A nurse is caring for a client who is receiving an infusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client develops sudden chills, lower back pain, and a heart rate of 118 beats/min. Place the following nursing interventions in the correct order to reduce the risk of further physiological deterioration. (Arrange the steps from first action to last action)
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of normal saline with new tubing.
- 3Perform a rapid assessment of the client's vital signs and respiratory status.
- 4Notify the healthcare provider and the blood bank of the suspected reaction.
- 5Send the remaining blood product, attached tubing, and tags back to the blood bank.
Answer
The correct sequence is to first stop the transfusion, replace the tubing to infuse normal saline, assess the client, notify the provider and blood bank, and finally return the blood product and equipment.
When an acute hemolytic transfusion reaction is suspected (indicated by lower back pain, chills, and tachycardia), the overriding priority to reduce risk is to stop the offending agent. Immediately stopping the transfusion limits the amount of incompatible blood received. The nurse must then maintain IV access for emergency drugs, but must do so by disconnecting the blood tubing at the hub and attaching new tubing primed with normal saline to avoid pushing residual blood into the client. Assessing the client's vital signs and respiratory status follows to determine the extent of physiological decompensation. The healthcare provider and blood bank are then notified so orders can be received and the facility's reaction protocol can be initiated. Finally, the blood bag and tubing are sent to the blood bank for crossmatch re-testing.
Step-by-Step Solution
Key Concept
Management of acute hemolytic transfusion reactions