- Decreased Cardiac Output related to rapid transfusion and rapid filling of blood in the ventricles as evidenced by Tachycardia and S3 heart sound upon auscultation
- Excess Fluid Volume related to blood transfusion reaction as evidenced by Crackles or rales on auscultation and Pulmonary congestion
- Hyperthermia related to adverse reaction from a blood transfusion as evidenced by Increase in body temperature and Chills
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Difficulty breathing Anxiety Weight gain or swelling Objective data: -Shortness of breath -Adventitious breath sounds -High blood pressure -Edema -Decreased hemoglobin or hematocrit -Increased central venous pressure Jugular vein distention Pulmonary congestion/edema | Decreased Cardiac Output related to rapid transfusion and rapid filling of blood in the ventricles as evidenced by Tachycardia and S3 heart sound upon auscultation | Patient will not report symptoms of anxiety, dyspnea, or heart palpitations. Patient will demonstrate a respiratory rate within normal limits and clear breath sounds upon auscultation. | 1. Ensure patient safety. Ensure the patient’s safety by cautiously regulating the blood transfusion rate. This will prevent circulatory overload and decreased cardiac output. Transfuse slowly (but still within the recommended transfusion timeframe) for patients with cardiovascular or kidney disease. 2. Premedicate with a diuretic. Patients at risk for circulatory overload may need to be premedicated with a diuretic like furosemide. Additional doses of a diuretic may be necessary if symptoms persist. 3. Stop the infusion immediately if a reaction is identified. If the patient reports any dyspnea or vital signs are unstable, stop the infusion immediately. 4. Apply oxygen. After stopping the infusion, sit the patient upright and apply supplemental oxygen. | Patient reported symptoms of anxiety, dyspnea, or heart palpitations. Patient demonstrated respiratory rate within normal limits and clear breath sounds upon auscultation. |
| Subjective data: Expresses concerns about difficulty to breathe Objective data: -Crackles or rales on auscultation -Jugular vein distention -Elevated blood pressure -Dyspnoea or cough -Adventitious breath sounds -Pulmonary congestion | Excess Fluid Volume related to blood transfusion reaction as evidenced by Crackles or rales on auscultation and Pulmonary congestion | Patient will remain normovolemic as evidenced by clear lung sounds, normal blood pressure readings, and the absence of jugular vein distention | 1. Administer diuretics as indicated. Diuretics are usually indicated in cases of excess fluid volume following blood transfusions as it helps in the excretion of excess fluids in the body. For patients with a history of CHF, diuretics may be ordered prior to the transfusion to prevent fluid volume overload. 2. Regulate the rate of IV fluids or blood products as indicated. Strict adherence to the rates of IV fluids is vital as it can help avoid excess fluid volume. Transfuse blood at the slowest possible rate to meet protocols but prevent fluid overload. 3. Provide supplemental oxygenation as needed. Providing oxygenation will help facilitate breathing during circulatory overload. 4. Place the patient in a semi-Fowler’s position. This position allows for the proper evaluation of jugular vein distention. It also offers ease of breathing for optimal chest and lung expansion. 5. Elevate oedematous extremities if present. Elevation of affected body parts can reduce edema by promoting an increased venous return to the heart. | Patient remained normovolemic as evidenced by clear lung sounds, normal blood pressure readings, and the absence of jugular vein distention |
| Subjective data: Verbalizes increased Body Temperature Objective data: -Increase in body temperature -Flushed or warm skin -Chills -Lethargy | Hyperthermia related to adverse reaction from a blood transfusion as evidenced by Increase in body temperature and Chills | Patient will maintain body temperature within normal limits as evidenced by stable vital signs and the absence of chills. | 1. Stop the transfusion and report adverse reactions to the physician. When fever is exhibited during the transfusion, the procedure must be stopped and findings must be reported to the physician. 2. Obtain urinalysis or blood samples. Haemolytic reactions can be investigated and confirmed through urine or blood tests. This can also help confirm the patient was correctly typed and crossmatched. 3. Administer antipyretics as indicated. Antipyretics such as acetaminophen will aid in the reduction of the patient’s body temperature. 4. Make use of a cooling blanket as needed. A cooling blanket will help reduce the patient’s elevated body temperature which may reach up to 104.0 F (40.0 C). 5. Administer IV fluids. If not already infusing, 0.9% normal saline should be infused to keep the IV open and clear. | Patient maintained body temperature within normal limits as evidenced by stable vital signs and the absence of chills. |