Primary Nursing Diagnosis

Risk for ineffective airway clearance related to airway swelling and obstruction

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level; Infection status; Knowledge: Treatment regime

INTERVENTIONS. Airway management; Airway insertion and stabilization; Airway suction-ing; Anxiety reduction; Oxygen therapy; Respiratory monitoring


PREVENTION. Typing, screening, and matching of blood units before administration eliminates most incompatibilities, but not all of them. If a transfusion reaction does occur, stop the transfusion immediately. The severity of the reaction is usually related to the amount of blood received. Begin an assessment to determine the severity and type of reaction. In minor reactions (urticaria or fever), the transfusion may be restarted after discussion with the physician and after giving the patient an antipyretic, antihistamine, or anti-inflammatory agent. Ongoing monitoring during the rest of the transfusion is essential. If the patient develops anaphylaxis, the patient's airway and breathing are maintained with oxygen supplement, intubation, and mechanical ventilation if needed.

134 Blood Transfusion Reaction

Pharmacologic Highlights

With an acute hemolytic reaction there are three conditions to consider: renal failure, shock, and disseminated intravascular coagulation (DIC). To counteract shock and minimize renal failure, the physician prescribes aggressive normal saline or colloid intravenous infusion. Mannitol is often used to promote diuresis. Dopamine may be used if hypotension is a problem. Furosemide (Lasix) may be given to keep urine output at 50 to 100 mL/hr. For pyretic reactions, after the possibility of a hemolytic reaction is ruled out, an antipyretic such as acetaminophen may be given and the transfusion may be restarted with caution. For severe reactions, see the table that follows.

Medication or Drug Class




Epinephrine Glucocorticoids

0.1-0.25 mg of 1:10,000 concentration IV over 5-10 min

Varies by drug

Sympathomimetic; catecholamine


Given for severe reactions for its pressor effect and bronchodilation.

Anti-inflammatory agents that limit laryngeal swelling

Other Drugs: Antihistamines may be given for minor allergic reactions.


Adhere strictly to the policies regarding typing, cross-matching, and administering blood. Make sure that the recipient's blood sample is correctly labeled when it is sent to the laboratory. Check each unit before administration to make sure that it is not outdated, that the unit has been designated for the correct recipient, that the patient's medical records' number matches the number on the blood component, and that the blood type is appropriate for the patient. All patients should have their identification band checked by two people before the transfusion is begun. Notify the blood bank, and withhold the transfusion for even the smallest discrepancy when checking the blood with the patient identification. Maintain universal precautions when handling all blood products to protect yourself, and dispose of used containers appropriately in the hazardous waste disposal.

Begin the transfusion at a rate of 75 mL or less per hour. Remain with the patient for the first 15 minutes of the transfusion to monitor for signs of a hemolytic reaction. If the patient develops a reaction, stop the transfusion immediately; evaluate the adequacy of the patient's airway, breathing, and circulation; take the patient's vital signs; notify the physician and blood bank; and return the unused portion of the blood to the blood bank for analysis. If the patient develops chills, monitor the patient's temperature, and cover him or her with a blanket unless the temperature is above 102°F. Remain with the patient and explain that a reaction has occurred from the transfusion. If the patient has excessive fears or concerns about the risk of HIV or hepatitis infection, provide specific information to him or her and arrange for a consultation as needed with either a physician or a counselor.

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