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III. Evaluation: Evaluate the response of your patient to nursing & medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Eight hours later… I&O 1 IV: Enteral: 180 265 VS: T: 36.1 P: 134 R: 48 BP: 96/54 02 sats: 98 % o Urine/stool: Emesis: 277 60 What data is most relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: Nursing Assessment: Gen: Asleep, comfortable, reactive to stimulation. Resp: no congestion or nasal discharge, MMM. No increased WOB, no nasal flaring or retractions, lungs clear bilaterally A&P, no wheezing. CV: RRR, brachial and femoral pulses 2+ equal bilat, cap refill <3s. Ab: Soft, active BS, less spit up. Feeding well every 2-3 hours with prompts from staff. Ext: WNL, no edema or cyanosis, moves all extremities equally. Neuro: normal grasp and suck, normal tone, normal strength. Skin: diaper rash clearing up. SL in right hand. Site without redness or edema. Mom paying more attention to baby, more responsive to cues and crying. Pain FLACC 1/10 PEWS 1 What assessment data is relevant to this patient that must be recognized as clinically significant to the nurse? Rationale: 1. Has the status of the patient improved or not as expected to this point? 2. What data supports this evaluation assessment? 3. Based on this assessment data, now what will be your nursing priorities and current plan of care?
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