Nurses' Notes
1510: The clinic nurse observes an intake visit for a client with nightmares and hypervigilance after a traumatic event. The interviewer begins by demanding a detailed trauma account before discussing consent. The client becomes tense and looks toward the door. The nurse then offers a seat where the client can see the exit. The nurse explains the visit steps and states that questions may be paused. The client says that a support person may join if the client chooses. At 1518, the interviewer asks permission before discussing possible trauma reminders. The client identifies crowded rooms as a trigger and practices slow breathing. The plan states that all distress should disappear after the first counseling visit. The client says this promise feels impossible and discouraging. The nurse confirms that treatment options and likely benefits will be reviewed through shared decision-making. The interviewer next starts an unsupervised exposure exercise without an agreed treatment plan. The client asks to stop, and the nurse stops the exercise. The nurse documents that the client denies current thoughts of self-harm. Before leaving, the client selects one grounding strategy to practice at home. Follow-up with a qualified trauma-focused therapist is arranged.
護理紀錄
1510：診所護理師觀察一位在創傷事件後出現噩夢與過度警覺的個案進行初診會談。會談者一開始在討論同意前要求詳述創傷經歷。個案變得緊張並看向門口。護理師接著提供個案可以看到出口的座位。護理師說明會談步驟，並表示問題可以暫停。個案表示如果個案選擇，支持者可以陪同。1518 時，會談者在討論可能的創傷提醒前請求許可。個案指出擁擠的房間是觸發因素，並練習慢速呼吸。計畫中寫道第一次諮商會談後所有痛苦都應消失。個案表示這個承諾感覺不可能且令人沮喪。護理師確認治療選項與可能的益處將透過共享決策進行審查。會談者接著在沒有同意治療計畫下開始無監督的暴露練習。個案要求停止，護理師停止練習。護理師記錄個案否認目前有自傷想法。離開前，個案選擇一項接地策略在家練習。已安排合格創傷焦點治療師的後續追蹤。