Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet
www.bsu.edu.ph/ 422- 2127

NURSES NOTES
Name: Dela Cruz, Juan Felipe Hospital no. 00001

Date and Time Focus DATA ACTION RESPONSE

03/20/2024 Pre-Blood D> Received awake lying in bed on a semi-fowlers position, with
7:00AM Transfusion Care an ongoing IVF of PLRS 1L x 12hrs at 900mL level, infusing well
at the right metacarpal vein; Conversant and coherent;
Scheduled for Blood Transfusion due to low hemoglobin levels;
Has pale skin and dry lips; Patient appears to be anxious; With
initial vital signs of BP=100/60mmHg, Temp=36.7ºC, PR=88bpm,
RR=18cpm, SPO2=96%.
A>Established rapport; Assessed general health status;
Monitored and recorded vital signs; Verified physician’s order;
Checked patency of IV access; Verified signed informed consent;
Obtained blood sample for blood typing and cross matching;
Confirmed availability of blood product; Checked blood product
for leakage, contamination, unusual color, clots, and excessive
frothing; Educated about the procedure, its benefits, and
potential transfusion reactions; Prepared all the materials
needed for the procedure; Encouraged verbalization of feelings
and other concerns.
8:00AM R>Patient verbalized understanding and gave consent for the
procedure.
8:30AM
Blood transfusion A> Administered 450mL packed RBC, the first 50mL slowly for 15
minutes then administered the remaining 400mL in a prescribed
rate within 4 hrs; Observed closely for any signs of transfusion
reactions in the first 15 minutes after starting the transfusion;
Monitored and recorded vital signs every 15 minutes for the first
hour, then every 30 minutes for the second hour, then every
hour until procedure is done; Monitored for any transfusion
reactions after the blood transfusion.
3:00PM End of Shift R>Patient tolerated the procedure well with no signs of
transfusion reactions.
BALCAC, Eloisa Gayle I. / Allaica Mae
BSU-SN-II BSU-CI