Nurses' Notes
2200: The client is 18 hours after the first chemotherapy dose for bulky Burkitt lymphoma. At 2210, the chemistry panel shows that serum potassium increased to 6.1 mEq/L from 4.2 mEq/L. The handoff notes that nausea improved and no vomiting recurred after the prescribed antiemetic was given. The pretreatment report confirms that uric acid was 5.8 mg/dL on the completed panel before chemotherapy began. The current panel shows that serum phosphorus increased to 6.8 mg/dL from 3.7 mg/dL. The nurse verifies that serum calcium was 9.1 mg/dL on the completed pretreatment panel. At 2215, the flow sheet shows that urine output falls to 12 mL/hr while creatinine rises to 2.1 mg/dL. The intravenous assessment confirms that prescribed hydration is infusing through a patent line without alarms or leakage and the programmed hourly volume is displayed correctly. Telemetry currently shows that sinus rhythm continues without premature complexes on the bedside monitor. The client also reports that fatigue is unchanged from handoff and has continued since the chemotherapy session ended. At 2220, the client reports that new perioral tingling occurs with visible carpal spasm. The nurse places the client on continuous monitoring and immediately reports suspected tumor lysis syndrome. Repeat electrolyte testing and emergency treatment are prepared as prescribed.
護理紀錄
2200：個案為 bulky Burkitt lymphoma，首次化療劑量後 18 小時。2210 時，生化檢驗顯示 血清鉀從 4.2 mEq/L 上升至 6.1 mEq/L。交班紀錄指出 給予處方止吐藥後噁心改善且未再嘔吐。治療前報告確認 化療開始前完成的檢驗中尿酸為 5.8 mg/dL。目前檢驗顯示 血清磷從 3.7 mg/dL 上升至 6.8 mg/dL。護理師確認 治療前完成的檢驗中血清鈣為 9.1 mg/dL。2215 時，流量表顯示 尿量降至 12 mL/hr，同時肌酸酐上升至 2.1 mg/dL。靜脈輸液評估確認 處方輸液正透過通暢的管路輸注，無警報或滲漏，且設定的每小時輸注量正確顯示。目前遠距監測顯示 床邊監視器上持續為竇性心律，無早期收縮。個案也主訴 自交班以來疲勞未改變，且自化療結束後持續。2220 時，個案主訴 新發生口周麻木感，並可見腕部痙攣。護理師將個案置於持續監測下，並立即通報疑似腫瘤溶解症候群。依醫囑準備重複電解質檢驗與緊急治療。