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Difficulty: MediumPharmacological and Parenteral Therapies

While monitoring a client undergoing a packed red blood cell (PRBC) transfusion, the nurse observes the client suddenly shivering. The client reports intense bilateral flank pain and dyspnea. Current vital signs indicate a temperature of 38.6∘C38.6^\circ\text{C} (101.5∘F101.5^\circ\text{F}), a heart rate of 122 beats/min122\text{ beats/min}, and a blood pressure of 86/52 mmHg86/52\text{ mmHg}. After immediately halting the transfusion, what is the nurse's next priority action?

  1. Disconnect the blood administration set and initiate an infusion of 0.9%0.9\% sodium chloride with new tubing.Answer
  2. B
    Flush the existing blood administration tubing with 0.9%0.9\% sodium chloride to maintain intravenous patency.
  3. C
    Administer prescribed as-needed intravenous diphenhydramine and acetaminophen for symptom relief.
  4. D
    Collect a urine sample and send the discontinued blood bag to the laboratory for crossmatch verification.

Answer

Disconnect the blood administration set and initiate an infusion of 0.9% sodium chloride with new tubing.
The client is exhibiting classic signs of an acute hemolytic transfusion reaction, including severe flank pain, fever, tachycardia, and hypotension. After immediately stopping the transfusion, the nurse must maintain intravenous access to support blood pressure and facilitate the administration of emergency medications. This is safely accomplished by attaching completely new intravenous tubing primed with 0.9% sodium chloride. Using new tubing ensures that the remaining incompatible blood in the old tubing is not inadvertently flushed into the client.

Step-by-Step Solution

1
Recognize the clinical signs of an acute hemolytic transfusion reaction.
Identify that flank pain, chills, tachycardia, and hypotension signify a severe, life-threatening reaction.
Incompatible blood causes rapid hemolysis, leading to systemic inflammation, acute renal compromise, and shock.
2
Determine the physiological requirements after stopping the blood.
Identify the immediate need to support blood pressure and maintain venous access.
The client is hypotensive and will require emergency fluid resuscitation to maintain organ perfusion.
3
Select the safest method to provide intravenous fluids.
Choose to replace the entire blood administration set with completely new tubing primed with 0.9% sodium chloride.
Reusing the existing tubing would forcefully push the remaining incompatible packed red blood cells into the client's bloodstream.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Pharmacological and Parenteral Therapies

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