A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
A. Ask the patient to lie down on the exam table.
B. Draw blood for chemistry panel and arterial blood gas (ABG).
C. Send the patient for a chest x-ray.
D. Check blood pressure.
Correct Answer: D. Check blood pressure.
A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient’s blood pressure should be the first action. Monitor BP and central venous pressure (CVP). Hypertension and elevated CVP suggest fluid volume excess and may reflect developing pulmonary congestion, HF.
Option A: Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Maintain chair or bed rest in semi-Fowler’s position during acute phase. Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.
Option B: Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment. Investigate reports of sudden extreme dyspnea and air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.
Option C: The patient may be sent for an xray after initial assessment. Monitor chest x-ray. Reveals changes indicative of resolution of pulmonary congestion. Maintain fluid and sodium restrictions as indicated. Reduces total body water and prevents fluid reaccumulation.