Tina Jones Cardiovascular Shadow Health Objective Data Essay
Objective Data Collection: 23 of 23 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
Inspected chest
1 of 1 point
Symmetry (1/2 point)
- Symmetric
- Asymmetric
Appearance (1/2 point)
- No visible abnormal findings
- Prominent pulsation
- Abnormal apical impulse
- Heaves or lifts
Inspected for jugular venous distention
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 hands and fingernails
1 of 1 point
Right: Nail Changes (1/3 point)
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
Left: Nail Changes (1/3 point)
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
Capillary Refill Time (1/3 point)
- 3 seconds or less
- Greater than 3 seconds
Inspected lower extremities and toenails
1 of 1 point
Right: Edema (1/9 point)
- No edema
- Pitting
- Non-pitting
Right: Severity Of Edema (1/9 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
Right: Appearance (1/9 point)
- No visible abnormal findings
- Visible distortion or swelling
- Discoloration
- Skin thickening
- Ulceration
- Varicose veins
Right: Nail Changes (1/9 point)
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
Left: Edema (1/9 point)
- No edema
- Pitting
- Non-pitting
Left: Severity Of Edema (1/9 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: Appearance (1/9 point)
- No visible abnormal findings
- Visible distortion or swelling
- Discoloration
- Skin thickening
- Ulceration
- Varicose veins
Left: Nail Changes (1/9 point)
- No visible abnormal findings
- Pallor
- Cyanosis
- Splinter hemorrhages
- Clubbing
Capillary Refill Time (1/9 point)
- 3 seconds or less
- Greater than 3 seconds
Palpated temporal 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 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
Amplitude (1/3 point)
- Brisk and tapping
- Increased amplitude (hyperkinetic)
Diameter (1/3 point)
- Less than 3 cm
- Greater than 3 cm
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 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 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
Auscultated temporal arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Auscultated carotid arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
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 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 abdominal aorta
1 of 1 point
Sounds (1/1 point)
- No bruit
- Bruit
Auscultated renal arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Auscultated iliac arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Auscultated femoral arteries
1 of 1 point
Right (1/2 point)
- No bruit
- Bruit
Left (1/2 point)
- No bruit
- Bruit
Performed ankle-brachial index test
1 of 1 point
Abi (1/1 point)
- > 1.40 (noncompressable)
- 1.00 – 1.40 (normal)
- 0.90 – 0.99 (borderline ischemia)
- < 0.90 (abnormal)
Performed EKG
1 of 1 point
Sinus Rhythm (1/2 point)
- Regular
- Irregular
St Changes (1/2 point)
- No ST changes
- ST changes present