Nurses' Notes
1025:
The client arrived from home by private vehicle accompanied by the spouse. The client is brought to the emergency department after two days of fever and gastrointestinal illness. The client has taken prednisone daily for autoimmune disease for the past eight months. The spouse reports that the client stopped taking prednisone three days ago because the prescription bottle was empty. The client has had six episodes of vomiting since last night and cannot keep liquids or medication down. Chronic fatigue and gradual weight loss were documented at a clinic visit last month without an acute change. The skin has stable darkening over old scars that has been present for months and has not changed recently. On arrival, the blood pressure is 78/44 mm Hg with a weak peripheral pulse. The pulse is 126 beats per minute, respirations are 24 breaths per minute, and oxygen saturation is 96% on room air. The client answers slowly and reports diffuse weakness. Point-of-care testing shows a blood glucose level of 52 mg/dL. The abdomen is mildly tender without rigidity, guarding, or rebound tenderness. Laboratory results show sodium 124 mEq/L and potassium 5.9 mEq/L. The spouse reports one loose stool this morning. The nurse places the client on continuous monitoring, obtains intravenous access, and alerts the emergency provider.
護理紀錄
1025:
個案由配偶陪同，自行開車從家中抵達。個案因發燒與腸胃道疾病兩天被送至急診。個案過去八個月因自體免疫疾病每日服用prednisone。配偶表示個案三天前因處方藥瓶已空而停止服用prednisone。個案從昨晚起已嘔吐六次，且無法留住液體或藥物。上個月門診記錄有慢性疲勞與漸進性體重減輕，無急性變化。皮膚在舊疤痕上有穩定變黑，已存在數月且近期無變化。抵達時，血壓為78/44 mm Hg，周邊脈搏微弱。脈搏每分鐘126次，呼吸每分鐘24次，室內空氣下血氧飽和度96%。個案回答緩慢，主訴全身無力。定點檢測顯示血糖值52 mg/dL。腹部輕微壓痛，無僵硬、反彈痛或肌衛。檢驗結果顯示血鈉124 mEq/L，血鉀5.9 mEq/L。配偶表示今早有一次稀便。護理師將個案置於持續監測，建立靜脈通路，並通知急診醫師。