Nurses' Notes
0810:
The client arrives for the fourth cycle of a chemotherapy regimen that includes bleomycin. Previous infusions were completed without an acute hypersensitivity reaction or respiratory complaint. The client reports a dry cough that began five days ago and now wakes the client at night. The client also reports shortness of breath while walking from the parking area to the clinic. Mild nausea occurs on the first day after treatment and improves with the prescribed antiemetic. The nurse notes fine crackles at both posterior lung bases that were not documented at the previous visit. The oral temperature is 37.2 °C, and the client denies fever, chills, or recent sick contacts. The client has stable darkening of the skin over the elbows since the second cycle. Hair thinning is unchanged from the prior assessment and the scalp remains intact. Pulse is 96/min and respirations are 22/min at rest. Room-air oxygen saturation has decreased from a baseline of 98% to 92% today. The client reports a small mouth sore that healed three days ago. Weight is unchanged, and there is no new lower-extremity swelling or calf tenderness. The client says fatigue improves after resting in the afternoon. The nurse delays releasing the infusion and contacts the oncology provider with the respiratory assessment.
護理紀錄
0810:
個案抵達進行包含 bleomycin 的化療第四週期。先前輸注均未發生急性過敏反應或呼吸道主訴。個案主訴五天前開始的乾咳，現在夜間會讓個案醒來。個案也主訴從停車場走到診間時呼吸急促。治療後第一天出現輕度噁心，使用處方止吐劑後改善。護理師注意到雙側肺底細微囉音，上次就診時未記錄。口溫為 37.2 °C，個案否認發燒、寒顫或近期接觸生病者。個案自第二週期起雙肘皮膚穩定變黑。頭髮稀疏與先前評估相同，頭皮仍完整。脈搏 96/min，休息時呼吸 22/min。室內空氣血氧飽和度今日從基準值 98% 降至 92%。個案表示三天前有一個小口腔潰瘍已癒合。體重不變，無新的下肢水腫或小腿壓痛。個案表示下午休息後疲倦改善。護理師延遲釋出輸注，並聯繫腫瘤科醫師告知呼吸評估結果。