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Condition and Etiology
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Assessment: Signs and Symptoms
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Nursing Care Plan/Implementation
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Transfusion Reactions—Allergic, Febrile, and Hemolytic (Continued)
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Hemolytic ireacton—
infusion of incompatible blood (less common more serious)
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Early:
chills and fever; throbbing headache, feeling of burning in face; hypotension; tachycardia; chest, back, or flank pain; nausea, vomiting, feeling of doom; later: spontaneous and diffuse bleeding; icterus; oliguria; anuria; hemoglobinuria
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Stop infusion immediately; take vital signs and notify physician
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Send patient blood sample and unused blood to lab for analysis
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Send stat urine to blood
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Save
all
urine for observation of discoloration
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Administer parenteral infusions to
combat shock, as ordered
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Administer medications as ordered—diuretics, sodium bicarbonate, hydrocortisone and vasopressors
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Emotional Complications
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Emotional disturbances
—grief asso-
ciated with loss of body part or
loss of body image; previous emotional problems; decreased sen-
sory overload; fear and pain;
decreased resistance to stress as
a result of age, exhaustion, or
debilitation
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Restlessness, insomnia, depression, hallucina
tions, delusions, agitation, suicidal thoughts
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Report symptoms to physician
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Encourage verbalization of feelings; give realistic reassurance
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Orient to time and place as necessary
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Provide safety measures, such as side
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Keep room lit, to reduce incidence of
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Administer tranquilizers as ordered.
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Use restraints as a
last
resort
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