Assignment Task: R.R. is an 82-year-old male with BPH, CHF, COPD, emphysema, HTN, and IDDM type 2, admitted to the hospital for a CHF exacerbation. During his stay, he is up independently, full weight- bearing, and takes short, shuffled steps. At home, he has fallen numerous times when "rushing" to the bathroom, about 5-6 times each night. He has a walker and cane at home, but he frequently forgets to take them with him when he goes to the store. He states that he "uses furniture to steady"; himself. R.R. is prescribed furosemide (Lasix) 40mg IV while in the hospital, along with tamsulosin (Flomax), budesonide/formoterol (Symbicort), amlodipine (Norvasc), and Glucophage (metformin). After a rush to the bathroom, he sits down and expresses a feeling of shortness of breath, which he states is normal for him. He has mild crackles to his lower lungs and 3+ pitting edema to his lower extremities that have clear seeping. His oxygen level is 93% on the 2 liters of oxygen that he uses at home. His other vital signs are as follows: heart rate 102, blood pressure 146/88, temperature 98.5, and pain 2 out of 10 from his "achy bones"
Topic: Safety Documentation includes:
- Subjective data
- Objective data
- NANDA (Nursing Diagnosis)
- Interventions