A nurse is caring for a client who is postoperative following administration of general anesthesia.

Exhibits

Select from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential condition:

TACO is a complication that can occur during or shortly after a blood transfusion, particularly in children. It happens when the volume of blood infused exceeds the circulatory system's ability to handle it, leading to fluid overload. In this case, the child is receiving 250 mL of packed red blood cells (PRBCs), and there are signs that the child may be experiencing fluid overload, such as tachycardia, hypotension, headache, and flushing. The elevated heart rate (115 beats/minute) and low blood pressure (88/44 mm Hg) after the transfusion started suggest that the child may be at risk for circulatory overload. These symptoms, combined with the increased temperature (100.9°F, 38.3°C), further support the likelihood of TACO.

Actions to Take:

Stop the blood transfusion: This is the first and most important step when transfusion-related complications, such as TACO, are suspected. Stopping the transfusion immediately helps to prevent further exacerbation of the fluid overload, which could lead to worsening respiratory distress and circulatory compromise.

Administer an antipyretic: The child has developed a fever (100.9°F), which could be a response to the transfusion. Administering an antipyretic such as acetaminophen or ibuprofen can help manage the fever, provide comfort, and prevent further complications. Fever management is important, especially in transfusion reactions, as it helps reduce the risk of complications such as febrile non-hemolytic transfusion reactions (FNHTR).

Parameters to Monitor:

Blood pressure: Monitoring the blood pressure is critical in assessing the child’s circulatory status. A low blood pressure (88/44 mm Hg), especially in the context of tachycardia, indicates that the child is experiencing hypotension, which is often associated with circulatory overload. Close monitoring of blood pressure will help guide the decision to start appropriate treatments, such as diuretics, to manage the overload.

Hematocrit: The hematocrit value provides information about the oxygen-carrying capacity of the blood. Given that the child’s hemoglobin was 6.5 g/dL (65 g/L) prior to the transfusion, it’s important to continue monitoring the hematocrit to assess the effectiveness of the PRBC transfusion. If the hematocrit remains low despite transfusion, it could indicate an ongoing issue with blood volume or oxygen delivery to tissues.

A. Feelings of disorientation may be a symptom of heroin use, but addressing the client’s mental health, particularly suicidal tendencies, takes precedence.
B. Undiagnosed social anxiety symptoms may be important for long-term care, but the immediate concern is the risk of self-harm or overdose.
C. Family history of schizophrenia is relevant for mental health but does not take priority over assessing suicide risk in a client using heroin.
D. A history of suicide attempts is crucial for the nurse to consider because individuals using heroin may be at an increased risk of self-harm due to the psychological effects of substance use and potential for overdose. Immediate safety and suicide risk assessment are critical.