A nurse is monitoring a client who is receiving a unit of packed red blood cells. Fifteen minutes into the infusion, the client reports sudden, severe lower back pain and a feeling of impending doom. The client's heart rate is 124 beats per minute, blood pressure is 86/52 mm Hg, and the nurse observes dark, reddish-brown urine in the Foley catheter tubing. Arrange the following nursing actions in the correct priority sequence from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate a normal saline infusion with new tubing.
- 3Assess the client's cardiopulmonary status and obtain a complete set of vital signs.
- 4Notify the healthcare provider and the blood bank of the reaction.
- 5Collect required blood and urine specimens and send them with the blood bag to the laboratory.
Answer
The correct priority sequence is: 1. Stop the blood transfusion immediately. 2. Disconnect the blood tubing and initiate a normal saline infusion with new tubing. 3. Assess the client's cardiopulmonary status and obtain a complete set of vital signs. 4. Notify the healthcare provider and the blood bank of the reaction. 5. Collect required blood and urine specimens and send them with the blood bag to the laboratory.
Acute hemolytic transfusion reactions are life-threatening emergencies caused by ABO incompatibility. The absolute priority is to stop the offending agent immediately. Next, intravenous access must be maintained with new tubing and 0.9% sodium chloride to prevent hemodynamic collapse and maintain renal perfusion, while carefully avoiding flushing the incompatible blood currently in the old tubing into the client. Only after securing the line and stopping the blood should the nurse assess the client's status, notify the provider for further orders, and finally handle the diagnostic and laboratory follow-up.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reaction