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Part I: Recognizing RELEVANT Clinical

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(oral) P: 128 (regular) Quality: Ache R: 24 (regular) Region/Radiation: Left arm that radiates into neck BP: 108/58 Severity: 5/10 O2 sat: 99% room air Timing: Intermittent-20-30" at a time Stuvia.com HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"- HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"The HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"Marketplace HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"to HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"Buy HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"and HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"Sell HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"your HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"Study HYPERLINK "https://www.stuvia.com/" HYPERLINK "https://www.stuvia.com/"Material Stuvia.com - The Marketplace to Buy and Sell your Study Material What VS data are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: - P: 128 - R: 24 - BP: 108/58 • Tachycardia may be due to pain • Tachypnea may be due to pain, SOB, pulmonary edema • Slight hypotensive, patient may have received nitroglycerin or beta blockers © 2018 Keith Rischer/www.KeithRN.com Current Assessment: GENERAL APPEARANCE: Anxious, appears uncomfortable, body tense RESP: Respirations labored, coarse crackles present in bases bilaterally anterior/posterior CARDIAC: Pale, diaphoretic, no edema, heart sounds regular S1S2 with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present

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