The nurse enters the client's room and introduces themself. The nurse notes the client is coughing with an
increased respiratory rate. The nurse obtains the client's vital signs and performs an assessment. The client's
vital signs are temp 98.9° F, BP 188/92, pulse 102 beats/min, respiratory rate 24 breaths/min, SaO, 93% on
room air. The client is oriented x 4, answers questions appropriately, and follows simple commands; moves all
extremities without difficulty but appears weak. S1,S2 on auscultation, heart beat regular and rapid; pulses to
upper extremities +3, lower extremities +2: +1 pitting edema to lower extremities. The client denies chest pain.
Respirations even, slightly labored. Chest with wheezes throughout upper lung fields. Client states he feels
short of breath, continues with a nonproductive cough. Clubbing noted to fingers. Abdomen nondistended,
nontender, with bowel sounds present in 4 quadrants. Client reports voiding without difficulty, yellow urine.
Fluids continue to infuse 50/hr, IV site within expected parameters. Client continues to report dizziness and
headache. Reports headache pain of 6 on a 0 to 10 pain scale.
Sbar assessment