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S: Subjective
A 71-year-old simulated patient with a history of hypertension and a heart attack 3 years ago reports that both ankles have been swollen for 5 days and that her shoes feel tight. She has gained 2.3 kg (5 lb) in 4 days by her home scale. She gets short of breath climbing one flight of stairs, which she could manage a month ago, and now sleeps on three pillows because she "can't breathe lying flat." She wakes at night needing to sit up. She denies chest pain. She says she ran out of her "water pill" a week ago. She eats canned soup most days.
O: Objective
- Vital signs: blood pressure 152/88, heart rate 102 and regular, respiratory rate 24, temperature 36.8 °C, SpO₂ 92% on room air. Weight 78.4 kg.
- Neck: jugular venous pressure visible 6 cm above the sternal angle with the head of the bed at 45 degrees.
- Heart: point of maximal impulse displaced laterally to the anterior axillary line; S1 and S2 present, with an additional low-pitched sound in early diastole (S3) heard best with the bell at the apex in the left lateral position.
- Lungs: fine crackles at both bases that don't clear with coughing.
- Extremities: 2+ pitting edema of both ankles and lower shins; skin warm; pedal pulses 2+ and equal; capillary refill under 3 seconds.
A: Assessment
The findings fit fluid volume excess with reduced heart function: raised jugular venous pressure, an S3, bibasilar crackles, bilateral pitting edema, rapid weight gain, orthopnea and waking at night short of breath. Missed diuretic doses and a high-sodium diet are likely contributors. Her oxygenation is mildly reduced. These are signs to report promptly, not to treat at home. As a nursing assessment, the note uses consistent terms for each finding so changes can be tracked (Bickley et al., 2021).
P: Plan
- Report findings to the provider using SBAR, including the missed diuretic and the weight trend.
- Raise the head of the bed and apply oxygen if ordered to keep SpO₂ at the ordered target; reassess breathing and lung sounds after interventions.
- Weigh daily at the same time on the same scale, record strict intake and output, and monitor blood pressure, heart rate and edema each shift.
- Begin self-care teaching once she is comfortable: taking medications as prescribed, weighing herself every morning, limiting sodium, and calling the care team about a rapid weight gain or worsening breathlessness. Heart failure guidelines recommend specific education and support for self-care (Heidenreich et al., 2022).
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., . . . Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145(18), e895–e1032. https://doi.org/10.1161/CIR.0000000000001063
