Patient Preparation Worksheet

Time Meds/Care Priorities Misc.

Adm. Date *Today* Days since adm. 1 POD# N/A
1145 Collect CBC and send to lab
Chief Complaint/Primary Problem:
1200 PRBC transfusion for low Hgb Postpartum hemorrhage following a vaginal delivery resulting in low
hemoglobin requiring a blood transfusion.
1235 Benadryl for allergic reaction Delivered 1.5hrs ago with estimated blood loss of 1500ml.
to blood transfusion Hemorrhage managed with fundal massage.

1305 Resume transfusion at

50ml/hr until complete
Monitor closely for
further reactions
Past Medical History
G5P4
Hypothyroidism
Mild anxiety
Previous miscarriage

CV Resp Neuro GI GU Skin/Pain Misc. VS

Prior Nursing Tachycardic
Assessment Hypotensive WDL Slightly WDL Foley catheter
insitu, draining WDL Fundus firm and BP - 88/60
midline at level
Pale
anxious clear yellow of umbilicus,
>>> HR - 110
urine small rubra lochia
O2 - 95% (RA)

RR - 20

T - 37.1C

Current Hypotensive Anxious BP - 88/60

Nursing Pale WDL WDL Foley catheter
insitu, draining
Red rash on both Fundus firm and
midline at level
arms, no itchiness
Assessment No N/V/D clear yellow or pain of umbilicus, HR - 98
urine small rubra lochia
>>> O2 - 96% (RA)

RR - 19

T - 36.8C

End of Shift SBAR to Oncoming Nurse

Lab Test Current Most Recent Allergies Peanut butter, dust, grass
Na+ Code Status Full code Situation:
IV site Right hand Marissa Grant, 40yr FM
K+ Postpartum hemorrhage and subsequent
Mg+ IV Maintenance 125ml/hr low Hgb, current blood transfusion reaction
IV Drips RL w/ 20units oxytocin
Creat.
Activity AAT Background: G5P4, vaginal delivery today at 1030hrs
Hemorrhage managed
WBC Fall Risk/Safety x1 assist 1 unit PRBC transfusion started at 1200hrs
Neut. % Diet DAT Red rash noted to both arms at 1235hrs
Hgb. 64g/L Bladder/Bowel Foley catheter insitu Assessment:
Rash only on arms, no itchiness or pain
Chest clear, no SOB
Still hypotensive, but other vitals are WDL

Recommendation:
IV benadryl given at 1235hrs
Resume blood transfusion in 30mins if no further
reactions at 50ml/hr until complete.