Funds review test 3
Recognizing blood transfusions reactions
**If a reaction is suspected, the priority is to stop the transfusion while keeping IV
access open using an infusion of 0.9% sodium chloride.
In some cases, it is necessary to replace the administration set because a
significant amount of blood may still be present within the tubing
What should the nurse do if there is a reaction with blood transfusions
The blood unit label and client identification should be compared again to verify
the blood product was administered to the correct client.
The nurse should remain with the client, continue to monitor the client's status,
support respirations if needed, and notify the provider
**A nurse should always stay with a client for the first 15 minutes of a blood or
blood product transfusion.***
Transfusions reaction symptoms
Fever
Chills
Altered blood pressure (elevated or decreased)
Respiratory difficulty (wheezing, coughing, dyspnea)
Pain in the chest, abdomen, low back, or flank
Nausea and/or vomiting
Skin manifestations including pruritus, urticaria, flushing, edema (localized), and
rash
Jaundice
Urinary changes including oliguria, anuria, and hematuria
The most common acute transfusion reactions
,*acute hemolytic reactions, which occur when the blood transfused is not
compatible with the blood of the client*
- febrile non-hemolytic transfusion reactions
- allergic reactions, which can range from mild to anaphylactic.
-transfusion-related acute lung injury (TRALI), which results in edema of the lung
tissues and airways;
- and transfusion-associated circulatory overload (TACO), which is often the
result of too-rapid administration of blood products.
Transfusion-associated circulatory overload (TACO)
Happens when a large volume is transfused over a short period of time.
Those at greatest risk include infants and clients older than 70 years of age.
Transfusion-related acute lung injury (TRALI)
Occurs when the client has antibodies to WBCs in the donor blood
Allergic reaction (mild)
Occurs when the client is allergic to something in the infusion
Manifestations:
Pruritis, urticaria, wheezing, facial flushing
Hypokalemia causes
**occurs when levels of potassium fall below 3.5
**The most common cause of hypokalemia is loss of potassium from the kidneys
or gastrointestinal tract.
, Medications that most commonly result in hypokalemia: Potassium-wasting
diuretics (loop, thiazide, and osmotic) are the medications that most commonly
result in hypokalemia through urinary loss.
Hypokalemia can occur from several causes:
Medications
Certain cardiac conditions
Gastrointestinal losses
Metabolic alkalosis
Decreased oral intake of potassium
Excessive alcohol use
Chronic kidney disease
Diabetic ketoacidosis
Excessive sweating
Folic acid deficiency
signs and symptoms of hypokalemia
Common manifestations: muscle weakness, cardiac arrhythmias, constipation,
and fatigue.
With severe life-threatening hypokalemia, defined as a potassium level less than
2.5 mEq/L, respiratory paralysis and failure can occur
Other manifestations of severe hypokalemia: may include paralytic ileus
(obstruction in the intestine), hypotension, tetany, rhabdomyolysis (muscle tissue
breakdown), and life-threatening cardiac arrhythmias
**The provider may order an electrocardiogram (ECG) to determine if the level of
potassium is affecting the rhythm of the heart.
Hyperkalemia causes
**is defined as a potassium value greater than 5 mEq/L
Recognizing blood transfusions reactions
**If a reaction is suspected, the priority is to stop the transfusion while keeping IV
access open using an infusion of 0.9% sodium chloride.
In some cases, it is necessary to replace the administration set because a
significant amount of blood may still be present within the tubing
What should the nurse do if there is a reaction with blood transfusions
The blood unit label and client identification should be compared again to verify
the blood product was administered to the correct client.
The nurse should remain with the client, continue to monitor the client's status,
support respirations if needed, and notify the provider
**A nurse should always stay with a client for the first 15 minutes of a blood or
blood product transfusion.***
Transfusions reaction symptoms
Fever
Chills
Altered blood pressure (elevated or decreased)
Respiratory difficulty (wheezing, coughing, dyspnea)
Pain in the chest, abdomen, low back, or flank
Nausea and/or vomiting
Skin manifestations including pruritus, urticaria, flushing, edema (localized), and
rash
Jaundice
Urinary changes including oliguria, anuria, and hematuria
The most common acute transfusion reactions
,*acute hemolytic reactions, which occur when the blood transfused is not
compatible with the blood of the client*
- febrile non-hemolytic transfusion reactions
- allergic reactions, which can range from mild to anaphylactic.
-transfusion-related acute lung injury (TRALI), which results in edema of the lung
tissues and airways;
- and transfusion-associated circulatory overload (TACO), which is often the
result of too-rapid administration of blood products.
Transfusion-associated circulatory overload (TACO)
Happens when a large volume is transfused over a short period of time.
Those at greatest risk include infants and clients older than 70 years of age.
Transfusion-related acute lung injury (TRALI)
Occurs when the client has antibodies to WBCs in the donor blood
Allergic reaction (mild)
Occurs when the client is allergic to something in the infusion
Manifestations:
Pruritis, urticaria, wheezing, facial flushing
Hypokalemia causes
**occurs when levels of potassium fall below 3.5
**The most common cause of hypokalemia is loss of potassium from the kidneys
or gastrointestinal tract.
, Medications that most commonly result in hypokalemia: Potassium-wasting
diuretics (loop, thiazide, and osmotic) are the medications that most commonly
result in hypokalemia through urinary loss.
Hypokalemia can occur from several causes:
Medications
Certain cardiac conditions
Gastrointestinal losses
Metabolic alkalosis
Decreased oral intake of potassium
Excessive alcohol use
Chronic kidney disease
Diabetic ketoacidosis
Excessive sweating
Folic acid deficiency
signs and symptoms of hypokalemia
Common manifestations: muscle weakness, cardiac arrhythmias, constipation,
and fatigue.
With severe life-threatening hypokalemia, defined as a potassium level less than
2.5 mEq/L, respiratory paralysis and failure can occur
Other manifestations of severe hypokalemia: may include paralytic ileus
(obstruction in the intestine), hypotension, tetany, rhabdomyolysis (muscle tissue
breakdown), and life-threatening cardiac arrhythmias
**The provider may order an electrocardiogram (ECG) to determine if the level of
potassium is affecting the rhythm of the heart.
Hyperkalemia causes
**is defined as a potassium value greater than 5 mEq/L
