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Current Assessment:
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:

 

 

 

 

 
SCIENCE
HEALTH SCIENCE
NURSING
NUR 209