Document your focused postoperative assessment for Lloyd Bennett. 2. Document Lloyd Bennett’s allergies in his chart. 3. Document Lloyd Bennett’s vital signs during the transfusion reaction. 4. Document the priority nursing actions completed during the transfusion reaction. 5. Identify and document key nursing diagnoses for Lloyd Bennett. 6. Referring to your feedback log, document the nursing care you provided.
The Correct Answer and Explanation is:
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1. Focused Postoperative Assessment for Lloyd Bennett
Date/Time: June 16, 2025, 08:30
Patient: Lloyd Bennett
Postoperative Assessment:
- Airway: Patent, no distress noted.
- Breathing: Respiratory rate 18 breaths per minute; lungs clear to auscultation bilaterally.
- Circulation: Heart rate 86 bpm, BP 124/76 mmHg, capillary refill <2 seconds. No active bleeding.
- Surgical Site: Clean, dry, intact dressing over left abdominal quadrant. Minimal serosanguinous drainage noted.
- Pain: Patient reports 5/10 pain, managed with prescribed analgesia.
- Level of Consciousness: Alert and oriented to person, place, time.
- Urinary Output: 200 mL clear yellow urine in last 3 hours via Foley catheter.
- Mobility: Assistance required for ambulation. Transferred from bed to chair with help.
- Nausea/Vomiting: Denies nausea or vomiting.
2. Allergy Documentation
Allergies:
- Penicillin – Rash
- Latex – Anaphylaxis
3. Vital Signs During Transfusion Reaction
Date/Time: June 16, 2025, 10:10
Vital Signs During Reaction:
- Temperature: 38.7°C
- Blood Pressure: 100/62 mmHg
- Heart Rate: 112 bpm
- Respiratory Rate: 24 breaths per minute
- Oxygen Saturation: 91% on room air
4. Priority Nursing Actions During Transfusion Reaction
- Transfusion stopped immediately.
- IV line kept open with normal saline using new tubing.
- Patient monitored continuously.
- Physician and transfusion services notified.
- Vital signs monitored every 5 minutes.
- Blood bag and tubing sent to lab for analysis.
- Administered prescribed antipyretic and antihistamine.
- Documented full incident in patient chart and adverse event report filed.
5. Key Nursing Diagnoses for Lloyd Bennett
- Risk for allergic reaction related to blood transfusion
- Acute pain related to surgical intervention
- Risk for infection related to surgical site and invasive procedures
- Impaired physical mobility related to postoperative condition
- Risk for decreased cardiac output during transfusion reaction
6. Nursing Care Provided (From Feedback Log)
- Provided immediate intervention for transfusion reaction.
- Maintained IV access and ensured patient safety.
- Monitored and documented vital signs.
- Supported patient with reassurance and ongoing communication.
- Communicated effectively with healthcare team.
- Followed institutional protocols for transfusion reaction management.
Explanation
Accurate documentation is essential in the delivery of quality nursing care, especially during critical situations like transfusion reactions. The focused postoperative assessment for Lloyd Bennett highlights all vital parameters that indicate recovery status. Monitoring airway, breathing, and circulation ensures that complications such as hemorrhage or respiratory distress are promptly identified. Pain assessment and site evaluation help guide appropriate postoperative interventions.
Recording patient allergies—especially to medications and materials like latex—is critical to prevent future adverse events. In Lloyd Bennett’s case, noting both the nature and severity of allergic responses supports safe clinical decision-making.
Vital signs during a transfusion reaction provide essential data. Changes such as fever, tachycardia, and hypotension are hallmark signs of an acute hemolytic reaction. Continuous monitoring helps guide timely interventions and clinical judgments.
The documentation of nursing actions reflects prompt and effective response. Stopping the transfusion and maintaining IV access are critical first steps. Notifying the physician, sending the blood bag for analysis, and administering medications all contribute to patient stabilization.
Nursing diagnoses offer a framework for planning care. Identifying risks such as infection, pain, and allergic reaction ensures holistic management. These diagnoses also inform multidisciplinary collaboration and prioritization of interventions.
Finally, referring to the feedback log ensures reflective practice. Describing the care provided highlights professional accountability, clinical skills, and adherence to protocol. This supports continuous improvement and enhances patient safety.
