Focused Exam: Depression Abigail Harris Shadow health

Focused Exam: Depression Abigail Harris Shadow health

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

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

Nicole Diaz PTSD shadow health

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

Focused Exam: Depression Abigail Harris Shadow health

Objective Data Collection: 31 of 31 (100%)