A client receiving a packed red blood cell (PRBC) transfusion suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, arrange the following nursing actions in the correct priority order to mitigate further risk to the client.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate a normal saline infusion with new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Send the discontinued blood bag and tubing to the blood bank.
Answer
The correct sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, followed by assessing the client, notifying the provider, and finally sending the equipment to the blood bank.
In any severe adverse reaction to a therapeutic infusion, the immediate priority is to stop the causative agent. Once stopped, IV access must be preserved for emergency management by initiating normal saline with entirely new tubing, ensuring no residual blood is flushed into the patient. Assessment follows to gauge the patient's stability, which dictates the crucial clinical data provided when notifying the healthcare provider. Finally, institutional protocols for laboratory analysis (sending the bag and tubing) are completed once the client is stabilized.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reactions