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 exa

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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 Exa 1 (72.25 KiB) Viewed 42 times

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: Assessment Subjective data Objective data NANDA (Nursing Diagnosis) Interventions