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?

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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 frothy,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; limiting 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.

The Nurse in a Skilled Nursing Facility Is Caring for an 80-Year-Old