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The Nursing Process image, Provide comfort to the patient and…

- - - - Assist patient to safe position
      - Assess environment for safety hazards
    - - Assess skin & IV site
        
        Skin: warm to touch and dry
        
        IV site: Slightly reddened
  - - - RR: 26 breaths/min
      - BP: 90/50mmHg
      - P: 120 bpm
      - SpO2: 94% on oxygen
      - T: 38.8C
        
        Measure temperature
    - - Breathing: Tachypnic
      - Circulation: pulse strong, tachycardic
      - Airway: patent
    - - CBC: Hgb: 82g/L
        
        Transfuse 2 units RBC, each unit over 2 hrs
- - - - Redden IV site
      - Drop from baseline BP
      - Elevated temperature
      - Tachypnea/tachycardia
      - Skin warm to touch
    - - Pt feeling dizzy, hot, nauseated, agitated and anxious
        
        Transfusion Reaction
- - - - Contact physician for medical assessment
        
        Use ISBARR for effective communication
      - Vital signs q15min until pt is stable
      - Keep IV line open with 0.9% normal saline
      - Contact blood bank
      - Check labels, tags, treatment order, forms and pt ID band