Heart Failure Exacerbation
A 72-year-old client with chronic heart failure comes to the emergency department reporting shortness of breath that worsens when lying flat. The client takes furosemide and lisinopril at home.
Recognize cues
Vital signs: BP 158/92, HR 104 and irregular, RR 28, SpO2 88% on room air, temperature 37.1 C. The client reports sleeping on three pillows and gaining 4 lb since yesterday. Bilateral crackles are heard in the lower lung fields; 2+ pitting edema is present in both ankles.
Which finding requires the most immediate follow-up?
Take action
The provider orders oxygen at 2 L/min by nasal cannula, IV furosemide 40 mg, a basic metabolic panel, and a chest x-ray.
Which two actions should the nurse take first?
Evaluate outcomes
Two hours later the client has voided 900 mL. Vital signs: BP 132/78, HR 88, RR 20, SpO2 94% on 2 L/min. The client is speaking in full sentences.
Which finding best indicates the treatment is working?
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