Learner Response Summary

Successful
Scenario: Virtual Simulation Blood Transfusion Reaction (082)
Started On September 16, 2022

Question 1

Your Choices:
- Review local policy
- Initiate dedicated intravenous access
- Confirm blood transfusion consent has been obtained
- Confirm type and screen and/or cross and match laboratory testing is completed
- Infuse a compatible intravenous solution through blood administration set to keep vein open

How is consent obtained for blood transfusion?

Your Choices:
- The prescriber obtains written consent

Question 3

Your Choices:
- “There is a small risk for transfusion reaction. We will monitor you closely and ask that you please let us know if you
experience chills, itching, difficulty breathing or pain.”

Is this intravenous solution compatible with blood products?

No response submitted.

Questions 4 NS

Your Choices:
- Yes

Is this intravenous solution compatible with blood products?

No response submitted.
Questions 4 LR

Your Choices:
- No

Is this intravenous solution compatible with blood products?

No response submitted.

Questions 4 D5

Your Choices:
- Yes

Is this intravenous solution compatible with blood products?

No response submitted.

Questions 4 KCL

Your Choices:
- No

Question 5

Your Choices:
- Verify the health care provider’s orders
- Identify patient using at least two, person specific identifiers (i.e., name and date of birth, or name and medical record
number)
- Check expiry date on unit of blood
- Visually inspect blood bag for any signs of contamination or leaks
- Ensure compatibility of blood product with client blood type

Ordered List

Your Choices:
- Initiate infusion within 30 minutes of arrival from blood bank
- Obtain baseline vital signs
- Verify that transfusion record number and patient identification number match
- Administer the blood product within 4 hours of arrival
- Verbally compare and correctly verify patient, blood product, and blood type with another qualified health care
professional

Question 6

No response submitted.

Question 6

Your Choices:
- Immediately assess the client

Question 7

Your Choices:
- Stop the transfusion and call for help

Question 8

Your Choices:
- Re-check vital signs
- Focused respiratory assessment

Question 9 Questions

Your Choices:
- Allergic reaction

How would you reassure the client?

Your Response:
Tracy, your breathing is normal and you are alert and oriented. You do have a rash to both arms which from the blood
transfusion you're receiving. I will stop the transfusion to ensure no further rash, call another nurse in to confirm my
assessment, phone the doctor to make them aware of this reaction, and recheck your vital signs to ensure you are
comfortable and stable throughout. I will stay by your side throughout this process! Do you have any questions for me?

Question 11

Your Response:
I: Hi, this is Marina, Marissa Grant's nurse from south wing.
S: Marissa Grant is a 40 year old female Gravida 5 Para 4. She delivered vaginally 1.5 hours ago and experienced a
significant PPH. She is currently receiving 1 unit of O- PRBC for low hemoglobin.
B: Marissa used fertility treatments to become pregnant. She has developed a transfusion reaction of urticaria to bilateral
arms, which was not present prior to transfusion. She has not had a transfusion in the past. She has no history of
integumentary issues.
A: Marissa's vital signs are as follows: Temp 36.8degrees celcius tympanically, BP to right arm 88/60, HR 98 regular, O2
sat 96% on RA. She is having no pain or nausea.She presents pale, her chest is clear, alert and oriented, and she is
slightly anxious. The lab is present to draw some blood work.
R: The transfusion is currently stopped. I have contacted blood bank to inform them of this reaction. A bag of normal
saline has been hung. Regarding her current condition, would you like to see Marissa to reassess her plan of care? Is
there anything else I can do while we wait?

Question 12

Your Choices:
- Re-start transfusion

How should nurse Sandy prioritize her patient assignment?

Your Choices:
- Ask charge nurse to re-assign workload to ensure Sandy can closely monitor the client experiencing the transfusion
reaction.

Self-Debriefing & Reflection

Your Response:
The patient was overwhelmed by the amount of staff in the room and lack of information being provided to her in a
timely manner. The patient would benefit from staff taking turns when assessing and performing vital signs and for a
thorough explanation of the situation.
This situation is similar to an experience post operatively when a patient was receiving blood for low hemoglobin and
developed swelling and redness at the IV site. The s/l was relocated and the transfusion was restarted 30 minutes later
at a rate of 50cc/hr.
There were no choices that surprised me from this situation as I perform many blood transfusions on my surgical unit
and I have experienced multiple transfusion reactions. In this scenario; however, the nurse should not have gone on
break without assessing the patient with the covering nurse to achieve an accurate view of the patient's current
condition. With the patient having a reaction, the nurse shouldn't have gone on break.
From this situation, I will learn to continuously reassess patients throughout transfusions. Despite this patient not having
a respiratory reaction, this patient still had an allergic reaction. Allergic reactions may present in a multitude of ways.

Thank you for participating in this virtual simulation.

Your Choices:
- View & Download Results
Session ID: 348245