Nurses' Notes
1300: The nurse verifies the prescription, consent, and compatibility report before transfusion. The record confirms that two identifiers match the blood product label and compatibility tag. Baseline temperature is 36.9 °C, blood pressure is 128/74 mm Hg, and oxygen saturation is 97%. The client reports chronic bilateral knee discomfort rated 2/10. At 1315, the peripheral IV remains patent without redness or swelling. The red blood cell transfusion begins slowly. At 1330, the client develops a temperature of 38.4 °C with shaking rigors. The client then reports new aching pain across the lower back and left flank. The nurse notes that chronic knee discomfort remains unchanged at 2/10. At 1335, blood pressure decreases to 82/48 mm Hg from the baseline value. Oxygen saturation remains 96% on room air. The nurse confirms that the oxygen saturation is unchanged from the pretransfusion reading. At 1340, the client voids a small amount of newly dark red-brown urine. The client states that breathing felt comfortable when the transfusion began. The blood tubing remains connected while the nurse stays with the client.
Nurses' Notes
1300: The nurse verifies the prescription, consent, and compatibility report before transfusion. The record confirms that two identifiers match the blood product label and compatibility tag. Baseline temperature is 36.9 °C, blood pressure is 128/74 mm Hg, and oxygen saturation is 97%. The client reports chronic bilateral knee discomfort rated 2/10. At 1315, the peripheral IV remains patent without redness or swelling. The red blood cell transfusion begins slowly. At 1330, the client develops a temperature of 38.4 °C with shaking rigors. The client then reports new aching pain across the lower back and left flank. The nurse notes that chronic knee discomfort remains unchanged at 2/10. At 1335, blood pressure decreases to 82/48 mm Hg from the baseline value. Oxygen saturation remains 96% on room air. The nurse confirms that the oxygen saturation is unchanged from the pretransfusion reading. At 1340, the client voids a small amount of newly dark red-brown urine. The client states that breathing felt comfortable when the transfusion began. The blood tubing remains connected while the nurse stays with the client.