Nurses' Notes
1830:
The client is six hours postoperative following a total thyroidectomy. The client reports mild throat irritation that has improved after ice chips. During the assessment, the client reports new tingling around the lips and corners of the mouth. A small area of bruising below the incision is unchanged from the previous outline. The client states both fingertips have become numb during the past 1 hour. The voice is mildly hoarse but has improved steadily since extubation. When the blood-pressure cuff inflates, the client's hand tightens into a painful carpopedal spasm. The neck remains soft without rapidly increasing swelling or difficulty swallowing. Laboratory results show the serum calcium level has decreased to 7.1 mg/dL. The surgical drain contains 25 mL of thin serosanguineous fluid since arrival. The dressing is dry and intact, and the trachea remains midline. The client is awake and follows commands. The nurse keeps emergency airway equipment available and promptly contacts the surgical team about the neuromuscular findings and calcium result.
護理紀錄
1830:
個案於甲狀腺全切除術後六小時。個案表示喉嚨輕微不適，含冰屑後已改善。評估時，個案表示嘴唇及嘴角周圍出現新的刺痛感。切口下方小範圍瘀傷與先前描繪範圍相同。個案表示過去 1 小時內雙手指尖變得麻木。聲音輕微嘶啞，但自拔管後持續改善。當血壓計壓脈帶充氣時，個案的手部緊縮成疼痛的腕足痙攣。頸部維持柔軟，無快速腫脹或吞嚥困難。檢驗結果顯示血清鈣濃度下降至 7.1 mg/dL。手術引流管自抵達後引流 25 mL 稀薄漿液血性液體。敷料乾燥完整，氣管維持中線。個案清醒且能遵從指令。護理師備妥緊急呼吸道設備，並立即就神經肌肉發現與血鈣結果聯繫外科團隊。