A nurse is caring for a client receiving a packed red blood cell (PRBC) transfusion. Fifteen minutes after the transfusion begins, the client reports sudden chills, severe lower back pain, and dyspnea. The client's heart rate is 115 beats/min and blood pressure is 88/52 mm Hg. What is the correct sequence of priority for the nurse's actions? Arrange the following steps in the correct order.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood tubing and initiate an infusion of 0.9% sodium chloride with new tubing.
- 3Assess the client's vital signs and respiratory status.
- 4Notify the healthcare provider of the client's status.
- 5Return the blood bag and attached administration set to the blood bank.
Cevap
The correct sequence is to first stop the transfusion, then maintain the IV with normal saline using new tubing, assess the client, notify the healthcare provider, and finally send the blood and tubing to the blood bank.
In any suspected blood transfusion reaction, the absolute highest priority is to stop the transfusion immediately to prevent further antigens from entering the client's bloodstream. The second step is to maintain the IV line with normal saline using entirely new tubing; the old tubing must be disconnected to avoid flushing remaining blood into the client. Once the source is stopped and the IV is secured, the nurse performs a thorough assessment of vital signs and respiratory status. This complete clinical picture is then communicated to the healthcare provider to obtain orders for emergency interventions. Finally, as a follow-up action, the blood bag, labels, and tubing are sent to the blood bank for investigation into the cause of the reaction.
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Anahtar Kavram
Management of acute hemolytic transfusion reactions prioritizes immediate cessation of the blood product, maintenance of IV access, and rapid clinical assessment.