Y tá xem xét hồ sơ trong quá trình truyền hồng cầu. Những phát hiện nào cần theo dõi ngay lập tức vì nghi ngờ phản ứng tan máu cấp do truyền máu? Đánh dấu các phát hiện phản ứng mới.

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.