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

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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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