A client receiving a transfusion of packed red blood cells (PRBCs) suddenly reports severe lower back pain, chills, and shortness of breath. Suspecting an acute hemolytic transfusion reaction, the nurse must intervene immediately. Arrange the following nursing actions in the correct chronological sequence.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride using a new administration set.
- 3Assess the client's vital signs, oxygen saturation, and cardiopulmonary status.
- 4Notify the healthcare provider and the blood bank of the suspected reaction.
- 5Return the remaining blood product, attached tubing, and labels to the blood bank.
Answer
The correct chronological sequence is to first stop the transfusion, then maintain IV access with normal saline using new tubing, assess the client's current status, notify the healthcare provider and blood bank, and finally return the blood products for analysis.
In the event of a transfusion reaction, the absolute highest priority is to stop the offending agent (the blood product). Second, IV access must be maintained for emergency interventions, but this MUST be done with completely new tubing to avoid flushing residual blood into the client. Once the client is protected from further immediate harm, the nurse assesses vital signs and cardiopulmonary status to provide accurate data to the healthcare provider. With assessment findings ready, the provider and blood bank are notified. Finally, the remaining blood product and tubing are sent to the laboratory for investigation.
Step-by-Step Solution
Key Concept
Nursing Management of Acute Transfusion Reactions