Age/Sex 60years female.
Admitting Diagnosis Hemoglobin 6.9,Hematocrit of 22.1
Location: Medical/Surgical floor.
Room Number: 30041
Alert and oriented x4.
02 2L NC.
Transfuse 2uints of PRBC.
Vital sign Q4hours.
Vital sign :15minutes before transfusions.
BP 140/71,Hr 67,Resp 18,02 saturation with 02 at 2 Liter NC. 98°F.
Tylenol 650mg po 30minutes before transfusions.
Patient received the two units of blood packed blood red cells.
During the transfusion of the second unit, the patient develops a transfusion reaction. The physician orders Benadryl 25mg IV. ×1.The nurse recognizes that the side effect of benadryl is dry mouth. Anticholinergic activity side effects are drowsiness, nausea.
Blood transfusion completed.Documentation completed. Check Hemoglobin and Hematocrit one hour after transfusion. No further reactions. Patient eat lunch and fell asleep.
Vital Sign BP 128/74,Hr.70,RR 18,Saturation 94°F RA.
Monitor Intake and output.
Encourage to use Incentive Spirometry.
CASE SCENARIO 23RD B.
(1)Two units of blood packed red blood cells are ordered by the doctor for a 73years old patient. The nurse receives a unit of PRBC from the blood bank labeled AB+.The patient blood type is O+.Which of the following actions should the nurse take first.
Answer: The nurse should return the blood to the blood bank.Must verify name ID#,blood type of patient blood type of unit, unit of donor #,unit expiration date.
Patient with O blood type can only receive type O blood components. But can be a donor type for all other types ( Universal Donor).Patients with AB blood type can receive A,B,O or AB blood components ( Universal Recipient)PRBC should be given 1.5 to 2hours( if it is not contraindicated). 0.9 Normal Saline. Normal Saline is added to decrease viscosity.
(D) Transfusion should be given using 16,18 or 20guage,patent/clean/Dry. Check vital sign before starting transfusion to establish a baseline. Start infusion slowly 2ml/minute. Signs of reactions are usually seen with infusion of first 50 to 100ml.Retake vital sign in 15 minutes. Infuse unit in about 2hours. Take vital sign again after transfusion.
(2)One unit of packed red blood cells is ordered for a patient who is anemic. After the transfusion is started. Which of the following actions taken by the nurse, would be most appropriate?.
(A)Leave the room immediately.
(B)Call the doctor.
(C)Tell the patient to call you whenever he needs you.
(D)Stay with patient during the first 20minutes of the transfusion because early signs of transfusion reaction is within 15minutes.
Correct answer ( D).
(3)The patient has been receiving blood transfusion for approximately 30minutes.
Which of the these assessment if made by the nurse would document allergy reaction:
(A) I think my skin color is back.
(B) What time is launch.
(C) Temperature of 37.0C.
(D) Respiratory wheezing.
Correct Answer is D .Allergic reaction is characterized by wheezing, urticaria, facial flushing, and epiglottis edema.