Blood Transfusion Reaction Nursing Diagnosis: A Comprehensive Guide for Nurses

Blood transfusions are a life-saving medical procedure used to replace blood lost due to surgery, trauma, bleeding disorders, or conditions that impair blood production. While generally safe, blood transfusions carry the risk of complications, the most significant being transfusion reactions. Recognizing and managing these reactions is a critical aspect of nursing care. This article provides a detailed guide for nurses on blood transfusion reactions, focusing on nursing diagnoses, assessments, and interventions to ensure patient safety and optimal outcomes.

Understanding Blood Transfusion Reactions

What is a Blood Transfusion Reaction?

A blood transfusion reaction is an adverse systemic response that occurs in a patient following the transfusion of blood or blood products. These reactions can range from mild to severe and can occur during or shortly after the transfusion, or even be delayed by several days. Prompt recognition and intervention are crucial to minimize patient harm.

Types of Blood Transfusion Reactions

Understanding the different types of transfusion reactions is essential for accurate nursing diagnosis and effective management. Reactions are broadly classified as acute or delayed and can be further categorized by their underlying mechanism. The major types include:

• Febrile Non-Hemolytic Transfusion Reaction (FNHTR): This is the most common type of transfusion reaction. It is characterized by a rise in temperature of ≥1°C or ≥2°F associated with the transfusion, often accompanied by chills and sometimes headache or malaise. FNHTRs are thought to be caused by cytokines released from leukocytes in the stored blood component or by recipient antibodies reacting to donor leukocytes or HLA antigens.

• Allergic Transfusion Reactions: These reactions occur due to recipient antibodies reacting to allergens in the donor plasma, or less commonly, donor antibodies reacting to recipient allergens. Symptoms can range from mild urticaria (hives), itching, and flushing to more severe anaphylactic reactions with bronchospasm, wheezing, and hypotension.

• Acute Hemolytic Transfusion Reaction (AHTR): This is a severe and potentially life-threatening reaction caused by ABO-incompatible blood transfusion. Recipient antibodies (usually pre-existing) react with donor red blood cell antigens, leading to rapid intravascular hemolysis. Symptoms can include fever, chills, back pain, chest pain, nausea, vomiting, hypotension, hemoglobinuria (red urine), and disseminated intravascular coagulation (DIC).

• Transfusion-Associated Circulatory Overload (TACO): TACO is a non-immunologic reaction caused by transfusing blood too rapidly or in too large a volume, particularly in patients with pre-existing cardiac or renal conditions. It results in hypervolemia and symptoms of fluid overload, such as dyspnea, cough, orthopnea, hypertension, tachycardia, jugular venous distention, and pulmonary edema.

• Transfusion-Related Acute Lung Injury (TRALI): TRALI is a serious and potentially fatal reaction characterized by acute respiratory distress occurring within 6 hours of transfusion. It is thought to be caused by donor antibodies (in plasma products) reacting with recipient leukocytes, leading to neutrophil activation and pulmonary capillary damage. Symptoms include acute onset dyspnea, hypoxemia, fever, hypotension, and bilateral pulmonary infiltrates.

• Septic Transfusion Reactions: These reactions are caused by bacterial contamination of the blood product. Symptoms usually develop rapidly and can include high fever, chills, marked hypotension, and septic shock. Gram-negative bacteria are the most common culprits due to their ability to grow at refrigeration temperatures.

• Delayed Hemolytic Transfusion Reactions (DHTR): DHTRs occur more than 24 hours post-transfusion (typically 3-14 days) and are often caused by alloantibodies to minor red blood cell antigens that were not detected during pre-transfusion testing or have increased in titer after previous exposure. DHTRs are usually less severe than AHTRs, but can still cause a decrease in hemoglobin levels, jaundice, and a positive direct antiglobulin test (DAT or Coombs’ test).

• Transfusion-Associated Graft-versus-Host Disease (TA-GVHD): This rare but almost always fatal reaction occurs when viable donor lymphocytes in the transfused blood product engraft and attack the recipient’s tissues. It is seen primarily in immunocompromised patients. Symptoms typically appear 1-6 weeks post-transfusion and include fever, skin rash, diarrhea, liver dysfunction, and pancytopenia. Irradiated blood products are used for at-risk patients to prevent TA-GVHD.

Image alt text: Close-up of a blood bag label detailing patient identifiers, blood component, blood type, compatibility, and expiration date, crucial for blood transfusion safety checks.

Signs and Symptoms of Blood Transfusion Reactions

Recognizing the signs and symptoms of a transfusion reaction is paramount for nurses. These can vary depending on the type and severity of the reaction. It is crucial to monitor patients closely throughout the transfusion and in the hours following. Key signs and symptoms to watch for include:

• Fever and Chills: Often the first signs of a reaction, particularly in FNHTR and septic reactions.
• Skin Reactions: Urticaria (hives), itching, flushing, and rash can indicate allergic reactions.
• Respiratory Distress: Dyspnea, wheezing, cough, and chest tightness can occur in allergic reactions, TRALI, and TACO.
• Cardiovascular Changes: Tachycardia, hypotension, hypertension, palpitations, and chest pain can be seen in various reaction types, especially AHTR, TACO, and septic reactions.
• Pain: Back pain (especially lumbar region) and chest pain are classic symptoms of AHTR.
• Gastrointestinal Symptoms: Nausea, vomiting, and diarrhea may occur in hemolytic and septic reactions.
• Hemoglobinuria: Red or tea-colored urine is a hallmark of AHTR due to the release of hemoglobin from hemolyzed red blood cells.
• Anxiety and Restlessness: These can be non-specific signs of distress and may accompany various reaction types.
• Oliguria or Anuria: Decreased or absent urine output can indicate kidney injury, particularly in AHTR.
• Bleeding: Unexplained bleeding or bruising can be a sign of DIC, a complication of AHTR and septic reactions.

Nursing Assessment for Blood Transfusion Reactions

A thorough nursing assessment is critical before, during, and after blood transfusions to identify and manage potential reactions promptly.

Pre-Transfusion Assessment

• Review Patient History: Assess for previous transfusion reactions, allergies, and medical conditions that may increase the risk of reactions (e.g., heart failure, kidney disease, history of allergic reactions). Document any prior reactions in detail, including symptoms and management.
• Verify Physician’s Order and Blood Product: Double-check the physician’s order for the specific blood component, dosage, and rate of transfusion. Ensure the blood product ordered is appropriate for the patient’s condition and blood type.
• Obtain Baseline Vital Signs: Measure and document baseline temperature, pulse, respiratory rate, and blood pressure before starting the transfusion. This provides a reference point for detecting changes during the transfusion.
• Assess Patient Understanding and Consent: Explain the transfusion procedure, potential benefits, and risks, including transfusion reactions, to the patient and family. Ensure informed consent is obtained and documented. Address any patient concerns or questions.
• Confirm Patient Identity and Blood Product Compatibility: This is a critical safety step. With another qualified healthcare professional, verify the patient’s identity using two patient identifiers. Compare the patient’s identification band information with the blood product label and transfusion compatibility report. Check for ABO and Rh compatibility, blood product type, unit number, and expiration date. Any discrepancy must be resolved before starting the transfusion.
• Establish IV Access: Ensure a patent intravenous line is in place, preferably a 18-20 gauge catheter or larger to allow for adequate flow rate and to manage potential reactions. Use only 0.9% normal saline to prime the blood administration set and keep the vein open, as other solutions can cause red blood cell damage or incompatibility.

Intra-Transfusion Monitoring

• Initial Monitoring: Begin the transfusion slowly and remain with the patient for the first 15 minutes. This is the period when most acute reactions occur. Monitor vital signs closely at 5-minute intervals for the first 15 minutes and observe for any early signs of a reaction (fever, chills, flushing, urticaria, respiratory distress, pain).
• Vital Sign Monitoring: Continue to monitor vital signs every 15-30 minutes during the transfusion and as per facility policy. Pay close attention to changes from baseline, particularly increases in temperature, heart rate, or decreases in blood pressure.
• Continuous Observation: Throughout the transfusion, continuously observe the patient for subjective and objective signs of a transfusion reaction. Ask the patient to report any unusual symptoms such as chills, itching, pain, or difficulty breathing.
• Maintain Correct Transfusion Rate: Administer the blood product at the prescribed rate, not exceeding the recommended transfusion time (typically 2-4 hours for packed red blood cells, and shorter for plasma and platelets). Avoid rapid transfusions unless clinically indicated and carefully monitored to prevent TACO.

Post-Transfusion Assessment

• Vital Signs Post-Transfusion: Obtain a set of vital signs at the completion of the transfusion and compare to baseline and intra-transfusion readings.
• Continued Monitoring: Continue to monitor the patient for at least one hour post-transfusion, and educate the patient about potential delayed transfusion reactions and symptoms to report to their healthcare provider.
• Assess Transfusion Effectiveness: Evaluate the patient’s response to the transfusion by assessing for improvement in symptoms related to the indication for transfusion (e.g., increased energy, decreased pallor, improved vital signs, and follow-up laboratory tests like hemoglobin and hematocrit).
• Monitor for Delayed Reactions: Educate the patient about the signs and symptoms of delayed hemolytic reactions (jaundice, fatigue, dark urine) and TA-GVHD (rash, fever, diarrhea) that may occur days to weeks after transfusion, and instruct them to seek medical attention if these develop.

Image alt text: Illustration of a blood transfusion setup, showing blood bag, administration set with filter, IV catheter inserted into patient’s arm, emphasizing the components and process of blood delivery.

Nursing Diagnoses Related to Blood Transfusion Reactions

Based on the assessment findings, several nursing diagnoses may be appropriate for a patient experiencing or at risk for blood transfusion reactions. Prioritized diagnoses directly related to transfusion reactions include:

• Risk for Allergic Reaction: This is relevant for all patients receiving blood transfusions, but especially those with a history of allergies or previous transfusion reactions.
• Hyperthermia: Related to febrile non-hemolytic transfusion reaction or septic reaction.
• Impaired Gas Exchange: Related to transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), or severe allergic reactions causing respiratory distress.
• Ineffective Breathing Pattern: Related to respiratory distress from TRALI, TACO, or anaphylaxis.
• Decreased Cardiac Output: Related to transfusion-associated circulatory overload (TACO) overwhelming the cardiovascular system.
• Excess Fluid Volume: Related to transfusion-associated circulatory overload (TACO) due to rapid or excessive volume infusion.
• Risk for Injury: Related to acute hemolytic transfusion reaction (AHTR) and disseminated intravascular coagulation (DIC).

Nursing Care Plans for Blood Transfusion Reactions

The following are examples of nursing care plans for common nursing diagnoses associated with blood transfusion reactions. These plans outline assessment parameters, expected outcomes, and nursing interventions.

Nursing Care Plan: Hyperthermia

Nursing Diagnosis: Hyperthermia related to adverse reaction from blood transfusion.

As evidenced by: Increased body temperature above normal range, chills, flushed skin, warm to touch, and possible headache or malaise.

Expected Outcomes:

• Patient will maintain body temperature within normal limits (97.6°F – 99.6°F or 36.4°C – 37.6°C) as evidenced by stable vital signs.
• Patient will report absence of chills and reduction in discomfort related to fever.

Assessment:

1. Monitor Vital Signs Frequently: Assess temperature, pulse, respirations, and blood pressure every 5-15 minutes during a suspected reaction. Note the onset and pattern of fever.
2. Assess for Other Reaction Symptoms: Evaluate for associated symptoms like chills, rigors, headache, nausea, and muscle aches that may accompany fever.
3. Review Patient History: Determine if the patient has a history of febrile transfusion reactions or other conditions predisposing to fever.

Interventions:

1. Stop the Transfusion Immediately: If fever develops during transfusion, stop the blood product infusion immediately while maintaining IV access with normal saline.
2. Notify Physician: Report the reaction and patient’s symptoms to the physician promptly for further orders.
3. Manage Fever:
   • Administer antipyretics as ordered (e.g., acetaminophen) to reduce fever and improve comfort.
   • Apply cooling measures such as cool compresses or a cooling blanket if temperature is significantly elevated and as ordered.
4. Obtain Blood and Urine Samples: As per protocol and physician orders, send the remaining blood product and administration set to the blood bank for repeat compatibility testing and bacterial culture. Obtain post-transfusion blood and urine samples from the patient to investigate for hemolysis.
5. Monitor Patient Comfort: Provide comfort measures such as warm blankets during chills, and adjust room temperature for patient comfort.

Nursing Care Plan: Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), or anaphylactic reaction.

As evidenced by: Dyspnea, tachypnea, use of accessory muscles for breathing, decreased oxygen saturation (SpO2 < 90%), cyanosis, restlessness, anxiety, and abnormal breath sounds (wheezing, crackles).

Expected Outcomes:

• Patient will maintain adequate gas exchange as evidenced by SpO2 ≥ 95% or patient’s baseline, respiratory rate within normal limits (12-20 breaths/min), and absence of respiratory distress.
• Patient will report reduced dyspnea and improved breathing comfort.

Assessment:

1. Assess Respiratory Status Continuously: Monitor respiratory rate, depth, and effort. Observe for signs of respiratory distress such as nasal flaring, use of accessory muscles, and retractions.
2. Auscultate Lung Sounds: Assess for adventitious breath sounds such as wheezing (suggesting bronchospasm in allergic reaction or TRALI) or crackles (indicating pulmonary edema in TACO).
3. Monitor Oxygen Saturation: Continuously monitor SpO2 using pulse oximetry.
4. Assess for Other Reaction Signs: Evaluate for associated symptoms like fever, hypotension, urticaria, and jugular venous distention to help differentiate between reaction types (TRALI, TACO, anaphylaxis).
5. Assess Level of Consciousness: Changes in mentation such as restlessness, confusion, or lethargy can indicate hypoxia.

Interventions:

1. Stop the Transfusion Immediately: If respiratory distress develops, stop the blood transfusion immediately, maintaining IV access with normal saline.
2. Position Patient Upright: Place the patient in a high Fowler’s position to maximize lung expansion.
3. Administer Oxygen Therapy: Apply supplemental oxygen as ordered to maintain SpO2 at the prescribed level. Be prepared to escalate oxygen delivery if needed (nasal cannula, face mask, non-rebreather mask).
4. Notify Physician Stat: Immediately notify the physician about the patient’s respiratory distress and assessment findings.
5. Administer Medications as Ordered:
   • For allergic reactions: Administer antihistamines (e.g., diphenhydramine) and bronchodilators (e.g., albuterol) as ordered. For severe anaphylaxis, epinephrine may be required.
   • For TACO: Diuretics (e.g., furosemide) may be ordered to reduce fluid overload.
   • For TRALI: Supportive care is primary, including oxygen therapy and potentially mechanical ventilation. Corticosteroids may be considered but are not routinely recommended.
6. Prepare for Advanced Respiratory Support: Be prepared to assist with intubation and mechanical ventilation if the patient develops severe respiratory failure.

Nursing Care Plan: Excess Fluid Volume

Nursing Diagnosis: Excess Fluid Volume related to transfusion-associated circulatory overload (TACO).

As evidenced by: Dyspnea, orthopnea, cough, crackles or rales on auscultation, jugular venous distention (JVD), peripheral edema, elevated blood pressure, tachycardia, and weight gain.

Expected Outcomes:

• Patient will achieve fluid balance as evidenced by clear lung sounds, absence of JVD and peripheral edema, blood pressure and heart rate within patient’s normal limits, and stable weight.
• Patient will report reduced dyspnea and orthopnea.

Assessment:

1. Monitor Fluid Balance: Accurately measure and record intake and output. Note positive fluid balance (intake greater than output).
2. Assess Respiratory Status: Auscultate lung sounds for crackles or rales, indicating pulmonary edema. Assess for dyspnea, orthopnea, and cough.
3. Cardiovascular Assessment: Monitor blood pressure for hypertension and pulse for tachycardia. Assess for JVD in a semi-recumbent position.
4. Assess for Edema: Examine for peripheral edema in dependent areas (ankles, feet, sacrum).
5. Review Patient History: Identify pre-existing conditions that increase risk for TACO, such as heart failure, renal insufficiency, and advanced age.

Interventions:

1. Slow or Stop Transfusion: If TACO is suspected, slow the transfusion rate or stop it temporarily. Maintain IV access with normal saline at a keep-vein-open rate.
2. Position Patient Upright: Place the patient in a high Fowler’s position to promote lung expansion and reduce venous return.
3. Administer Diuretics as Ordered: Administer diuretics (e.g., furosemide) as prescribed to promote fluid excretion and reduce circulatory volume. Monitor urine output and electrolyte levels.
4. Administer Oxygen Therapy: Provide supplemental oxygen as needed to alleviate dyspnea and hypoxemia.
5. Monitor Vital Signs and Respiratory Status: Continue to monitor vital signs, respiratory status, and oxygen saturation frequently.
6. Elevate Legs: Elevate edematous extremities to promote venous return and reduce edema.
7. Consider Smaller Transfusion Aliquots: For patients at high risk of TACO, discuss with the physician the possibility of transfusing smaller aliquots of blood products over a longer period.

Nursing Interventions for Managing Blood Transfusion Reactions

Prompt and appropriate nursing interventions are crucial in managing transfusion reactions. The general steps to take when a transfusion reaction is suspected are:

1. Stop the Transfusion Immediately: Discontinue the transfusion of blood or blood products. This is the priority action.
2. Maintain IV Access: Keep the intravenous line open with 0.9% normal saline solution, using a new administration set. Do not flush the line with the blood product still in it.
3. Assess Patient: Immediately assess the patient’s condition, focusing on vital signs, respiratory status, and any new signs and symptoms.
4. Notify Physician: Contact the physician promptly and report the patient’s signs and symptoms, vital signs, and the time the reaction started. Follow the physician’s orders.
5. Prepare for Emergency Medications and Support: Be ready to administer emergency medications as ordered (e.g., epinephrine, antihistamines, corticosteroids, vasopressors, diuretics). Prepare for potential respiratory support, including oxygen therapy and intubation.
6. Blood Bank Procedures:
   • Send the remaining blood product and administration set, along with attached tags and labels, to the blood bank for investigation.
   • Draw post-transfusion blood samples from the patient as ordered for repeat type and crossmatch, direct antiglobulin test (DAT), and other tests to investigate the reaction.
   • Collect a urine sample to check for hemoglobinuria if a hemolytic reaction is suspected.
7. Document the Reaction: Thoroughly document the transfusion reaction in the patient’s medical record, including:
   • Time the reaction started and stopped.
   • Signs and symptoms exhibited by the patient.
   • Nursing interventions implemented.
   • Physician notification and orders.
   • Blood product unit number and component.
   • Patient outcomes.
   • Completion of a transfusion reaction report form according to institutional policy.
8. Monitor Patient Closely: Continue to monitor the patient’s vital signs and condition frequently after a reaction, as reactions can evolve or worsen.

Conclusion

Nurses play a vital role in ensuring the safety of blood transfusions. Understanding blood transfusion reaction nursing diagnoses, coupled with diligent assessment, prompt intervention, and thorough documentation, are essential to minimizing the risks associated with this common medical procedure. By being vigilant and knowledgeable, nurses can significantly improve patient outcomes and safety in blood transfusion therapy.

References

• American Association of Blood Banks (AABB). (Current Edition). Standards for blood banks and transfusion services. Bethesda, MD: AABB.
• Brecher, M.E. (Ed.). (Current Edition). Technical manual. Bethesda, MD: AABB.
• Daniels, S.F., & Rossi, E. (Eds.). (Current Edition). Transfusion medicine. Bethesda, MD: AABB.
• Hillyer, C.D., Strauss, R.G., Luban, N.L.C., Quesenberry, P.J., & Westoff, C.M. (Eds.). (Current Edition). Transfusion medicine and hemostasis: Clinical and laboratory aspects. Waltham, MA: Elsevier.
• Joint Commission. (Current Edition). National patient safety goals. Oakbrook Terrace, IL: Joint Commission Resources.
• UpToDate. (Current Edition). Transfusion reactions. Retrieved from [UpToDate Website] (Replace with actual UpToDate link if available and permissible).
• Nursing textbooks and resources on blood transfusion and transfusion reactions. (e.g., Wilkinson, J.M., Treas, L.S., Barnett, K.L., & Smith, M.H. (Current Edition). Fundamentals of nursing. Philadelphia, PA: F.A. Davis Company).