion. Its signs and symptoms include urticaria, watery eyes, itching, mild wheezing, and shortness of breath. 
  • Anaphylaxis. This is a severe form of allergic reaction and is life-threatening. Its symptoms include anxiety, hypotension, severe wheezing, cyanosis, and extensive urticaria. 
  • Bacterial Reaction. This type of reaction occurs when there is bacterial contamination of the blood products being transfused. This can cause renal failure and shock. Its signs and symptoms include high fever and blood pressure fluctuations. 
  • Circulatory Overload. This occurs when there is decreased cardiac output or when fluids are transfused too quickly. Symptoms include anxiety, dyspnea, crackles, hypertension, tachycardia, and tachypnea.

The Nursing Process

Administering blood transfusions is a common nursing intervention. Once blood products are ordered, it is vital to provide patient education about the transfusion process and the signs and symptoms that the patient should report once the transfusion starts. 

Nurses are also responsible for double-checking the physician’s orders and comparing them to the actual blood product to ensure that the right blood components are being transfused. Most facilities require a two-nurse check of blood products. The patient’s name and other identifiers should match the patient’s identification band. If there are any discrepancies, the transfusion should not be started. 

During the transfusion process, the nurse is primarily responsible for monitoring the patient’s vital signs every 5 minutes during the first 15 minutes. The nurse must monitor for any signs and symptoms that may indicate a transfusion reaction. If there are no problems within the first 15 minutes, the transfusion flow rate must be regulated accordingly so it will be completed within 2 to 4 hours. 

If the patient experiences an adverse reaction, the transfusion is stopped immediately and the healthcare provider is alerted for orders to manage symptoms.

Nursing Care Plans Related to Blood Transfusions

Hyperthermia Care Plan 

Fever is the most common infusion reaction symptom and can be caused by hypersensitivity to donor blood cells or cytokines accumulating in stored blood products.

Nursing Diagnosis: Hyperthermia

Related to

  • Adverse reaction from a blood transfusion

As evidenced by:

  • Increase in body temperature
  • Flushed or warm skin
  • Chills
  • Lethargy

Expected Outcomes:

  • The patient will maintain body temperature within normal limits as evidenced by stable vital signs and the absence of chills

Hyperthermia Assessment

1. Assess and monitor vital signs every 5 minutes.
Constant monitoring is essential in patients undergoing blood transfusions. Monitoring can help determine the need for intervention.

2. Assess for a previous transfusion reaction.
Some patients who receive frequent or routine blood transfusions may commonly present with an elevated temperature as a normal response to the white blood cells. The healthcare provider may have the nurse premedicate with a fever reducer.

Hyperthermia Interventions

1. Stop the transfusion and report adverse reactions to the physician.
When fever is exhibited during the transfusion, the procedure must be stopped and findings must be reported to the physician.

2. Obtain urinalysis or blood samples.
Hemolytic reactions can be investigated and confirmed through urine or blood tests. This can also help confirm the patient was correctly typed and crossmatched.

3. Administer antipyretics as indicated.
Antipyretics such as acetaminophen will aid in the reduction of the patient’s body temperature.

4. Make use of a cooling blanket as needed.
A cooling blanket will help reduce the patient’s elevated body temperature which may reach up to 104.0 F (40.0 C).

5. Administer IV fluids.
If not already infusing, 0.9% normal saline should be infused to keep the IV open and clear.


Ineffective Breathing Pattern Care Plan 

The most common signs and symptoms of blood transfusion reactions include fever, chills, urticaria, and itching which may resolve with little or no treatment. In some cases, severe side effects can occur including respiratory distress, hypotension, and hemoglobinuria.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

  • Blood transfusion reaction

As evidenced by:

  • Increased respiratory rate
  • Tachypnea
  • Labored breathing
  • Cough
  • Nasal flaring
  • Hypoxia
  • Altered tidal volume
  • Bradypnea
  • Cyanosis

Expected Outcomes:

  • The patient will maintain an effective breathing pattern as evidenced by the absence of cough or dyspnea
  • The patient’s respiratory rate will remain within normal limits during blood transfusion

Ineffective Breathing Pattern Assessment

1. Assess respiratory rate and depth.
Subtle changes in the patient’s breathing pattern can indicate adverse reactions from a blood transfusion.

2. Monitor oxygen saturation.
Assess for decreasing Spo2 levels that signal respiratory distress.

Ineffective Breathing Pattern Interventions

1. Place the patient in Fowler’s position.
A sitting position allows the lungs to expand to their full potential. Proper positioning enables optimal breathing patterns.

2. Administer medications as indicated.
Medications will depend on the type of reaction and may include epinephrine, solumedrol, antihistamines, and vasopressors.

3. Administer supplemental oxygen as needed.
Supplemental oxygen can increase the oxygen in the blood and decrease symptoms of breathlessness.

4. Prepare for intubation.
Rarely, severe transfusion reactions that cannot be quickly and adequately managed may require emergency intubation.

5. Stay with the patient during episodes of acute respiratory distress.
Staying with the patient can help lessen the patient’s anxiety which can lessen oxygen demand as well.


Excess Fluid Volume Care Plan 

Circulatory overload can occur during a blood transfusion procedure when blood products are administered at a rate greater than what the circulatory system can accommodate.

Nursing Diagnosis: Excess Fluid Volume

Related to:

  • Blood transfusion reaction

As evidenced by:

  • Crackles or rales on auscultation
  • Jugular vein distention
  • Elevated blood pressure
  • Dyspnea or cough
  • Adventitious breath sounds
  • Pulmonary congestion

Expected Outcomes: 

  • The patient will remain normovolemic as evidenced by clear lung sounds, normal blood pressure readings, and the absence of jugular vein distention

Excess Fluid Volume Assessment

1. Assess and monitor the patient’s intake and output.
Intake and output can indicate the patient’s fluid volume status. If output does not match what is being transfused, the patient may be experiencing fluid volume overload.

2. Assess and auscultate breath sounds.
Breath sounds such as crackles and rales combined with dyspnea can indicate circulatory overload.

3. Assess and monitor the patient’s vital signs.
Increased blood pressure and sinus tachycardia are early signs of fluid volume excess.

4. Consider the patient’s history.
A patient with a history of congestive heart failure or other cardiopulmonary condition will need to be monitored very carefully.

Excess Fluid Volume Interventions

1. Administer diuretics as indicated.
Diuretics are usually indicated in cases of excess fluid volume following blood transfusions as it helps in the excretion of excess fluids in the body. For patients with a history of CHF, diuretics may be ordered prior to the transfusion to prevent fluid volume overload.

2. Regulate the rate of IV fluids or blood products as indicated.
Strict adherence to the rates of IV fluids is vital as it can help avoid excess fluid volume. Transfuse blood at the slowest possible rate to meet protocols but prevent fluid overload.

3. Provide supplemental oxygenation as needed.
Providing oxygenation will help facilitate breathing during circulatory overload.

4. Place the patient in a semi-Fowler’s position.
This position allows for the proper evaluation of jugular vein distention. It also offers ease of breathing for optimal chest and lung expansion.

5. Elevate edematous extremities if present.
Elevation of affected body parts can reduce edema by promoting an increased venous return to the heart.


References and Sources

  1. Blood Transfusion. Cleveland Clinic. Last reviewed by a Cleveland Clinic medical professional on 10/29/2020. https://my.clevelandclinic.org/health/treatments/14755-blood-transfusion
  2. Blood transfusion. NHS. Page last reviewed: 18 January 2021. https://www.nhs.uk/conditions/blood-transfusion/
  3. Blood Transfusion Safety and Risks. AAMDS Internal Foundation. 2022. https://www.aamds.org/blood-transfusion-safety-and-risks
  4. Blood Transfusion: What to Know If You Get One. Medically Reviewed by Sabrina Felson, MD on November 01, 2021. https://www.webmd.com/a-to-z-guides/blood-transfusion-what-to-know
  5. Red Blood Cell Transfusions. American Red Cross. 2022. https://www.redcrossblood.org/donate-blood/blood-donation-process/what-happens-to-donated-blood/blood-transfusions/types-of-blood-transfusions.html
  6. Suddock JT, Crookston KP. Transfusion Reactions. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482202/
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Maegan Wagner, BSN, RN, CCM

Maegan Wagner is registered nurse with over 10 years of healthcare experience. She earned her BSN at Western Governors University. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public.