What ongoing assessment required to keep this patient safe

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Assignment:

Mr. Zuniga, a 67-year-old male, presents to the Emergency Department (ED) with shortness of breath. After a quick evaluation by an ER physician, he is admitted to the medical floor. During admission, he reports that he has had pneumonia once a year for the past 3 years. He smokes 2 packs a day and has been smoking for about 38 years. Other medical history provided is the history of hypertension and diabetes type 2, his medications include enalapril, hydrochlorothiazide, metformin, and fluticasone/salmeterol. On assessment, D. Zuniga is visibly shortness of breath (SOB), and unable to speak in complete sentences. He is cachexic and disheveled. He is irritable and anxious, states he has been unable to rest or sleep for a couple of nights, and states "I'm tired all the time". He has a cough and is expectorating thick yellow-green phlegm. You position Mr. Zuniga and auscultate his lungs, you hear decreased breath sounds, expiratory wheezing throughout the lung fields, and coarse crackles at the bases.

  • What further nursing assessments need to be performed for Mr. Zuniga?
  • What interventions do you anticipate being ordered by the provider?
  • What intervention should you, as the nurse, perform right away? Why?
  • What medication should be the first one administered to this patient? Why? How often?
  • What ongoing assessment is required to keep this patient safe?

Reference no: EM133658455

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