Nurses' Notes
1410: The client received the third outpatient cyclophosphamide treatment two days ago. The morning weight is unchanged from the previous treatment visit. The client reports mild fatigue after walking to the kitchen. The oral mucosa is moist, and the small mouth ulcer from last week has healed. At 1330, the client noticed red urine with two small clots in the toilet. Appetite improved after the prescribed antiemetic was taken. The client says that urine was clear yellow earlier this week. During the call, the client describes suprapubic burning that becomes worse during urination. The temperature is 37.1 °C. The home pulse reading is similar to the usual resting value. The client reports drinking the fluids listed in the treatment plan. A routine blood count is scheduled for tomorrow morning at the infusion center. Since noon, the client has voided small amounts six times with a strong urge. The client denies flank trauma or a recent urinary procedure. The bowel movement today was soft and brown. The client can state when the next oncology appointment is scheduled. No nosebleed or gum bleeding is reported. The nurse reviews the medication list and confirms no new anticoagulant was started.
護理紀錄
1410：個案於兩天前接受第三次門診 cyclophosphamide 治療。早晨體重與前次治療回診時相同。個案表示走到廚房後有輕度疲倦。口腔黏膜濕潤，上週的小口腔潰瘍已癒合。1330 時，個案注意到馬桶中有紅色尿液及兩個小血塊。服用處方止吐藥後食慾改善。個案表示本週稍早尿液為清澈黃色。通話中，個案描述恥骨上灼熱感，排尿時加劇。體溫 37.1 °C。居家脈搏讀數與平時休息值相似。個案表示有依照治療計畫飲水。常規血液檢查預定明早於輸注中心進行。自中午起，個案已少量排尿六次，伴隨強烈尿意。個案否認腰部創傷或近期泌尿處置。今日排便為軟便、棕色。個案能說出下次腫瘤科門診時間。無流鼻血或牙齦出血。護理師檢視用藥清單，確認未新增抗凝血劑。