Nurses' Notes
0915:
The client takes warfarin for atrial fibrillation and calls before the scheduled clinic visit. The client reports a black, tarry bowel movement this morning without taking an iron supplement. The client eats about the same portion of leafy green vegetables each week. For knee pain, the client has taken over-the-counter ibuprofen every morning for the past four days. Warfarin is taken at 1900 each evening using a weekly medication organizer. Yesterday, the client slipped on wet stairs, struck the back of the head, and did not seek care. A soft toothbrush and electric razor are used for daily hygiene. The laboratory portal shows today's INR is 5.8, compared with a prescribed target range of 2 to 3. The client wears a medical-alert bracelet when away from home. A small forearm bruise has remained the same size for three days, is painless, and is becoming lighter. The client recalls missing Monday's dose and states, two warfarin tablets were taken together on Tuesday morning. The client denies chest pain or shortness of breath. The nurse instructs the client not to take additional medication until the urgent anticoagulation plan is confirmed.
護理紀錄
0915:
個案因心房顫動服用 warfarin，在預定門診前來電。個案表示今早解出黑色柏油樣便，且未服用鐵劑。個案每週攝取大約相同份量的深綠色蔬菜。因膝蓋疼痛，個案過去四天每天早上服用市售 ibuprofen。Warfarin 每天晚上 1900 使用每週藥盒服用。昨天，個案在濕滑的樓梯上滑倒，撞到後腦勺，且未就醫。每天使用軟毛牙刷和電動刮鬍刀進行個人衛生。檢驗室資料顯示今天的 INR 為 5.8，而處方目標範圍為 2 到 3。個案離家時會配戴醫療警示手環。一個前臂小瘀青三天來大小不變、不痛，且顏色變淡。個案想起漏服了星期一的劑量，並表示星期二早上一次服用了兩顆 warfarin。個案否認胸痛或呼吸急促。護理師指示個案在緊急抗凝血計畫確認前，不要服用額外藥物。