A nurse is monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs) for severe anemia. Ten minutes after the infusion begins, the client reports sudden, intense lower back pain and a feeling of impending doom. The nurse notes that the client is tachycardic, tachypneic, and hypotensive. To safely manage this suspected acute hemolytic transfusion reaction and reduce the risk of further physiological compromise, arrange the following nursing actions in the correct priority sequence.
- 1Halt the blood transfusion immediately and clamp the blood administration tubing.
- 2Disconnect the blood tubing at the intravenous hub and attach a new administration set primed with 0.9% sodium chloride.
- 3Conduct a rapid assessment of the client's vital signs and cardiopulmonary status.
- 4Notify the healthcare provider and the blood bank of the suspected adverse reaction.
- 5Obtain required blood and urine specimens and send them with the discontinued blood bag to the laboratory.
Cevap
The correct sequence is to first stop the transfusion, then replace the tubing to infuse saline, conduct a rapid assessment, notify the provider and blood bank, and finally collect the necessary diagnostic specimens.
In a suspected acute hemolytic transfusion reaction, the primary goal is to minimize physiological harm. The nurse must immediately stop the exposure (halt transfusion), maintain systemic perfusion and venous access without introducing more blood (attach new tubing with saline), evaluate the client's current status (rapid assessment), communicate findings for medical intervention (notify HCP), and finally assist in determining the cause and extent of the injury (collect specimens).
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Anahtar Kavram
Prioritization in Emergency Transfusion Reactions