Nurses' Notes
1420: The emergency nurse assesses a client who developed chest discomfort while carrying groceries. The client states that the pain increases when the upper chest is pressed and then decreases after pressure is released. Seconds later, the client describes abrupt severe pain that was maximal at onset and moved toward the back. The client appears frightened and remains still on the stretcher. The monitor shows heart rate 88 beats per minute and oxygen saturation 98% on room air remain steady. At 1424, the nurse obtains right arm blood pressure 186/94 mm Hg and left arm pressure 142/78 mm Hg. The client reports no recent fever, cough, or injury. The nurse notes that both lung fields remain clear while symmetric chest movement continues without distress. At 1427, the client develops new weakness of the left arm and difficulty speaking. The blood glucose is 112 mg/dL. The client reports that an antacid relieved similar gradual burning pain after a large meal without later symptoms. The skin is initially warm and dry. At 1431, the nurse finds blood pressure 84/52 mm Hg with cool mottled legs. A second intravenous line is prepared while the emergency team is activated. At 1434, the nurse confirms that the client identifies today's date, follows commands, and recalls recent events accurately. The nurse maintains continuous monitoring and avoids delaying definitive imaging and treatment.
護理紀錄
1420：急診護理師評估一位在提雜貨時發生胸部不適的個案。個案表示按壓上胸部時疼痛加劇，放開後疼痛減輕。幾秒後，個案描述突發劇烈疼痛，一開始即達最大強度，並轉移至背部。個案顯得驚恐，在擔架上保持不動。監視器顯示心率每分鐘88次，室內空氣下血氧飽和度98%，維持穩定。1424時，護理師測得右臂血壓186/94 mm Hg，左臂血壓142/78 mm Hg。個案表示近期無發燒、咳嗽或外傷。護理師注意到雙側肺音清晰，對稱性胸廓運動持續，無窘迫現象。1427時，個案出現新發生的左臂無力及說話困難。血糖值為112 mg/dL。個案表示先前在大餐後曾發生類似的漸進性灼熱痛，服用制酸劑後緩解，之後無症狀。皮膚起初溫暖乾燥。1431時，護理師發現血壓84/52 mm Hg，雙腿冰冷且出現花斑。在啟動緊急團隊的同時，準備第二條靜脈管路。1434時，護理師確認個案能正確說出今天的日期、遵從指令，且能準確回憶近期事件。護理師持續監測，並避免延遲確診性影像檢查與治療。