Nurses' Notes
1630: The client returned from ERCP 40 minutes ago. The client reports mild throat soreness that improves after an ice chip. At 1640, the client describes severe epigastric pain that radiates to the back and worsens. The client is sleepy after sedation but awakens to name and follows commands. Oxygen saturation is 97% on the prescribed nasal oxygen. The nurse records that sedation level is improving with repeated verbal stimulation. The abdomen initially has mild fullness that began after the endoscopy procedure. The client now has the abdomen is rigid with involuntary guarding. The earlier bloating was relieved slightly after passing flatus. The blood pressure remains within the documented preprocedure range. At 1650, temperature is 38.4 °C and heart rate is 122/min as fever developed with new tachycardia. The client denies nausea at this time. The intravenous site is soft and dry. The client has no new rash or facial swelling. The procedure note documents biliary sphincterotomy. The nurse keeps the client fasting while contacting the endoscopy clinician. Emergency imaging has not yet been performed. No discharge teaching has begun.
護理紀錄
1630：個案於 40 分鐘前自 ERCP 返回。個案主訴吃冰片後改善的輕度喉嚨痛。1640 時，個案描述嚴重上腹痛並放射至背部且加劇。個案在鎮靜後嗜睡，但對姓名有反應且能遵從指令。血氧飽和度為依醫囑使用鼻導管氧氣下 97%。護理師記錄重複口語刺激下鎮靜程度正在改善。腹部最初有內視鏡檢查後開始的輕度飽脹感。個案現在腹部僵硬且有非自主性防衛。稍早的腹脹在排氣後稍微緩解。血壓維持在記錄的術前範圍內。1650 時，體溫 38.4 °C，心率 122 次/分，因發燒合併新發生心搏過速。個案此時否認噁心。靜脈注射部位柔軟且乾燥。個案無新發皮疹或臉部腫脹。術程紀錄記載膽道括約肌切開術。護理師在聯繫內視鏡醫師期間維持個案禁食。尚未進行緊急影像學檢查。尚未開始出院衛教。