A nurse is monitoring a client who is receiving a transfusion of packed red blood cells. Ten minutes into the transfusion, the client reports sudden lower back pain, chills, and shortness of breath. Arrange the following nursing actions in the correct priority sequence.
- 1Stop the blood transfusion immediately.
- 2Replace the blood tubing with a new set and initiate an infusion of 0.9% sodium chloride.
- 3Assess the client's vital signs and oxygen saturation.
- 4Notify the healthcare provider and the blood bank.
- 5Return the remaining blood product and attached tubing to the blood bank.
Answer
The correct sequence of actions for a suspected acute hemolytic transfusion reaction is to first stop the transfusion, then maintain intravenous access with new tubing and normal saline, assess the client's vital signs, notify the healthcare provider and blood bank, and finally return the blood products to the blood bank for analysis.
When a client experiences symptoms of a severe transfusion reaction (such as lower back pain, which indicates an acute hemolytic reaction), the absolute first priority is to stop the offending agent. Immediately stopping the blood minimizes the volume of incompatible cells infused. The next step is to maintain a patent intravenous line for emergency medications; this must be done with entirely new tubing primed with normal saline so that the blood remaining in the old tubing is not flushed into the client. Next, the nurse performs a rapid assessment of vital signs and respiratory status to gather necessary clinical data. This data is then immediately communicated to the healthcare provider and blood bank. Finally, as a post-crisis procedural step, the blood bag and tubing are returned to the blood bank for serological testing and investigation.
Step-by-Step Solution
Key Concept
Nursing Priority Management of Acute Hemolytic Transfusion Reactions