Nurses' Notes
0830: The home-care nurse completes a medication follow-up. The client states that digoxin is taken at the prescribed time each morning. The client denies missing or doubling a dose. At rest, the apical pulse is regular at 72/min. During breakfast, the client reports new nausea and yellow halos around the kitchen lights. The current weight is unchanged from last week's measurement. Today's laboratory report shows a potassium level of 4.2 mEq/L. At 0900, reassessment shows an apical pulse of 46/min with new dizziness on standing. A digoxin level was collected eight hours after yesterday's dose. The record confirms that the blood sample was timed eight hours after the dose. Last month's creatinine was 0.9 mg/dL. Today, creatinine is 1.8 mg/dL and potassium is 3.0 mEq/L. The medication list has not otherwise changed. The client reports that the daily weight remains within 0.5 kg of baseline. The nurse observes that the client uses a dated pill organizer for all scheduled doses. The next digoxin dose has not been taken.
護理紀錄
0830：居家護理師完成用藥追蹤。個案表示每天早晨按時服用digoxin。個案否認漏服或重複服藥。休息時，心尖脈搏規則，72次/分。早餐時，個案主訴新發噁心及廚房燈光周圍有黃色光暈。目前體重與上週測量值相同。今日實驗室報告顯示血鉀4.2 mEq/L。0900重新評估顯示心尖脈搏46次/分，站立時新發頭暈。Digoxin濃度是在昨日給藥後八小時採檢。紀錄確認血液檢體是在給藥後八小時採集。上個月肌酸酐為0.9 mg/dL。今日，肌酸酐1.8mg/dL、血鉀3.0mEq/L。用藥清單其他部分未變動。個案表示每日體重維持在基準值0.5公斤內。護理師觀察到個案使用標註日期的藥盒放置所有排定劑量。下一劑digoxin尚未服用。