University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2022
Views:

98

Pages:

6
Author:

Trevon Bernard

Gastrointestinal Objective Data Collection: 18 of 18 (100%) Inspected skin turgor 1 of 1 point Observations (1/1 point) No tenting Tenting Inspected abdomen 1 of 1 point Symmetry (1/3 point) Symmetric Asymmetric Contour (1/3 point) Flat Rounded Protuberant Hollowed Appearance (1/3 point) No visible abnormalities Rash Striae Bulging around umbilicus Distension Visible masses (warts, cysts, or tumors) Freckles, birthmark, or discoloration Excessive hair growth Scarring Laceration, lesion or wound Bruising Auscultated breath sounds 1 of 1 point Breath Sounds (1/3 point) Present in all areas Diminished in some areas Absent in some areas Adventitious Sounds (1/3 point) No adventitious sounds Wheezing Fine crackles Stridor Rhonchi Rales Location (1/3 point) 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 Auscultated heart sounds 1 of 1 point Heart Sounds (1/2 point) S1 and S2 audible S1, S2, and S3 audible S1, S2, and S4 audible S1, S2, S3, and S4 audible Extra Heart Sounds (1/2 point) No extra sounds Gallops Murmur Friction rub Valve clicks Auscultated bowel sounds 1 of 1 point Sounds (1/2 point) Absent Hypoactive Normoactive Hyperactive Location Of Non Normoactive Bowel Sounds (1/2 point) All quadrants normoactive Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Auscultated abdominal aorta 1 of 1 point Sound (1/1 point) No bruit Bruit Auscultated renal arteries 1 of 1 point Right (1/2 point) No bruit Bruit Left (1/2 point) No bruit Bruit Auscultated iliac arteries 1 of 1 point Right (1/2 point) No bruit Bruit Left (1/2 point) No bruit Bruit Auscultated femoral arteries 1 of 1 point Right (1/2 point) No bruit Bruit Left (1/2 point) No bruit Bruit Percussed abdomen 1 of 1 point Observations (1/1 point) All areas generally tympanic Some areas dull, some tympanic Some areas resonant Percussed CVA tenderness 1 of 1 point Patient Reaction (1/1 point) Did not react Pain reaction Percussed spleen 1 of 1 point Spleen (1/1 point) Tympany Dullness Percussed liver span 1 of 1 point Size (1/1 point) Smaller than 6 cm Between 6 and 12 cm Greater than 12 cm Palpated abdomen - light 1 of 1 point Tenderness (1/3 point) None reported Tenderness reported Location Of Tenderness (1/3 point) No quadrants tender Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Observations (1/3 point) No additional observations Masses Guarding Distension Palpated abdomen - deep 1 of 1 point Presence Of Unexpected Mass (1/2 point) No palpable mass Palpable mass Location Of Mass (1/2 point) No palpable mass Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant Palpated liver 1 of 1 point Detection (1/1 point) Not palpable Palpable Palpated spleen 1 of 1 point Detection (1/1 point) Not palpable Palpable Palpated kidneys 1 of 1 point Right (1/2 point) Not palpable Palpable Left (1/2 point) Not palpable Palpable