SITUATION:

S This is Nurse. In regards to our mutual patient Ms. Meredith Grey, She appears calmer but
lethargic and feel some chills and moaning

BACKGROUND:
B Mrs. Meredith is a 55 year old woman, diagnosed non-small cell cancer of the lung. She
complaint felt very tired, bruises easily and has no appetite because of sore throat since his first
chemotherapy 1 ½ weeks ago. She describes getting weaker every day and slightly short of breath
with activity. CBC shows pancytopenia. Doctors’ orders to transfuse 2 units of PRBC. Her mental
status is lethargic and Responsive but fatigued, she has Bruising on extremities, Pale skin, Dry
mucous membranes, Flat vocal tone This is M. Grey’s first blood transfusion. transfusion begins
within 5 min after receiving unit she developed dyspnea within the last 15 minutes and his blood
pressure is also elevated and administered o2 therapy @2L.
ASSESSMENT:
A Upon assessment Meredith’s vital signs HR: 114, weak, RR: 28, BP: 90/60, T: 99.4° F, O₂ sat: 90%.
Transfusion stopped is She is in mild recovery state and feel some chills and moaning. She appears
calmer but lethargic. Her skin is pale, She’s on 2L nasal cannula

RECOMMENDATION:
R I would like you to see her often and monitor vital signs