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Zorluk: Çok zorPharmacological and Parenteral Therapies

A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Ten minutes into the transfusion, the client develops sudden, severe lower back pain, tachycardia, and hypotension. Place the following nursing actions in the correct priority order to manage this complication.

  1. 1Stop the blood transfusion immediately.
  2. 2Disconnect the blood administration tubing from the intravenous catheter hub.
  3. 3Attach a new intravenous tubing set primed with 0.9% sodium chloride and initiate an infusion.
  4. 4Assess the client's vital signs, oxygen saturation, and respiratory status.
  5. 5Notify the healthcare provider and the facility's blood bank.
  6. 6Return the remaining blood product and original administration tubing to the blood bank.

Cevap

The correct sequence is: Stop the transfusion, disconnect the blood tubing, attach new saline tubing, assess the client, notify the healthcare provider and blood bank, and return the blood product to the blood bank.
In the event of a severe transfusion reaction, the priority is minimizing harm. The sequence follows the nursing process adapted for emergencies: intervene to stop harm (stop transfusion, disconnect tubing, maintain access with new saline), assess the impact (vital signs), communicate for further orders (notify HCP), and perform follow-up diagnostics (return product to blood bank).

Adım Adım Çözüm

1
Stop the continuous flow of the packed red blood cells.
The client receives no further incompatible or contaminated blood.
Lower back pain, tachycardia, and hypotension are classic signs of a life-threatening acute hemolytic transfusion reaction. Immediate cessation is the most critical intervention.
2
Disconnect the existing blood administration set from the IV hub.
The source of the reaction is physically separated from the client's vascular access.
Leaving the tubing connected risks inadvertently pushing more of the reactant into the bloodstream during subsequent flushes.
3
Connect a new IV tubing setup primed with normal saline.
Intravenous access is maintained for emergency medications and volume expansion.
Normal saline must be infused through new tubing to prevent clotting of the IV site and to treat the resulting hypotension.
4
Perform a focused physiological assessment.
Baseline data during the reaction is obtained.
The nurse needs current vital signs, airway status, and hemodynamic parameters to accurately report the client's condition.
5
Communicate with the healthcare provider and blood bank.
Emergency medical orders are obtained and the facility's reaction protocol is activated.
Medical intervention (such as vasopressors, antihistamines, or diuretics) is required, and the blood bank must investigate the cause.
6
Package and send the blood bag, tubing, and required lab specimens.
Diagnostic testing can determine the exact cause of the reaction.
Analyzing the remaining product and the client's post-reaction blood and urine is necessary for root-cause analysis.

Anahtar Kavram

Management of Acute Hemolytic Transfusion Reactions
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Konular

Pharmacological and Parenteral Therapies

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