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