Nurses' Notes
0730:
The caregiver sends a portal message about a 7-year-old child who is 6 days postoperative after a tonsillectomy. The procedure was performed for recurrent throat infections. The caregiver notes a white-gray coating over the tonsillar beds. The child has strong mouth odor despite gentle oral care. The caregiver reports the child swallows repeatedly even while asleep. The caregiver states that the child spit bright-red blood into a tissue twice this morning. The caregiver reports pain that radiates toward both ears when the child swallows. The child's oral temperature is 37.7 °C (99.9 °F). The caregiver reports no liquids since last evening and no urination for 10 hours. The caregiver administered acetaminophen for pain rated 6/10 that improved to 2/10 after the medication. The child ate cool applesauce without vomiting yesterday afternoon. The caregiver states that the child is difficult to awaken and answers with one-word responses. The child is breathing without stridor. The caregiver reports no rash, facial swelling, or neck stiffness. Another adult is available to drive to the emergency department.
護理紀錄
0730:
照顧者透過入口網站傳送訊息，關於一名 7 歲兒童，在扁桃腺切除術後第 6 天。手術是因反覆喉嚨感染而進行。照顧者注意到 扁桃腺窩上有白色灰色覆蓋物。兒童有 儘管溫和口腔護理仍有強烈口臭。照顧者報告 兒童即使在睡眠中也反覆吞嚥。照顧者表示 兒童今早兩次將鮮紅色血液吐在衛生紙上。照顧者報告 吞嚥時疼痛放射至雙耳。兒童的 口溫為 37.7 °C (99.9 °F)。照顧者報告 從昨晚起未進食液體且 10 小時未排尿。照顧者給予 acetaminophen 治療 疼痛 6/10，服藥後改善至 2/10。兒童昨天下午吃了涼的蘋果泥且未嘔吐。照顧者表示 兒童難以喚醒且以單字回應。兒童呼吸無喘鳴。照顧者報告無皮疹、臉部腫脹或頸部僵硬。有另一位成人可開車前往急診。