Objective Data – Brian foster chest pain shadow health assessment

Objective Data – Brian foster chest pain shadow health assessment

Objective Data Collection: 30 of 33 (90.91%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 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)
  • Objective Data – Brian foster chest pain shadow health assessment
 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)
  • Objective Data – Brian foster chest pain shadow health assessment
 Inspected abdomen
0.67 of 1 point
Symmetry (1/3 point)
  •  Symmetric
  •  Asymmetric
Contour (No 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
  • Objective Data – Brian foster chest pain shadow health assessment
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
0.5 of 1 point
Right (No point)
  •  No bruit
  •  Bruit
Left (1/2 point)
  •  No bruit
  •  Bruit
 Auscultated heart sounds
0.5 of 1 point
Heart Sounds (No 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
0.33 of 1 point
Breath Sounds (1/3 point)
  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas
Adventitious Sounds (No point)
  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Course crackles
Location (No 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
  • Objective Data – Brian foster chest pain shadow health assessment
 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
0.5 of 1 point
Right: Vibration (No point)
  •  No thrill
  •  Thrill
Right: Amplitude (No 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
0.5 of 1 point
Right: Vibration (1/4 point)
  •  No thrill
  •  Thrill
Right: Amplitude (No 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 (No 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
  • Objective Data – Brian foster chest pain shadow health assessment
 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
  • Objective Data – Brian foster chest pain shadow health assessment
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