Nurses' Notes
0915:
The client is 8 days postpartum following a cesarean birth and calls the obstetric clinic. She was discharged on postoperative day 3 after an uncomplicated recovery. The client reports a headache that began yesterday and has not improved after acetaminophen and fluids. She states, "I see flashing spots when I stand and walk across the room." She reports sleeping in 2-hour blocks while feeding the newborn. The client states that both ankles are mildly swollen by evening and improve when elevated. She reports pink-brown lochia that is lighter than at hospital discharge. The client reports new pain under the right ribs with intermittent nausea. She states that her breasts feel full before feeding and soften after the newborn nurses. During the call, the nurse notes that the client becomes short of breath while speaking and pauses to finish a sentence. The client reports incisional discomfort rated 3/10 with turning that improves at rest. She reports one soft bowel movement this morning after taking the prescribed stool softener. The client states that her oral temperature is 37.4 °C (99.3 °F). The incision is dry with the edges approximated. She denies unilateral calf pain, and her partner is available to drive.
護理紀錄
0915：
個案為剖腹產後第8天，致電產科門診。她在術後第3天出院，恢復過程無併發症。個案表示昨日起頭痛，acetaminophen 與補水後未改善。她說：「我站起來走過房間時會看到閃光。」她表示每2小時醒來餵新生兒。個案表示雙腳踝到傍晚輕微腫脹，抬高後會改善。她表示粉棕色惡露比出院時更少。個案表示右側肋骨下方新發疼痛，伴隨間歇性噁心。她表示餵奶前乳房脹，新生兒吸吮後會變軟。通話中，護理師注意到個案說話時呼吸急促，需停頓才能說完一句話。個案表示翻身時切口不適，疼痛指數3/10，休息後改善。她表示今早服用處方軟便劑後解了一次軟便。個案表示口溫為37.4 °C (99.3 °F)。切口乾燥，邊緣對合良好。她否認單側小腿疼痛，其伴侶可開車。