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.
護理紀錄
1115:
一位老年個案由成年兒子陪同前來糖尿病追蹤門診。個案使用手杖行走，並接受兒子協助交通往返約診。在協助個案更衣時，護理師觀察到上臂有兩處環形瘀傷，一側手腕有新鮮紅色印記。兒子表示瘀傷是「撞到門」造成的，但無法說出何時發生。當護理師要求獨處時間時，兒子拒絕離開，並在個案開口前反覆代答問題。個案腹部有舊的癒合手術疤痕，無疼痛或分泌物。個案因本週假牙送修而食用軟質食物。在兒子短暫走到走廊時，個案輕聲說兒子抓住其雙手腕，並威脅要將其帶離朋友。個案表示兒子過去六個月來管理交通與財務。藥局紀錄顯示降血壓與糖尿病處方已兩個月未領藥，但兒子持有個案的銀行卡。個案否認過去一個月內跌倒，並表示近期無頭暈。體重與前次訪視相同；個案清潔、儀容整齊，並表示當天早上自行選擇衣物。兒子返回並要求結束訪視，因為他有另一個約診。護理師安排私下安全評估，並遵循機構疑似虐待通報政策。