Question

Part 3

S.R. is a 65- year-old woman who presents to the emergency department complaining of shortness of breath, productive cough, and swelling in both legs. The patient has a past medical history of congestive heart failure (CHF), hypertension, and diabetes. Vital signs are T 97.5, P 85, R 16, and BP 160/90. Physical exam reveals +2 edema bilateral lower extremities, heart rate and rhythm regular, and lungs with rhonchi in the bases. The patient is started on a nebulizer treatment, and an electrocardiogram has been ordered.

What subjective information should the nurse obtain?

The nurse is assessing the patient’s pulses. Which locations should the nurse check?

The nurse needs to evaluate the adequacy of the collateral circulation before obtaining an arterial blood gas (ABG) sample. How should the nurse proceed?

What is the most likely cause of this patient’s shortness of breath, productive cough, and swelling in both legs?

Answer 1

Solution 1.

The nurse should asses the:-

1.history of pain

2.history of blood pressure

3.any urinary disturbance to rule out the kidney related diseases as the patient present with swelling in lower limb so it is important to rule out kidney disease.

4.Family history

Solution 2.

The nurse should check radial pulse carotid pulse or apical pulse!! Radial pulse is checked in forearm in the radial artery.. Carotid pulse in the carotid artery located in the neck.

Solution 3.

Collateral circulation can be checked by ALLENS test.. Where before going ABG the blood supply to the hand with both hands are checked for circulation of both ateries! The nurse should proceed by asking patient to clench his finger for a minute apply pressure on both radial artery then release it. The colour has to change from pallor to red and occlude ulnar artery if redness returns quickly its Normal if slowly then test is positive and there is problem in circulation.

Solution 4.

Most likely cause is related with pulmonary edema where fluid accumulates in lung and patient develop difficulty in breathing and may spit mucus in cough and circulation is impaired in limbs due to which odema.