Matt M is a 70 male who was recently diagnosed with CHF. Matt has a history of hypertension, and NIDDM. His is a retired

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Matt M is a 70 male who was recently diagnosed with CHF. Matt
has a history of hypertension, and NIDDM. His is a retired teacher.
He is a widow, who lives alone. Matt has 1 daughter who lives an
hour away. His hobbies are watching sports and doing crossword
puzzles.
You are the day nurse at XYZ rehab center. This is the first
time that you are caring for this patient. Matt has been a patient
at XYZ rehab center for 5 days.
During your initial assessment of Matt you find:
Matt is A&OX3. He is pleasant and cooperative. V/S
WNL. PO 99% on room air. He requires minimal assistance with
his am care. He is a stand pivot for transfer. He has a 16 fr.
Indwelling catheter draining clear yellow urine. He is continent of
bowel; His last BM was yesterday (moderate soft brown stool in
toilet). Trace edema on bilateral lower extremities.
Matts Medications:
Lopressor 50 mg by mouth twice a day. Lasix 40mg by mouth daily.
Macrobid 100 mg q 6 by mouth. Glucophage 500 mg twice a day
Aspirin 81mg by mouth daily and Lipitor 10 mg at HS.
You administer all am meds at 9am.
At 11 am you enter the room and find Matt lying flat in bed. He
is complaining of difficulty breathing and of lower abdominal pain,
he is also thirsty. He had a moderate amount of edema in bilateral
lower extremities. His daughter is at bedside and is offering Matt
the fluids at his bedside (water and ensure). You auscultate Matt’s
lung sounds and hear crackles. His PO is now 88%. He states that he
is having difficulty breathing. His abdominal pain continues
9/10 T 98.8 AR 96 BP 168/90 . Matt
and his daughter at very concerned.
WRITE A NURSES NOTE DESCRIBING YOU ASSESSMENT AND INTERVENTIONS.
WHAT CAN YOU DO ABOUT THE CRACKLES IN MATT LUNGS AND DECREASED
PO? WHY IS MATT ABDOMINAL PAIN? UPON ASSESSMENT MATT ABDOMEN
IS DISTENDED AND THE FOLEY IS OUT. WHAT ARE YOUR INTERVENTIONS?