A 4-year-old child with β-thalassemia major is admitted to the pediatric unit for routine blood transfusion. Which assessment finding would be most concerning and require immediate nursing intervention?
The nurse is caring for a pediatric patient with β-thalassemia major who requires regular blood transfusions.
1Mild fatigue and decreased activity level
2Pale conjunctiva and nail beds
3Fever of 101.2°F (38.4°C) with chills during transfusion✓ 정답
4Enlarged spleen palpated 2 cm below the left costal margin
해설
Fever with chills during blood transfusion indicates a potential transfusion reaction, which can be life-threatening and requires immediate intervention including stopping the transfusion and notifying the physician.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's ability to prioritize assessment findings in a patient with β-thalassemia major during a blood transfusion. The core theme is recognizing a life-threatening complication versus expected, chronic manifestations of the underlying disease. β-thalassemia major is a genetic disorder causing severe anemia due to defective hemoglobin production, requiring lifelong regular transfusions. While patients live with chronic symptoms like fatigue and organomegaly, an acute transfusion reaction is an immediate safety threat.
Answer Rationale: Key Point!Fever and chills occurring during the transfusion are classic signs of a febrile non-hemolytic transfusion reaction (FNHTR) or, more critically, could signal the beginning of a septic or hemolytic reaction. This requires immediate nursing intervention: STOP the transfusion, keep the IV line open with normal saline, notify the physician, and monitor vital signs closely. This finding is "most concerning" because it indicates an acute, potentially dangerous response to the treatment itself.
Distractor Analysis:
Watch out for confusion! Options ① and ② (Mild fatigue, decreased activity, pale conjunctiva) are chronic, expected findings in β-thalassemia major due to chronic anemia. They require monitoring and are addressed by the transfusion therapy itself, but they do not constitute an emergency during the procedure.
Watch out for confusion! Option ④ (Enlarged spleen or splenomegaly) is a long-term complication of the disease and repeated transfusions (extramedullary hematopoiesis and iron overload). It is a significant finding but develops over time and is not an acute reason to stop a transfusion.
Related Concepts: The priority is always ABCs (Airway, Breathing, Circulation) and patient safety. An acute change during a procedure (like a transfusion) takes precedence over chronic, baseline conditions. Other signs of a severe transfusion reaction include chest/back pain, hypotension, dyspnea, hemoglobinuria (dark urine), and anaphylaxis (hives, wheezing).Nursing Clinical Practice GuideClinical Scenario: You are the nurse in a pediatric hematology clinic. A 4-year-old named Leo, diagnosed with β-thalassemia major, is receiving his scheduled packed red blood cell (PRBC) transfusion. About 20 minutes into the infusion, he becomes fussy, complains of being cold, and you notice he feels warm to thetouch.
Nursing Intervention Strategy:
Immediate Action (STOP): Halt the transfusion immediately. Do not flush the line with the blood product.
Maintain Vascular Access: Disconnect the blood tubing and keep the IV line patent with normal saline at a slow rate.
Assess & Monitor: Check vital signs (Temp, BP, HR, RR, O2 saturation). Perform a focused assessment for other reaction signs: rash, wheezing, back pain, respiratory distress.
Notify: Inform the physician/hematologist and the blood bank immediately. Send the blood bag, tubing, and a new blood sample from the patient to the lab for investigation.
Document: Record the time the reaction started, symptoms, vital signs, actions taken, and communications.
Patient Safety and Precautions: Always verify patient identity and blood product compatibility (two-nurse check) before starting. Administer the first 15 minutes slowly and stay with the patient. For future transfusions, pre-medication with antipyretics (e.g., acetaminophen) and/or antihistamines may be ordered to prevent febrile reactions.
Nursing Procedure & Medication FlowBlood Transfusion Reaction Protocol:
1. STOP transfusion.
2. Keep IV open with NS (0.9% Sodium Chloride).
3. Assess patient (ABCs).
4. Notify MD and Blood Bank.
5. Monitor and document.
Medication Note: For a febrile reaction, acetaminophen may be given per order after stopping the transfusion and assessing the patient. Diphenhydramine may be given for allergic symptoms. IV fluids and vasopressors may be needed for hypotensive reactions.
A Word from Your Senior Nurse
"In pediatrics, kids can't always articulate what's wrong. That fever and those chills during a transfusion are your patient's body screaming that something isn't right. Your quick recognition and action—stopping the infusion—is what protects them. Remember, managing chronic illness is about balancing the long-term plan with vigilance for acute threats. Your knowledge turns you from a task-completer into a life-saving guardian during these routine yet high-risk procedures."
β-thalassemia major — A severe genetic hemoglobinopathy where reduced or absent synthesis of beta-globin chains leads to chronic hemolytic anemia, requiring lifelong regular blood transfusions.
Transfusion Reaction — An adverse response to the transfusion of blood products. Types include febrile non-hemolytic, allergic, hemolytic, septic, and transfusion-related acute lung injury (TRALI).
Febrile Non-Hemolytic Transfusion Reaction — A common transfusion reaction characterized by fever (≥1°C rise) and/or chills during or shortly after transfusion, often due to cytokines in the blood product or recipient antibodies.
Splenomegaly — Enlargement of the spleen. In thalassemia, it results from extramedullary hematopoiesis (blood cell production outside the bone marrow) and sequestration of abnormal red blood cells.
Iron Overload — A major complication of chronic transfusions where excess iron deposits in organs (liver, heart, endocrine glands), leading to dysfunction. Managed with iron chelation therapy.
Concept Summary
Concept
Key Point
Nursing Implication
β-thalassemia Major
Chronic anemia from defective hemoglobin; requires regular transfusions.
Monitor for chronic symptoms (fatigue, pallor) and long-term complications (iron overload, splenomegaly).
Blood Transfusion
Life-sustaining treatment but carries risk of reaction.
Meticulous verification, slow initiation, constant monitoring during infusion.
Acute Transfusion Reaction
Fever/chills, dyspnea, hypotension, pain, rash.
STOP transfusion immediately, maintain IV access with