Blood Transfusion Flashcards
Complication
Acute Hemolytic Transfusion Reaction
Findings include chills, fever, low-back pain, tachycardia, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom.
Onset: Immediate or can manifest during subsequent transfusions
–> Results from a transfusion of blood products that are incompatible with the client’s blood type or Rh factor. Can occur following the transfusion of as few as 10 mL of a blood product.
–> Can be mild or life-threatening, resulting in disseminated intravascular coagulation (DIC) or circulatory collapse.
Nursing Action: STOP transfusion. Remove blood tubing from IV access to avoid infusing any further blood product. Initiate infusion of 0.9% Na Cl using NEW tubing. Monitor V/S & fluid status. Send blood bag and admin. set to lab for testing.
A nurse is preparing to administer packed RBCs to a client who has a Hgb of 6 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion?
Assess for an acute hemolytic reaction.
The nurse should plan to generate solutions to address the potential for blood transfusion reactions while receiving packed RBCs. The nurse should plan to assess for an acute hemolytic reaction during the first 15 min of the transfusion. This type of a reaction can occur following the transfusion of as little as 10 mL of blood product.
Complication
Febrile Transfusion Reaction
Findings include chills, increase of 1° C (2° F) or greater from the pretransfusion temperature, hypotension, and tachycardia.
Onset: Commonly occurs within 2 hr of starting the transfusion
–> Results from the development of anti-WBC antibodies. Can be seen when the client has received multiple transfusions.
Nursing Action: Use WBC filter for admin. to catch WBCs & prevent reaction from occurring. Stop transfusion & admin. antipyretics. Initiate infusion of 0.9% Na Cl using NEW tubing.
A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction?
Heart rate change from 88/min pretransfusion to 120/min & the client appears flushed.
The nurse should analyze cues from the client’s manifestations and determine that tachycardia and a flushed appearance can be indications of a febrile transfusion reaction.
Complication
Allergic Transfusion Reaction
Findings are usually mild and include itching, urticaria (hives), and flushing.
Onset: During or up to 24 hr after transfusion
–> Results from a sensitivity reaction to a component of the transfused blood products.
–> The client can develop an anaphylactic transfusion reaction resulting in bronchospasm, laryngeal edema, hypotension, and shock.
Nursing Action:
–> MILD reaction
Stop the trasnfusion. Initiate infusion of 0.9% Na Cl using NEW tubing. Admin. antihistamine such as diphenhydramine (Benadryl). If provider prescribes to restart infusion, do so slowly.
–> ANAPHYLACTIC reaction
Stop the trasnfusion, Admin. epinephrine, corticosteroids, vasopressors, oxygen or CPR if necessary. Remove blood tubing from the client’s IV access. Inititate infusion of 0.9% Na Cl using NEw tubing.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if the client develops manifestations of an allergic transfusion reaction?
Stop the transfusion. Maintain IV infusion with 0.9% Na Cl through new tubing. Admin. dipehnhydramine (Benadryl).
Complication
Bacterial Transfusion Reaction
Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock.
Onset: During or up to several hours after transfusion
–> Results from a transfusion of contaminated blood products.
Nursing Action: Stop the transusion. Admin. antibiotics & an IV infusion of 0.9% Na Cl using NEW tubing. Send a blood culture specimen to the lab for analysis.
Complication
Circulatory Overload
Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia. Manifestations can progress to pulmonary edema.
Onset: Can occur any time during the transfusion
–> Results from a transfusion rate that is too rapid for the client. Older adult clients or those who have a preexisting increased circulatory volume are at an increased risk.
Nursing Action:
Slow or stop the transfusion depending on severity of manifestations. Position client upright with feet lower than the level of the heart. Admin O2, diuretics, & moprhine as prescribed.
Blood Transfusion
A charge nurse is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
Obtains vital signs every 15 min throughout the procedure.
The nurse should plan to generate solutions to address the older adult’s increased risk of fluid overload which include checking the client’s vital signs every 15 min throughout the transfusion to allow for early detection of fluid overload or other transfusion reaction.
