Maureen Hopkins Shadow health Objective Data Collection
During the Nursing Assessment and Objective Data Collection, various aspects of the patient’s health were examined using clinical skills, including the Physical Examination and techniques for assessing different body systems.
Here are the detailed findings from Shadow Health Nursing Assessment:
Head-to-Toe Nursing Assessment: Objective Data Collection
Head and Scalp Inspection: Normocephalic and Atraumatic Findings
Presence of Injuries (1/3 point):
Normocephalic and atraumatic—no signs of trauma or abnormalities.
- Hair Distribution (1/3 point): Normal hair distribution noted, consistent with healthy scalp findings.
- Scalp Epidermis (1/3 point): The scalp epidermis is intact, with no visible scaling or lesions.
Eye Assessment Nursing Exam
- Left Eye Orbital Area (1/8 point): No visible abnormal findings, indicating a normal physical exam for cranial nerve integrity.
- Left Eye Sclera (1/8 point): White sclera, which is within normal limits.
- Left Eye Conjunctiva (1/8 point): Moist and pink, indicating healthy eye tissue.
- Left Eye Conjunctival Discharge (1/8 point): No discharge, which is typical for an intact eye exam.
- Right Eye Orbital Area (1/8 point): No visible abnormal findings.
- Right Eye Sclera (1/8 point): White sclera, normal in appearance.
- Right Eye Conjunctiva (1/8 point): Moist and pink, consistent with objective health data of healthy eye tissue.
- Right Eye Conjunctival Discharge (1/8 point): No discharge, indicating no infection or irritation.
Ear Inspection and Discharge Assessment
- Left Ear Auditory Canal Color (1/6 point): Pink, indicating a healthy ear canal.
- Left Ear Tympanic Membrane Appearance (1/6 point): No visible abnormal findings on the tympanic membrane, ensuring normal ear function.
- Left Ear Discharge (1/6 point): No discharge, suggesting no infection.
- Right Ear Auditory Canal Color (1/6 point): Pink, normal ear canal color.
- Right Ear Tympanic Membrane Appearance (1/6 point): No visible abnormal findings.
- Right Ear Discharge (1/6 point): No discharge.
Nose and Throat: Color, Discharge, Turbinate Patency
- Nose Color (1/4 point): Pink, which is within normal limits.
- Nose Discharge (1/4 point): No discharge noted, suggesting clear nasal passages.
- Turbinate Patency (1/4 point): Patent, confirming unobstructed nasal airways.
- Observations (1/4 point): No additional visible abnormal findings such as polyps or septal deviation.
Skin and Thyroid Inspection: Hydration, Integrity, Goiter
- Oral Mucosa (1/3 point): Moist and pink, indicating normal hydration and health of the oral mucosa.
- Tonsils (1/3 point): No visible abnormal findings, confirming healthy tonsils.
- Posterior Oropharynx Color (1/3 point): Pink, which is normal.
- Skin (1/1 point): Skin well hydrated and no epidermal flaking or dermal scaling on both arms.
- Thyroid (1/1 point): No goiter appreciated, indicating normal thyroid function.
Auscultation of Breath and Heart Sounds in Nursing
Breath Sounds
- Breath Sounds (1/3 point): Present in all areas, with clear lung sounds upon auscultation.
- Adventitious Sounds (1/3 point): No adventitious sounds such as wheezing or crackles, suggesting normal lung function.
- Location (1/3 point): All areas clear, with no abnormal breath sounds detected.
Auscultated Heart Sounds
- Heart Sounds (1/2 point): S1 and S2 audible, with normal heart rhythm.
- Extra Heart Sounds (1/2 point): No extra sounds such as murmurs, gallops, or friction rub, indicating a healthy heart.
Assessment of Musculoskeletal Strength
Upper Musculoskeletal Strength
- Sensation In Hands (1/2 point): Expected sensation, indicating normal nerve function.
- Squeezing Strength Test (1/2 point): Active movement against gravity and resistance noted, indicating normal muscle strength.
Lower Musculoskeletal Strength
- Hip Strength (1/1 point): Active movement against gravity and resistance observed, showing full musculoskeletal function.
Palpation of Thyroid and Hair Inspection
Hair Inspection
- Hair Thickness (1/3 point): Hair has normal thickness.
- Hair Integrity (1/3 point): Hair intact with palpation, with no signs of breakage or thinning.
- Hair Shaft Integrity (1/3 point): Hair shaft does not break with palpation, indicating healthy hair.
Palpated Thyroid
- Observations (1/2 point): No palpable abnormal findings, and thyroid is non-enlarged.
- Tenderness (1/2 point): No tenderness reported on palpation, suggesting normal thyroid function.
Health Data Collection Tools
The above findings are documented and supported by the health data collection tools used throughout the assessment, which include various nursing assessment forms and nursing informatics techniques to ensure accurate patient exam documentation.
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These findings provide an overall assessment of various aspects of Maureen Hopkins’ health during her nursing assessment. By integrating techniques such as clinical skills, physical examination, and objective data collection, we ensure thorough documentation of her clinical findings for proper care and treatment planning.
Maureen Hopkins Shadow health Objective Data Collection: 15 of 15 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- 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
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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