Gastrointestinal system hourly rounds shadow health Objective Data Collection

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
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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
Assessed Vitals
1 of 1 points
Blood Pressure (0.20/0.20 point)

  • Normotensive
  • Hypertensive
  • Hypotensive
Heart Rate (0.20/0.20 point)

  • No abnormal findings
  • Bradycardic
  • Tachycardic
Respiratory Rate (0.20/0.20 point) 

  • Normal
  • Bradypnea
  • Tachypnea
Temperature (0.20/0.20 point) 

  • Normothermic
  • Hyperthermic
  • Hypothermic
O2 Saturation (0.20/0.20 point)

  • Normal
  • Hypoxemia
Inspected Conjunctiva
1 of 1 points
Conjunctiva (0.50/0.50 point)

  • Pink
  • Moist appearance
  • Pale
  • Dry appearance
  • Erythema
  • Edema
Conjunctival Discharge (0.50/0.50 point)

  • No discharge
  • Clear, watery discharge
  • Purulent discharge
Gastrointestinal system hourly rounds shadow health Objective Data Collection Inspected Abdomen
1 of 1 points
Symmetry (0.33/0.33 point)

  • Symmetric
  • Asymmetric
Contour (0.33/0.33 point)

  • Flat
  • Rounded
  • Protuberant
  • Hollowed
Appearance (0.33/0.33 point)

  • No visible abnormal findings
  • Rash
  • Bulging around umbilicus
  • Distension
  • Visible Masses
Auscultated Abdomen
1 of 1 points
Bowel Sounds (No point)

  • Absent
  • Hypoactive
  • Normoactive
  • Hyperactive
Auscultated Breath Sounds Gastrointestinal system hourly rounds shadow health Objective Data Collection
1 of 1 points
Breath Sounds (0.50/0.50 point)

  • Clear in all areas
  • Diminished in some areas
  • Absent in some areas
Adventitious Sounds (0.50/0.50 point)

  • No adventitious sounds
  • Wheezing
  • Fine crackles
  • Stridor
  • Rhonchi
  • Rales
Auscultated Heart Sounds
1 of 1 points
Heart Sounds (0.50/0.50 point)

  • S1 and S2 audible
  • S1, S2, and S3 audible
  • S1, S2, and S4 audible
  • S1, S2, S3, and S4 audible
Extra Heart Sounds (0.50/0.50 point)

  • No extra sounds
  • Gallops
  • Murmur
  • Friction rub
  • Valve clicks
Palpated Abdomen (Light)
0.67 of 1 points
Tenderness (0.33/0.33 point)

  • None Reported
  • Tenderness Reported
Location of Tenderness (0.33/0.33 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 points
Presence of Unexpected Mass (0.50/0.50 point)

  • No masses palpable
  • Palpable mass
Location of Mass (0.50/0.50 point)

  • No masses palpable
  • Right upper quadrant
  • Right lower quadrant
  • Left upper quadrant
  • Left lower quadrant
  • Around umbilicus
  • Gastrointestinal system hourly rounds shadow health Objective Data Collection

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