Reference no: EM133848186

Question

Patient Background

On Friday, November 12, 2021, at 6.00 pm C.B., an 85-year-old female, was interviewed and reported that he was admitted on November 10 2021, to Saint Clare's Denville Hospital, NJ in the Emergency Room with increased shortness of breath on exertion. The patient reports that she has been short of breath for 3 years and past medical history of COPD, CHF, and hypertension. C.B. reported two previous falls, one at the previous admission to the hospital, and another during her last hospital stay. She does complain of cough with mucus production, most of the time white-colored at times yellow-colored. She does have generalized weakness. No pleurisy was reported, no nausea vomiting was reported. She otherwise has a good appetite however she suffered a weight loss of 40 pounds over the last 3 years. A CT scan of her chest was ordered and it does show a semisolid pulmonary nodule in the posterior segment of the right lower lobe measuring 2.3* 1.8 cm. All her vitals are stable. The patient is currently on a 2 L nasal cannula and her SPO2 is 96%.

Medications list the patient is on:

Acetaminophen

Albuterol 2.5 mg nebulization

Bisacodyl (dulcolax) 10 mg oraly daily

budesonide (Pulmicort) nebulizer 0.5 mg 2 times daily.

lasix 20 mg daily

ondasentron (zofran -ODT) 4 mg

Accurately analyses the patient's safety risks. Develops an individualized, accurate, and relevant plan of care to minimize the patient's safety risks. The problems that have been identified will be used to develop a care plan to address the issue.