Maureen Hopkins Shadow health Objective Data Collection

•  Normocephalic and atraumatic
•  Traumatic scalp injury

Interaction of Nurse Informaticists with Other Professionals

•  Normal hair distribution
•  Central scalp hair loss
•  Male-pattern hair loss

•  Scalp epidermis intact
•  Scaling of scalp epidermis

•  No visible abnormal findings
•  Allergic shiners
•  Exophthalmos
•  Eyelid edema
•  Lesion
•  Ptosis

•  White
•  Scleral icterus
•  Scleral erythema
•  Injected

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema
• Maureen Hopkins Shadow health Objective Data

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

•  No visible abnormal findings
•  Allergic shiners
•  Exophthalmos
•  Eyelid edema
•  Lesion
•  Ptosis

•  White
•  Scleral icterus
•  Scleral erythema
•  Injected

•  Moist and pink
•  Pale
•  Dry appearance
•  Erythema
•  Edema

•  No discharge
•  Clear, watery discharge
•  Purulent discharge

•  Pink
•  Red
•  Pallor

•  No visible abnormal findings
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Pink
•  Red
•  Pallor

•  No visible abnormal findings
• Maureen Hopkins Shadow health Objective Data
•  Fluid observed
•  Visible scars
•  Bulging
•  Perforation
•  Retraction

•  No discharge
•  Cerumen
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Pink
•  Pale
•  Erythemic
•  Bluish

•  No discharge
•  Clear discharge
•  Bloody discharge
•  Purulent discharge

•  Patent
•  Decreased patency
•  Not patent

•  No additional visible abnormal findings
•  Foreign body present
•  Polyp
•  Septum perforated
•  Septum deviated
•  Lesion

•  Moist and pink
•  Dry appearance
•  Erythemic

•  No visible abnormal findings
•  Edema
•  Erythema

•  Pink
•  Erythemic

•  Skin well hydrated
•  Epidermal flaking noted
•  Extensive dermal scaling noted

•  Skin well hydrated
•  Epidermal flaking noted
•  Extensive dermal scaling noted

•  No goiter appreciated
•  Goiter present

•  Present in all areas
•  Diminished in some areas
•  Absent in some areas

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

•  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

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

•  Cranial nerves II-XII intact
•  Facial asymmetry noted
•  Dysarthria noted
•  Abnormal eye movements noted

•  Expected sensation
•  Decreased sensation

•  0 – No muscle contraction
•  1 – Barely detectable contraction
•  2 – Active movement with gravity eliminated
•  3 – Active movement against gravity
•  4 – Active movement against gravity and resistance
•  5 – Active movement against full resistance without fatigue (normal)

•  0 – No muscle contraction
•  1 – Barely detectable contraction
•  2 – Active movement with gravity eliminated
•  3 – Active movement against gravity
•  4 – Active movement against gravity and resistance
•  5 – Active movement against full resistance without fatigue (normal)

•  Hair has normal thickness
•  Hair is thin
•  Hair has excessive thickness

•  Hair intact with palpation
•  Hair falls out with palpation

•  Hair shaft does not break with palpation
•  Hair shaft breaks with palpation

•  No palpable abnormal findings
•  Nodules
•  Enlarged
•  Irregular

•  None reported
•  Tenderness reported

•  Brand name medication listed
•  Generic name medication listed
• Maureen Hopkins Shadow health Objective Data

Maureen Hopkins Shadow Health – Objective Data Collection: 15 of 15 (100%)
During the examination, various aspects were assessed to collect objective data. Here are the findings:

Head
– Presence of Injuries (1/3 point): Normocephalic and atraumatic
– Hair Distribution (1/3 point): Normal hair distribution
– Scalp Epidermis (1/3 point): Scalp epidermis intact

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Eyes
– Left Eye Orbital Area (1/8 point): No visible abnormal findings
– Left Eye Sclera (1/8 point): White
– Left Eye Conjunctiva (1/8 point): Moist and pink
– Left Eye Conjunctival Discharge (1/8 point): No discharge
– Right Eye Orbital Area (1/8 point): No visible abnormal findings
– Right Eye Sclera (1/8 point): White
– Right Eye Conjunctiva (1/8 point): Moist and pink
– Right Eye Conjunctival Discharge (1/8 point): No discharge

Ears
– Left Ear Auditory Canal Color (1/6 point): Pink
– Left Ear Tympanic Membrane Appearance (1/6 point): No visible abnormal findings
– Left Ear Discharge (1/6 point): No discharge
– Right Ear Auditory Canal Color (1/6 point): Pink
– Right Ear Tympanic Membrane Appearance (1/6 point): No visible abnormal findings
– Right Ear Discharge (1/6 point): No discharge

Nose
– Color (1/4 point): Pink
– Discharge (1/4 point): No discharge
– Turbinate Patency (1/4 point): Patent
– Observations (1/4 point): No additional visible abnormal findings

Throat
– Oral Mucosa (1/3 point): Moist and pink
– Tonsils (1/3 point): No visible abnormal findings
– Posterior Oropharynx Color (1/3 point): Pink

Skin, Arms
– Left Arm (1/2 point): Skin well hydrated
– Right Arm (1/2 point): Skin well hydrated

Thyroid
– Thyroid (1/1 point): No goiter appreciated

Auscultated Breath Sounds
– Breath Sounds (1/3 point): Present in all areas
– Adventitious Sounds (1/3 point): No adventitious sounds
– Location (1/3 point): All areas clear

Auscultated Heart Sounds
– Heart Sounds (1/2 point): S1 and S2 audible
– Extra Heart Sounds (1/2 point): No extra sounds

Assessed Cranial Nerves
– Cranial Nerve Exams (1/1 point): Cranial nerves II-XII intact

Assessed Upper Musculoskeletal Strength
– Sensation In Hands (1/2 point): Expected sensation
– Squeezing Strength Test (1/2 point): Active movement against gravity and resistance

Assessed Lower Musculoskeletal Strength
– Hip Strength (1/1 point): Active movement against gravity and resistance

Palpated Hair
– Hair Thickness (1/3 point): Hair has normal thickness
– Hair Integrity (1/3 point): Hair intact with palpation
– Hair Shaft Integrity (1/3 point): Hair shaft does not break with palpation

Palpated Thyroid
– Observations (1/2 point): No palpable abnormal findings
– Tenderness (1/2 point): None reported

Checked Pill Bottle
– Medication Name (1/1 point): Brand name medication listed

These findings provide an overall assessment of various aspects of Maureen Hopkins’ health.

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