Fatima Khan Endocrine System Hourly Rounds Shadow health Objective data
Objective Data Collection: 10 of 10 (100.0%)
Assessed General Appearance:
1 of 1 points
– Patient Appearance (1.00/1.00 point)
– Patient appears comfortable and is not displaying any signs of acute distress or illness.
– Patient appears uncomfortable or is displaying signs of acute distress or illness.
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Assessed Vitals:
1 of 1 points
– Blood Pressure (1.00/1.00 point)
– Normotensive
– Hypertensive
– Hypotensive
– Heart Rate (0.20/0.20 point)
– No abnormal findings
– Bradycardic
– Tachycardic
– O2 Saturation (0.20/0.20 point)
– No abnormal findings
– Hypoxemia
– Respiratory Rate (0.20/0.20 point)
– No abnormal findings
– Bradypnea
– Tachypnea
– Temperature (0.20/0.20 point)
– Normothermic
– Hyperthermic
– Hypothermic
Assessed IV:
1 of 1 points
– Insertion Site (0.33/0.33 point)
– No visible abnormal signs
– Erythema
– Infiltration
– Dressing (0.33/0.33 point)
– Dressing is dry and intact
– Dressing is moist and/or not intact
– IV Fluid (0.33/0.33 point)
– Patent upon flushing
– Not patent upon flushing
Understanding Triage Nursing and Its Importance
Assessed Peripheral Pulses:
1 of 1 points
– Radial Artery Amplitude (0.50/0.50 point)
– 0: Absent
– 1+: Diminished or barely palpable
– 2+: Expected
– 3+: Increased
– 4+: Bounding pulse
– Dorsalis Pedis Artery Amplitude (0.50/0.50 point)
– 0: Absent
– 1+: Diminished or barely palpable
– 2+: Expected
– 3+: Increased
– 4+: Bounding pulse
Checked Capillary Blood Glucose:
1 of 1 points
– Timing (0.33/0.33 point)
– Preprandial
– Postprandial
– Level (0.33/0.33 point)
– < 80 mg/dL
– 80-130 mg/dL
– 130-180 mg/dL
– > 180 mg/dL
– Assessment (0.33/0.33 point)
– Normoglycemic
– Hypoglycemic
– Hyperglycemic
Check Insulin Pump:
1 of 1 points
– Last Bolus (1.00/1.00 point)
– No recent bolus administered
– Manual bolus administered between 11 AM and 12 PM
– Manual bolus administered between 10 AM and 11 AM
Auscultated Breath Sounds:
1 of 1 points
– Breath Sounds (0.50/0.50 point)
– Clear in all areas
– Diminished in some areas
– Absent in some areas
– Adventitious Sounds (0.50/0.50 point)
– No adventitious sounds
– Wheezing
– Fine crackles
– Stridor
– Rhonchi
– Rales
Auscultated Heart Sounds:
1 of 1 points
– Heart Sounds (1.00/1.00 point)
– S1 and S2 audible
– S1, S2, and S3 audible
– S1, S2, and S4 audible
– S1, S2, S3, and S4 audible
– Extra Heart Sounds (0.50/0.50 point)
– No extra sounds
– Gallops
– Murmur
– Friction rub
– Valve clicks
Inspected IV Pump:
1 of 1 points
– Fluid (0.50/0.50 point)
– Correct fluid
– Incorrect fluid
– Flow Rate (0.50/0.50 point)
– Correct rate
– Incorrect rate
Palpated Skin:
1 of 1 points
– Skin Palpation (1.00/1.00 point)
– Warm and dry
– Cool and diaphoretic
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