Jeremy knows Mr. Blejnar well, but each time he visits, he takes time to review his chart to ensure he is aware of any important updates from other team members.
Today he reviews Sharon's documentation which identifies important changes that she noticed during her visit:
Mr. Blejnar's breathing and restlessness are worse than his norm. His respiratory rate was 28 breaths per minute, he was breathing shallow and quick breaths.
Mrs. Blejnar is concerned about the changes over the past few weeks with his condition.
Mr. Blejnar was having difficulty focusing but his mental status has not changed. He was restless, not lethargic or hyperactive.
When asked, Mr. Blejnar denied that he was in pain.
I assisted him to sit upright supported with pillows. I provided him with a cool cloth and a fan. He settled when we sat with him but when we left his side, he became restless again.
He took his rescue puffer before I arrived, he finds if he takes it too often, it makes his heart race and makes him feel more anxious.
The supervisor was contacted to provide an update and Lori, a community paramedic, came to offer support.