Focused Exam: Depression Abigail Harris Shadow health Objective data

Assessment of Vital Signs:

Temperature:
– Body temperature is within the normal range.

Blood Pressure:
– Blood pressure falls within the normal range.

Heart Rate:
– Heart rate is normal.

Respiratory Rate:
– Breathing rate is normal.

Oxygen Saturation:
– Oxygen saturation is normal.

Assessment of IV Bag:

Appropriate Fluid:
– The IV bag contains normal saline.

Appropriate Label:
– The label on the bag shows the correct name and dosage.

Fluid Appearance:
– The fluid in the bag appears normal with no visible abnormalities.

Assessment of IV Pump:

Infusion Rate:
– The IV pump is infusing the fluid at the ordered rate.

Assessment of IV Site:

Insertion Site:
– No abnormal signs are observed at the insertion site.

Dressing:
– The dressing is dry and intact.

Assessment of Blood Glucose:

Timing:
– Blood glucose level is within the normal range.

Level:
– Blood glucose level is within the normal range.

Assessment of Urine Quality:

Clarity of Urine:
– Urine is clear.

Color of Urine:
– Urine color is within the normal range.

Odor:
– No noticeable odor is detected.

Assessment of Eyes:

Pupil Response to Light:
– Pupils respond normally to light.

Assessment of Mouth:

Oral Health:
– Oral mucosa, gums, and lips appear moist and pink.

Assessment of Skin:

Skin Integrity:
– No wounds or sores are observed.

Skin Trauma Signs:
– No signs of skin trauma are present.

Skin Color and Appearance:
– Skin color and appearance are normal.

Skin Texture and Masses:
– No abnormalities in skin texture or masses are observed.

Assessment of Carotid Arteries:

Auscultation Results:
– No abnormal sounds are heard over the carotid arteries.

Assessment of Breath Sounds:

Breath Sounds:
– Breath sounds are clear in all areas.

Adventitious Sounds:
– No abnormal breath sounds are detected.

Assessment of Heart Sounds:

Heart Sounds:
– Normal heart sounds are heard.

Extra Heart Sounds:
– No extra heart sounds are present.

Rate and Rhythm:
– Heart rate and rhythm are regular.

Assessment of Thyroid:

Palpation Findings:
– No palpable abnormalities are detected.

Assessment of Fine Motor Skills:

Observations:
– Fine motor skills are intact.

Assessment of Skin Turgor:

Skin Turgor:
– Skin returns to normal position promptly after being pinched.

Assessment of Capillary Refill:

Capillary Refill Time:
– Capillary refill time is less than 2 seconds.

Assessment of Gait:

Observations:
– Gait initiation and pattern are normal.

Assessment of General Appearance:

Observations:
– Abigail presents herself appropriately and maintains good eye contact.

Assessment of Attitude Toward Medical Staff:

Attitude:
– Abigail is generally open and cooperative during the examination.

Assessment of Speech:

Speech:
– Abigail speaks at an appropriate rate and volume with clear articulation.

Assessment of Mood and Affect:

Mood and Affect:
– Abigail’s mood is stable, and her affect is normal.

Assessment of Thought Process:

Thought Process:
– Abigail’s thought process is coherent and logical.

Assessment of Thought Content:

Thought Content:
– Abigail’s thought content is free from disturbances.

Perceptual Disturbances:
– Abigail does not experience perceptual disturbances.

Confirmation of Orientation:

Orientation:
– Abigail is oriented to person, place, time, and situation.

Assessment of Memory:

Memory:
– Abigail’s memory is intact for both remote and immediate events.

Assessment of Abstract Thinking:

Abstract Thinking:
– Abigail demonstrates abstract thinking ability.

Assessment of Visuospatial Ability:

Visuospatial Ability:
– Abigail’s visuospatial ability is intact.

Assessment of Insight:

Insight:
– Abigail demonstrates awareness of her condition and willingness to seek treatment.

Assessment of Judgment:

Judgment:
– Abigail demonstrates good judgment.

Tina Jones Neurological Shadow Health Review Questions

Focused Exam: Depression Abigail Harris Shadow health Objective data