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.
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 health record. Healthcare provider contacted regarding client’s changing condition.
| White blood cells |
4.8 x 109 cells/L |
| Hemoglobin |
14 g/dL (140 g/L) |
| Hematocrit |
28% |
| Platelets |
150,000 |
| Sodium |
135 mEq/L (135 mmol/L) |
| Potassium |
2.5 mEq/L (2.5 mmol/L) |
| Chloride |
95 mEq/L (95 mmol/L) |
| CO2 |
28 mEq/L (28 mmol/L) |
| BUN |
16 mg/dL |
| Creatinine |
1.4 mg/dL (106.75 µmol/L) |
| Glucose |
96 mg/dL (5.33 mmol/L) |
| CK |
28 U/L (0.47 µkat/L) |
| CK-MB |
5 IU/L |
| Troponin |
<0.4 ng/mL (<0.4 µg/L) |
| BNP |
1,500 pg/mL (1,500 ng/L) |
Chest X-ray: cardiomegaly, diffuse pleural effusions
Echocardiogram: left ventricular ejection fraction 35%
Electrocardiogram: sinus tachycardia, left bundle branch block, left axis deviation
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
Body mass index of 28 kg/m2
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