1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
- Infuse 1 unit of packed red blood cells
- Sickle cell anemia
- Depression
hemoglobin: 6.9 g/dL [14–18 g/dL]
hematocrit: 20.7% [42%–52%]
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry.
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
Actions to Take: pause the transfusion and discontinue the vascular access device | discontinue the packed red blood cell transfusion and return it to the blood bank | start a new 20-gauge vascular access device in the opposite extremity | pause the transfusion obtain an order for acetaminophen
Potential Conditions: febrile transfusion reaction | infiltration at the vascular access device | hemolytic transfusion reaction | circulatory overload
Parameters to Monitor: discomfort and swelling at vascular access site | hemoglobin and hematocrit | temperature | blood pressure
Actions to Take: pause the transfusion and discontinue the vascular access device | discontinue the packed red blood cell transfusion and return it to the blood bank | start a new 20-gauge vascular access device in the opposite extremity | pause the transfusion obtain an order for acetaminophen
Parameters to Monitor: discomfort and swelling at vascular access site | hemoglobin and hematocrit | temperature | blood pressure
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