Nurses' Notes
0745: The client is scheduled for elective colorectal surgery at 0930. During teach-back, the client states that the possible permanent ostomy was not explained. The client correctly states that a blood transfusion may be needed if major bleeding occurs. The nurse confirms that the consent form is written in the client's preferred language. The signed form lists the planned procedure and the responsible surgeon. At 0755, 15 minutes after the medication was administered, the record shows midazolam was given before consent was signed. The client asks the nurse to watch while the client writes the signature. The client points to the marked abdominal site and identifies the planned operation. The record shows that a certified interpreter stayed for the entire consent discussion. The daughter is present because the client requested her support during the discussion. The client then states that the daughter pressured an unwilling client to sign. The client accurately repeats the expected recovery activities. The nurse confirms that the client received a copy of the signed form. The client asks when oral fluids may restart after surgery. The preoperative checklist shows the procedure and client identity were verified together before operating room transport. The client remains alert and oriented during the current assessment. The client states that additional questions can be asked before transport. No emergency condition is documented.
護理紀錄
0745：個案預定於0930進行選擇性結直腸手術。在回覆示教中，個案表示可能的永久性造口未被解釋。個案正確表示若發生大出血可能需要輸血。護理師確認同意書以個案偏好的語言書寫。已簽署的表單列出計畫的手術和負責的外科醫師。0755，給藥後15分鐘，紀錄顯示midazolam在同意書簽署前給予。個案要求護理師在個案書寫簽名時觀看。個案指向標記的腹部部位並確認計畫的手術。紀錄顯示一位認證口譯員全程參與同意討論。女兒在場是因為個案要求她在討論期間提供支持。個案隨後表示女兒施壓不願意的個案簽署。個案準確重複預期的恢復活動。護理師確認個案收到已簽署表單的副本。個案詢問術後何時可重新開始口服液體。術前查核表顯示手術和個案身分在運送至手術室前已一同核對。個案在目前評估中保持警覺且定向感正常。個案表示在運送前可提出其他問題。無緊急狀況紀錄。