Nurses' Notes
1030:
The client is 63 years old and attends a preventive-care visit. The client reports no rectal bleeding, unexplained weight loss, or change in bowel habits. The record shows no inflammatory bowel disease, prior colorectal polyps, or known hereditary cancer syndrome. A normal screening colonoscopy was completed 10 years ago. During shared planning, the client says, I would be comfortable completing a FIT every year. The client adds, if a FIT is positive, I will repeat the FIT next month before deciding about colonoscopy. The nurse reviews the need to complete follow-up after an abnormal stool test. The client says, I could choose colonoscopy every 10 years if each result remains normal. When discussing another stool-based option, the client states, I plan to repeat stool DNA-FIT every 4 years if the result stays negative. The client also says, CT colonography every 5 years is an option I could discuss. After comparing preparation requirements, the client adds, a 7-year interval should be enough if I choose CT colonography. The nurse explains that each accepted strategy has its own interval and follow-up pathway. The client states, I will choose among recommended strategies after discussing benefits, burdens, and follow-up. The client says, I understand that an abnormal stool-based test needs follow-up colonoscopy. The client notes, new rectal bleeding would need diagnostic evaluation rather than waiting for routine screening. The nurse asks about relatives with colorectal cancer and prior abnormal testing. The client responds, my family and personal history should be checked before using the average-risk schedule. The nurse documents the three plans that need clarification before the screening order is placed.
護理紀錄
1030:
個案63歲,接受預防保健訪視。個案表示沒有直腸出血、不明體重減輕或排便習慣改變。紀錄顯示沒有發炎性腸道疾病、先前大腸直腸息肉或已知的遺傳性癌症症候群。10年前完成一次正常的篩檢性大腸鏡。在共同規劃期間,個案說,我願意每年完成一次FIT。個案補充,如果FIT陽性,我會在下個月重複FIT,然後再決定是否做大腸鏡。護理師檢視異常糞便檢查後完成追蹤的必要性。個案說,如果每次結果都正常,我可以選擇每10年做大腸鏡。在討論另一種糞便檢查選項時,個案表示,如果結果持續陰性,我計畫每4年重複糞便DNA-FIT。個案也說,每5年電腦斷層大腸攝影是我可以討論的選項。在比較準備要求後,個案補充,如果我選擇電腦斷層大腸攝影,7年間隔應該足夠。護理師解釋每種公認策略都有自己的間隔和追蹤路徑。個案表示,我會在討論益處、負擔和追蹤後,在建議的策略中做出選擇。個案說,我了解異常的糞便檢查需要追蹤性大腸鏡。個案指出,新的直腸出血需要診斷評估,而不是等待常規篩檢。護理師詢問有關大腸直腸癌的親屬和先前異常檢查。個案回應,在使用平均風險時程前,應檢查我的家族和個人病史。護理師記錄在開立篩檢醫囑前需要澄清的三個計畫。