BT

Assessment

1. Assess for symptoms of acute hemolytic reactions including fever with or without chills, chest
and lumbar pain, hypotension, dyspnea, oliguria or anuria and abdominal bleeding.

2. Assess for the non hemolytic reactions which includes the symptoms of fever, chills, flushing,
headache, muscle pain and anxiety

3. Assess for an allergic reactions flushing, itching or an anaphylactic reaction on which

symptoms of respiratory distress, chest pain, hypotension, abdominal cramps, vomiting and
diarrhea, loss of consciousness or cardiopulmonary arrest will be present

4. Assess for citrate reaction including circumoral tingling, hypotension, nausea, vomiting and
cardiac dysrrthmias

5. Assess for sepsis which includes symptoms of chills, fever, nausea, hypotension, and shock
6. Assess for circulatory overload, noting dyspnea, cyanosis, severe headache, elevelate systolic
blood pressure, tachycardia, jugular vein distention, crackles and elevated CVP. Assess for
hypothermia and cardiac dysrrthmias caused by cold blood cooling the right ventricle affecting
the conduction system.

7. Assess for GVHD in the immunocompromised client who may present with fever, skin rash,
diarrhea, bone marrow suppression and liver dysfunction.

8. Assess for the delayed hemolytic reaction, continued anemia despite receiving a transfusion or
hepatitis that may be present weeks after the transfusion with weakness after the transfusion
with weakness, nausea, fatigue and jaundice

Planning: Expected outcome

1. The client will have a normal temperature and no chills

2. The client will have a normal tissue perfusion and cardiac output

3. The client will be calm and comfortable

4. The client will show no signs of irritation

Implementation

1. Immediately stop the transfusion

2. With gloved hand remove tubing with blood and replace with new tubing

3. Maintain the patient IV with normal saline. Don’t use any soln containing dextrose
4. Obtain v/s including o2 sat

5. Remove gloves and wash hands

6. Notify health care provider of client’s transfusion reaction, including v/s and specific symptoms
of severity of reaction and time frame. Know protocol to follow. Client’s may need oxygen and
to be placed in trendelenburg position if shock occurs.

7. Monitor client’s v/s at least every 15 mins

 8. Read the blood component bag to ensure that the correct unit was given to correct pt.

9. Administer meds as prescribed:

• Diphenhypramine

• Epinephrine

• Broad spectrum antibiotics

• Iv fluids

10. Start cardiopulmonary resuscitation

11. Obtain the blood samples from the arm opposite the transfusion

12. Return the remaining blood and tubing to blood bank

13. Obtain test voided urine. (within 1hr of reaction)

Evaluation

1. Obtain the client’s response to discontinuing the transfusion and reaction to medication or
other treatment administered

2. Observe for worsening of symptoms that could lead to a severe reaction or cardiopulmonary
arrest

Documentation

1. Date, time and type of reaction that occurred

2. Time the charge nurse and health care provider were notify??

3. Response of the client after discontinuing the transfusion

4. Response to the treatment given for the reaction. Time the blood and urine specimen were
sent to the blood bank.