Transfusion Reactions & Priority Interventions PDF

Transfusion Reactions & Priority Interventions Med Surg: Hematology 4 Types of Reactions F FEBRILE REACTION (mild allergic rx) A ANAPHYLACTIC REACTION...

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