blood administration Flashcards
acute hemolytic reaction (why & manifestations)
due to an incompatibility of blood
most dangerous reaction
occurs within a few milliliters of blood
manifestations: LOW BACK PAIN, red urine, SOB, increased HR, chills, decreased BP, fever, uncontrollable bleeding, cardiac arrest, death
nursing actions for acute hemolytic reaction
stop the transfusion
start normal saline
call rapid
emergency fluids
treat shock
send urine sample to lab if red and bloody
collect blood specimen to check BUN, creatinine, H/H
allergic reaction (manifestations)
more mild
manifestations: flushing, itching
allergic reaction nursing care
stop transfusion
normal saline
call doctor to decide if medications can help enough to continue transfusion
if you restart blood, start the process so vital signs, start slow, stay with pt every 15 mins, etc.
can lead to anaphylaxis
anaphylactic reaction manifesations
SOB, wheezing, tachycardia, hypotension
emergency situation
circulatory overload reaction (why & manifestations)
reaction to the amount of blood not the type
manifestations: SOB, cough, tachycardia, pulmonary edema, BP increases
nursing actions for circulatory overload reaction
stop the transfusion
increase HOB
normal saline to KVO
notify provider
may restart at slower rate
sepsis reaction (why & manifestation)
due to an infection component of blood or contaminated setup
manifestations: high fever, chills, vomiting, diarrhea, drop in vitals
nursing care for a sepsis reaction
stop transfusion
normal saline to KVO
notify MD
blood bag and tubing sent back to lab to determine antibiotic
delayed hemolytic reaction (why & manifestations)
occurs days to weeks after infusion
less severe
important to monitor because it may be a precursor to a more severe reaction in future transfusions
manifestations: low grade fever, fatigue, gradual decrease in h/h
hyperkalemia
due to prolonged storage of blood, cell destruction, improper handling
hypocalcemia
a preservative used for blood storage binds with calcium which can cause a deficiency
15 minute rule for blood administration
vital signs at start of infusion and 15 mins into the infusion
stay with pt for 15 mins
administer very slowly for first 15 mins
pre-transfusion nursing care
IV line 18-20 gauge or greater
establish patency before requesting blood
sterile technique
normal saline IV tubing at bedside
obtain vital signs
monitor lab values
check orders
check pt ID and blood ID with another RN or MD
post-transfusion nursing care
take another set of vitals
document any issues, site of infusion, what pt received, reaction vs no reaction
complete adverse reaction forms if needed
monitor labs
