Mr. Armitage is a 56-year-old patient admitted 1 day ago with atrial fibrillation, an abnormal heart rhythm, along with fatigue and dizziness. During an assessment of Mr. Armitage, the nurse notes the presence of rales in his lung bases bilaterally. Upon further assessment, the patient is noted to have 1+ pitting edema in his feet bilaterally. Neither of these findings were relayed at change of shift report. The patient states that he does not want to stay in the hospital and, if possible, he would like to continue care at home. The nurse checks the previous nursing assessment findings in the electronic medical record and finds no mention of rales or edema. Considering the causes of edema and rales, the nurse checks the electronic medical record and finds a report of an echocardiogram completed a day ago that shows an ejection fraction of 35%. The patient’s medication list includes Cardizem 30 mg once a day, Lopressor 50 mg twice a day, and aspirin 81 mg once a day. The patient states that his physician ordered a water pill for him to take twice a day but he couldn’t afford the medication since he is self-employed with private insurance so he didn’t take it.

1.

What CUES (Assessment) might the nurse consider?

2.

What additional information might the nurse need to form a conclusion about the patient’s assessment findings?

3.

What HYPOTHESIS (Diagnosis) can the nurse consider?

4.

What ACTION (Plan and Implement) plan will be most effective for the nurse to take to ensure the safety of the patient while adhering to the patient’s preferences for care?

5.

What should the nurse evaluate for the purpose of arriving at a satisfactory clinical OUTCOME (Evaluation)?

6.

How could the nurse incorporate the patient’s preferences into treatment of the patient?