Current Assessment: GENERAL APPEARANCE: Resting on stretcher,…
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GENERAL APPEARANCE: Resting on stretcher, appears anxious.
RESP: RR equal, appears labored. Shortness of air without exertion noted. Lungs clear bilaterally, no adventitious sounds noted.
CARDIAC: Heart sounds S1/S2 noted. No murmurs noted. All distal pulses noted 2+. No edema noted.
NEURO: Alert and oriented x 4. Moves all extremities without difficulty. No weakness noted.
GI: Bowel sounds active x 4 quadrants. No tenderness upon palpation. Pt reports heartburn nausea x 2 weeks. No reports of vomiting.
GU: No abnormalities noted.
SKIN: Pink and warm. Skin intact.
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
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