During the administration of packed red blood cells, a client abruptly reports intense lower back pain, sudden chills, and difficulty breathing. To minimize further physiological injury, arrange the following nursing actions in the correct sequence of execution.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing from the intravenous catheter hub.
- 3Initiate an infusion of normal saline using new intravenous tubing.
- 4Assess the client's vital signs and respiratory status.
- 5Notify the healthcare provider and the facility's blood bank.
Answer
The correct sequence is to first stop the transfusion, disconnect the blood tubing, initiate normal saline with new tubing, assess the client, and finally notify the provider and blood bank.
In the event of a suspected hemolytic transfusion reaction (indicated by lower back pain, chills, and dyspnea), the nurse's first action must always be to stop the transfusion to limit physiological damage. Next, the nurse must disconnect the blood tubing at the hub and replace it with new tubing primed with normal saline to keep the vein open for emergency drugs without pushing residual blood into the client. Once the line is secure, the nurse assesses the client's vital signs to determine the severity of the reaction. Finally, with the client stabilized and assessment data gathered, the nurse notifies the healthcare provider to obtain orders and contacts the blood bank to initiate a reaction investigation.
Step-by-Step Solution
Key Concept
Acute Hemolytic Transfusion Reaction Protocol
Estimated Time:1m 30s