About
Hemolytic, allergic, febrile, bacterial, or circulatory overload.
Assess
Spike in temperature, shortness of breath, rash, itching, sudden feeling of impending doom, crackles at the lung bases, increase blood pressure.
Complications
Fluid overload
Anaphylaxis
Death
Diagnosis
- Impaired gas exchange related to bronchial constriction and laryngeal edema
- Anxiety related to possibility of harm from blood transfusions
Goals
- The client will remain free form injury.
- The client will be able to identify symptoms to notify the nurse of immediately when initiating a transfusion.
Interventions
- Stop blood transfusion immediately; Notify physician.
- Monitor clients vitals, intake and output, and pulse oximetry.
- Auscultate lungs and heart, noting any dysrhythmias or onset of adventitious lung sounds.
- Keep IV line patent, administer medications as ordered.
- Follow agency protocol regarding reactions: Send blood samples, tubing, urinalysis, etc down to lab. Closely monitor client.
- Encourage client to notify nurse of any abnormal symptoms they may be feeling.
- Monitor for signs/ symptoms of complications.
ليست هناك تعليقات:
إرسال تعليق