Nurses' Notes
1840: The client with moderate dementia begins pacing and says, “I need to pick up my children.” One nurse responds by repeatedly correcting the client's belief and arguing that the children are adults. A second nurse approaches slowly and speaks in a calm voice while reassuring the client about immediate safety. At 1845, staff prepare for the scheduled bath. The first nurse insists that bathing continue while the client cries and pulls away. The assigned nurse pauses and checks for pain, urinary urgency, constipation, hunger, and fatigue. Environmental services is asked to wait, and television volume and hallway noise are reduced near the room. The client is offered a familiar folding activity and a warm drink. Another staff member suggests that wrist restraint be applied before possible physical or environmental triggers are assessed. When the client swings an arm, staff maintain a safe distance and move other clients away. At 1855, the care plan shows that the usual evening routine and familiar caregiver are maintained when possible. The nurse also reports the sudden behavior change during the current shift for evaluation of infection or medication effects. The client accepts the drink and sits with the familiar caregiver. The team documents the trigger assessment and response without forcing the bath.
護理紀錄
1840：中度失智症個案開始踱步並說：「我需要去接我的孩子。」一位護理師回應時反覆糾正個案的信念，並爭論說孩子們已經是成人了。另一位護理師慢慢靠近，並以平靜的語氣說話，同時安撫個案當下的安全。1845，工作人員準備進行預定的洗澡。第一位護理師在個案哭泣且退縮時，仍堅持繼續洗澡。負責的護理師暫停並檢查疼痛、尿急、便秘、飢餓和疲倦。要求環管人員稍候，且病房附近的電視音量和走廊噪音被調低。提供個案熟悉的摺疊活動和一杯溫飲。另一位工作人員建議在評估可能的生理或環境誘因前，就使用手腕約束。當個案揮動手臂時，工作人員保持安全距離並將其他個案移開。1855，照護計畫顯示盡可能維持平常的晚間常規和熟悉的照顧者。護理師也通報本班次突然的行為改變，以評估感染或藥物作用。個案接受了飲料，並與熟悉的照顧者坐在一起。團隊記錄了誘因評估和處置，而未強迫洗澡。