CHF nursing situation

Patient is a 82 year old male who presented to the ED at 5am for shortness of breath worsening over the past day, PMH includes CHF, HTN, hyperlipidemia, CAD s/p cardiac stents in 2014, DM, osteoarthrtis, BPH, depression, CKD st 3 Admitted for CHF exacerbation, pneumonia, acute on chronic renal disease You receive him on the floor at 11:30 am, he appears to be alert and oriented, but lethargic, states he hasn't taken any home meds yet today, has not eaten yet either. Lives at ALF, uses walker In the ED, he received IV furosemide 40mg, 650mg Tylenol, 500mg IV levofloxacin and an albuterol/ipratropium nebulizer treatment Selected labs, diagnostics, and orders WBC 18.2 Hgb 10.4 K (potassium) 3.1 creatinine 4.1 blood glucose 308 BNP 8023 Urine - blood large Urine - leukocytes +3 Urine - culture pending COVID 19 PCR - negative chest x-ray bilateral infiltrates, pleural effusions sputum sample to be collected normal sinus rhythm on tele monitor vital signs 170/64, P55, R23, O2 90% room air, temp 100.4, ht 178cm, wt 90kg Diet: cardiac, 1800 ADA, 1 liter free water restriction Activity: as tolerated Strict I&O home medications - have all been profiled to MAR Hospital meds metoprolol 25mg BID albuterol/ipratropium Q6hrs amlodipine 5mg QAM furosemide IV 40mg once 6pm lisinopril 20mg QAM levafloxacin IV 500mg Q24hrs atorvastatin 40mg QPM tylenol 650mg Q6hrs PRN tamsulosin 0.4mg QPM IV potassium 10 meq x3 clopidogrel 75mg QAM aspirin 81mg QAM escitalopram 10mg QAM metformin 1000mg BID tramadol 50mg Q8hrs PRN gabapentin 200mg BID temazepam 7.5mg QHS PRN Consults pending - cardiology, ID, nephrology Personal history former smoker, quit 35 years ago does not drink alcohol did not get flu shot this year Discussion What would you expect breath sounds may be like (document this in EHR)? What would you expect skin condition/lower extremities to be like (document this in EHR)? What interventions would you perform (safety, patient care, medication, etc) What else are you concerned about when assessing? Think about questions to ask the patient so you have a better report to give to consulting providers if they call What does each medication do? Would you hold any?