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Tina Jones Shadow Health gastrointestinal physical exam
Advanced Health Assessment (NURP 530)
Simmons University
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Tina Jones Shadow Health –
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
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
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
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
Tina Jones Shadow Health gastrointestinal physical exam
Course: Advanced Health Assessment (NURP 530)
University: Simmons University
