SUSPECTED TRANSFUSION REACTION Nursing Care

STOP THE TRANSFUSION CRITICAL STEPS IN FURTHER EVALUATION

OF POSSIBLE TYPE OF TRANSFUSION
Maintain IV access with normal saline (0.9% NaCl) [if possible,aspirate

any blood product in line before hanging Normal Saline solution]
REACTION
Disconnect blood product
CONTACT PHYSICIAN ON SITE with attached tubing should
be handled aseptically and
returned to blood bank;
ASSESS PATIENT Unit will be cultured if
patient signs and symptoms
Obtain complete Set of Vital Signs
suggestive of sepsis; blood
Verify ,with another RN , patient and blood product identifiers cultures should also be
obtained from patient if
Auscultate all lung fields and obtain pulse oximetry reading as respiratory sepsis suspected.
status can change suddenly with all types of transfusion reactions. Maintain
Blood bank should also be
pulse oximeter until resolution of all signs and/or symptoms of reaction. sent description of reaction
While obtaining above inspect patient for signs of any isolated hive or and a patient blood
generalized urticarial rash specimen for a direct
antiglobulin test (Coombs
Ask patient to describe, in their own words, what they are feeling or in test)
younger pediatric patuents, what parent may be observing . Depending on reaction and
blood bank analysis,
additional specimens of
blood and/or urine may be
requested
POSSIBLE CLINICAL INTERVENTIONS

ANAPHYLAXIS/HTR
CONTINUE
TO OBSERVE Fluids
FEVER
Oxygen
Antipyretics Severe
Antihistamines
Respiratory
Corticosteroids
Antipyretics FEVER WITH Distress/
Analgesics RIGORS Epinephrine
Shock
Prepare for intubation
Antihistamines HIVES Prepare to Intubate
SEPSIS
TRALI
Obtain blood cultures
IV Diuretics
Broad spectrum antibiotic coverage
Oxygen