1. As you walk into your patient’s room, you notice the patient appears to be short of breath. Your patient states “I have been short of breath and tired for the past week.” Upon assessment of your patient, you notice JVD, labored breathing, lung sounds with crackles in the posterior bases, and +2 edema to the lower extremities bilaterally.
From your assessment findings, determine the most likely disease state that is being described.
- Pulmonary Embolism
- Heart Failure
2. Your patient puts on the call light. You enter the room and notice the patient appears to be in distress. The patient states, “I cannot catch my breath and my heart feels like it is going to explode.” The patient’s vital signs are T 98, P 148, BP 112/68, and pulse oximetry 88% on room air. You apply oxygen at 2 liters/minute via nasal cannula and notify the health care provider (HCP). The HCP orders a stat ECG. The patient’s pulse oximetry increases to 94% with the oxygen, and the patient states, “I feel less short of breath but my heart is still racing.” Upon assessment of heart sounds, the apical pulse is 134 and irregular. The ECG results indicate atrial fibrillation.
What would be your next action?
- Leave the room and see your other patients.
- Stay with the patient and notify the HCP of the ECG results.
- Have the CNA stay with your patient as you take a break.
- Stay with the patient and wait for them to calm down.