The nurse in a skilled nursing facility is caring for an 80-year-old patient who develops a productive cough with pink, frothy sputum. Which independent interventions should the nurse implement immediately? (Select all that apply.)
a. Limit the patient's activity.
b. Administer morphine.
c. Administer lasix.
d. Place the patient in high Fowler position.
e. Weigh the patient daily.
A, D
Acute pulmonary edema (acute left ventricular failure) is a medical emergency that must be treated promptly. The patient with this condition has severe dyspnea; a cough productive of fro-thy, pink-tinged sputum; tachycardia; and moist, bubbling respirations with cyanosis. Nursing interventions for acute pulmonary edema include placing the patient in high Fowler position to relieve the dyspnea; administering oxygen, diuretics, morphine, and other prescribed drugs; li-miting and monitoring activity; and assessing cardiopulmonary status. Limiting activity and placing the patient in high Fowler do not require a physician's order and should be implemented immediately. Acute pulmonary edema is a medical emergency, and activity necessary to obtain a daily weight is not indicated at this time. Administering morphine and diuretics are dependent nursing interventions.
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