| Reaction: Cause | Clinical Signs | Nursing Intervention* |
| 1) Hemolytic reaction: incompatibility between client’s blood and donor’s blood | Chills, fever, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, hypotension | 1. Discontinue the transfusion immediately. NOTE: When the transfusion is discontinued, the blood tubing must be removed as well. Use new tubing for the normal saline infusion. 2. Keep the vein open with normal saline, or according to agency protocol. 3. Send the remaining blood, a sample of the client’s blood, and a urine sample to the laboratory. 4. Notify the physician immediately. 5. Monitor vital signs.6. Monitor fluid intake and output. |
| 2) Febrile reaction: sensitivity of the client’s blood to white blood cells, platelets, or plasma proteins. | Fever; chills; warm, flushed skin; headache; anxiety, muscle pain | 1. Discontinue the transfusion immediately. 2. Give antipyretics as ordered. 3. Notify the physician. 4. Keep the vein open with a normal saline infusion. |
| 3) Allergic reaction (mid): sensitivity to infused plasma proteins. | Flushing, itching, urticaria, bronchial wheezing | 1. Stop or slow the transfusion, depending on agency protocol. 2. Notify the physician. 3. Administer medication (antihistamines) as ordered. |
| 4) Allergic reaction (severe): antibody-antigen reaction | Dyspnea, chest pain, circulatory collapse, cardiac arrest | 1. Stop the transfusion 2. Keep the vein open with normal saline. 3. Notify the physician immediately. 4. Monitor vital signs. Administer cardiopulmonary resuscitation if needed. 5. Administer medications and/or oxygen as ordered. |
| 5) Circulatory overload: blood administered faster than the circulation can accommodate | Cough, dyspnea, crackles (rales), distended neck veins, tachycardia, hypertension | 1. Place the client upright, with feet dependent 2. Administer diuretics and oxygen as ordered. 3. Notify the physician. 4. Stop or slow the transfusion |
| 6) Sepsis: contaminated blood administered | High fever, chills, vomiting, diarrhea, hypotension | 1. Stop the transfusion. 2. Send the remaining blood to laboratory 3. Notify the physician. 4. Obtain a blood specimen from the client for culture. 5. Administer IV fluids, antibiotics. 6. Keep the vein open with a normal saline infusion. |
* Nurses should follow agency’s protocol regarding interventions. These may vary among agencies.