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A patient is transferred from the emergency department to a medical-surgical unit at 6:30 p.m. The nurse arriving on duty at 8 p.m. reviews the patient's clinical record. Which information documented in the clinical record reflects the evaluation step of the nursing process?

Nurse's Transfer Note From the Emergency Department
Patient admitted to the emergency department at 3 p.m. complaining of shortness of breath, which patient reported became worse over the last few days. Sputum culture and metabolic panel and complete blood count drawn and sent to laboratory. Oxygen ordered at 2 L via nasal cannula, acetaminophen 650 mg PO administered at 5 p.m. Patient transferred to 5 South with a diagnosis of R/O pneumonia at 6 p.m.

Vital Signs Sheet
Oxygen saturation: 85%
Temperature: 102.4°F, temporal
Pulse: 92 beats per minute, regular rate
Respirations: 28 breaths per minute
Blood pressure: 160/90 mm Hg

Nurse's Progress Note
7 p.m.: IV 0.45% sodium chloride running at 100 mL per hour. IV site is clean, dy, and
intact. Patient has a productive cough, and respirations are 28 breaths per minute related
to excessive respiratory secretions. Called primary health-care provider for an order for
chest physiotherapy. Patient states feeling tired and nauseated. Patient had 4 ounces of soup and 3 ounces of water and refused rest of dinner. Patient assisted to the bathroom to void; no dizziness reported by the patient.

1. Productive cough
2. Seek order for chest physiotherapy
3. No dizziness reported by the patient
4. Acetaminophen 650 mg administered at 5 p.m.