Chapter 18

There are several cues that should be concerning to the nurse. First, thinking about the ABC priorities, the nurse should notice that the patient is experiencing dyspnea on exertion and labored breathing with an oxygen saturation of less than 90 percent. Additionally, the nurse hears crackles in the bases of the lungs, which is likely contributing to the patient’s poor respiratory status. Other cues to recognize include the presence of jugular venous distension, sinus tachycardia, and peripheral pitting edema of the lower extremities.

Jugular venous distension, lower extremity edema, and a BP of 145/82 are indicative of hypertension. Jugular venous distension, lower extremity edema, tachycardia, crackles in the lungs, and dyspnea are all consistent with a HF exacerbation. An O₂ saturation of less than 90 percent, crackles in lungs, and dyspnea on exertion are consistent with COPD. It is important for the nurse to be able to not only recognize cues but also determine which cues are consistent with the patient’s clinical presentation and past medical history.

The most likely cause of the patient’s symptoms is HF. The patient has a history of HF, and the current symptoms are indicative of an acute exacerbation of the condition.

The supplemental oxygen is ordered to improve the patient’s oxygen saturation level. This will help with tissue perfusion and hopefully improve the patient’s dyspnea and tachypnea. The rationale for the IV insertion is so that the nurse will be able to administer medications more quickly. This is especially important for patients exhibiting respiratory and cardiac issues as these can quickly become life threatening. The furosemide (Lasix) is ordered to rid the body of excess fluid, which will hopefully improve the crackles in the lungs and dyspnea as well as decrease the peripheral lower extremity edema. Intake and output monitoring and documentation are ordered because the patient is exhibiting signs of fluid overload and is being given a diuretic. Both situations can cause fluid imbalances, so it is important to monitor overall fluid status carefully and intervene as needed.

The priority action by the nurse would be to administer supplemental oxygen because the patient’s oxygen saturation is low. Thinking back to the ABCs of nursing care, airway and breathing always come first. Next, the nurse would want to establish the IV and administer the diuretic to rid the lungs of excess fluid, further improving overall oxygenation status.

The nurse would expect to see an increase in the patient’s oxygenation saturation and improvement in their breathing pattern. If the medication is working effectively, the nurse should hear less crackles in the lungs, see improvement in the peripheral edema, and notice that the patient is urinating more frequently or voiding larger amounts.