template chest pain

OBJETIVEDATACOLLECTIONCHESTPAIN.docx

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OBJETIVE DATA COLLECTION: IN RED THE DATA COLLECTED FROM THE CLIENT

Inspected face

1 of 1 point

Appearance (1/1 point)

· No visible abnormal findings

· Rash or lesion

· Cyanosis

· Pallor

· Redness or flushing

· Evidence of trauma (scar, laceration, or bruising)

Inspected for jugular venous distension

1 of 1 point

Height Of Venous Pressure (1/1 point)

· 4 cm or less above the sternal angle

· More than 4 cm above the sternal angle

Inspected chest

1 of 1 point

Symmetry (1/2 point)

· Symmetric

· Asymmetric

Appearance (1/2 point)

· No visible abnormal findings

· Rash or lesion

· AP diameter abnormal

· Intercostal retraction while breathing

· Excessive use of accessory muscles while breathing

· Pectus excavatum

· Skin growths (freckles or moles)

· Evidence of skin trauma (scar, laceration, or bruising)

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 abnormal findings

· Rash

· Striae

· Bulging around umbilicus

· Distension

· Visible masses (warts, cysts, or tumors)

· Freckles, birthmark, or discoloration

· Excessive hair growth

· Visible scars

· Laceration, lesion or wound

· Bruising

Inspected hands and fingernails

1 of 1 point

Right: Appearance (1/4 point)

· No visible abnormal findings

· Redness

· Moles or skin tags

· Masses (warts, cysts, or tumors)

· Freckles, birthmark, or other discoloration

· Excessive dry or flaking skin

· Purpura

· Scarring

· Laceration, lesion, or wound

· Bruising

· Rash

Right: Nail Changes (1/4 point)

· No visible abnormal findings

· Pallor

· Cyanosis

· Splinter hemorrhages

· Clubbing

Left: Appearance (1/4 point)

· No visible abnormal findings

· Redness

· Moles or skin tags

· Masses (warts, cysts, or tumors)

· Freckles, birthmark, or other discoloration

· Excessive dry or flaking skin

· Purpura

· Scarring

· Laceration, lesion, or wound

· Bruising

· Rash

Left: Nail Changes (1/4 point)

· No visible abnormal findings

· Pallor

· Cyanosis

· Splinter hemorrhages

· Clubbing

Inspected lower extremities and toenails

1 of 1 point

Right: Appearance (1/4 point)

· No visible abnormal findings

· Visible distortion or swelling

· Brownish pigmentation

· Skin thickening

· Ulceration

· Varicose veins

Right: Nail Changes (1/4 point)

· No visible abnormal findings

· Pallor

· Cyanosis

· Splinter hemorrhages

· Clubbing

Left: Appearance (1/4 point)

· No visible abnormal findings

· Visible distortion or swelling

· Brownish pigmentation

· Skin thickening

· Ulceration

· Varicose veins

Left: Nail Changes (1/4 point)

· No visible abnormal findings

· Pallor

· Cyanosis

· Splinter hemorrhages

· Clubbing

Inspect lower extremities for edema

1 of 1 point

Right: Edema (1/4 point)

· No edema

· Pitting

· Non-pitting

Right: Severity Of Edema (1/4 point)

· No edema

· 1+ Slight pitting

· 2+ Deeper pit, disappears in 10 to 15 seconds

· 3+ Noticeably deep pit that lasts more than a minute

· 4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

· No edema

· Pitting

· Non-pitting

Left: Severity Of Edema (1/4 point)

· No edema

· 1+ Slight pitting

· 2+ Deeper pit, disappears in 10 to 15 seconds

· 3+ Noticeably deep pit that lasts more than a minute

· 4+ Very deep pit that lasts 2 to 5 minutes

Tested capillary refill time

1 of 1 point

Fingers (1/2 point)

· Less than 3 seconds

· Greater than 3 seconds

Toes (1/2 point)

· Less than 3 seconds

· Greater than 3 seconds

Auscultated carotid arteries

1 of 1 point

Right (1/2 point)

· No bruit

· Bruit

Left (1/2 point)

· No bruit

· Bruit

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 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 abdominal aorta

1 of 1 point

Sounds (1/1 point)

· No bruit

· Bruit

Auscultated abdominal and lower extremity arteries

1 of 1 point

Right: Renal (1/6 point)

· No bruit

· Bruit

Left: Renal (1/6 point)

· No bruit

· Bruit

Right: Iliac (1/6 point)

· No bruit

· Bruit

Left: Iliac (1/6 point)

· No bruit

· Bruit

Right: Femoral (1/6 point)

· No bruit

· Bruit

Left: Femoral (1/6 point)

· No bruit

· Bruit

Auscultated bowel sounds

1 of 1 point

Bowel 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

Palpated carotid arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated PMI

1 of 1 point

Location (1/3 point)

· Present at midclavicular line and 5th intercostal space

· Displaced laterally

Diameter (1/3 point)

· Less than 3 cm

· Greater than 3 cm

Amplitude (1/3 point)

· Brisk and tapping

· Increased amplitude (hyperkinetic)

Palpated brachial arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated radial arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated femoral arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated popliteal arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated tibial arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Palpated dorsalis pedis arteries

1 of 1 point

Right: Vibration (1/4 point)

· No thrill

· Thrill

Right: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

Left: Vibration (1/4 point)

· No thrill

· Thrill

Left: Amplitude (1/4 point)

· 0 Absent

· 1+ Diminished or barely palpable

· 2+ Expected

· 3+ Increased

· 4+ Bounding pulse

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

· Muscle resistance

· Rigidity

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

· Around umbilicus

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

Tested skin turgor

1 of 1 point

Observations (1/1 point)

· No tenting

· Tenting

Auscultated organs

1 of 1 point

Liver (1/2 point)

· No friction rub

· Audible friction rub

Spleen (1/2 point)

· No friction rub

· Audible friction rub

Percussed abdomen

1 of 1 point

Observations (1/1 point)

· All areas generally tympanic

· Some areas dull, some tympanic

· Some areas resonant

Percussed spleen

1 of 1 point

Spleen (1/1 point)

· Tympany

· Dullness

Percussed liver

1 of 1 point

Liver Span (1/1 point)

· Smaller than 6 cm

· Between 6 and 12 cm

· Greater than 12 cm

Performed EKG

1 of 1 point

Sinus Rhythm (1/2 point)

· Regular

· Irregular

St Changes (1/2 point)

· No ST elevation

· ST elevation present