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Zorluk: OrtaPharmacological and Parenteral Therapies

During a routine assessment on a medical-surgical unit, a nurse evaluates a client who is 15 minutes into a transfusion of packed red blood cells (PRBCs). The client suddenly reports severe flank pain, chills, and an impending sense of doom. Vital signs reveal a temperature of 38.8°C (101.8°F) and a blood pressure of 88/50 mm Hg. The nurse immediately stops the transfusion. Which of the following actions should the nurse take next?

  1. Disconnect the blood tubing directly at the intravenous catheter hub and attach new tubing primed with 0.9% sodium chloride.Cevap
  2. B
    Connect a bag of 0.9% sodium chloride to the Y-site of the existing blood administration set and open the roller clamp.
  3. C
    Administer a prescribed PRN dose of intravenous diphenhydramine to rapidly halt the suspected hypersensitivity response.
  4. D
    Auscultate the client's lung sounds and apply supplemental oxygen to treat early indicators of cardiogenic shock.

Cevap

The correct action is to disconnect the blood tubing directly at the intravenous catheter hub and attach a completely new IV tubing set primed with 0.9% sodium chloride.
When an acute hemolytic transfusion reaction occurs, the immediate priority after stopping the transfusion is to maintain intravenous access and provide hemodynamic support without infusing any more of the reactive blood product. Disconnecting the blood tubing directly at the hub and attaching completely new tubing primed with normal saline ensures that the residual blood in the old tubing is removed and not inadvertently pushed into the client's circulatory system.

Adım Adım Çözüm

1
Recognize the clinical manifestations of an acute hemolytic transfusion reaction.
The client's flank pain, chills, hypotension, and feeling of impending doom indicate a severe incompatibility reaction.
Early recognition dictates the immediate cessation of the transfusion, which the nurse has already completed.
2
Determine the safest method to maintain intravenous access for emergency interventions.
The existing blood tubing must be disconnected directly at the intravenous catheter hub.
Leaving the old tubing connected and flushing it would force the residual reactive blood contained within the line directly into the client's circulatory system, exacerbating the life-threatening reaction.
3
Initiate an infusion of 0.9% sodium chloride.
A new tubing set primed with normal saline is attached to the hub, and the infusion is started.
Normal saline is compatible with blood products, helps maintain venous access for subsequent emergency medications, and provides fluid volume to support the client's dropping blood pressure.

Anahtar Kavram

Management of Acute Hemolytic Transfusion Reactions
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Konular

Pharmacological and Parenteral Therapies

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