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.
護理紀錄
1300：護理師於輸血前核對醫囑、同意書及相容性報告。紀錄確認兩項辨識資料與血品標籤及相容性標籤相符。基準體溫為36.9 °C，血壓為128/74 mm Hg，血氧飽和度為97%。個案主訴慢性雙側膝蓋不適，疼痛分數2/10。1315時，周邊靜脈管路通暢，無發紅或腫脹。紅血球輸血開始緩慢輸注。1330時，個案出現體溫38.4 °C合併寒顫。個案隨後主訴新發生的下背及左側腰痛。護理師注意到慢性膝蓋不適仍為2/10，無變化。1335時，血壓從基準值下降至82/48 mm Hg。血氧飽和度在室內空氣下維持96%。護理師確認血氧飽和度與輸血前讀數相比無變化。1340時，個案解出少量新發生的暗紅棕色尿液。個案表示輸血開始時呼吸感覺舒適。輸血管路仍保持連接，護理師陪伴個案。