Nurses' Notes
1010: The nurse receives a client after an ultrasound-guided percutaneous liver biopsy. The initial recovery note states that mild puncture-site soreness improves with supported positioning. At 1025, the dressing remains dry and the client is alert and answers orientation questions correctly. The nurse then observes that blood pressure is falling while the pulse becomes progressively faster. At 1035, the client reports that abdominal pain is increasing with new guarding. The puncture dressing still shows no external drainage. The respiratory assessment now finds that new shortness of breath occurs with reduced breath sounds on one side. The client reports that small sips of water are tolerated without nausea or swallowing difficulty. A repeat blood count shows that hemoglobin has fallen substantially from the preprocedure value. The nurse confirms that the peripheral intravenous line remains patent. The client says that mild right shoulder discomfort has not increased. At 1045, the nurse applies ordered oxygen, maintains intravenous access, and calls the rapid response team. The nurse prepares the client for urgent imaging and additional laboratory testing. The provider is informed that instability developed despite a dry external dressing.
護理紀錄
1010：護理師接獲一位接受超音波導引經皮肝臟切片後的個案。初步恢復紀錄顯示輕微穿刺部位痠痛在支托性擺位下改善。1025時，敷料仍乾燥且個案警醒並正確回答定向感問題。護理師隨後觀察到血壓正在下降而脈搏逐漸變快。1035時，個案主訴腹痛加劇且出現新的肌衛。穿刺處敷料仍無外滲。呼吸評估此時發現新發呼吸急促伴隨單側呼吸音減弱。個案表示少量啜飲開水可耐受，無噁心或吞嚥困難。重複血球計數顯示血紅素自術前數值大幅下降。護理師確認周邊靜脈管路仍通暢。個案表示輕微右肩不適並未加劇。1045時，護理師依醫囑給予氧氣、維持靜脈通路，並呼叫快速反應小組。護理師為個案準備緊急影像檢查及額外實驗室檢驗。已通報醫師儘管外敷料乾燥，仍出現不穩定狀況。