Current Assessment: GENERAL Appears anxious, restless APPEARANCE: RESP: Breath sounds have coarse crackles scattered throughout both lung fields ant/post,

The hospice nurse sat with Ann's husband, Ben. Ann was resting quietly as the increased dosage of IV pain medication gradually reached its therapeutic level.
November 13, 2019
You are working as a Nurse at a rural high school and have been asked to assess the body composition and overall health of the students.
November 13, 2019

Current Assessment: GENERAL Appears anxious, restless APPEARANCE: RESP: Breath sounds have coarse crackles scattered throughout both lung fields ant/post,

Current Assessment: GENERAL Appears anxious, restless APPEARANCE: RESP: Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored respiratory effort, patient sitting upright Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema lower extremities from knees down bilaterally, S3 gallop, irregular, no jugular venous distention (JVD) noted Alert and oriented to person, place, time, and situation (x4) CARDIAC NEURO: GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU Voiding without difficulty, urine clear/yellow Skin integrity intact, skin turgor elastic, no tenting present SKIN: What assessment data is RELEVANT and must be recognized as clinically significant by the nurse Clinical Significance: RELEVANT Assessment Data: Cardiac Telemetry Strip: Interpretation: Clinical Significance:

 

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