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Sagot :
The nurse monitors a client receiving a blood transfusion. the nurse should intervene if which is observed the blood infuses at 10 mL/min for the first 15 minutes
R: If there is no response, adjust blood flow to the recommended rate. Blood flow should start off slowly (no faster than 5 mL/min for the first 15 minutes).
Fluid + Electrolyte Balance, 27/30 (Kaplan)
A specialized transfusion record or an electronic device that can produce a report should be used to capture transfusion observations before they are entered into the clinical record. The following should be the minimum monitoring of each unit transfused:
Throughout the transfusion, the patient will be regularly observed visually, and they will be urged to report any new symptoms.
Prior to the transfusion, baseline values for pulse rate, blood pressure (BP), temperature, and respiration rate (RR) must be taken.
Around 15 minutes after the commencement of the transfusion, pulse, blood pressure, and temperature should be assessed (many serious reactions, such as ABO incompatibility or bacterial transmission present early in the transfusion episode). Check RR as well to see if any of these observations have altered.
Repeat the baseline observations if the patient reports new symptoms and take the necessary action. Within 60 minutes after the transfusion's conclusion, check the patient's temperature, blood pressure, and pulse (and as a baseline before any further units are transfused).
Day-care patients should be encouraged to report symptoms that emerge after discharge, and inpatients should be monitored for delayed responses over the course of the following 24 hours (ideally with the issuance of a "Contact Card" providing access to urgent professional guidance).
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