Editing Medical-Surgical Nursing (section)

=== Transfusion Reactions ===

Verify the blood product and the patient with two qualified individuals per policy, use normal saline only as the compatible solution, use appropriate filtered tubing, start slowly, and remain with the patient for the first fifteen minutes, when most severe reactions occur. Take a baseline set of vital signs and repeat per policy.

If any reaction is suspected, stop the transfusion immediately, keep the line open with normal saline using new tubing, take vital signs, and notify the provider and the blood bank. Acute hemolytic reaction presents with fever, chills, low back or flank pain, hypotension, dark urine, and a sense of doom. Febrile nonhemolytic reaction presents with fever and chills. Allergic reaction presents with hives and itching, and anaphylaxis adds wheezing and hypotension. Transfusion-associated circulatory overload presents with dyspnea, crackles, hypertension, and distended neck veins.