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個案在輸注濃厚紅血球10分鐘後出現發燒、寒顫、呼吸困難及背痛，請將護理措施依序排列。

Ordered Response

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Notify the responsible clinician and blood bank promptly and obtain the prescribed reaction workup and treatment orders 立即通知負責醫師及血庫，並取得醫囑之反應檢查及治療處置

Assess airway, breathing, circulation, vital signs, oxygen saturation, lung sounds, pain, and urine appearance 評估呼吸道、呼吸、循環、生命徵象、血氧飽和度、肺音、疼痛及尿液外觀

Recheck client and product identifiers and send the blood bag, tubing, and ordered blood or urine specimens according to policy 重新核對個案及血品辨識資料，依政策將血袋、輸血套管及醫囑之血液或尿液檢體送檢

Stop the transfusion immediately, disconnect the blood tubing, and remain with the client 立即停止輸血，移除輸血套管，並留在個案身旁

Maintain venous access with 0.9% sodium chloride through new tubing without flushing blood into the client 以0.9%氯化鈉溶液及新的輸血套管維持靜脈通路，勿將血液沖入個案體內

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