A nurse is monitoring a client who is 15 minutes into a packed red blood cell (PRBC) transfusion. The client suddenly reports severe lower back pain, chills, and a feeling of impending doom. The nurse observes that the client's urine in the Foley catheter tubing has become dark red. Arrange the following nursing interventions in the correct order of priority from first to last.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood administration set from the client's intravenous catheter.
- 3Attach new intravenous tubing primed with 0.9% sodium chloride and maintain the infusion.
- 4Assess the client's vital signs and respiratory status.
- 5Notify the healthcare provider and the hospital blood bank.
Cevap
The correct sequence is to first stop the transfusion, then disconnect the blood tubing, maintain access with normal saline using new tubing, assess the client's vital signs, and finally notify the provider and blood bank.
In any severe adverse reaction to a parenteral infusion, especially a blood product, the absolute first priority is to stop the infusion to prevent further harm. Following this, the nurse must ensure the toxic substance is disconnected and secure patent IV access using entirely new tubing and a compatible solution (0.9% sodium chloride). Once the immediate threat of further exposure is mitigated and the airway/circulation is supported with IV access, the nurse gathers assessment data (vital signs) to provide an accurate SBAR report to the healthcare provider and blood bank for further emergency orders.
Adım Adım Çözüm
Anahtar Kavram
Management of Acute Hemolytic Transfusion Reaction