Exam (elaborations) NUR 305L Shadow Health Danny Rivera Objective Focused Exam Cough Results Completed

Exam (elaborations) NUR 305L Shadow Health Danny Rivera Objective Focused Exam Cough Results Completed No visible abnormal findings Ptosis Eyelid Lesion Sclera (1/4 point) White Yellow tint Redness Conjunctiva (1/4 point) Moist and pink Dry appearance Redness Swelling Conjunctival Discharge (1/4 point) No discharge Clear, watery discharge Purulent discharge Inspected nasal cavities 11 ooff 11 ppooiinntt Color (1/4 point) Pink Red Bluish Discharge (1/4 point) No discharge Clear discharge Bloody discharge Purulent discharge Turbinate Patency (1/4 point) Patent Decreased patency Not patent Observations (1/4 point) No additional visible abnormal findings Foreign body present Polyp Objective Data Collection: 14.8 of 15 (98.67%) Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation SBAR This study source was downloaded by from CourseH on :01:32 GMT -05:00 This study resource was shared via CourseH Septum perforated Septum deviated Lesion Inspected ears 11 ooff 11 ppooiinntt Right: Auditory Canal Color (1/10 point) Pink Red Pallor Right: Tympanic Membrane Color (1/10 point) Pearly gray Red Opaque Yellow Not visible because of cerumen Right: Tympanic Membrane Appearance (1/10 point) No visible abnormal findings Fluid observed Visible scars Bulging Perforation Retraction Right: Cone Of Light (1/10 point) 5:00 Cone of light distorted Right: Discharge (1/10 point) No discharge Cerumen Clear discharge Bloody discharge Purulent discharge Left: Auditory Canal Color (1/10 point) Pink Red Pallor Left: Tympanic Membrane Color (1/10 point) Pearly gray Red Opaque Yellow Not visible because of cerumen Left: Tympanic Membrane Appearance (1/10 point) No visible abnormal findings Fluid observed Visible scars Bulging Perforation Retraction Left: Cone Of Light (1/10 point) 7:00 Cone of light distorted Left: Discharge (1/10 point) No discharge Cerumen Clear discharge Bloody discharge Purulent discharge Inspected mouth and throat 00..88 ooff 11 ppooiinntt Oral Mucosa (1/5 point) Moist and pink Dry appearance Redness Tonsils (No point) No visible abnormal findings Swelling Redness Throat Color (1/5 point) Pink Throat Texture (1/5 point) No abnormal findings This study source was downloaded by from CourseH on :01:32 GMT -05:00 This study resource was shared via CourseH Red Cobblestoning Exudate Post Nasal Drip (1/5 point) No discharge Clear discharge Purulent discharge Inspected neck 11 ooff 11 ppooiinntt Symmetry (1/2 point) Symmetric Asymmetric Appearance (1/2 point) No visible abnormal findings Swelling Visible pulsation Visible mass Discoloration Inspected chest 11 ooff 11 ppooiinntt Symmetry (1/2 point) Symmetric Asymmetric Appearance (1/2 point) No visible abnormal findings Rash Barrel chest Intercostal retraction while breathing Excessive use of accessory muscles while breathing Skin growths (freckles or moles) Auscultated breath sounds 11 ooff 11 ppooiinntt 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 for bronchophony 11 ooff 11 ppooiinntt This study source was downloaded by from CourseH on :01:32 GMT -05:00 This study resource was shared via CourseH Bronchophony (1/1 point) Positive Negative Auscultated heart sounds 11 ooff 11 ppooiinntt 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 Percussed chest wall 11 ooff 11 ppooiinntt Observations (1/2 point) All areas resonant Some areas dull, some resonant Some areas hyperresonant, some resonant Location (1/2 point) No areas of dullness Dullness, anterior right upper lobe Dullness, anterior right middle lobe Dullness, anterior right lower lobe Dullness, anterior left upper lobe Dullness, anterior left lower lobe Dullness, posterior right upper lobe Dullness, posterior right lower lobe Dullness, posterior left upper lobe Dullness, posterior left lower lobe Measured diaphragmatic excursion 11 ooff 11 ppooiinntt Range (1/1 point) 3-5 cm Greater than 3-5 cm Less than 3-5 cm Palpated sinuses 11 ooff 11 ppooiinntt Frontal (1/2 point) None reported Tenderness reported Maxillary (1/2 point) None reported Tenderness reported Palpated lymph nodes 11 ooff 11 ppooiinntt Head And Neck (1/3 point) No palpable nodes Palpable nodes on right side Palpable nodes on left side Supraclavicular (1/3 point) No palpable nodes Palpable nodes on right side Palpable nodes on left side Axillary (1/3 point) No palpable nodes This study source was downloaded by from CourseH on :01:32 GMT -05:00 This study resource was shared via CourseH Palpable nodes on right side Palpable nodes on left side Palpated fremitus 11 ooff 11 ppooiinntt Symmetry (1/2 point) Equal bilaterally Unequal bilaterally Vibration (1/2 point) Expected fremitus Decreased fremitus Palpated chest expansion 11 ooff 11 ppooiinntt Symmetry (1/1 point) Equal bilaterally Unequal bilaterall