Transfusion Reactions

& Priority Interventions

Med Surg: Hematology

4 Types of Reactions

F FEBRILE REACTION
(mild allergic rx) A ANAPHYLACTIC
REACTION C CIRCULATORY
OVERLOAD H HEMOLYTIC

F FEBRILE REACTION
(mild allergic rx)
A ANAPHYLACTIC
REACTION

Flushing (redness) Wheezing

Itchy Hives
Hypotension (low BP) NORMAL

HIGH
LOW
C CIRCULATORY ATI KAPLAN
OVERLOAD Difficulty breathing and crackles after
The nurse is caring for a patient who is
administration of PRBCs … priority
actions?
receiving a blood transfusion. The client
Signs & Symptoms begins to exhibit dyspnea, crackles in lung
Select all that apply
Lung crackles Crackles bases, and becomes restless. Which action
Administer furosemide 40 mg IVP should the nurse anticipate?
Restlessness Elevate HOB at least to 45 degrees
Dark Urine Slow the infusion rate
Monitor for HTN, tachycardia,
SOB & Dyspnea tachypnea, hypoxia
Notify HCP
JVD (jugular vein distention)
Risk: HF - Heart Failure
HF - Heavy Fluid
Action:
SLOW the infusion- 4 hours max H O P E
NCLEX TIP
Wait 2 hrs between infusions PRBC

H - HOB Elevated “SIT UP!” STOP

O - Oxygen
P - Push Diuretics (FurosemIDE)
4hrs MAX
FurosemIDE

E - End all IV fluids

H
KEY TERM
HEMOLYTIC
KAPLAN
Hypotension (Low BP)
Which of the following indicates a
Low back pain
hemolytic reaction?
Fever
Low back pain and apprehension
Tachycardia (Fast HR)
Urine specimen: “check for
hemolyzed RBC” NCLEX TIP

Over 5.0 Hemolyzed RBCs

PRIORITY Interventions

K
High Potassium (Hyperkalemia)
1. Slow or STOP the infusion Over 5.0
� Potassium Priority Pumps heart
2. Using new tubing 0.9% sodium � Peaked T Waves on ECG NCLEX TIP

chloride (normal saline)

ATI
3. Report to HCP immediately Ordered Response: Reaction to blood
transfusion
4. Assess: 1. STOP transfusion

Vital signs 2. Hang new IV infusion set

3. Start 0.9% sodium chloride infusion

Urine specimen: “check for K K
K
4. Call HCP
K K
K
K K K
K K K K
K

hemolyzed RBC” NCLEX TIP

K
K
5. Assess BP, HR, RR
K K
K K
6. Obtain blood and urine specimens