Prior To Working With Mk I Had Made A Judgment After Reading

1693 WordsFeb 12, 20177 Pages
Prior to working with MK I had made a judgment after reading his MAR and brief description Sunday night that he would be a palliating client as I had noticed all his meds were through NG tube. During my first day working with MK I did a brief scan of his chart and noticed all NG meds were now given orally. I then received morning report about his status and was surprised to find that there was not much written about him other than “patient slept well, no concerns”. This is when my whole judgment shifted and I realized that this client must have really improved since his admission. I have had the chance to work with a stroke client on one other occasion but I diffidently wasn’t full comfortable with it quite yet. I entered the room to MK…show more content…
I started my morning by reviewing his Kardex and noticed that chest pain had been noted and that he had an ECG and CT of his chest. I went into his room to find him wide-awake in bed. I performed my safety check and took his vitals. His resp rate was quite high at this time and his Sp02 was on the lower side. MK expressed through nodding that he was having chest pain during that time. I also did a respiratory assessment because I was concerned with his SpO2 and resp rate. I found decreased air entry to his bases, expiratory wheeze, and a visual use of accessory muscle to breath. His breathes where short and labored. When asked if he was experiencing SOB, he nodded and this directed my care for that morning. I reported to my instructor with my findings as this was the first time I had a client say yes to chest pain. I quickly addressed his SOB with his PRN bronchodilator using a spacer and put him on two liters of O2 via nasal prongs. I checked back in after 5 minutes and his resp rate had lowered and his SpO2 had risen to a more adequate level. I noticed he did not have audible wheeze any longer and was not using his accessory muscles. Overall he looked way more relaxed in his bed after addressing his respiratory distress. Unfortunately, he still was nodding yes to chest pain in that moment. The RN on my team left a doctors note about another CT and ECG and noted that the client was still
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