Gastrointestinal system hourly rounds shadow health Objective Data Collection
Evaluated Vital Signs
1 out of 1 point
Blood Pressure (0.20/0.20 point)
Normal Blood Pressure
High Blood Pressure
Low Blood Pressure
Heart Rate (0.20/0.20 point)
No unusual findings
Slow Heart Rate
Fast Heart Rate
Respiratory Rate (0.20/0.20 point)
Normal Breathing Rate
Slow Breathing Rate
Fast Breathing Rate
Temperature (0.20/0.20 point)
Normal Body Temperature
High Body Temperature
Low Body Temperature
Oxygen Saturation (0.20/0.20 point)
Normal Oxygen Levels
Low Oxygen Levels
Examined Conjunctiva
1 out of 1 point
Conjunctiva (0.50/0.50 point)
Pink Color
Moist Appearance
Pale Color
Dry Appearance
Redness
Swelling
Conjunctival Secretions (0.50/0.50 point)
No secretions
Clear, watery secretions
Pus-like secretions
Performed Abdominal Examination
1 out of 1 point
Symmetry (0.33/0.33 point)
Equal on both sides
Unequal on both sides
Shape (0.33/0.33 point)
Flat Appearance
Round Appearance
Bulging Appearance
Sunken Appearance
Appearance (0.33/0.33 point)
No visible irregularities
Skin Rash
Bulging around the belly button
Swelling
Visible Lumps
Listened to Abdomen
1 out of 1 point
Bowel Sounds (No point)
No sounds
Decreased sounds
Normal sounds
Increased sounds
Listened to Breathing Sounds
1 out of 1 point
Breath Sounds (0.50/0.50 point)
Clear sounds in all areas
Reduced sounds in some areas
No sounds in some areas
Extra Sounds (0.50/0.50 point)
No added sounds
Wheezing
Fine Crackling Sounds
Harsh Breathing Sounds
Gurgling Sounds
Grating Sounds
Listened to Heart Sounds
1 out of 1 point
Heart Sounds (0.50/0.50 point)
Audible first and second heart sounds
Audible first, second, and third heart sounds
Audible first, second, and fourth heart sounds
Audible first, second, third, and fourth heart sounds
1 out of 1 point
Blood Pressure (0.20/0.20 point)
Normal Blood Pressure
High Blood Pressure
Low Blood Pressure
Heart Rate (0.20/0.20 point)
No unusual findings
Slow Heart Rate
Fast Heart Rate
Respiratory Rate (0.20/0.20 point)
Normal Breathing Rate
Slow Breathing Rate
Fast Breathing Rate
Temperature (0.20/0.20 point)
Normal Body Temperature
High Body Temperature
Low Body Temperature
Oxygen Saturation (0.20/0.20 point)
Normal Oxygen Levels
Low Oxygen Levels
Examined Conjunctiva
1 out of 1 point
Conjunctiva (0.50/0.50 point)
Pink Color
Moist Appearance
Pale Color
Dry Appearance
Redness
Swelling
Conjunctival Secretions (0.50/0.50 point)
No secretions
Clear, watery secretions
Pus-like secretions
Performed Abdominal Examination
1 out of 1 point
Symmetry (0.33/0.33 point)
Equal on both sides
Unequal on both sides
Shape (0.33/0.33 point)
Flat Appearance
Round Appearance
Bulging Appearance
Sunken Appearance
Appearance (0.33/0.33 point)
No visible irregularities
Skin Rash
Bulging around the belly button
Swelling
Visible Lumps
Listened to Abdomen
1 out of 1 point
Bowel Sounds (No point)
No sounds
Decreased sounds
Normal sounds
Increased sounds
Listened to Breathing Sounds
1 out of 1 point
Breath Sounds (0.50/0.50 point)
Clear sounds in all areas
Reduced sounds in some areas
No sounds in some areas
Extra Sounds (0.50/0.50 point)
No added sounds
Wheezing
Fine Crackling Sounds
Harsh Breathing Sounds
Gurgling Sounds
Grating Sounds
Listened to Heart Sounds
1 out of 1 point
Heart Sounds (0.50/0.50 point)
Audible first and second heart sounds
Audible first, second, and third heart sounds
Audible first, second, and fourth heart sounds
Audible first, second, third, and fourth heart sounds
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Extra Heart Sounds (0.50/0.50 point)
No additional sounds
Heart Gallops
Heart Murmur
Friction Rubbing
Valve Clicks
Palpated Abdomen (Light)
0.67 out of 1 point
Tenderness (0.33/0.33 point)
No pain reported
Pain reported
Location of Pain (0.33/0.33 point)
No tender areas
Upper right area
Lower right area
Upper left area
Lower left area
Observations (No point)
No further observations
Lumps
Guarding
Swelling
Palpated Abdomen (Deep)
1 out of 1 point
Presence of Unanticipated Mass (0.50/0.50 point)
No detectable masses
Detectable mass
Location of Mass (0.50/0.50 point)
No detectable masses
Upper right area
Lower right area
Upper left area
Lower left area
Around the belly button
No additional sounds
Heart Gallops
Heart Murmur
Friction Rubbing
Valve Clicks
Palpated Abdomen (Light)
0.67 out of 1 point
Tenderness (0.33/0.33 point)
No pain reported
Pain reported
Location of Pain (0.33/0.33 point)
No tender areas
Upper right area
Lower right area
Upper left area
Lower left area
Observations (No point)
No further observations
Lumps
Guarding
Swelling
Palpated Abdomen (Deep)
1 out of 1 point
Presence of Unanticipated Mass (0.50/0.50 point)
No detectable masses
Detectable mass
Location of Mass (0.50/0.50 point)
No detectable masses
Upper right area
Lower right area
Upper left area
Lower left area
Around the belly button
Assessed Vitals
1 of 1 points
Inspected Conjunctiva
1 of 1 points
Conjunctiva (0.50/0.50 point)
Conjunctival Discharge (0.50/0.50 point)
Gastrointestinal system hourly rounds shadow health Objective Data Collection Inspected Abdomen
1 of 1 points
Symmetry (0.33/0.33 point)
Contour (0.33/0.33 point)
Appearance (0.33/0.33 point)
Auscultated Abdomen
1 of 1 points
Bowel Sounds (No point)
Auscultated Breath Sounds Gastrointestinal system hourly rounds shadow health Objective Data Collection
1 of 1 points
Breath Sounds (0.50/0.50 point)
Adventitious Sounds (0.50/0.50 point)
Auscultated Heart Sounds
1 of 1 points
Heart Sounds (0.50/0.50 point)
Extra Heart Sounds (0.50/0.50 point)
Palpated Abdomen (Light)
0.67 of 1 points
Tenderness (0.33/0.33 point)
Location of Tenderness (0.33/0.33 point)
Observations (No point)
Palpated Abdomen (Deep)
1 of 1 points
Presence of Unexpected Mass (0.50/0.50 point)
Location of Mass (0.50/0.50 point)
- Gastrointestinal system hourly rounds shadow health Objective Data Collection