Wk 2 Transfusion Reactions Flashcards
What should you do if you suspect a transfusion reaction?
Stop the transfusion, change the tubing and infuse just the NS
What else should you do if you suspect your patient is having a blood transfusion reaction?
Assess patient
Notify blood bank and HCP
Recheck ID tag and numbers
Monitor VS and urine output
When will urine output be effected during a blood transfusion reaction?
During a hemolytic reaction
Most likely, the HCP will say what about a blood transfusion reaction?
Give them some Tylenol and resume the blood transfusion
If your patient has a blood transfusion, you may be asked to do what?
Save the blood bag and send it back to the blood bank
After a blood transfusion reaction occurs, what form should you fill out?
Transfusion reaction report form
What is the most life threatening blood transfusion reaction?
Acute hemolytic reaction
What is an acute hemolytic reaction?
Incompatibility of blood product
What is a febrile, nonhemolytic reaction?
Fever develops during infusion
What is a mild allergic reaction?
Sensitization of donor’s WBCs, platelets, or plasma proteins
What is a severe reaction concerning allergies during a blood transfusion?
Anaphlyaxis
What infection can be a blood transfusion reaction?
Bacteremia/sepsis
What reaction is circulatory overload?
Too much blood volume administered
What is another name for circulatory overload?
TACO
transfusion-associated circulatory overload
Leukocytes in a blood product are considered
a contaminant and can cause adverse reactions
Most blood in the United States is…
Pre-storage leukoreducted
What are the signs and symptoms of acute hemolytic transfusion reaction
Immediate Onset Facial flushing Fever Headache Low back pain Hemoglobinuria Dyspnea, tachypnea Hypotension Cardiac arrest/death
What do you do if your patient is experiencing a hemolytic reaction?
Treat shock, maintain BP with IV colloids
What should you do concerning the kidneys if your patient had a hemolytic reaction?
Obtain first voided urine and insert foley to monitor I&Os
What sample should you collect after a patient has a hemolytic reaction?
Blood sample from IV site
What else will you send to the lab after a patient has a hemolytic reaction?
Unit, tubing, and filter
What are the s/s of a non hemolytic febrile reaction?
Sudden chills and fever Headache Flushing Anxiety Vomiting Muscle pain
What will the provider most likely order for a patient experiencing a non-hemolytic febrile reaction?
Administer antipyretic
Restart the blood transfusion
How can non-hemolytic febrile reactions be prevented?
Ensure patient is receiving leukocyte reduced products
Give Tylenol prophylactically
What are the s/s of a mild transfusion reaction?
Flushing
Itching
Urticaria
What should the nurse do if the patient is experiencing a mild transfusion reaction?
Stop blood and notify HCP
In the case of a mild transfusion reaction, the HCP will most likely order…
Antihistamine - diphenhydramine
Corticosteroid
Restart if symptoms are transient/mild
What are prevention methods for a mild transfusion reaction?
Treat prophylactically with antihistamines and corticosteroids
Consider giving washed RBCs and platelets
What are the s/s of a severe allergic reaction?
Anxiety
Urticaria
Dyspnea/wheezing
Progressing to cyanosis, bronchospasm, hypotension, shock, and cardiac arrest
What should the nurse response be to a patient experiencing anaphylaxis?
Initiate CPR, start o2
Administer epi, also antihistamines, corticosteroids, b2 agonists
Someone who experienced an anaphylactic reaction to a blood transfusion would need what prevention measures?
Extensively washed RBCs, and potentially autologous components
What are the s/s of a bacterial/sepsis reaction?
Rapid onset of chills and high fever
Vomiting and diarrhea
Marked hypotension
What should you do with any type of blood transfusion reaction first?
Stop the transfusion
Notify the provider
Return the blood
What should you do if your patient is having a septic reaction to a blood transfusion?
Obtain blood culture and return blood bag to bank
Treat septicemia with abx, IVFs, and vasopressors
What is the prevention for a septic reaction?
Get the blood in in 4 hours!!
What are the s/s of a TACO reaction?
cough and dyspnea pulmonary congestion headache increased VS distended neck veins
What is the nursing response to a patient experiencing a transfusion-associated circulatory overload reaction?
Slow or stop infusion
Administer diuretics, morphine, o2
CXR stat
What is the best way to prevent a TACO reaction?
Recognize who is at risk and administer slow
What is another name for autologous transfusions?
Auto transfusions
What is an autologous donation?
Patient donates their own blood before a planned procedure
How long can autologous blood be kept?
frozen and stored for years
If blood is not frozen, it must be used…
within a few weeks
Why is autologous blood not used as much?
Expensive
Insurance often won’t pay
Often the blood is wasted
What is a blood salvage system?
During surgery the patient loses blood, they keep it and put it back into the patient
