Nurses' Notes
0910: The oncology nurse calls a client on treatment day 4 after the first fluorouracil infusion. The client reports that watery diarrhea occurred 8 times since midnight. The client denies blood in the stool but feels weak when standing. The nurse learns that mild nausea improved after the prescribed antiemetic. The client states that painful mouth ulcers now prevent drinking fluids. Oral intake has fallen to a few small sips since yesterday evening. The client reports that urine remains pale yellow without burning. A family member says that the client slept for 7 hours overnight. At 0920, the client has new confusion and difficulty walking across the room. The family member denies any fall or sedating medication use. The client states that the infusion-site skin remains intact without redness. The temperature is 37.2 °C, and the client can speak in complete sentences. The medication list shows that the prescribed oral rinse was used after meals. The record contains no pretreatment DPYD result because therapy was urgent. The nurse keeps the next dose on hold while contacting the oncology prescriber.
護理紀錄
0910：腫瘤科護理師在第一次 fluorouracil 輸注後的第 4 天致電個案。個案表示自午夜以來已發生 8 次水瀉。個案否認糞便帶血，但站立時感到虛弱。護理師得知輕微噁心在服用處方止吐藥後改善。個案表示疼痛的口腔潰瘍現在導致無法飲水。自昨晚以來，口服攝取量已降至僅能小口啜飲幾次。個案表示尿液仍呈淡黃色，無灼熱感。家屬表示個案夜間睡了 7 小時。0920 時，個案出現新發生的意識混亂和行走困難。家屬否認任何跌倒或使用鎮靜藥物。個案表示輸注部位皮膚仍完整無發紅。體溫 37.2 °C，個案能說出完整句子。用藥清單顯示處方漱口水已於飯後使用。病歷中無治療前 DPYD 結果，因為治療是緊急的。護理師暫停下一劑藥物，同時聯繫腫瘤科處方醫師。