Prescription verified in clients electronic medical record

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Reference no: EM133764565

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Nurses' Notes 1030: Client prescribed one unit of packed red blood cells, prescription verified in client's electronic medical record. Blood obtained from blood bank and verified with second RN. Peripheral IV patent in right hand. Informed consent on file. Transfusion started. 1045: Remained with client for first 15 minutes of transfusion. Client states, "I do not feel well. I think something is wrong." Client reports low back pain, nausea, chills, and headache. Headache pain rated as a 7 on a pain scale of 0 to 10. Client's respirations are labored and rapid. Vital Signs 1030: Temperature 37° C (98.6° F) Heart rate 88/min Blood pressure 130/60 mm Hg Respiratory rate 20/min Oxygen saturation 99% on room air 1045: Temperature 38.3° C (101° F) Heart rate 135/min Blood pressure 88/46 mm Hg Respiratory rate 28/min Oxygen saturation 91% on room air For each potential nursing intervention, click to specify if the intervention is anticipated or contraindicated for the client. - Potential Order Anticipated Contraindicated Stop transfusion Flush blood transfusion tubing Notify blood bank Notify primary physician Return blood and tubing to blood bank Administer IV diphenhydramine Administer oxygen.

Reference no: EM133764565

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