Question

A client postoperative fractured hip repair is prescribed 1 unit of packed cells. The nurse monitoring the transfusion notes a 2 degree temperature elevation. Which action is appropriate? A. Stop the transfusion B. Notify the charge nurse of the temperature C. Recheck the temperature with another thermometer D. Apply extra blankets

Short answer

Answer: Notify the charge nurse of the temperature elevation.

Step-by-step solution

Identifying the issue and potential risks

The patient has undergone surgery and is prescribed 1 unit of packed cells. It's essential to understand that complications can arise during or after a transfusion, hence the importance of monitoring. The 2-degree temperature elevation indicates a possible reaction or complication from the transfusion.

Analyzing the given options

We need to consider the consequences of each choice in terms of safety for the patient, and the efficiency and effectiveness of the intervention. A. Stopping the transfusion might be appropriate if the temperature elevation is a sign of an allergic reaction, but it may also hinder the patient's recovery. B. Notifying the charge nurse could be an appropriate course of action, as it escalates the issue to a higher authority, potentially enabling faster intervention. C. Rechecking the temperature with another thermometer might eliminate any concerns due to potential instrument malfunction, but it could also delay necessary action if the temperature increase is indeed caused by a complication. D. Applying extra blankets may increase the patient's comfort, but it would not address the cause of the temperature elevation nor ensure the patient's safety.

Choosing the most appropriate action

Based on an analysis of the possible outcomes associated with each choice, the most appropriate action is to notify the charge nurse of the temperature (Option B), as it ensures that the potential complication is immediately addressed by an experienced professional, keeping the patient's health and safety as the top priority.

Key concepts

Postoperative Care

Postoperative care is a crucial period when the patient recovers from the surgery. It involves rigorous monitoring to spot early signs of complications, such as infections, bleeding, or reactions to treatments. For a patient who has undergone a hip repair surgery, close observation is especially important.

During this time, it is the nurse's responsibility to manage pain, monitor vital signs, ensure the patient is adequately hydrated and nourished, and maintain a safe environment to prevent falls or additional injuries. Interventions might also include administering prescribed medications, including blood transfusions if necessary.

Monitoring for Complications

In the case of our exercise, the nurse notes a 2-degree temperature elevation, which requires a swift assessment and response. An increase in temperature could potentially indicate an infection or a transfusion reaction. Therefore, continuous temperature monitoring is recommended to detect and address issues promptly, minimizing the risk of them escalating.

Transfusion Reactions

Blood transfusions can be life-saving, but they can also lead to transfusion reactions. These reactions range from mild to severe and can manifest as fever, chills, itching, or respiratory distress. It's imperative for nursing staff to be vigilant when a patient is receiving a transfusion.

Recognizing the Signs

Temperature elevation, as noted in the exercise, could be the first sign of a transfusion reaction. Other signs to look for include hives, anxiety, back pain, and dark urine, indicating a hemolytic reaction, which is particularly dangerous.

Upon detecting signs of a transfusion reaction, the protocol usually involves stopping the transfusion, assessing the patient's condition, administering antihistamines or steroids if ordered, and notifying a physician swiftly. The key is to act promptly to reduce potential harm to the patient.

Nursing Interventions

Nursing interventions are actions taken by nurses to enhance patient outcomes. These may be independent, dependent, or collaborative actions based on the patient's condition and prescribed treatments.

Effective Decision-Making

In our scenario, the nurse must make a wise decision considering the potential for a serious transfusion reaction. After noting the temperature rise, the best initial nursing intervention is to alert the charge nurse (Option B). This promotes teamwork and rapid response, harnessing the collective expertise of the nursing staff.

Stopping the transfusion might be necessary if additional signs of a reaction develop, rechecking the temperature could ensure the accuracy of the initial reading, and applying extra blankets may be appropriate only if hypothermia were a concern, but these actions do not directly address or escalate the issue as effectively as notifying the appropriate authority.