Gastrointestinal system hourly rounds shadow health Objective Data Collection
Assessed Vitals in Nursing
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 in Nursing Assessment
- 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: Objective Data Collection
Inspected Abdomen in Nursing Physical Examination
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- 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
Abdominal Examination and Inspection
Auscultated Abdomen
- Bowel Sounds (No point)
- Absent
- Hypoactive
- Normoactive
- Hyperactive
Auscultation of Breath Sounds in Nursing Assessment
Gastrointestinal System Hourly Rounds Shadow Health: Objective Data Collection
- 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
Auscultation of Heart and Lungs in Nursing
Auscultated Heart Sounds
- 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) – Nursing Objective Data Collection
- 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) – Abdominal Exam for Nursing Students
- 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 on Shadow Health: Objective Data Collection
Nursing Assessment of the Gastrointestinal System
- Assessed Vitals in Nursing
- Blood Pressure: The patient’s blood pressure falls within the normal range, indicating a healthy blood pressure reading.
- Heart Rate: No irregularities were observed in the heart rate, which remains within the expected range.
- Respiratory Rate: The patient’s respiratory rate was found to be normal.
- Temperature: The patient’s body temperature was measured and found to be normal, indicating no fever or hypothermia.
- O2 Saturation: The patient’s oxygen saturation levels were found to be at a normal level.
Abdominal Exam for Nursing Students
Inspected Conjunctiva in Nursing Physical Examination
- Conjunctiva: The conjunctiva of the eye exhibited a healthy appearance with a pink coloration and moist texture.
- Conjunctival Discharge: No discharge was observed in the conjunctiva.
Inspected Abdomen: Gastrointestinal Assessment in Nursing
- Symmetry: The abdomen displayed a symmetrical appearance, suggesting even distribution.
- Contour: The abdominal contour was observed to be flat, with no unusual protrusions or depressions.
- Appearance: No apparent abnormalities were found on the abdomen, such as rashes, bulging, or visible masses.
Auscultated Abdomen
- Bowel Sounds: Bowel sounds were normoactive, indicating typical bowel activity.
Cardiovascular Assessment in Nursing
Auscultated Breath Sounds
- Breath Sounds: Clear breath sounds were heard, indicating healthy respiratory function.
- Adventitious Sounds: No adventitious sounds were detected, signifying clear lung function.
Auscultated Heart Sounds in Nursing
- Heart Sounds: The auscultation revealed S1 and S2 heart sounds, with no abnormal heart sounds noted.
Palpated Abdomen (Light) in Nursing Assessment
- Tenderness: The patient reported no tenderness during the abdominal palpation.
- Location of Tenderness: No tenderness was found in any quadrant, confirming the absence of discomfort.
Palpated Abdomen (Deep) in Nursing Objective Data Collection
- Presence of Unexpected Mass: No palpable masses were discovered during deep palpation, suggesting no abnormal growths.
- Location of Mass: No masses were palpable in any quadrant or around the umbilicus.
Blood Pressure (0.20/0.20 point)
Heart Rate (0.20/0.20 point)
Respiratory Rate (0.20/0.20 point)
Temperature (0.20/0.20 point)
O2 Saturation (0.20/0.20 point)
Conjunctiva (0.50/0.50 point)
Conjunctival Discharge (0.50/0.50 point)
Symmetry (0.33/0.33 point)
Contour (0.33/0.33 point)
Appearance (0.33/0.33 point)
Bowel Sounds (No point)
Breath Sounds (0.50/0.50 point)
Adventitious Sounds (0.50/0.50 point)
Heart Sounds (0.50/0.50 point)
Extra Heart Sounds (0.50/0.50 point)
Tenderness (0.33/0.33 point)
Location of Tenderness (0.33/0.33 point)
Observations (No point)
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
Gastrointestinal System Hourly Rounds on Shadow Health: Objective Data Collection
Assessed Vitals
– Blood Pressure: The patient’s blood pressure falls within the normal range, indicating a healthy blood pressure reading.
– Heart Rate: During the assessment, no irregularities were observed in the patient’s heart rate, which remains within the expected range for normalcy.
– Respiratory Rate: The patient’s respiratory rate was assessed and found to be normal, suggesting healthy breathing patterns.
– Temperature: The patient’s body temperature was measured and found to be well within the normal range, indicating no fever or hypothermia.
– O2 Saturation: The patient’s oxygen saturation levels were assessed and found to be at a normal level, indicating sufficient oxygen in the bloodstream.
Inspected Conjunctiva
– Conjunctiva: The conjunctiva of the eye exhibited a healthy appearance with a pink coloration and a moist texture.
– Conjunctival Discharge: No discharge was observed in the conjunctiva, indicating the absence of any abnormal secretions.
Inspected Abdomen
– Symmetry: The abdomen displayed a symmetrical appearance, suggesting an even distribution of abdominal features.
– Contour: The abdominal contour was observed to be flat, with no unusual protrusions or depressions.
– Appearance: There were no apparent abnormalities on the abdomen, such as rashes, bulging around the umbilicus, distension, or visible masses, suggesting a healthy abdominal region.
Auscultated Abdomen
– Bowel Sounds: Bowel sounds were present and exhibited normoactive patterns, indicating typical bowel activity.
Auscultated Breath Sounds
– Breath Sounds: Clear breath sounds were heard in all areas of the chest, with no abnormal findings suggesting healthy respiratory function.
– Adventitious Sounds: No adventitious sounds, including wheezing, fine crackles, stridor, rhonchi, or rales, were detected, signifying clear lung function.
Auscultated Heart Sounds
– Heart Sounds: Heart sounds were assessed, and the auscultation revealed the presence of the S1 and S2 heart sounds, with no additional or abnormal heart sounds noted.
Palpated Abdomen (Light)
– Tenderness: The patient reported no tenderness during the abdominal palpation, indicating a lack of discomfort or pain in this region.
– Location of Tenderness: No tenderness was identified in any of the quadrants of the abdomen, further confirming the absence of abdominal discomfort.
Palpated Abdomen (Deep)
– Presence of Unexpected Mass: No palpable masses were discovered during the deep abdominal palpation, suggesting a lack of abnormal growths or masses.
– Location of Mass: No masses were palpable in any quadrant or around the umbilicus, indicating a healthy state with no abnormal growths or swelling in the abdominal region.
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