Based on the information what are all the relevant nursing diagnosis for the next 2hr
Mr John Brown is a 29 year old male, 170cm tall and weighs 70kgs. Drinks and smokes socially and is not currently taking any medications. Past history of Von Willebrand's Disorder and is allergic to shellfish. He presented to emergency via ambulance after fracturing his right tibia skiing yesterday, and is booked for an open reduction and internal fixation later this afternoon. Plaster of paris back slab currently insitu and lower leg has moderate swelling. IV inserted into right arm and neurovascular observations taken 4/24.
Medical team has ordered 4/24 PRN morphine 7.5 IV for pain relief, current pain score 2/10. Six (6) units of platelets has also be ordered and to be given prior to theatre. Commenced on 12/24 Ceftriaxone 1g IV with the first does given. Baseline observations are as follows; HR 84bpm, BP 135/80mmHg, RR 16, T 36.2°C, SpO2 99%. All platelet infusion checking completed according to correct policy and procedure, bag intact. Giving set primed with normal saline and commenced.
Ten minutes into the infusion Mr. Brown complained of back pain and feeling itchy. A new set of observations revealed the following; HR 86bpm, BP 130/80mmHg, RR 20, T 37.1°C, SpO2 98%.
On further investigation John informs you that he is experiencing significant pain in his back which was not there prior to the infusion. The pain has lasted for 5 minutes does not radiate anywhere and he describes it as a dull ache in his lower back. Nothing appears to relive the pain. His leg pain is at 3/10 from movement and he expresses no change in the characteristics of the pain in his leg. John is complaining of feeling itchy.
John informs you that he remembers having this antibiotic before on another hospital admission and he did not have a reaction to it at that time.
You cease the transfusion and recheck the blood product with a colleague to ensure it is correct.
On inspection John's airway is patent and he appears flushed. John has small red urticaria on his chest, back and neck. He is scratching at his chest and neck. John is holding his lower back, is restless and unable to lie still.
Assessment of respiratory fields indicates air entry is equal with no adventitious sounds. Neurological assessment indicates a GCS of 15. The medical officer is informed of the assessment findings and after reviewing John he diagnoses an allergic reaction to the blood product transfusion. He orders 12.5 mg Phenergan IV and 1 gram Panadol IV for lower back pain. He orders that the transfusion to be recommenced slowly If the symptoms of the reaction subside in 30 minutes.
You commence normal saline 0.9% IV as ordered and administer the medications. You obtain blood and urine samples as per protocol and send specimens to blood bank for testing. You complete the relevant documentation. In 30 minutes John symptoms have resolved and the infusion is slowly recommenced.