Question

What findings identified by the nurse on an assessment of a patient being treated for heart failure would cause the nurse to notify the patient's health care provider that the patient's status was deteriorating?

1. S3 and S4 heart sounds
2. Oxygen saturation 80% on 4 liters oxygen nasal cannula
3. Urine output 10 mL over the last hour
4. Onset of production cough
5. Weight loss of 3 lbs from previous weight

Answer 1

Findings that indicate deterioration in a heart failure patient include severe hypoxemia with an Oxygen saturation of 80%, very low urine output of 10 mL/hour, and the onset of a productive cough. These findings suggest acute worsening of heart failure and potential kidney dysfunction or respiratory issues, requiring immediate medical attention.

Step-by-step explanation:

When assessing a patient being treated for heart failure, a nurse should notify the health care provider if they identify signs that the patient's condition is deteriorating, which may include:

• An Oxygen saturation of 80% on 4 liters of oxygen via nasal cannula, indicating severe hypoxemia.
• Urine output of 10 mL over the last hour, suggesting kidney dysfunction or progression towards acute kidney injury.
• Onset of a productive cough, which could suggest pulmonary edema or an underlying respiratory infection.

While the presence of S3 and S4 heart sounds and weight loss are concerning, they do not necessarily indicate an acute deterioration in the context of heart failure.