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Client presents with a partner who states, “He has been experiencing shortness of breath over the last day and in the past hour, became confused” prompting this visit to the ED. Alert, oriented to person, but not place or time. Denies any pain. Has difficulty speaking more than a few words at a time. Currently sitting up, leaning on the bedside table with forearms, and using accessory muscles to support breathing efforts. Nail beds and mucous membranes dusky. Lung sounds diminished bilaterally, with no wheezes, crackles, or rubs noted. Symmetrical chest movement. Hand grasps equal and weak bilaterally. Pupils are equal and reactive to light. Able to move eyebrows and face bilaterally.
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Please do nursing notes question in which action to be taken is there
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Client presents with a partner who states, “He has been experiencing shortness of breath over the last day and in the past hour, became confused” prompting this visit to the ED. Alert, oriented to person, but not place or time. Denies any pain. Has difficulty speaking more than a few words at a time. Currently sitting up, leaning on the bedside table with forearms, and using accessory muscles to support breathing efforts. Nail beds and mucous membranes dusky. Lung sounds diminished bilaterally, with no wheezes, crackles, or rubs noted. Symmetrical chest movement. Hand grasps equal and weak bilaterally. Pupils are equal and reactive to light. Able to move eyebrows and face bilaterally.
Plz explain
The question is too long I can’t even write here
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Thank you
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