Blood Transfusion Reactions And Immediate Actions - NCLEX-RN

Provide oxygen and supportive respiratory care. Oxygenation and ventilation support address hypoxemia while the condition resolves.

Acute hypoxemia with dyspnea and pulmonary edema signs. TRALI involves donor antibodies causing noncardiogenic pulmonary edema and respiratory failure.

Antihistamine (e.g., diphenhydramine) as prescribed. It blocks histamine receptors, alleviating allergic symptoms like itching and hives.

Stop the transfusion immediately. Halting the infusion prevents further administration of potentially incompatible blood, minimizing the severity of the reaction.

0.9% sodium chloride (normal saline) with new tubing. Normal saline is compatible with blood products and maintains IV patency without causing hemolysis, while new tubing prevents contamination.

Assess airway, breathing, circulation, and vital signs. Evaluating ABCs and vital signs identifies life-threatening complications like shock or respiratory distress promptly.

Disconnect blood tubing; do not flush blood into the patient. Disconnecting without flushing avoids infusing residual incompatible blood, reducing further hemolysis or antigen exposure.

Send blood bag and tubing to the blood bank per policy. Returning them allows lab analysis to identify the reaction cause, such as incompatibility or contamination.

Notify the health care provider and the blood bank immediately. Immediate notification ensures prompt medical intervention and blood bank investigation to confirm the reaction type.

Symptoms, vital signs, time started/stopped, and interventions. Accurate records support diagnosis, guide treatment, and meet legal requirements for transfusion incidents.

Two-person verification of patient ID and blood product label. Dual verification reduces clerical errors that could lead to ABO incompatibility and hemolytic reactions.

Back or flank pain with fever and hypotension. These indicate intravascular hemolysis from ABO incompatibility, causing renal pain and systemic effects.

Hemoglobinuria (dark or red-brown urine). Free hemoglobin from lysed RBCs is excreted in urine, signaling acute hemolysis.

Maintain IV fluids; anticipate diuretics as prescribed. Hydration and diuresis promote renal clearance of hemoglobin, preventing acute kidney injury from tubular obstruction.

Fever and chills without hypotension or hemoglobinuria. Caused by leukocyte antibodies, it presents as an immune response without hemolysis or circulatory instability.

Acetaminophen as prescribed. It reduces fever by inhibiting prostaglandin synthesis in the hypothalamus.

Urticaria, pruritus, and flushing without respiratory distress. These reflect histamine release from IgE-mediated response to plasma proteins, without systemic involvement.

Hypotension, wheezing/stridor, angioedema, and shock. These signify severe IgA deficiency or allergy leading to systemic anaphylactic response.

Epinephrine per emergency protocol/prescription. As an adrenergic agonist, it reverses bronchospasm and hypotension in anaphylaxis.

Dyspnea, hypertension, crackles, and jugular venous distention. These indicate fluid overload leading to cardiogenic pulmonary edema in at-risk patients.

High fever with rigors and hypotension during transfusion. Bacterial endotoxins cause rapid sepsis-like symptoms during infusion.

Stop transfusion and obtain ordered blood cultures promptly. Stopping prevents further bacterial load, and cultures identify the pathogen for targeted antibiotics.

Postreaction blood sample for hemolysis workup per policy. It allows comparison to prereaction levels to confirm hemolysis via markers like LDH and bilirubin.

Remain with patient and monitor closely for the first 15 minutes. Most severe reactions occur early due to initial antigen exposure, enabling prompt intervention.