NR 509 Shadow Health Focused Exam Abdominal Objective Data Collection: 24 of 26 (92.31%)

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Chamberlain College of Nursing NR 509 Shadow Health Focused Exam Abdominal Objective Data Collection Objective Data Collection: 24 of 26 (92.31%)  Correct  Partially correct  Incorrect ...  Missed Inspected head and face 1 of 1 point Skull Symmetry (1/3 point)  Symmetric  Asymmetric Facial Feature Symmetry (1/3 point)  Symmetric  Asymmetric Appearance (1/3 point)  No visible abnormal findings  Flushed appearance  Rash or lesion  Skin growths (freckles, moles, or birth mark)  Excessive hair growth  Evidence of skin trauma (scar, laceration, or bruising) Inspected nasal mucosa 1 of 1 point Appearance (1/1 point) Moist and pink  Dry appearance  Redness Inspected mouth 0 of 1 point Oral Mucosa (No point)  Moist and pink (correct)  Dry appearance  Redness Inspected abdomen 0.67 of 1 point Symmetry (1/3 point)  Symmetric  Asymmetric Contour (1/3 point)  Flat  Rounded  Protuberant  Hollowed Appearance (No point)  No visible abnormal findings  Rash  Striae  Bulging around umbilicus  Distension  Visible masses (warts, cysts, or tumors)  Freckles, birthmark, or discoloration  Excessive hair growth  Scarring  Laceration, lesion, or wound  Bruising  Redness  Jaundice  Prominent veins Inspected for edema in lower extremities 1 of 1 pointRight: Edema (1/4 point)  No edema  Pitting  Non-pitting Right: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Left: Edema (1/4 point)  No edema  Pitting  Non-pitting Left: Severity Of Edema (1/4 point)  No edema  1+ Slight pitting  2+ Deeper pit, disappears in 10 to 15 seconds  3+ Noticeably deep pit that lasts more than a minute  4+ Very deep pit that lasts 2 to 5 minutes Auscultated heart sounds 1 of 1 point Heart Sounds (1/2 point)  S1 and S2 audible  S1, S2, and S3 audible  S1, S2, and S4 audible  S1, S2, S3, and S4 audible Extra Heart Sounds (1/2 point)  No extra sounds  Gallops  Murmur  Friction rub  Valve clicks Auscultated breath sounds1 of 1 point Breath Sounds (1/3 point)  Present in all areas  Diminished in some areas  Absent in some areas Adventitious Sounds (1/3 point)  No adventitious sounds  Wheezing  Fine crackles  Stridor  Rhonchi  Rales Location (1/3 point)  All areas clear  Adventitious sounds in anterior right upper lobe  Adventitious sounds in anterior right middle lobe  Adventitious sounds in anterior right lower lobe  Adventitious sounds in anterior left upper lobe  Adventitious sounds in anterior left lower lobe  Adventitious sounds in posterior right upper lobe  Adventitious sounds in posterior right lower lobe  Adventitious sounds in posterior left upper lobe  Adventitious sounds in posterior left lower lobe Auscultated abdominal aorta 1 of 1 point Sound (1/1 point)  No bruit  Bruit Auscultated bowel sounds 1 of 1 point Bowel Sounds (1/2 point)  Absent  Hypoactive  Normoactive  HyperactiveLocation Of Non Normoactive Bowel Sounds (1/2 point)  All quadrants normoactive  Right upper quadrant  Right lower quadrant  Left upper quadrant  Left lower quadrant Auscultated abdominal arteries 1 of 1 point Right: Renal (1/6 point)  No bruit  Bruit Right: Iliac (1/6 point)  No bruit  Bruit Right: Femoral (1/6 point)  No bruit  Bruit Left: Renal (1/6 point)  No bruit  Bruit Left: Iliac (1/6 point)  No bruit  Bruit Left: Femoral (1/6 point)  No bruit  Bruit Auscultated organs 1 of 1 point Liver (1/2 point)  No friction rub  Audible friction rubSpleen (1/2 point)  No friction rub  Audible friction rub Percussed abdomen 1 of 1 point Observations (1/1 point)  All areas generally tympanic  Some areas dull, some tympanic  Some areas resonant Percussed spleen 1 of 1 point Spleen (1/1 point)  Tympany  Dullness Percussed liver 1 of 1 point Liver Span (1/1 point)  Smaller than 6 cm  Between 6 and 12 cm  Greater than 12 cm Percussed CVA tenderness 1 of 1 point Patient Reaction (1/1 point)  Did not react  Pain reaction Palpated abdomen - light 0.33 of 1 point Tenderness (No point) None reported  Tenderness reported Location Of Tenderness (1/3 point)  No quadrants tender  Right upper quadrant  Right lower quadrant  Left upper quadrant  Left lower quadrant Observations (No point)  No additional observations  Masses  Guarding  Distension Palpated abdomen - deep 1 of 1 point Presence Of Unexpected Mass (1/2 point)  No palpable mass  Palpable mass Location Of Mass (1/2 point)  No palpable mass  Right upper quadrant  Right lower quadrant  Left upper quadrant  Left lower quadrant  Around umbilicus Palpated aortic width 1 of 1 point Size (1/1 point)  3 cm or less  Greater than 3 cm Palpated liver 1 of 1 point Detection (1/1 point) Not palpable  Palpable Palpated spleen 1 of 1 point Detection (1/1 point)  Not palpable  Palpable Palpated bladder 1 of 1 point Detection (1/1 point)  Not palpable  Palpable Palpated kidneys 1 of 1 point Right (1/2 point)  Not palpable  Palpable Left (1/2 point)  Not palpable  Palpable Tested skin turgor 1 of 1 point Observations (1/1 point)  No tenting  Tenting Performed pelvic exam 1 of 1 point Observations (1/1 point) No abnormal findings  Inflammation or irritation  Discharge  Bleeding  Tenderness  Masses or growths Performed digital rectal exam 1 of 1 point Observations (1/1 point)  No abnormal findings  Hemorrhoids  Fissures  Ulceration  Weak sphincter tone  Fecal mass in rectal vault Checked urinalysis 1 of 1 point Clarity (1/4 point)  Clear  Cloudy Color (1/4 point)  Pale yellow  Dark yellow  Pinkish hue  Red or brown Acidity (1/4 point)  Acidic (6.5 - 6.9)  Neutral (7.0)  Alkaline (7.1 - 8.0) Presence Of Additional Substances (1/4 point)  No additional substances detected  Blood  Protein  Sugar  Ketones  Bilirubin Nitrites  Leukocyte esterase [Show More]

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