Nurses' Notes
1000: The client begins a scheduled infliximab infusion after the nurse verifies the prescription and emergency supplies. At baseline, the client's temperature remains 36.8 °C without chills or malaise. The record confirms that tuberculosis screening was negative before biologic therapy began. At 1015, the client reports that new chest tightness and audible wheezing begin during the infusion. The nurse notes that the peripheral intravenous site remains soft and free of redness. The pump display shows that the programmed rate matches the current infusion prescription. At 1020, the client says, “I suddenly feel faint.” The monitor shows that blood pressure decreases from 128/76 to 86/52 with dizziness. The pulse oximeter shows that oxygen saturation remains 97% on room air. The client then develops spreading hives across the neck with new swelling of both lips. A prior note states that mild fatigue was present before the medication arrived. The nurse stops the infusion and begins an immediate airway and circulation assessment. The rapid-response medications and provider notification are initiated according to the infusion-reaction protocol.
護理紀錄
1000：個案在護理師核對醫囑及急救設備後，開始接受預定的infliximab輸注。基礎值顯示，個案的體溫維持在36.8 °C，無寒顫或不適。紀錄確認，開始生物製劑治療前的結核菌篩檢為陰性。1015時，個案表示，輸注期間出現新的胸悶及可聽見的喘鳴聲。護理師注意到，周邊靜脈管路部位仍柔軟、無發紅。輸注幫浦顯示，設定速率符合當前的輸注醫囑。1020時，個案說：「我突然覺得快暈倒了。」監測器顯示，血壓從128/76下降至86/52，伴隨頭暈。脈搏血氧儀顯示，在未使用氧氣下，血氧飽和度維持在97%。個案隨後出現，蔓延至頸部的蕁麻疹，伴隨雙唇新發生的腫脹。先前的紀錄提到，在藥物送達前即有輕度疲勞。護理師停止輸注，並立即開始呼吸道與循環評估。依輸注反應處理規範，啟動緊急藥物及通知醫師。