Chapter 15

The patient’s chief complaint about shortness of breath and feeling “off” are important cues to notice since this is what brought them to the hospital for care. Additionally, another important cue to recognize is the patient’s past medical history, which may be relevant to their symptoms. Noticing that the patient is anxious and leaning forward is another important cue to recognize because it is consistent with the patient’s chief complaint.

Though the patient is reported as being alert and oriented ×4, the nurse should still perform a GCS assessment to have a tangible baseline for the patient’s level of consciousness. This can be documented and checked periodically to watch for subtle changes in the patient’s neurological status. The nurse should also take note of the patient’s mobility and functional status during the general survey, such as noticing if they require assistive devices or have a limited range of motion. It would also be important for the nurse to assess how the patient is dressed, if they are height/weight proportional, and if they are well groomed. Assessing these characteristics can present additional pieces of information that can be used to help effectively treat and care for the patient.

The nurse might expect to see a low oxygen saturation related to the crackles in the lungs and shortness of breath, both of which occur from heart failure due to a backup of blood into the lungs. The nurse would also expect the patient to exhibit tachycardia as they are anxious, and the heart is trying to compensate for the heart failure exacerbation.

The nurse should palpate the radial pulse, as it is usually the easiest one to find and feel. Because the patient may be experiencing heart failure exacerbation, the nurse may also want to auscultate the apical pulse of the heart to listen for associated abnormalities such as a murmur. The nurse may anticipate that the patient’s pulse will be fast (tachycardia) and weak, because the heart is working overtime to compensate for the organ failure, and the patient is experiencing anxiety.

The most concerning vital signs are the oxygen saturation and respiratory rate. Airway and breathing are always the top priority, so the nurse should implement interventions to address those issues first. To start, the nurse should probably retake the vitals and double-check that the pulse oximeter is working correctly and that the patient is not wearing fingernail polish, as this can skew the readings. If those numbers are accurate, the nurse should contact the treating provider right away and report the findings. It is likely that the provider will order supplemental oxygen to improve the oxygen saturation level and maybe antianxiety medication to slow the patient’s breathing rate.

First, the nurse would expect to see an increase in oxygen saturation. This patient does have COPD, so their baseline oxygen saturation may be high 80s or low 90s, but it should be improved from the initial 82 percent. The nurse would also expect to see a slowed respiratory rate (12 to 20 breaths per minute) and a normal respiratory pattern if the supplemental oxygen application was effective.