Nurses' Notes
1315: The emergency nurse assesses a client with myasthenia gravis after a respiratory infection. The client reports that eyelid drooping improves briefly after resting. At 1320, the nurse documents that the single-breath count falls markedly from the earlier assessment. The room is kept cool, and the client reports less fatigue away from direct heat. During conversation, the client can speak only short phrases before taking another breath. The medication record confirms that the usual pyridostigmine schedule was followed today. At 1328, the monitor shows that oxygen saturation remains within the prescribed target range. The client remains alert and follows commands. The nurse hears gurgling and finds that a weak cough cannot clear pooled oral secretions. The limb examination shows that hand strength is unchanged from the client's baseline. The nurse observes that the abdomen moves inward during inspiration as the chest rises. A chest image completed earlier shows no new focal pulmonary opacity, pleural fluid, or lobar collapse. At 1335, the nurse raises the head of the bed, keeps suction available, and calls for immediate airway evaluation. The team prepares ventilatory support while repeating bedside respiratory measurements.
護理紀錄
1315：急診護理師評估一位因呼吸道感染就診的重症肌無力個案。個案表示休息後眼瞼下垂短暫改善。1320時，護理師記錄單次呼吸計數較先前評估明顯下降。房間保持涼爽，且個案表示遠離直接熱源後疲勞感減輕。交談時，個案只能說出短句就需換氣。用藥記錄確認今日已依常規給予pyridostigmine。1328時，監視器顯示血氧飽和度維持在處方目標範圍內。個案仍清醒且能遵從指令。護理師聽到咕嚕聲，發現無力咳嗽無法清除積聚的口腔分泌物。肢體檢查顯示手部肌力與個案基準值相同。護理師觀察到吸氣時腹部向內移動，同時胸部上升。稍早完成的胸部影像顯示無新發局部肺實質化、肋膜積液或肺葉塌陷。1335時，護理師搖高床頭，備妥抽吸設備，並呼叫立即氣道評估。團隊準備通氣支持，同時重複床邊呼吸測量。