After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?
1. A patient who reported dizziness after receiving the first dose of captopril
2. A patient who is cool and clammy, with new-onset confusion and restlessness
3. A patient who has crackles bilaterally in the lung bases and is receiving oxygen.
4. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62
The correct answer and explanation is:
The nurse should assess the second patient first, the one who is cool and clammy, with new-onset confusion and restlessness.
Explanation:
This patient’s symptoms—cool and clammy skin, confusion, and restlessness—suggest signs of acute deterioration and possibly hypoperfusion. The restlessness and confusion may indicate a decreased oxygen supply to the brain or decreased cardiac output, both of which are critical in heart failure patients. These symptoms could signal shock, particularly if related to poor cardiac output or hypovolemia, which requires immediate intervention.
The other patients, while requiring attention, do not present with the same level of urgency:
- A patient who reported dizziness after receiving the first dose of captopril: Although dizziness can occur with captopril due to its vasodilatory effect, this is typically more of a transient side effect and may not be as immediately life-threatening as signs of hypoperfusion. It is important to monitor this patient closely, but they do not need to be assessed first.
- A patient who has crackles bilaterally in the lung bases and is receiving oxygen: Crackles suggest pulmonary edema, which is a common issue in heart failure patients. While the patient needs monitoring and treatment, they are already receiving oxygen, which indicates that their respiratory needs are being managed.
- A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure of 100/62: Although this patient’s blood pressure is lower than normal, IV nesiritide is often used to help manage acute heart failure by reducing preload and afterload. A blood pressure of 100/62 is not immediately alarming, but it does warrant monitoring.
In summary, the patient with signs of poor perfusion or shock (cool and clammy, confusion, and restlessness) is the most critical and should be assessed first.