Transfusion Reaction

Transfusion Reaction: Nursing Interventions
1. Stop the transfusion.
2. Change the intravenous (IV) tubing down to the IV site
and keep the IV line open with normal saline.
3. Notify the health care provider (HCP) and blood bank.
4. Stay with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
5. Prepare to administer emergency medications as prescribed.
6. Obtain a urine specimen for laboratory studies (perform any other laboratory studies as prescribed).
7. Return blood bag, tubing, attached labels, and transfusion record to the blood bank.
8. Document the occurrence, actions taken, and the client’s response.
If the client exhibits signs of a transfusion reaction, the
nurse immediately stops the transfusion and changes the
IV tubing down to the IV site to prevent the entrance of addi-
tional blood solution into the client. Normal saline solution
is hung and infused to keep the IV line open in the event that
emergencymedications need to be administered. The HCP is
notified and the nurse also notifies the blood bank of the
occurrence. The nurse stays with the client and monitors
the client closely while other personnel obtain needed sup-
plies to treat the client. As prescribed by the HCP, the nurse
administers emergency medications such as antihistamines,
vasopressors, fluids, and corticosteroids. The nurse then
obtains a urine specimen for laboratorystudies and anyother
laboratorystudies as prescribed to check for free hemoglobin
indicating that red blood cells were hemolyzed. The blood
bag, tubing, attached labels, and transfusion record are
returned to the blood bank so that the blood bank can check
the items to determine the reason that the reaction occurred.
Finally the nurse documents the occurrence, actions taken,and the client’s response.
Reference
Ignatavicius, Workman (2016), pp. 824-825.