Nurses' Notes
1015: A right internal jugular central venous catheter is placed without immediate difficulty. At 1030, new severe shortness of breath begins. The temperature is 37.1 °C. The nurse documents that the temperature remains unchanged from the preprocedure value. Before the procedure, chest expansion was symmetric with clear breath sounds. At 1035, right-sided breath sounds are absent. The insertion dressing is dry and intact. The client reports mild tenderness limited to the catheter insertion site. At 1040, the respiratory rate increases from 18/min to 34/min. The nurse notes that the earlier respiratory rate was 18/min at rest. At 1042, blood pressure is 78/46 mm Hg; hypotension occurs with new tracheal deviation. The oxygen saturation had been 97% on 2 L/min before the change. The record confirms that oxygen saturation was stable before the procedure. The catheter lumens flush without resistance. The nurse documents that each lumen flushes and has a labeled cap. Emergency equipment is brought to the bedside.
護理紀錄
1015：右側內頸靜脈中心靜脈導管置入，無立即困難。1030時，突發嚴重呼吸急促開始。體溫37.1 °C。護理師記錄體溫與置入前數值相比維持不變。置入前，胸部擴張對稱，呼吸音清晰。1035時，右側呼吸音消失。置入部位敷料乾燥且完整。個案表示輕微壓痛僅限於導管置入部位。1040時，呼吸速率從18次/分增加至34次/分。護理師記錄稍早休息時呼吸速率為18次/分。1042時，血壓78/46 mm Hg；低血壓伴隨新發生的氣管偏移。變化前，血氧飽和度在2 L/min下為97%。紀錄確認置入前血氧飽和度穩定。導管管腔沖洗無阻力。護理師記錄每個管腔均可沖洗且具有標示的蓋子。急救設備已備至床邊。