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2017 PNLE REVIEW MATERIALS FOR SALE

Sunday, June 3, 2012

Blood Transfusion Reaction





Blood Transfusion Reaction


Reaction
Cause
Clinical Signs
Nursing Intervention
Hemolytic Reaction
Incompatibility between client’s blood and the donor’s blood
Chills, fever
Headache, backache
Dyspnea
Cyanosis
Chest pain
Tachycardia
Hypotension
·   STOP transfusion
·   KVO with PNSS
·   Send remaining blood, a sample of client blood and urine sample to the laboratory.
·   Notify the physician
·   Monitor VS
·   Monitor I & O
Febrile Reaction
Sensitivity of the client’s blood to WBC, platelets or plasma protein
Fever, Chills
Warm, flushed skin
Headache
Anxiety
Muscle pain
·   STOP transfusion
·   Give antipyretics
·   Notify the physician
·   KVO with PNSS
Allergic Reaction
Mild




Severe

Sensitivity to infused plasma proteins



Antibody-antigen reaction

Flushing
Itching
Urticaria
Brochial wheezing

Dyspnea
Chest pain
Circulatory collapse
Cardiac arrest

·   STOP transfusion
·   Notify the physician
·   Administer antihistamine as ordered

·   STOP transfusion
·   KVO with PNSS
·   Notify the physician immediately
·   Monitor VS
·   Administer CPR as needed
·   Administer medication / oxygen as needed
Circulatory Overload
Blood administered faster than the circulation can accommodate
Cough
Dyspnea
Crackles
Distended neck veins
Tachycardia
Hypertension
·   STOP or SLOW the transfusion
·   Place the client upright, with feet dependent
·   Administer diuretics and oxygen as needed
·   Notify physician
Sepsis
Contaminated blood administration
High fever, chills
Vomiting
Diarrhea
Hypotension
·   STOP transfusion
·   Send remaining blood to laboratory
·   Notify the physician
·   Obtain a blood specimen from the client for culture
·   Administer IV fluids and antibiotics
·   KVO with PNSS



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