Nurses' Notes
0730: The client with Graves disease is admitted for pneumonia after missing antithyroid medication for several days. The history notes that a fine hand tremor has been present for several months and is unchanged since clinic. The chart also shows that body weight decreased 4 kg over the previous 3 months according to clinic records. At 0740, the nurse records that oral temperature is 40.2 °C despite removal of heavy bedding. The prior laboratory report shows that thyroid-stimulating hormone remains below the reportable range on the current panel. The client says that mild heat intolerance usually occurs during household activity and improves with rest. At 0745, telemetry shows that atrial fibrillation continues at an extremely rapid ventricular rate. The neck assessment confirms that a diffuse goiter was documented previously and remains unchanged in the handoff. The nurse observes that new disorientation and severe agitation develop during the assessment. The medication record shows that the first prescribed antibiotic dose was administered as scheduled for pneumonia. At 0750, the monitor shows that blood pressure decreases to 82/46 with cool distal extremities. The nurse activates rapid evaluation for suspected thyroid storm and prepares ordered emergency measures. Continuous cardiac, temperature, respiratory, and neurologic monitoring is started.
護理紀錄
0730：患有格雷夫斯病的個案因肺炎入院，已數日未服用抗甲狀腺藥物。病史記載細微手部顫抖已存在數月，且自診所以來無變化。病歷亦顯示根據診所紀錄，過去3個月體重減輕4公斤。0740時，護理師記錄儘管已移除厚重寢具，口溫仍為40.2 °C。先前的檢驗報告顯示目前檢驗組中，甲促素仍低於可報告範圍。個案表示輕度怕熱通常在進行家務活動時發生，休息後可改善。0745時，遠距監測顯示心房顫動持續以極快速的心室速率進行。頸部評估確認先前已記錄有瀰漫性甲狀腺腫，交班時仍無變化。護理師觀察到評估期間出現新發生的定向力障礙及嚴重躁動。用藥紀錄顯示已依醫囑按時給予第一劑肺炎抗生素。0750時，監視器顯示血壓降至82/46，合併肢端冰冷。護理師啟動疑似甲狀腺風暴的快速評估，並準備醫囑的緊急措施。開始持續心臟、體溫、呼吸及神經學監測。