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Zorluk: ZorPharmacological and Parenteral Therapies

A nurse is caring for a client with a history of chronic heart failure who is receiving a transfusion of packed red blood cells (PRBCs) at a rate of 120 mL/hr120 \text{ mL/hr}. Approximately forty-five minutes into the infusion, the client suddenly reports shortness of breath. The nurse's assessment reveals a bounding heart rate of 112 bpm112 \text{ bpm}, blood pressure of 178/96 mmHg178/96 \text{ mmHg}, jugular venous distention, and new-onset bibasilar crackles. The client's temperature remains unchanged at 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}). Which of the following sequences of actions is the priority for the nurse?

  1. Stop the transfusion, elevate the head of the bed, administer supplemental oxygen, and prepare to administer an intravenous loop diuretic.Cevap
  2. B
    Stop the transfusion, disconnect the blood tubing, initiate a continuous infusion of 0.9%0.9\% sodium chloride through new tubing, and notify the blood bank.
  3. C
    Pause the transfusion, administer prescribed intravenous diphenhydramine, and reassess the client's lung sounds after 15 minutes.
  4. D
    Stop the transfusion, place the client in a supine position with legs elevated, and prepare to administer epinephrine.

Cevap

The priority action is to stop the transfusion, elevate the head of the bed, administer supplemental oxygen, and prepare to administer an intravenous loop diuretic.
The client is experiencing Transfusion-Associated Circulatory Overload (TACO), as evidenced by hypertension, a bounding pulse, distended neck veins, and bibasilar crackles in the absence of a fever. The priority interventions for TACO are to stop the fluid source (the transfusion), improve oxygenation and ventilation by elevating the head of the bed and administering oxygen, and reduce the fluid volume through the administration of a prescribed diuretic.

Adım Adım Çözüm

1
Analyze the client's vital signs and physical assessment findings.
The client has severe hypertension (178/96 mmHg178/96 \text{ mmHg}), a bounding pulse (112 bpm112 \text{ bpm}), jugular venous distention, and bibasilar crackles without a fever.
Identifying the specific pattern of symptoms is necessary to differentiate the type of transfusion complication occurring.
2
Diagnose the specific transfusion complication based on the assessment.
The findings indicate Transfusion-Associated Circulatory Overload (TACO), which is exacerbated by the client's history of chronic heart failure.
Accurate identification prevents the administration of contraindicated standard transfusion reaction protocols (such as fluid boluses).
3
Determine the priority nursing interventions for TACO.
The nurse must stop the transfusion, place the client in an upright position, administer oxygen, and prepare for diuretic therapy.
These actions immediately halt excess fluid intake, improve lung expansion, and actively reduce the circulating fluid volume.

Anahtar Kavram

Management of Transfusion-Associated Circulatory Overload (TACO)
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Konular

Pharmacological and Parenteral Therapies

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