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SOLVED1261

Nurses’ Notes Date/Time Nurses’ Notes 8/18/20XX 2355 56-year-old male admitted with pulmonary edema secondary to end-stage liver disease (ESLD); spouse reports history of heart failure for 4 years, cirrhosis of the liver, renal insufficiency, active hepatitis A and B infections, tobacco use, and weight gain of 15 pounds in last three days; client alert and oriented to person and time of day, cannot say where they are or why they are here; reoriented to place and situation; VS: T 97.0 áµ’F (36.1 áµ’C), P 124, R 28, BP 104/60 (right arm), oxygen saturation (O2 sat) 82% on room air; abdominal circumference 55 inches/139.7 cm at umbilicus; client sitting in tripod position, respirations labored and rapid; lung sounds diminished with coarse crackles in all fields Select the highest priority clinical problem for this client (center column), the top two cues/evidence supporting the hypothesis, and the top two client conditions that support the hypothesis.​ Evidence Supporting Hypothesis Hypothesized Alteration in Health Conditions Contributing to Hypothesis
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