A nurse is monitoring a client who is receiving an intravenous transfusion of packed red blood cells (PRBCs). Fifteen minutes after the transfusion is initiated, the client suddenly reports severe lower back pain, shortness of breath, and a feeling of impending doom. Arrange the following nursing actions in the correct priority sequence. All options must be used.
- 1Stop the blood transfusion immediately.
- 2Disconnect the blood administration set and initiate an infusion of 0.9% sodium chloride using new tubing.
- 3Assess the client's vital signs, respiratory status, and hemodynamic stability.
- 4Notify the healthcare provider and the blood bank of the suspected hemolytic reaction.
- 5Return the remaining blood product, bag, and attached tubing to the blood bank for analysis.
Cevap
The correct sequence of actions for a suspected hemolytic transfusion reaction is to first stop the transfusion, maintain IV access with new tubing and normal saline, assess the client's clinical status, notify the provider and blood bank, and finally return the blood products for analysis.
A hemolytic transfusion reaction is a life-threatening emergency characterized by flank pain, dyspnea, and hypotension. The first step is always to stop the infusion of the incompatible blood. Second, the nurse must maintain patent IV access for emergency drugs by using entirely new tubing primed with normal saline, because using the old tubing would flush more blood into the client. Third, the nurse conducts a rapid assessment to determine hemodynamic stability. Fourth, the nurse notifies the healthcare provider with the assessment data to obtain emergency prescriptions. Finally, the blood bag and tubing are sent to the blood bank for investigation.
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Anahtar Kavram
Management of acute hemolytic transfusion reactions requires immediately halting the offending agent, maintaining venous access with new equipment, and rapidly assessing the client before notifying the provider.
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