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Mrs. Johnson, 68, presents to the ED with severe GI bleeding. She has a history of atrial fibrillation and is on Warfarin.

Labs:

Hgb 6.2/Hct 19

INR 4

Vitals: T 98.8 BP 98/54, HR 102, RR 18, SPO2 94% RA. Two units of PRBCs and a unit of Fresh Frozen Plasma (FFP) is ordered.

Why are both PRBCs and FFP ordered?

Key Nursing Considerations:

At 15 minutes into the first unit of PRBCs, a new set of vitals is obtained: T 100.2, BP 90/50, HR 113, RR 22 SPO2 92% RA

1. What should be your immediate nursing action?

2. How would you assess and manage this reaction?

3. What patient education would you provide after stabilizing the patient?

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Alex, 25 y/o, day 7 post-allogeneic BMT, develops fever of 101.3°F. ANC < 100.

What does allogeneic mean?

What additional assessments are needed?

Required Nursing Interventions:

What are additional potential complications to monitor for?

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Scenario Details: A 75 year old patient is receiving a blood transfusion

History: Heart Failure, HTN, hyperlipidemia, no history of blood transfusions

Vitals at start: T 98.2 HR 82 RR 18 SPO2 93% RA BP 120/72

Vitals at 15 min: T 98.3 HR 80 RR 18 SPO2 93% RA BP 124/76

Vitals at 45 min: T 98.3 HR 82 RR 20 SPO2 91% RA BP 138/84

Answer the following questions:

How would you assess and manage suspected circulatory overload?

What immediate actions are required to prevent further complications?

What follow-up care is essential in this case?

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ANSWERS Scenario 1, Part 1

Mrs. Johnson has severe anemia (Hgb 6.2) and an elevated INR of 4 due to Warfarin therapy:

PRBCs (Packed Red Blood Cells):

To replace lost red blood cells and improve oxygen-carrying capacity due to hemorrhage.

FFP (Fresh Frozen Plasma):

To reverse the anticoagulant effect of Warfarin, since FFP contains clotting factors

This is critical to stop active bleeding in someone with an INR of 4.

Give FFP FIRST followed by PRBCs to maximize effect of PRBCs

Key Considerations:

Baseline assessment:

Vitals, respiratory effort, mental status, skin color, cap refill.

IV access patent? At least one large-bore.

Monitor for transfusion reactions closely:

First 15–30 minutes are highest risk (stay in room for 15 min).

Frequent vitals (q15 min x first hour, follow policy).

Pre-medications?

Check if ordered for history of prior transfusion reactions (e.g., acetaminophen, diphenhydramine).

Informed consent & verification:

Double-check patient ID and blood product with second nurse.

Monitor lab trends:

CBC, INR post-transfusion.

Watch for improving Hgb and INR decrease.

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Answers Scenario 1, Part 2

Immediate Actions:

STOP the transfusion immediately.

Maintain IV access with normal saline via new tubing.

Notify provider and blood bank.

Reassess and monitor patient closely.

Check the blood product bag for any discoloration or clots.

Send required specimens:

Blood and urine samples.

Return the blood bag and tubing to the lab/blood bank.

Assessment:

Full set of vitals, lung sounds.

Ask about symptoms: chills, chest/back pain, dyspnea, nausea, anxiety.

Monitor urine output for hematuria (sign of hemolysis).

Management:

Febrile non-hemolytic:

Often mild; managed with acetaminophen.

Hemolytic (more serious):

Fever, hypotension, chills, flank pain, dark urine.

Supportive care, possible IV fluids, diuretics, and close monitoring for DIC.

Septic (from contaminated blood product):

Rapid fever, hypotension, possible rigors.

Start broad-spectrum IV antibiotics as ordered.

Education

Explain what happened in simple terms:

“You experienced a reaction during your transfusion, which we’ve stopped and treated.”

Future precautions:

Inform her that the reaction will be documented.

A transfusion reaction alert will be added to her chart for all future transfusions.

Symptoms to report immediately:

Fever, chills, back pain, dark urine, chest tightness, shortness of breath.

Medication education:

Review her Warfarin use—likely needs adjustment or bridging therapy post-bleed.

Follow-up labs and monitoring:

Explain the need for post-transfusion labs to ensure blood counts are improving and INR is corrected

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Answers Scenario 3

Allogeneic means that the bone marrow (or stem cells) came from a donor—either related or unrelated—but genetically different from the recipient.

This is in contrast to autologous transplant, where the patient’s own stem cells are used.

Allogeneic transplants carry more risk of complications like graft-versus-host disease (GVHD), but they can also have a stronger anti-cancer effect in certain conditions.

Given Alex’s fever and critically low ANC (Absolute Neutrophil Count), this is a medical emergency. Key assessments include:

Vital signs trending:

Monitor for signs of sepsis (hypotension, tachycardia, tachypnea, low O2 sats).

Focused physical exam:

Skin (rashes, wounds, mucositis), mouth/throat, catheter/IV sites, lungs, GI symptoms.

Labs:

Blood cultures (peripheral & central line) before antibiotics.

Urinalysis and culture.

CBC with differential.

Liver/kidney function tests.

CMV, EBV, fungal markers if symptoms suggest.

Imaging:

Chest X-ray or CT chest (especially with respiratory symptoms).

Medication review:

Check for recent changes, immunosuppressants, prophylactic antimicrobials.

Nursing Interventions:

Initiate neutropenic precautions (protective isolation):

Hand hygiene, mask use, no fresh flowers/plants, avoid raw foods.

Start empiric IV antibiotics ASAP (after cultures):

Monitor and manage fever:

Administer antipyretics (acetaminophen).

Keep Alex comfortable and hydrated.

Strict I/O monitoring:

Especially important with fever, IV fluids, possible nephrotoxic meds.

Psychosocial support:

BMT recovery is tough, mental/emotional support is vital.

Close monitoring:

Frequent vital signs.

Early signs of deterioration: notify provider promptly

Additional potential complications to monitor for:

Sepsis & Septic Shock

Neutropenic patients can deteriorate rapidly, early signs can be subtle.

Graft-versus-host disease (GVHD)

Skin rash, diarrhea, liver enzyme elevation.

Can be acute (within first 100 days) or chronic.

Fungal infections (e.g. candidasis)

Especially in prolonged neutropenia.

Viral reactivation

CMV, EBV, herpes simplex/zoster.

Mucositis

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Answers Scenario 2

TACO is a common complication in older adults with heart failure, as they can’t always tolerate the volume of a standard transfusion.

Assessment Signs of Circulatory Overload:

Increased BP: Now 138/84 (↑ from baseline).

Increased RR: 20 (mildly elevated).

↓ SpO₂: 91% on room air (↓ from 93%).

Stable temp: Rules out febrile reaction.

No tachycardia yet, but monitor closely.

Listen to lungs: Crackles, especially at bases?

Assess for:

Dyspnea or orthopnea.

Jugular venous distention (JVD).

Peripheral edema.

Anxiety or restlessness.

If circulatory overload is suspected:

STOP the transfusion immediately.

Maintain IV access with normal saline at a slow rate.

Notify the provider and blood bank.

Position patient upright (high Fowler's) to help breathing.

Administer oxygen as needed to maintain saturation ≥94%.

Prepare to administer diuretics (e.g., IV furosemide) if ordered, especially given heart failure history.

Monitor closely:

Continuous SpO₂, vitals q15 mins or as needed.

Lung sounds and respiratory effort.

I/O, especially urine output after diuretic.

What follow-up care is essential in this case?

Post-reaction monitoring:

Monitor vitals and respiratory status closely for several hours.

Reassess lung sounds.

Check urine output and response to diuretics.

Notify transfusion services/blood bank:

Complete reaction documentation and send any required samples (e.g., post-transfusion blood, used blood bag).

Future transfusion precautions:

Flag patient as high risk for TACO.

Future transfusions may need:

Slower infusion rate (e.g., over 3-4 hours).

Pre-medication with diuretics.

Smaller volume/unit transfusions if possible.

Patient education:

Teach patient and family to recognize early signs of volume overload or transfusion reactions.

Re-evaluate transfusion need:

Especially in heart failure patients, make sure benefits outweigh the risks.

Consider alternatives like iron, EPO, or single-unit transfusions.