Nurses' Notes
1115:
An older client arrives with an adult son for a diabetes follow-up visit. The client walks with a cane and accepts the son's help with transportation to appointments. While helping the client change, the nurse observes two loop-shaped bruises on the upper arms and fresh red marks around one wrist. The son says the bruises occurred when the client "bumped into a door" but cannot say when. When the nurse requests time alone, the son refuses to leave and repeatedly answers questions before the client can speak. The client has an old healed abdominal surgical scar without pain or drainage. The client eats soft foods because the dentures are being repaired this week. During a brief moment when the son steps into the hallway, the client whispers that the son grabbed both wrists and threatened to move the client away from friends. The client says the son has managed transportation and finances for the past six months. Pharmacy records show blood-pressure and diabetes prescriptions have not been filled for two months although the son keeps the client's bank card. The client denies falling during the past month and reports no recent dizziness. Weight is unchanged from the previous visit; the client is clean, well groomed, and says the clothing was chosen independently that morning. The son returns and asks to end the visit because he has another appointment. The nurse arranges a private safety assessment and follows facility policy for suspected abuse.
간호사 기록
1115:
An older client arrives with an adult son for a diabetes follow-up visit. The client walks with a cane and accepts the son's help with transportation to appointments. While helping the client change, the nurse observes two loop-shaped bruises on the upper arms and fresh red marks around one wrist. The son says the bruises occurred when the client "bumped into a door" but cannot say when. When the nurse requests time alone, the son refuses to leave and repeatedly answers questions before the client can speak. The client has an old healed abdominal surgical scar without pain or drainage. The client eats soft foods because the dentures are being repaired this week. During a brief moment when the son steps into the hallway, the client whispers that the son grabbed both wrists and threatened to move the client away from friends. The client says the son has managed transportation and finances for the past six months. Pharmacy records show blood-pressure and diabetes prescriptions have not been filled for two months although the son keeps the client's bank card. The client denies falling during the past month and reports no recent dizziness. Weight is unchanged from the previous visit; the client is clean, well groomed, and says the clothing was chosen independently that morning. The son returns and asks to end the visit because he has another appointment. The nurse arranges a private safety assessment and follows facility policy for suspected abuse.