Medical DATE CLASSIFICATION GENERAL ACTION INDICATION OR CLIENT’S RESPONSE

Management/Tre ORDERED/ PURPOSE(S)

atment DATE
RESULT(S)
To immediately To increase patient Patient's hemoglobin
Blood Transfusion Date Ordered: restore blood hematocrit and level increased from 8.6
2 units 01/02/2018 volume to treat hemoglobin level. to 11.2 and hematocrit
Partial Red Blood anemia, to be able
02/03/2018 level from 28.9 to 38.6.
Cell to maintain oxygen
transport to the
Date Result: different parts of the The patient responded
01/02/2018 body. well to the treatment
02/03/2018 given which is blood
transfusion.

Nursing Responsibilities:

Before:

 Assess client for history of previous BT and any adverse reactions.

 Ensure that the client has an 18 to 19 gauge IV catheter in place.
 Use 0.9% sodium chloride IVF.
 Verify the ABO group, Rh type, client and blood numbers and expiration date.
 Take baseline vital signs before initiating Blood Transfusion.
 Identify the patient prior to blood transfusion.
 Explain the purpose of the blood transfusion.
During:

 Start transfusion slowly

 Maintain prescribed transfusion rate
 Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post transfusion.
After:

 Monitor for adverse reactions.