居家護理師檢視一份安寧緩和訪視紀錄。哪些發現需要立即追蹤?請標示出需要立即進行症狀或安全處置的發現。 | MyMerci
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Mobility/Immobility

居家護理師檢視一份安寧緩和訪視紀錄。哪些發現需要立即追蹤?請標示出需要立即進行症狀或安全處置的發現。

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Care area照護領域Current finding目前發現
Pain疼痛 Pain remains 8/10 and prevents turning after both prescribed rescue doses.疼痛仍為8/10,且在給予兩次醫囑救援劑量後,翻身仍會引發疼痛。
Nutrition營養 The client eats smaller preferred meals, stops when comfortably full, and reports no nausea or swallowing difficulty.個案進食偏好少量多餐,感到舒適飽足即停止,且無噁心或吞嚥困難。
Bowel function腸道功能 No stool has passed for five days, and abdominal distention now occurs with vomiting.已五天未解便,且現在出現腹脹伴隨嘔吐。
Mouth care口腔照護 Dry mouth improves with frequent ice chips and water-based oral moisturizer; the oral mucosa remains intact.頻繁使用冰塊及水性口腔保濕劑後,口乾改善;口腔黏膜仍完整。
Breathing呼吸 Shortness of breath at rest makes the client pause repeatedly while speaking.休息時呼吸急促,導致個案說話時需反覆停頓。
Sleep睡眠 The client sleeps two hours longer than last week but awakens easily to voice and remains oriented.個案睡眠時間比上週多兩小時,但對聲音容易喚醒,且定向感正常。
Goals照護目標 The client describes comfort goals, restates care choices in personal words, and participates in decisions.個案描述舒適目標,用自己的話複述照護選擇,並參與決策。
Behavior行為 New agitation and visual misperceptions began suddenly during the afternoon.下午突然出現新發生的躁動及視幻覺。
Medication use用藥情形 The caregiver crushes extended-release morphine tablets to make swallowing easier.照顧者將長效型嗎啡錠磨碎以利吞嚥。
解析
未控制的疼痛、阻塞型便秘、嚴重呼吸困難、新發生的躁動,以及不安全地磨碎長效型嗎啡,都需要立即處置。預期中的食慾或睡眠變化,仍應以舒適為重點進行監測。
相同主題的下一題A nurse is caring for a 75-year-old client with limited mobility and urinary incontinence …
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