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Acute transfusion reactions present as adverse signs or symptoms during or within 24 hours of a blood transfusion. The most frequent reactions are fever, chills, pruritus, or urticaria, which typically resolve promptly without specific treatment or complications. Other signs occurring in temporal relationship with a blood transfusion, such as severe shortness of breath, red urine, high fever, or loss of consciousness may be the first indication of a more severe potentially fatal reaction.

Below is the nursing checklists for the management of transfusion reaction.

Check (√) Yes or No

Before, during, and after the procedure, follows Principles-Based Checklist to Use With All Procedures, including: Identifies the patient according to hospital policy using two identifiers; attends appropriately to standard precautions, hand hygiene, safety, privacy, and body mechanics. - - -
1. Stops the transfusion immediately if signs or
symptoms of a transfusion reaction occur.
- - -
2. Do not flush the tubing. - - -
3. Disconnects the administration set from the
IV catheter.
- - -
4. Calls for help. - - -
5. Checks vital signs and auscultates heart and breath sounds. - - -
6. Maintains a patent IV catheter by hanging a new infusion
of normal saline solution, using new tubing.
- - -
7. Notifies primary provider as soon as the blood
has been stopped and patient has been assessed.
- - -
8. Places the administration set and blood product
container with the blood bank form attached inside a biohazard bag and
sends it to the blood bank immediately.
- - -
9. Obtains blood (in the extremity opposite the
transfusion site) and urine specimens according to hospital policy.
- - -
10. Continues to monitor vital signs frequently,
at least every 15 minutes.
- - -
11. Administers medications as prescribed. - - -

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