STOP THE INFUSION!!!!!!!
Maintain the IV line with normal saline solution through new IV tubing, given at a slow rate.
-Assess the patient carefully. Compare the vital signs with baseline, including oxygen saturation. Assess the patient’s respiratory status carefully. Note the presence of adventitious breath sounds; the use of accessory muscles; extent of dyspnea; and changes in mental status, including anxiety and confusion. Note any chills, diaphoresis, jugular vein distention, and reports of back pain or urticaria.
-Notify the primary provider of the assessment findings, and implement any treatments prescribed. Continue to monitor the patient’s vital signs and respiratory, cardiovascular, and renal status
-Notify the blood bank that a suspected transfusion reaction has occurred.
-Send the blood container and tubing to the blood bank for repeat typing and culture. The patient’s identity and blood component identifying tags and numbers are verified.