You receive morning report for Ms. Malone, age 63, admitted to the hospital yesterday with fatigue, a cough, and dyspnea; she is diagnosed with chronic heart failure. She states that she had increasing difficulty with shortness of breath and swelling in her legs. Pedal pulses are +1 bilaterally. On auscultation you hear bilateral crackles in the lung bases and an S3 gallop when auscultating the heart. Respiratory rate is 18; heart rate is 84 and regular. The patient has an occasional nonproductive cough. She is receiving 2 L of oxygen by nasal cannula.
· During the assessment Ms. Malone reports that she had difficulty breathing during the night while lying flat. Which assessment approach should the nurse take first?
Ø Raise the head of the bed up to a 45-degree angle to auscultate the lungs.
Ø Auscultate for adventitious sounds in the lung bases.
Ø Assess the patency of the nasal sinuses.
Ø Palpate legs to determine whether there is increased edema from circulating blood volume.
· When examining Ms. Malone’s lower extremities, you note bilateral pedal edema of +2. Which statement by the patient shows that she correctly understands this finding?
Ø “I ate too many fruits and vegetables with vitamin C, and that causes me to retain water.”
Ø “I know that when my heart condition is not well controlled, my feet swell.”
Ø “My parents both had foot swelling as they aged, and that’s why my feet swell too.”
Ø “When my heart isn’t strong, the circulation doesn’t get down to my feet.”
· After receiving medications to manage her heart failure, you return to reassess Ms. Malone’s cardiac status. Select the techniques you use to correctly examine her lungs.
Ø Listen to an entire inspiration and expiration.
Ø Place the diaphragm of the stethoscope over the ribs.
Ø Begin auscultation at the apex, moving downward, auscultating the entire right lung and then the left.
Ø If you auscultate an abnormal breath sound, check for the presence of bronchophony.
