Focused Exam: Depression Abigail Harris Shadow health
Objective Data Collection: 31 of 31 (100%)
Correct
Partially correct
Incorrect
Missed
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Assessed Vitals – 1 of 1 point
Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic
Blood Pressure (1/5 point)
Normotensive
Hypertensive
Hypotensive
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/dL
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
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
Cap
illary 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
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
NURS 6512 Advanced Health Assessment and Diagnostic Reasoning: A.G is a 38-year-old female
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
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Focused Exam: Depression Abigail Harris Shadow health
Objective Data Collection: 31 of 31 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
- Normal
- Tachypnea
- Bradypnea
- Normal
- Hypoxemia
- Bag is normal saline
- Bag is not normal saline
- Bag is not labeled
- Name and dosage are correct
- Name is incorrect
- Dosage is incorrect
- Infuse rate is incorrect
- Bag is not labeled
- No visible abnormal appearance
- Cloudy
- Inappropriate color
- Crystallization
- 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
- No visible abnormal signs
- Erythema
- Infiltration
- Dry and intact
- Moist dressing
- Preprandial
- Postprandial
- <80 mg/dL
- 80-130 mg/dL
- 130-180 mg/d
- >180 mg/dL
- Normal value
- Hypoglycemic
- Hyperglycemic
- Clear
- Cloudy
- Clear
- Pale yellow
- Dark yellow
- Pink or amber
- Red or brown
- Orange
- No noticeable odor
- Foul odor
- Sweet odor
- Normal (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- Moist and Pink
- Dry appearance
- Pale
- Moist and pink
- Dry appearance
- Redness
- Bleeding
- Discoloration
- Moist and pink
- Dry appearance
- Chapping
- Redness
- Bleeding
- Discoloration
- No abnormal findings
- Abrasion
- Laceration
- Exposed wounds or cuts
- Sore or pressure ulcer
- Focused Exam: Depression Abigail Harris Shadow health Objective data
- No abnormal findings
- Bruising
- Burn
- Ligature mark
- Scarring
- No abnormal findings
- Purpura or petechiae
- Redness
- Jaundice
- Rash
- Freckles, birthmarks, melasma, or other lesions
- No abnormal findings
- Visible masses (warts, cysts, or tumors)
- Varicosities
- Striae
- Moles or skin tags
- No abnormal findings
- Excessive dry or flaking skin
- Excessive hair growth
- No bruit
- Bruit
- No bruit
- Bruit
- Clear in all areas
- Diminished in some areas
- Absent in some areas
- No adventitious sounds
- Wheezing
- Fine crackles
- Stridor
- Rhonchi
- Rales
- S1 and S2 audible
- S1, S2, and S3 audible
- S1, S2, and S4 audible
- S1, S2, S3, and S4 audible
- No extra sounds
- Gallops
- Murmur
- Friction rub
- Valve clicks
- Regular rate and rhythm
- Arrhythmia
- No palpable abnormalities
- Nodules
- Enlarged
- Irregular
- None reported
- Tenderness reported
- Able to perform without difficulty; no tremor
- Tremor
- Performed with difficulty
- Unable to perform
- Able to perform without difficulty; no tremor
- Tremor
- Able to perform without difficulty; no tremor
- Tremor
- Performed with difficulty
- Unable to perform
- 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)
- No tenting
- Tenting
- Less than 2 seconds
- Greater than 2 seconds
- No hesitancy
- Hesitancy or multiple attempts to start
- Stepping foot passes stationary foot
- Stepping foot does not pass stationary foot
- Steps clear floor
- Steps do not clear floor completely
- Right and left step length equal
- Right and left step length unequal
- Steps are continuous
- Discontinuity between steps
- No deviation of path
- Some path deviation or use of walking aid
- Significant path deviation
- 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
- Heels set apart
- Heels almost touching while walking
- Less than or equal to 12 seconds (normal mobility)
- Greater than 12 seconds (increased likelihood of falls)
- Direct eye contact
- Indirect or no eye contact
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Clean clothing, appropriate to age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- Demonstrates an appropriate level of grooming
- Signs indicating lack of grooming or self-care
- Generally open and cooperative
- Generally suspicious, guarded, or evasive
- Demonstrates appropriate or expected rate of speech
- Excessively slow or rapid rate of speech
- Demonstrates appropriate or expected speech volume
- Excessively loud or soft speech volume
- No appreciable issues with articulation
- Issues with articulation, slurring, or stutters
- Stable mood with little or no fluctuation throughout the interview
- Frequent and appreciable mood changes throughout the interview
- 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)
- No presence of thought process disturbances
- Presence of rapid thinking, disorganized or illogical flow of thought, “word salad,” neologisms, echolalia, or clanging associations
- No presence of thought content disturbances
- Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation
- No presence of perceptual disturbances
- Presence of auditory or visual hallucinations
- Oriented to person
- Not oriented to person
- Oriented to place
- Not oriented to place
- Oriented to time
- Not oriented to time
- Oriented to situation
- Not oriented to situation
- Able to complete the series
- Unable to complete the series
- Remote and immediate memory intact
- Remote or immediate memory not intact
- Demonstrates abstract thinking with similarities test
- Demonstrates concrete thinking with similarities test
- Visuospatial ability intact for interlocking shapes test
- Visuospatial ability impaired with interlocking shapes test
- Demonstrates full awareness of illness and willingness to seek treatment
- Demonstrates limited or no awareness of illness and/or is unwilling to seek treatment
- Demonstrates good judgment
- Judgment poor or impaired judgment