N4 Blood Transfusion Reaction

Acute hemolytic transfusion reactions (AHTR) can cause serious, potentially fatal consequences. Fortunately, they're extremely rare. But when they do occur, it's usually because of ABO incompatibility between patient and donor during transfusion of red blood cells. Most cases of ABO incompatibility result from clerical error at some point in the transfusion process. So, it's vital for everyone involved in the transfusion procedure to ensure accuracy when drawing laboratory samples for typing and crossmatching and when identifying the patient and the blood or blood component at the time of transfusion.
Signs and symptoms of AHTR usually appear 5 to 15 minutes after the transfusion begins, but they can develop anytime during the transfusion. Possible symptoms during an AHTR include:
* temperature increase of more than 2° F (1° C)
* bloody urine
* chills
* hypotension
* severe low back, flank, or chest pain
* low or absent urine output
* nausea and vomiting
* dyspnea, wheezing
* anxiety, sense of impending doom
* diaphoresis
* generalized bleeding, especially from punctures and surgical wounds.
Should any of these symptoms occur, immediately discontinue the transfusion, hang 0.9% sodium chloride to maintain vascular access (be sure to use new tubing), and call for assistance. Closely monitor the patient's vital signs and symptoms. Notify the primary care provider and obtain orders to address the patient's symptoms. Recheck the patient's identifying information against the transfusion record and blood bag. All bags, tubings, filters, and paperwork should be retained and forwarded per facility policy.

From Nursing Center
http://www.nursingcenter.com/prodev/ce_article.asp?tid=525833