A Complete Patient Assessment
Susan Eisen RN
Ramapo College of New Jersey
A 63 y/o African American female presents to the emergency room
complaining of shortness of breath worsening over the past week. Patient states
she becomes severely short of breath while preforming everyday activities and
has noticed that her legs have been “getting bigger”. Patient had been sleeping
with 3-4 pillows a night for comfort and occasionally sleeping in a recliner.
Patient states this evening she got up to use the restroom and had a sudden onset
of severe shortness of breath. Felt as though she wasn’t moving any air. Patient
Patient lives off of social security in a
senior citizen complex. Patient’s family also resides in the same state and come
to visit often.
Family History: Father died by suicide at age 48. Mother died at 82 of
pneumonia. Two sisters both who suffer from Hypertension. Patient had Six
children alive and well
Physical Exam as follows: height 5’5”, weight 310lbs.
Vitals: Blood pressure 224/118, Heart rate of 121 irregular, Respiratory Rate 30
labored, O2 saturation on room air is 88%, on CPAP 97%. Patient is afebrile at
98.3 Head is normocephalic, eyes, ears, nose and mouth are within normal limits.
Neck is + for JVD. Lungs have scattered rhonchi throughout the lung fields,
diminished at the bases, crackle about halfway up. Patient has frothy productive
cough. Abdomen is obese, soft and non tender. Bowel sounds are present in all
four quadrants. Genitalia is intact with no obvious deficits. Bilateral lower
extremities show 4+ pitting edema extending to the knees. Pulses intact.
Neurologically patient is awake and oriented times 4 with no motor or sensory
EKG shows atrial fibrillation with a ventricular rate of 121.
Chest Xray shows cardiomegaly with diffuse pulmonary infiltrates consistent
with pulmonary edema.
Laboratory Results as follows: WBC 7.2, HGB 9.4, HCT 28.1, platelets 233.
Glucose was 278, BUN 22 Creatine 2.1 Sodium 130 Potassium 3.2 Bicarbonate
ABG on room air was pH 7.30, PaO2 55, PaCO2 28. Creatine Kinase 197
Troponin 0.11 and BNP of 3398.
Patient was subsequently admitted to Telemetry for Congestive Heart Failure.
There are multiple priorities when caring for patients with congestive
heart failure. It is imperative to treat the current symptoms while maintaining
their current state of functioning. Frequent hospitalizations from poor
medication management or follow up will lead to increased hospitalizations and
decreased levels of functioning. Assessment tools such as the Katz index of
Independence in Activities of Daily Living is key in assessing function during
hospitalization to improve deficits upon discharge.
Another assessment tool to be used with the diagnosis of congestive heart
failure is Urinary Incontinence Assessment in Older Adults: Part 1 Transient
Urinary Incontinence. The use of diuretics in the prevention of heart failure
episodes can lead to problems with incontinence. Daily bladder charting can
identify deficits and allow for adjustments in medications to prevent further
Oxygenation: Elimination Nutrition
Admit 5/1/10 CHF Nocturia preferences
Increased fatigue I&O bmp results
Sob 3-4 days stress incontinence daily weights
O2 3l nc Diaper 2g na diet
Moderate resp distress
Sleep 3 pillows 1. Decreased Cardiac Output
Vs q4 hours 2. Fluid Volume Excess...