A nurse in the emergency department is caring for client who is experiencing chest pain.

Exhibits

The nurse is reviewing the client’s assessment data to prepare the plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Oxygenation:

The client's SaO₂ is 90% on 2 L/min via nasal cannula, which indicates impaired oxygenation. The client is experiencing rapid, labored breathing, suggesting respiratory distress. Cyanosis (bluish tint to extremities) and mottled skin indicate poor oxygen delivery to tissues. Addressing oxygenation first is critical to prevent worsening hypoxia and potential respiratory failure.

Blood Pressure:

The client has hypotension (74/50 mm Hg), likely due to malnutrition, dehydration, and inadequate caloric intake. Weak pulses, cold skin, and poor turgor suggest circulatory compromise that needs intervention. After stabilizing oxygenation, the nurse should address the low blood pressure to prevent shock.

Condition most likely experiencing:

The client exhibits classic symptoms of left-sided heart failure, including dyspnea, nocturia, crackles, a dry hacking cough (worse at night), S3 gallop, and fatigue.

Low blood pressure (98/50 mm Hg), tachycardia (112/min), tachypnea (28/min), and oxygen saturation of 88% indicate poor cardiac output and pulmonary congestion.

Elevated BNP (410 pg/mL; normal <100 pg/mL) confirms heart failure.

The atrial fibrillation on ECG is a common complication of heart failure, further worsening cardiac function.

Actions to take:

Administer supplemental oxygen: The client’s SpO2 is 88%, indicating hypoxia. Oxygen therapy will improve oxygenation and reduce respiratory distress.

Elevate the head of the client’s bed: This helps reduce pulmonary congestion and improve breathing by promoting lung expansion.:

Parameters to monitor:

Weight: Daily weights are the best indicator of fluid retention and effectiveness of diuretic therapy. Sudden weight gain suggests worsening heart failure.

Urine output: Low urine output may indicate worsening heart failure and poor renal perfusion. Increased urine output after treatment suggests effective fluid removal.