A nurse is caring for a client with a history of severe anemia who is receiving a transfusion of packed red blood cells. Fifteen minutes after the transfusion begins, the client reports a sudden onset of lower back pain, chills, and difficulty breathing. Arrange the following nursing interventions in the prioritized sequence from first to last action.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of normal saline using new IV tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank.
- 5Send the remaining blood product, bag, and tubing to the blood bank.
Answer
The correct priority sequence for managing an acute hemolytic transfusion reaction is to first stop the transfusion, maintain the IV line with normal saline using new tubing, assess the client, notify the provider and blood bank, and finally return the blood bag and tubing to the laboratory.
When a client experiences an acute hemolytic transfusion reaction, the immediate priority is to stop the infusion to prevent further exposure to the antigen. Next, the nurse must maintain a patent IV line with normal saline using completely new tubing to avoid flushing residual blood from the old tubing into the client. Once the source is removed and the line is secured, the nurse performs a rapid assessment to gather vital data. This data is then reported to the healthcare provider to obtain emergency orders. Finally, the blood bag and tubing are sent to the blood bank for crossmatch re-evaluation.
Step-by-Step Solution
Key Concept
Management of Acute Hemolytic Transfusion Reaction