護理師檢視服用 clozapine 個案的追蹤資料。哪些發現需要立即追蹤?請標示需要緊急評估的發現。 | MyMerci
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Medication Administration

護理師檢視服用 clozapine 個案的追蹤資料。哪些發現需要立即追蹤?請標示需要緊急評估的發現。

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Follow-up area追蹤項目Current finding目前發現
Infection screen感染篩檢 Temperature is 38.2 °C with sore throat, and the current ANC is 900/mcL.體溫 38.2 °C、喉嚨痛,ANC 900/mcL。
Blood pressure血壓 Brief lightheadedness occurs on standing, then resolves after sitting; no fall or fainting occurs.站立時短暫頭暈,坐下後緩解;無跌倒或昏厥。
Cardiac screen心臟篩檢 New chest pain occurs with a resting pulse of 124/min that remains elevated.新發胸痛,休息時脈搏 124/min 且持續偏高。
Bowel pattern腸道型態 The last bowel movement was yesterday, and the abdomen remains soft without nausea or distention.最後一次排便為昨天,腹部仍柔軟,無噁心或腹脹。
Abdominal screen腹部篩檢 No stool has passed for five days, and abdominal distention now occurs with vomiting.已五天未解便,現出現腹脹及嘔吐。
Oral secretions口腔分泌物 Drooling occurs during sleep, but there is no daytime choking or difficulty swallowing meals.睡眠中流涎,但無日間嗆咳或吞嚥困難。
Neurologic screen神經學篩檢 A generalized seizure lasting one minute occurred for the first time this morning.今晨首次發生持續一分鐘的全身性癲癇。
Weight trend體重趨勢 Weight increased 1 kg this month while appetite, activity, and clothing fit remained unchanged.本月體重增加 1 kg,食慾、活動及衣著合身度不變。
Laboratory result檢驗結果 The repeat absolute neutrophil count is 420/mcL after a previous result of 610/mcL.複檢 ANC 為 420/mcL,前次為 610/mcL。
解析
發燒且 ANC 為 900/mcL、新發胸痛伴持續心搏過速、五天未解便後嘔吐,以及 ANC 為 420/mcL 需要緊急評估。其他發現優先度較低或在此情境下屬預期。
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