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Blood transfusion reaction
Terms in this set (18)
Hemolytic reaction from the transfusion of mismatched blood
Accompanying or following I.V. administration of blood components
Mediated by immune or nonimmune factors
Severity from mild to severe
Classified into the following groups: transfusion-related acute lung injury (TRALI); circulatory overload; bacterial contamination; acute hemolytic transfusion reaction (immune or nonimmune related); nonhemolytic febrile transfusion reaction; and allergic reactions
Recipient's antibodies, immunoglobulin (Ig) G or IgM, attach to donor red blood cells (RBCs), leading to widespread clumping and destruction of recipient's RBCs.
Transfusion with Rh-incompatible blood triggers a less serious reaction, known as Rh isoimmunization, within several days to 2 weeks. (See Understanding the Rh system.)
A febrile nonhemolytic reaction—the most common type of reaction—develops when cytotoxic or agglutinating antibodies in the recipient's plasma attack antigens on transfused lymphocytes, granulocytes, or plasma cells.
Transfusion with incompatible blood
Mild reactions occur in 1% to 2% of transfusions.
Reactions can occur at any age.
The most common transfusion reaction is a febrile, nonhemolytic reaction.
Acute tubular necrosis leading to acute renal failure (acute hemolytic reactions)
Disseminated intravascular coagulation (acute hemolytic reactions)
Multiorgan dysfunction syndrome
Transfusion of blood product
Nausea and vomiting
Chest and back pain
Fever (commonly the only finding with nonhemolytic febrile reaction; most common with acute hemolytic reaction) (see Signs and symptoms of transfusion reactions)
Hypotension (with acute hemolytic reaction)
Urticaria and angioedema (most common with allergic reaction)
In a surgical patient, blood oozing from the mucous membranes or incision site
With a hemolytic reaction, fever, an unexpected decrease in serum hemoglobin (Hb) level, frank blood in urine, and jaundice
Maculopapular rash or urticaria without fever or hypotension (allergic reaction)
Diagnostic Test Results-Laboratory
Serum Hb levels are decreased.
Serum bilirubin levels and indirect bilirubin levels are increased.
Urinalysis may reveal hemoglobinuria.
Indirect Coombs' test or serum antibody screen is positive for serum anti-A or anti-B antibodies.
Prothrombin time is increased and fibrinogen level is decreased.
Serum lactate dehydrogenase, blood urea nitrogen, and serum creatinine levels are increased.
Immediate halt of transfusion
Dialysis (may be necessary if acute tubular necrosis occurs)
I.V. normal saline solution to maintain systolic blood pressure and renal function
I.V. vasopressors such as dopamine hydrochloride to maintain systolic blood pressure
Epinephrine for anaphylaxis
Diphenhydramine to treat urticaria
Corticosteroids to help reduce inflammation
Antipyretics and analgesics, such as acetaminophen, to reduce fever (nonhemolytic transfusion reactions)
Diuretics such as furosemide (circulatory overload)
Osmotic diuretics, such as mannitol, to promote urinary excretion of hemoglobin (acute hemolytic transfusion reactions)
Oxygen, as needed, to maintain tissue perfusion
Nursing Considerations-Nursing Diagnoses
Decreased cardiac output
Impaired gas exchange
Impaired tissue integrity
Risk for imbalanced body temperature
Risk for injury
Nursing Considerations-Expected Outcomes
express feelings of comfort and relief of pain
verbalize measures to reduce his anxiety level
maintain adequate cardiac output
maintain adequate ventilation and oxygenation
have reduced redness, swelling, and pain at the site of impaired tissue
express feelings of control over his well-being
maintain a normal body temperature
remain free from injury.
Nursing Considerations-Nursing Interventions
Follow all agency protocols for administering blood transfusions. Begin transfusion slowly and increase the rate prescribed as tolerated.
Stop blood transfusion immediately and follow agency protocols for transfusion reactions.
Maintain a patent I.V. line with a normal saline solution infusion.
Insert an indwelling urinary catheter to evaluate urine output.
Report early signs of complications.
Cover the patient with blankets to ease chills; administer diphenhydramine as ordered for urticaria.
Administer supplemental oxygen, as needed, based on oxygen saturation levels.
Document the transfusion reaction in the patient's chart, noting the duration of the transfusion and the amount of blood absorbed.
Provide supportive therapy if the patient develops signs and symptoms of disseminated intravascular coagulation.
If the patient exhibits anaphylaxis, administer epinephrine as ordered.
Obtain specimens for laboratory testing, such as blood urea nitrogen and creatinine levels.
Vital signs, especially during the first 15 minutes of initiating the transfusion
Intake and output
Signs and symptoms of a possible reaction
Signs and symptoms of shock
Laboratory test results
Nursing Considerations-Associated Nursing Procedures
Blood and blood product transfusion reaction management
Blood pressure assessment
IV bag preparation
IV bolus injection
IV catheter insertion
Indwelling urinary catheter (Foley) care and management
Indwelling urinary catheter (Foley) insertion, female
Indwelling urinary catheter (Foley) insertion, male
Intake and output assessment
need to report unusual symptoms, such as a rash, itching, fever, or pain during the transfusion
signs and symptoms of a transfusion reaction
type of transfusion reaction and possible underlying cause, once the patient is stabilized
importance of informing other health care providers in the future about the transfusion reaction episode.
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