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Question

Difficulty: MediumPhysiological Adaptation

While monitoring a client receiving an initial unit of packed red blood cells, the nurse notes that 15 minutes into the infusion, the client abruptly reports severe lower back pain, chills, and a sensation of shortness of breath. The client's vital signs reveal a blood pressure of 90/60 mmHg, a heart rate of 116/min, a respiratory rate of 24/min, and a temperature of 101.2°F (38.4°C). Arrange the following nursing actions in the correct order of priority.

  1. 1Stop the blood transfusion.
  2. 2Disconnect the blood tubing and initiate an infusion of normal saline using new tubing.
  3. 3Assess the client's vital signs and respiratory status.
  4. 4Notify the healthcare provider and the blood bank.
  5. 5Send the remaining blood product and tubing to the blood bank for analysis.

Answer

1. Stop the blood transfusion.
2. Disconnect the blood tubing and initiate an infusion of normal saline using new tubing.
3. Assess the client's vital signs and respiratory status.
4. Notify the healthcare provider and the blood bank.
5. Send the remaining blood product and tubing to the blood bank for analysis.
In the event of a suspected acute hemolytic blood transfusion reaction, the absolute first priority is to stop the infusion to prevent further exposure to the incompatible antigen. Once the infusion is stopped, the nurse must maintain a patent IV line for emergency medications by infusing 0.9% sodium chloride using completely new tubing (to avoid pushing residual blood into the client). Next, the nurse performs a rapid physical assessment, including vital signs and respiratory status, to evaluate the severity of the physiological compromise. The nurse then notifies the healthcare provider to obtain emergency prescriptions and alerts the blood bank. Finally, the remaining blood, tubing, and labels are sent back to the blood bank for crossmatching and post-reaction analysis.

Step-by-Step Solution

1
Identify the complication occurring in the clinical scenario.
The client is experiencing a severe acute hemolytic transfusion reaction.
Lower back pain, chills, hypotension, and tachycardia shortly after starting a transfusion are hallmark physiological signs of an acute hemolytic reaction.
2
Determine the absolute first priority action.
Stop the blood transfusion.
The immediate priority in any adverse medication or blood reaction is to remove the causative agent to limit further physiological damage.
3
Determine the next action required to safely maintain venous access.
Disconnect the existing tubing and initiate normal saline using new tubing.
Venous access must be maintained for emergency interventions, but flushing the existing blood tubing would push more incompatible blood into the client.
4
Determine the next action to evaluate the client's condition.
Assess vital signs and respiratory status.
A rapid physiological assessment is necessary to determine the severity of the reaction and to prepare a complete, accurate report for the healthcare provider.
5
Determine the appropriate notification and follow-up protocol steps.
Notify the provider and blood bank, then send the remaining product to the laboratory.
The provider must prescribe emergency pharmacological interventions, and the blood bank must analyze the remaining product and tubing to confirm the reaction etiology.

Key Concept

Management Sequence for Acute Hemolytic Transfusion Reactions
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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