Question

Assessment of the Patient: What assessment findings have already been documented regarding this patient in the electronic medical record? What would your priority assessment be? 68 year old male admitted to ER with acute respiratory distress, has history of congestive heart failure (CHF). Patient complains of shortness of breath, weight gain, fatigue, and bilateral ankle edema. Crackles heard 1/2 way up from bases. placed on NC @ 4L. O2 sat 93%. IV started in R arm, labs drawn and sent to lab. Chest X ray done, EKG done, showing sinus tachycardia, echo done @ bedside.

What would your priority assessment be?

Answer 1

The 68-year-old male admitted to the ER with acute respiratory distress has a history of congestive heart failure (CHF).

Patients complains -

shortness of breath

weight gain

fatigue

bilateral ankle edema

The patient is on N/C 4 liter of O2, (SO2 93%)

priority assessment would be -

These are the clear signs of Heart failure, which is evidenced by edema and fatigue.

Shortness of breath and Crackles in the chest suggest pulmonary edema which also suggests pulmonary edema.

Echo and CXR can confirm the diagnosis and can help in further treatment