5. Abnormal findings

Abnormal findings and what they may signal — each warrants Mode B focused documentation and, where parameters are met, intervention and notification:

• Tachycardia or bradycardia; a new or irregular rhythm (new atrial fibrillation, ectopy); an apical–radial deficit.
• Blood pressure outside the ordered parameters; hypertensive urgency; symptomatic hypotension; an orthostatic drop.
• S3 (volume overload / heart failure), S4 (stiff ventricle, hypertension, ischemia), a new murmur, or a rub.
• Jugular venous distension indicating elevated right-sided pressure or volume overload.
• Diminished or absent pulses (peripheral arterial disease, embolism) or bounding pulses.
• Delayed capillary refill; cool, cyanotic, or mottled extremities.
• New or worsening edema (note location and grade); sudden weight gain suggesting decompensation.
• Chest pain or pressure; palpitations; dyspnea, orthopnea, or PND; dizziness or syncope; claudication; decreased activity tolerance.
• Medication-related findings — hypotension or bradycardia (beta-blocker), cough (ACE-inhibitor), bleeding (anticoagulant), or electrolyte effects and volume depletion (diuretics).