Focused Exam: Depression Abigail Harris Shadow health Objective data

Focused Exam: Depression Abigail Harris Shadow health Objective data

Objective Data Collection: 31 of 31 (100%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Assessed Vitals

1 of 1 point

Temperature (1/5 point)

•  Normothermic
•  Hyperthermic
•  Hypothermic

Blood Pressure (1/5 point)

•  Normotensive
•  Hypertensive
•  Hypotensive

ORDER HERE

Heart Rate (1/5 point)

•  Normal
•  Tachycardic
•  Bradycardic

Respiratory Rate (1/5 point)

•  Normal
•  Tachypnea
•  Bradypnea

O2 Saturation (1/5 point)

•  Normal
•  Hypoxemia

 Assessed IV Bag

1 of 1 point

Appropriate Fluid (1/3 point)

•  Bag is normal saline
•  Bag is not normal saline
•  Bag is not labeled

Appropriate Label (1/3 point)

•  Name and dosage are correct
•  Name is incorrect
•  Dosage is incorrect
•  Infuse rate is incorrect
•  Bag is not labeled

Fluid Appearance (1/3 point)

•  No visible abnormal appearance
•  Cloudy
•  Inappropriate color
•  Crystallization

 Assessed IV Pump

1 of 1 point

Infusion Rate (1/1 point)

•  IV pump is infusing IV fluid at the ordered rate
•  IV pump is infusing IV fluid at a slower than the ordered rate
•  IV pump is infusing IV fluid at a faster than the ordered rate

 Assessed IV Site

1 of 1 point

Insertion Site (1/2 point)

•  No visible abnormal signs
•  Erythema
•  Infiltration

Dressing (1/2 point)

•  Dry and intact
•  Moist dressing

 Assessed Blood Glucose

1 of 1 point

Timing (1/3 point)

•  Preprandial
•  Postprandial

Level (1/3 point)

•  <80 mg/dL
•  80-130 mg/dL
•  130-180 mg/d
•  >180 mg/dL

Assessment (1/3 point)

•  Normal value
•  Hypoglycemic
•  Hyperglycemic

 Assessed Urine Quality

1 of 1 point

Clarity Of Urine (1/3 point)

•  Clear
•  Cloudy

Color Of Urine (1/3 point)

•  Clear
•  Pale yellow
•  Dark yellow
•  Pink or amber
•  Red or brown
•  Orange

Odor (1/3 point)

•  No noticeable odor
•  Foul odor
•  Sweet odor

 Inspected Eyes

1 of 1 point

Perrl (1/1 point)

•  Normal (PERRL)
•  Unequal
•  Irregular
•  Miosis
•  Mydriasis
•  Non-reactive to light

 Inspected Mouth

1 of 1 point

Oral Mucosa (1/3 point)

•  Moist and Pink
•  Dry appearance
•  Pale

Gums (1/3 point)

•  Moist and pink
•  Dry appearance
•  Redness
•  Bleeding
•  Discoloration

Lips (1/3 point)

•  Moist and pink
•  Dry appearance
•  Chapping
•  Redness
•  Bleeding
•  Discoloration

 Inspected Skin

1 of 1 point

Wounds Or Sores (1/5 point)

•  No abnormal findings
•  Abrasion
•  Laceration
•  Exposed wounds or cuts
•  Sore or pressure ulcer
• Focused Exam: Depression Abigail Harris Shadow health Objective data

Signs Of Skin Trauma (1/5 point)

•  No abnormal findings
•  Bruising
•  Burn
•  Ligature mark
•  Scarring

Color Or Appearance (1/5 point)

•  No abnormal findings
•  Purpura or petechiae
•  Redness
•  Jaundice
•  Rash
•  Freckles, birthmarks, melasma, or other lesions

Masses Or Texture (1/5 point)

•  No abnormal findings
•  Visible masses (warts, cysts, or tumors)
•  Varicosities
•  Striae
•  Moles or skin tags

Skin Characteristics And Hair Growth (1/5 point)

•  No abnormal findings
•  Excessive dry or flaking skin
•  Excessive hair growth

 Auscultated Carotids

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 (1/2 point)

•  Clear in all areas
•  Diminished in some areas
•  Absent in some areas

Adventitious Sounds (1/2 point)

•  No adventitious sounds
•  Wheezing
•  Fine crackles
•  Stridor
•  Rhonchi
•  Rales

 Auscultated Heart Sounds

1 of 1 point

Heart Sounds (1/3 point)

•  S1 and S2 audible
•  S1, S2, and S3 audible
•  S1, S2, and S4 audible
•  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/3 point)

•  No extra sounds
•  Gallops
•  Murmur
•  Friction rub
•  Valve clicks

Rate And Rhythm (1/3 point)

•  Regular rate and rhythm
•  Arrhythmia

 Palpated Thyroid

1 of 1 point

Observations (1/2 point)

•  No palpable abnormalities
•  Nodules
•  Enlarged
•  Irregular

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

 Tested Fine Motor Skills

1 of 1 point

Observations At Rest (Arms And Hands At Patient’s Side) (1/3 point)

•  Able to perform without difficulty; no tremor
•  Tremor
•  Performed with difficulty
•  Unable to perform

Observations With Held Posture (Forward Extension Of Patient’s Arms) (1/3 point)

•  Able to perform without difficulty; no tremor
•  Tremor

Observations With Movement (Nose To Finger Test) (1/3 point)

•  Able to perform without difficulty; no tremor
•  Tremor
•  Performed with difficulty
•  Unable to perform

 Tested Grip Strength

1 of 1 point

Strength (1/1 point)

•  0 No muscle contraction
•  1 – Barely detectable contraction
•  2 – Active movement with gravity eliminated
•  3 – Active movement against gravity
•  4 – Active movement against gravity and resistance
•  5 – Active movement against full resistance without fatigue (normal)

 Tested Skin Turgor

1 of 1 point

Skin Turgor (1/1 point)

•  No tenting
•  Tenting

 Tested Capillary Refill

1 of 1 point

Capillary Refill Time (1/1 point)

•  Less than 2 seconds
•  Greater than 2 seconds

 Tested Gait

1 of 1 point

Initiation Of Gait (1/9 point)

•  No hesitancy
•  Hesitancy or multiple attempts to start

Step Length (1/9 point)

•  Stepping foot passes stationary foot
•  Stepping foot does not pass stationary foot

Step Height (1/9 point)

•  Steps clear floor
•  Steps do not clear floor completely

Step Symmetry (1/9 point)

•  Right and left step length equal
•  Right and left step length unequal

Step Continuity (1/9 point)

•  Steps are continuous
•  Discontinuity between steps

Path (1/9 point)

•  No deviation of path
•  Some path deviation or use of walking aid
•  Significant path deviation

Trunk (1/9 point)

•  No sway, no flexion of knees or back, no use of arms or walking aid for stability
•  No sway, but flexion of knees or back or arms spread out while walking for stability
•  Observable sway or use of walking aid

Walking Stance (1/9 point)

•  Heels set apart
•  Heels almost touching while walking

Time To Complete Test (1/9 point)

•  Less than or equal to 12 seconds (normal mobility)
•  Greater than 12 seconds (increased likelihood of falls)

 Assessed General Appearance

1 of 1 point

Eye Contact (1/4 point)

•  Direct eye contact
•  Indirect or no eye contact

ORDER NOW

Posture (1/4 point)

•  Upright posture without tension or rigidity
•  Bent or hunched posture, tension, or rigidity

Clothing (1/4 point)

•  Clean clothing, appropriate to age, fit, season and occasion
•  Dirty, disheveled, or inappropriate to age, fit, season, or occasion

Grooming (1/4 point)

•  Demonstrates an appropriate level of grooming
•  Signs indicating lack of grooming or self-care

 Assessed Attitude Toward Medical Staff

1 of 1 point

Attitude Toward Medical Staff (1/1 point)

•  Generally open and cooperative
•  Generally suspicious, guarded, or evasive

 Assessed Speech

1 of 1 point

Rate (1/3 point)

•  Demonstrates appropriate or expected rate of speech
•  Excessively slow or rapid rate of speech

Volume (1/3 point)

•  Demonstrates appropriate or expected speech volume
•  Excessively loud or soft speech volume

Articulation (1/3 point)

•  No appreciable issues with articulation
•  Issues with articulation, slurring, or stutters

 Assessed Mood and Affect

1 of 1 point

Mood (1/2 point)

•  Stable mood with little or no fluctuation throughout the interview
•  Frequent and appreciable mood changes throughout the interview

Affect (1/2 point)

•  Full or balanced (normal)
•  Expansive affect (excessively cheerful affect characterized by contagious laughter or smiling)
•  Blunted or flat affect (little to no variation of expression regardless of conversation topic)

 Assessed Thought Process

1 of 1 point

Thought Process (1/1 point)

•  No presence of thought process disturbances
•  Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations

 Assessed Thought Content

1 of 1 point

Thought Content (1/2 point)

•  No presence of thought content disturbances
•  Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation

Perceptual Disturbances (1/2 point)

•  No presence of perceptual disturbances
•  Presence of auditory or visual hallucinations

 Confirmed Orientation

1 of 1 point

To Person (1/4 point)

•  Oriented to person
•  Not oriented to person

To Place (1/4 point)

•  Oriented to place
•  Not oriented to place

To Time (1/4 point)

•  Oriented to time
•  Not oriented to time

To Situation (1/4 point)

•  Oriented to situation
•  Not oriented to situation

 Assessed Serial Sevens

1 of 1 point

Serial Sevens (1/1 point)

•  Able to complete the series
•  Unable to complete the series

 Assessed Memory

1 of 1 point

Memory (1/1 point)

•  Remote and immediate memory intact
•  Remote or immediate memory not intact

 Assessed Abstract Thinking

1 of 1 point

Abstract Thinking (1/1 point)

•  Demonstrates abstract thinking with similarities test
•  Demonstrates concrete thinking with similarities test

 Assessed Visuospatial Ability

1 of 1 point

Visuospatial Ability (1/1 point)

•  Visuospatial ability intact for interlocking shapes test
•  Visuospatial ability impaired with interlocking shapes test

 Assessed Insight

1 of 1 point

Insight (1/1 point)

•  Demonstrates full awareness of illness and willingness to seek treatment
•  Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment

 Assessed Judgment

1 of 1 point

Assessed Judgment (1/1 point)

•  Demonstrates good judgment
•  Judgment poor or impaired judgment