Question

Nurse note at 10:00 am

Client was brought into the ED by her daughter due to increased shortness of breath this morning.  The daughter reports that the client. has been running a fever for the past few days and the and has started to cough up greenish colored sputum and to complain of “soreness throughout the body”.    The client was recently hospitalized for issues related to atrial fibrillation 6 days ago.  The client has a history of hypertension.  Vital Signs T 101.1F(38.4C), P 92, RR 22B/P 152/88, pulse oximetry 94% on2L nasal cannula.  Assessment, Clients breathing appears slightly labored with course crackles noted bilateral lung bases.  Skin slightly cool to touch and pale, pink skin tone, pulses 3+, radial and irregular, cap refill 3 seconds.  Client is alert and oriented to person, place and time.  The clients daughter states, “Sometimes it seems like my mother is confused.”

12:00 pm

Called to the bedside by the  daughter who states that her mother “isn’t’ acting right.”  Assessment reveals, client difficult to arouse, pale, diaphoretic in appearance.  Vital signs: T 101.5 F (38.6 C) P 112 , RR- 32, B/P 90/62, pulse oximetry 91% on 2L/min via nasal cannula

After reviewing the nurse’s note  at 10:00 and 12:00,  

8.  List all the changes in the 12:00 assessment.  For each change, indicate what the nurse is worried about, feel free to list disease or condition

Change                                                                        What is your concern for client?

Answer 1

Patient developed tachycardia, tachypnea, developing hypotension

level of consciousness changed to difficulty in arousing her and she is diaphoretic and pale in appearance.

as patient has history of atrial fibrillation so patient must be developing heart failure as characterised by above symptoms. In atrial fibrillation, there is no sinus rhythm as a result , heart was not able to eject blood completely. It causes decreased stroke volume due to which patient must have develope congestive heart failure. There is buildup of blood in left ventricle whuch causes pulmonary hypertension . This causes the crackle sound on auscultation of lungs due to build up of fluid in lungs secondary to pulmonary hypertension. As there is reduced stroke volume, therefore less blood supply to brain and peripheral organ resulting in hypotension, difficulty in arousing patient, diaphoresis and pale appearance. To compensate the change, body adapts by increasing heart rate and respiratory rate.