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Blood Transfusion Reactions
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Acute Hemolytic Reaction
Signs and symptoms: fever, chills, low back pain, chest pain. Nursing Interventions: stop transfusion, maintain a patent IV line with saline, monitor vital signs, notify physician.
Transfusion-Associated Graft Versus Host Disease (TA-GVHD)
Signs and symptoms: fever, rash, diarrhea, pancytopenia. Nursing Interventions: TA-GVHD is usually not treatable, preventive measures include irradiation of blood products, notify physician.
Mild Allergic Reaction
Signs and symptoms: localized urticaria, pruritus, flushing. Nursing Interventions: stop transfusion and assess, consider antihistamine administration, restart transfusion at a slower rate if symptoms resolve.
Allergic Reaction
Signs and symptoms: urticaria, itching, bronchospasm. Nursing Interventions: stop transfusion, administer antihistamines, notify physician, monitor for anaphylaxis.
Transfusion-Related Acute Lung Injury (TRALI)
Signs and symptoms: acute respiratory distress, hypoxia, fever, non-cardiogenic pulmonary edema. Nursing Interventions: stop transfusion, provide respiratory support, administer corticosteroids if prescribed, notify physician.
Post-Transfusion Purpura
Signs and symptoms: widespread purpura, drop in platelet count. Nursing Interventions: report findings immediately, anticipate the need for platelet transfusion, monitor platelet count.
Alloimmunization
Signs and symptoms: difficulty finding compatible blood, unexplained anemia. Nursing Interventions: use leukocyte-reduced blood products, monitor for hemolytic reactions, consult with a blood bank for specialized crossmatching procedures.
Acute Immune Hemolytic Reaction
Signs and symptoms: fever, chest pain, back pain, renal failure. Nursing Interventions: stop transfusion, maintain blood pressure, provide diuretics to maintain urine flow, initiate hemodynamic monitoring.
Transfusion-Related Sepsis
Signs and symptoms: fever, hypotension, nausea, and vomiting. Nursing Interventions: stop transfusion promptly, maintain IV access with saline, collect blood cultures, provide supportive care as needed, notify the blood bank and physician.
Hypothermia
Signs and symptoms: shivering, dysrhythmias, cardiac arrest. Nursing Interventions: warm the patient, use blood warmer if necessary, monitor body temperature, notify physician if severe.
Transfusion-Associated Dyspnea
Signs and symptoms: shortness of breath, increased heart rate, increased blood pressure. Nursing Interventions: slow or stop transfusion, administer oxygen, diuretics if prescribed, elevate the head of the bed.
Septic Reaction
Signs and symptoms: rapid onset of chills, fever, shock, disseminated intravascular coagulation (DIC). Nursing Interventions: stop transfusion, culture blood and patient's specimen, administer antibiotics and vasopressors if necessary, notify the blood bank and physician.
Autoimmune Hemolytic Reaction
Signs and symptoms: jaundice, hemoglobinuria, fever. Nursing Interventions: stop transfusion, support renal function with fluids and diuretics, administer corticosteroids if prescribed.
Urticarial Transfusion Reaction
Signs and symptoms: hives, itching without other symptoms. Nursing Interventions: stop transfusion, administer antihistamine, observe for progression of symptoms, may restart transfusion if symptoms resolve.
Massive Transfusion Reaction
Signs and symptoms: coagulopathy, hypothermia, hypocalcemia, lactic acidosis. Nursing Interventions: closely monitor patient status, regulate blood product temperature, replace calcium and clotting factors as needed, ensure adequate oxygenation.
Air Embolism
Signs and symptoms: respiratory distress, hypotension, loss of consciousness. Nursing Interventions: place the patient on the left side and lower the head of the bed, administer oxygen, support blood pressure, prepare for advanced resuscitative measures.
Bacterial Contamination
Signs and symptoms: high fever, hypotension, vomiting. Nursing Interventions: stop transfusion, obtain blood cultures, administer antibiotics, notify physician, support blood pressure.
Febrile Non-Hemolytic Reaction
Signs and symptoms: sudden chills and fever, headache, muscle aches. Nursing Interventions: stop transfusion, administer antipyretics, notify physician, monitor patient closely.
Transfusion-Associated Circulatory Overload (TACO)
Signs and symptoms: hypertension, shortness of breath, tachypnea, pulmonary edema. Nursing Interventions: slow or halt the transfusion, provide supportive care for symptoms of heart failure, administer diuretics as prescribed.
Iron Deficiency Anemia Post-Transfusion
Signs and symptoms: fatigue, pallor, shortness of breath. Nursing Interventions: supplement iron as prescribed, monitor for signs of overload, provide patient education on iron-rich diet.
Fluid Shift Reaction
Signs and symptoms: peripheral or pulmonary edema, fluid overload. Nursing Interventions: slow infusion rate, monitor intake and output, administer diuretics if prescribed, support breathing as needed.
Circulatory Overload
Signs and symptoms: cough, dyspnea, pulmonary congestion, hypertension. Nursing Interventions: slow or stop the transfusion, place patient in upright position, administer diuretics if prescribed, monitor respiratory status.
Hyperkalemia
Signs and symptoms: muscle weakness, cardiac arrhythmias, ECG changes. Nursing Interventions: monitor electrolyte levels, provide emergency treatment for arrhythmias, limit potassium intake if required.
Iron Overload
Signs and symptoms: liver dysfunction, heart failure, diabetes mellitus. Nursing Interventions: chelation therapy to remove excess iron, monitor organ function, educate on symptoms of iron overload.
Electrolyte Imbalance
Signs and symptoms: changes in mental status, muscle cramps, twitching, or weakness. Nursing Interventions: monitor electrolyte levels, treat imbalances as prescribed, slow down or cease the transfusion if related.
Extravasation of Blood Product
Signs and symptoms: swelling, pain, tightness at the infusion site, possible blistering or necrosis. Nursing Interventions: stop infusion, apply cold then warm compress, elevate the limb, inform the physician.
Anaphylactic Reaction
Signs and symptoms: anxiety, wheezing, hypotension, shock. Nursing Interventions: stop transfusion immediately, call for emergency help, administer epinephrine, maintain airway and breathing.
Transfusion-Related Immune Modulation (TRIM)
Signs and symptoms: may be subclinical, but associated with higher infection rates and tumor recurrence. Nursing Interventions: there is no specific treatment, but leukoreduction of blood products may lessen its effects, maintain vigilant surveillance for infections.
Delayed Hemolytic Reaction
Signs and symptoms: fever, anemia, increased bilirubin, positive Coombs test. Nursing Interventions: monitor patient's hemoglobin and hematocrit, notify physician, prepare for supportive care.
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