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Question

Difficulty: MediumPhysiological Adaptation

A nurse is caring for an adult client who is receiving a unit of packed red blood cells (PRBCs) for symptomatic anemia. Twenty minutes after the transfusion is initiated, the client reports sudden lower back pain and feeling unusually cold. The nurse notes the client is restless with a blood pressure of 88/52 mmHg. Arrange the following nursing actions in the correct order of priority. (Place the highest priority action first.)

  1. 1Stop the packed red blood cell transfusion.
  2. 2Disconnect the blood tubing and initiate a 0.9% sodium chloride infusion with new tubing.
  3. 3Assess the client's vital signs and respiratory status.
  4. 4Notify the primary healthcare provider and the blood bank.
  5. 5Send the remaining blood bag and tubing to the blood bank.

Answer

The correct order of interventions is to first stop the transfusion, then initiate normal saline with new tubing, assess the client's vital signs, notify the provider and blood bank, and finally send the blood product to the blood bank.
In the event of a suspected acute hemolytic transfusion reaction (indicated by lower back pain, chills, and hypotension), the absolute first priority is to stop the infusion to prevent further exposure to the offending antigen. The next step is to maintain patent IV access with normal saline using completely new tubing; using the old tubing would infuse more of the reactive blood. Once the source is stopped and access is secured, the nurse performs a rapid clinical assessment. This assessment data is then communicated to the healthcare provider to guide emergency pharmacological interventions. Finally, after the client is stabilized and acute actions are completed, the remaining blood product and tubing are sent to the blood bank for investigation.

Step-by-Step Solution

1
Recognize the signs of an acute hemolytic transfusion reaction and immediately stop the transfusion.
Further entry of incompatible blood into the client's circulation is halted.
Stopping the source of the harm is always the most critical first step to minimize the severity of the reaction and prevent further physiological deterioration.
2
Maintain intravenous access with new tubing and 0.9% sodium chloride.
A patent intravenous line is secured without infusing the remaining blood.
The client is hypotensive and will likely require emergency intravenous medications and fluid resuscitation. New tubing prevents pushing the remaining reactive blood into the client.
3
Perform a rapid clinical assessment of vital signs and respiratory status.
Current hemodynamic and respiratory data are obtained.
Accurate clinical data is required to determine the severity of the reaction and to provide a complete report to the healthcare provider.
4
Notify the healthcare provider and the blood bank.
The provider is informed of the reaction and assessment data.
The provider must prescribe emergency interventions (e.g., vasopressors, antihistamines), and the blood bank must initiate their adverse reaction protocol.
5
Return the blood product, tags, and tubing to the blood bank.
The physical evidence of the transfusion is sent for laboratory analysis.
The blood bank must analyze the remaining product and equipment to confirm the type and underlying cause of the adverse reaction.

Key Concept

Management of Acute Hemolytic Transfusion Reactions
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Topics

Physiological Adaptation

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