Nurses' Notes
1340:
The client is preparing for discharge after treatment of a pulmonary embolism and a tibial fracture. The orthopedic follow-up visit is scheduled for six days after discharge. The client lives in a third-floor walk-up and must remain non-weight-bearing. A neighbor has agreed to drive the client to scheduled appointments. The client will need oxygen during activity. The oxygen supplier has not received a complete equipment order. The client correctly demonstrates cleansing the healing incision with the prescribed supplies. The medication list includes a newly prescribed oral anticoagulant. The client cannot afford the first anticoagulant prescription because of the copayment. The client points to the clinic number to call for new chest pain, shortness of breath, or bleeding. Physical therapy has reviewed transfer technique. During teach-back, the client plans to use a relative's leftover anticoagulant temporarily. The client identifies two friends who can bring groceries during the first week. The client requests written instructions in large print, and the preference is documented. The client accurately explains that both legs should be checked daily for skin injury. The nurse pauses the discharge process and contacts case management, pharmacy, respiratory therapy, and the prescriber.
護理紀錄
1340:
個案正準備在肺栓塞及脛骨骨折治療後出院。骨科追蹤門診安排在出院後六天。個案住在三樓無電梯公寓，且必須維持不承重。一位鄰居同意載個案去已排定的門診。個案活動時需要氧氣。氧氣供應商尚未收到完整的設備訂單。個案正確示範使用處方用品清潔癒合中的切口。藥物清單包含一種新處方的口服抗凝血劑。個案因自付額而無法負擔第一筆抗凝血劑處方。個案指出若有新發生的胸痛、呼吸急促或出血時要撥打的診所電話。物理治療已複習轉位技巧。在回覆示教中，個案打算暫時使用親戚剩下的抗凝血劑。個案指出兩位可以在第一週幫忙帶雜貨的朋友。個案要求提供大字版的書面指示，此偏好已記錄。個案正確解釋應每天檢查雙腿有無皮膚損傷。護理師暫停出院流程，並聯繫個案管理師、藥局、呼吸治療師及開立處方者。