Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases.

Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases. Productive cough is noted. S1 and S2 are auscultated, and S3 is noted. Radial pulses are strong; pedal pulses are thready. Capillary refill is greater than 3 seconds. There is +2 pitting edema in bilateral lower extremities. Skin color is pale, and skin is cool to touch. Muscle strength is weak in bilateral upper and lower extremities. Abdomen is distended, bowel sounds are present in all four quadrants, and there is no pain on palpation. 

Temperature: 98.2° F (36.8 ℃)

Heart rate: 122 beats/minute

Respirations: 32 breaths/minute

Blood pressure: 168/96 mmHg

Oxygen saturation: 88% on room air

The client is a 63-year-old female who arrived in the Emergency Department accompanied by her spouse.

0700 Triage RN Notes

The client is a 63-year-old female who arrived in the Emergency Department accompanied by her spouse. The client reports fatigue over the last 2 weeks and increasing shortness of breath as well as difficulty sleeping in bed. States has been unable to lose weight and seems to be gaining about 3-5 pounds per week, and has had minimal urinary output the last few days.

Past Medical History

Type II diabetes for 10 years

Coronary Artery Disease

Hypertension

Hyperlipidemia

New York Heart Association Class II Heart failure

Chronic Obstructive Pulmonary Disease

Past surgical history of cholecystectomy and gastrectomy

No known drug allergies

Social

Drinks 2-3 alcoholic beverages daily

Smoker, 2 packs per day for 5 years

Client’s Home Medications: 

Metformin 500 mg orally daily 

Lasix 20 mg orally daily

Lisinopril 20 mg orally daily

Pravastatin 40 mg orally daily

Metformin 40 mg orally daily

Aspirin 81 mg orally daily

Physical Assessment:

Neurological: Alert and oriented x 4

Respiratory: Bilateral crackles half up, labored breathing

Cardiovascular: S1, S2, S3 gallop noted, irregular rhythm, apical/radial difference, palpable 1+ peripheral pulses, +1 edema in the lower extremities, delayed capillary refill. 

GI: abdomen large, firm, distended, + hypoactive bowel sounds all 4 quads.

GU: Nocturia

Integumentary: skin pale, diaphoretic, cool to touch

Brain Natriuretic peptide 

Complete Blood count

Cardiac enzymes

Blood gases 

Blood glucose monitoring Q 6 hours 

Basic Metabolic Panel

Hemoglobin A1C

Triglycerides

HDL 

LDL

Urinalysis

Stat Portable chest x-ray

Stat Electrocardiogram

State Echocardiogram

Start Intravenous line

Vital signs per protocol 

Cardiac monitoring per protocol

O2 at 4 liters per minute, simple mask, adjust O2 to maintain O2 sat greater than or equal to 92%

0700 

Temperature 98.6 F , BP 160/110 mm Hg, Heart rate 155 BPM RR 36 O2 Saturation 84% on room air. Height 5’4”, 220 pounds (100 kg).

A 62-year-old male arrives at the emergency department accompanied by his wife. He reports increased shortness of breath with daily activities and exertion and feels more fatigued than normal. The nurse has reviewed the client’s history and physical and has documented his reported information regarding the purpose of his visit. The nurse is now determining the relevant information in order to address the needs of his acute condition.

The client reports the purpose of his visit is his increased shortness of breath and fatigue for the last two months. Increased work of breathing was noted with ambulation to the stretcher. Skin is pale and diaphoretic. The client states, “I gained 3 pounds this week without changes to my diet or activity routines. In fact, I don’t really have much of an appetite at all because I usually feel full.” He states that his shoes feel tight. Upon taking off his shoes, the nurse notices his socks leave an indentation around his ankles. The client also mentions an increase in urinary frequency overnight. 

The client arrives at the emergency department with a diagnosis of congestive heart failure. The paramedic states that the client is demonstrating signs of poor perfusion.

1800

The client arrives at the emergency department with a diagnosis of congestive heart failure. The paramedic states that the client is demonstrating signs of poor perfusion.

• Alert and oriented to person, place, time, and situation
• Promptly follows commands
• Altered mental status

1800

• Hypotension
• Bounding peripheral pulses
• Skin warm to touch

• Urine output less than 30 mL/hr
• Reduced urine osmolality
• Increased urine specific gravity

Client is sitting on stretcher with head of bed at 60 degrees. Increased work of breathing and pale skin color are noted on initial inspection. Cardiac monitoring and pulse oximetry initiated per department protocol.

1210

Client is sitting on stretcher with head of bed at 60 degrees. Increased work of breathing and pale skin color are noted on initial inspection. Cardiac monitoring and pulse oximetry initiated per department protocol. Vital signs taken per triage note. Client reports the purpose of his visit is his increased shortness of breath and fatigue for the last two months. Increased work of breathing noted with ambulation to the stretcher. Skin is pale and diaphoretic. Client states, “I gained 3 pounds this week without changes to my diet or activity routines. In fact, I don’t really have much of an appetite at all because I usually feel full.” He states that his shoes feel tight. Upon taking off his shoes, the nurse notices his socks leave an indentation around his ankles. Client mentions an increase in urinary frequency overnight. 

1215

Focused client assessment is completed. Client is alert and oriented to person, place, time, and situation. Client’s work of breathing is labored using accessory muscles. Crackles are auscultated bilaterally at the lung bases. Productive cough is noted. S1 and S2 are auscultated, and S3 is noted. Radial pulses are strong; pedal pulses are thready. Capillary refill is greater than 3 seconds. There is +2 pitting edema in bilateral lower extremities. Skin color is pale, and skin is cool to touch. Muscle strength is weak in bilateral upper and lower extremities. Abdomen is distended, bowel sounds are present in all four quadrants, and there is no pain on palpation.

1225

Healthcare provider is at bedside evaluating client.

1235

Client is placed on 5-lead cardiac monitor, and 4 L oxygen via nasal cannula are applied. 18-gauge IV catheters are placed in left wrist and right antecubital and flushed without resistance. Client tolerated well. Blood collected for ordered laboratory testing. Chest X-ray and echocardiogram are completed. 12-lead electrocardiogram performed.

1305

Client is anxious, reporting increased shortness of breath. Client is placed on non-rebreather mask at 10 L per minute of oxygen. Client is currently coughing up pink frothy sputum. Crackles are present in all lobes bilaterally.

1310

Laboratory and diagnostic results are posted to the electronic heath record. Healthcare provider contacted regarding client’s changing condition.

Chest X-ray: cardiomegaly, diffuse pleural effusions

Echocardiogram: left ventricular ejection fraction 35%

Electrocardiogram: sinus tachycardia, left bundle branch block, left axis deviation

Initial Orders 

Complete blood count

Basic metabolic panel

Cardiac enzymes

Brain natriuretic peptide

Chest X-ray

12-lead electrocardiogram

Echocardiogram STAT

Place IV catheter.

Initiate supplemental oxygen.

Titrate to saturation greater than 92%

Continuous cardiac monitoring 

Admission Orders

Furosemide 40 mg IV once

Morphine 2 mg IV every 4 hours as needed

CPAP 40%, 10 cmH2O, RR 12

Place indwelling urinary catheter

Intake and output every hour

Vital signs every hour

Furosemide 40 mg orally twice per day 

Potassium chloride 20 mEq orally twice per day

Lisinopril 40 mg orally once per day

Carvedilol 25 mg orally twice per day 

Simvastatin 20 mg orally once per day

Aspirin 81 mg orally once per day

Tiotropium 2.5 mcg inhalation 2 puffs once per day

Admit to Telemetry Unit

Cardiology consult

Chest X-ray in a.m.

Basic metabolic panel at 1800 today and in a.m.

Fluid restriction 1,500 mL per day

1200

Vital signs

Temperature: 101.3° F (38.5℃)

Heart rate: 127 beats/minute

Respirations: 29 breaths/minute

Blood pressure: 162/92 mmHg

Oxygen saturation: 90% on room air

Pain: 3 out of 10 on the numeric pain scale located primarily in the chest 

1215

Vital signs

Temperature: 98.2° F (36.8 ℃)

Heart rate: 122 beats/minute

Respirations: 32 breaths/minute

Blood pressure: 168/96 mmHg

Oxygen saturation: 88% on room air

1305

Vital signs

Temperature 99.3° F (37.4℃)

Heart rate: 136 beats/minute

Respirations: 42 breaths/minute

Blood pressure: 168/94 mmHg

Oxygen saturation: 85% on room air

Pain: 4 out of 10 on the numeric pain scale