Question

A 74-year-old woman was admitted to the hospital with heart failure. She had been growing progressively weaker and also had ankle edema, dyspnea on exertion, and three pillow orthopnea. On admission, she is severely dyspneic and can answer questions only with one-word phrases. She is diaphoretic, with a respiratory rate of 28/min, heart rate of 132 beats/min, and BP 98/70. Her oral temperature is 36.7 C and her SaO2 89%. She is extremely anxious. The nurse applies immediately oxygen at 2 L via NC as per unit protocol. The physician orders: Insert PIV then start Dobutamine 3 mcg/kg/hr Furosemide 40 mg IV stat, Digoxin 0.5 mg orally stat, then 0.125 mg every 6 h for three does with ECG before doses 3 and 4; morphine 2 mg IV stat, and then 2 mg IV every 1-2 h prn, increase O2 to 4 L/min. Schedule patient for an echocardiogram, no added salt diet, weigh patient daily and record: Strict I&O. Answer the questions below and give rationales for your answer. 1. Because the patient cannot breathe or talk easily, prioritize the immediate nursing assessments upon admission

Answer 1

Answer: Due to heart failure the patient is unable to breathe or talk properly. The immediate action nurse should do is to provide or apply oxygen so that the patient get sufficient amount of oxygen to breathe. The patient is having orthopnea so she needs some elevation from the back that means she is unable to breathe while laying so some support near the shoulder should be given.