Reporte zur Charge 4A3NL

Symptomtext

Charge nurse note: @ 2120, LNA reported resident "wasn't right", stated resident was noted to be "flailing his arms". Upon entry into the room resident was found to be unresponsive to sternal rub, labored breathing with RR of 28, blood trickling from the corner of his mouth. Initial VS: 97.9, 112, 28, 240/80, 97% RA. 2 L of O2 was applied as supportive measure. No convulsions noted with this RN's assessment. Supervisor called to floor. Resident a full code--EMS was activated. Within 5 minutes resident's RR came down to 20, nonlabored, making eye contact when his name is called. F/u b/p 180/80. Upon EMS arrival resident was speaking in short sentences when questioned. Resident out to ED @ 2140. Nurse to nurse report given to RN at ED. Nsg. Supervisor note: Called by charge nurse to see resident, LNA reported she heard resident thrashing loudly and that she thought there was someone else in the room with the resident. She stated he was "flailing his arms up here" as she demonstrated what she had observed. Upon entry into the room resident was found to be unresponsive, glazed stare, no response to verbal prompts, labored respirations of 24 on oxygen via face mask, LNA states blood came out of his mouth, repositioned on left side. Resident is a full code and EMS was activated. Upon EMS arrival resident more responsive and responded "hi" with no further further flailing noted. NP notified and resident out to ED @ 2140 with paperwork provided to the EMS staff.