Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Assessment of Vital Signs:
Table of Contents
– Temperature: Rachel’s body temperature falls within the normal range.
– Blood Pressure: Rachel’s blood pressure is within the normal range.
– Heart Rate: Rachel’s heart rate is normal.
– Respiratory Rate: Rachel’s breathing rate is normal.
– Oxygen Saturation: Rachel’s oxygen levels are normal.
Inspection of Eyes:
– Pupillary Reaction: Rachel’s pupils react normally to light.
– Accommodation: Rachel’s pupils constrict and dilate appropriately.
Inspection of Injury:
– Assessment of various body parts for signs of injury such as swelling, redness, bruising, or rash.
Assessment for Self-harm or Abuse:
– Observation for visible evidence of self-harm or abuse.
– Examination of wounds or scars and noting their location.
Auscultation of Breath and Heart Sounds:
– Listening for clear breath sounds in all areas.
– Listening for normal heart sounds and any additional sounds like murmurs or gallops.
Palpation of Radial Arteries:
– Checking for the presence of vibration and assessing the strength of the pulse in both arms.
Testing Capillary Refill:
– Examining the time it takes for blood to return to the capillaries after applying pressure.
Assessment of General Appearance:
– Observing Rachel’s eye contact, posture, clothing, and grooming for any abnormalities.
Attitude Toward Medical Staff:
– Evaluating Rachel’s demeanor and cooperation with medical staff.
Assessment of Speech:
– Noting the rate, volume, and articulation of Rachel’s speech.
Evaluation of Mood and Affect:
– Assessing Rachel’s emotional state and the expression of her emotions during the interview.
Assessment of Thought Process and Content:
– Observing the coherence and content of Rachel’s thoughts, looking for signs of disturbances.
Confirmation of Orientation:
– Checking Rachel’s awareness of person, place, time, and situation.
Serial Sevens and Abstract Thinking:
– Testing Rachel’s cognitive abilities, including abstract thinking and numerical reasoning.
Assessment of Memory and Visuospatial Ability:
– Evaluating Rachel’s memory recall and spatial reasoning skills.
Insight and Judgment:
– Gauging Rachel’s awareness of her condition and her ability to make sound decisions regarding her health.
Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
- Normal
- Tachypnea
- Bradypnea
- Normal
- Hypoxemia
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
- Normal
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- Normal constriction and dilation
- Unequal or no pupillary constriction
- Unequal or no pupillary dilation
- Normal
- Swelling
- Redness
- Bruising
- Rash
- Normal
- Swelling
- Redness
- Bruising
- Rash
- Normal
- Swelling
- Redness
- Bruising
- Rash
- Normal
- Swelling
- Redness
- Bruising
- Rash
- No visible evidence of self-harm or abuse
- Evidence of self-harm
- Evidence of abuse
- No visible wounds or scars
- Wound visible
- Scar visible
- No visible abnormality
- Right upper arm
- Right lower arm
- Right wrist
- Right hand
- Left upper arm
- Left lower arm
- Left wrist
- Left hand
- 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 thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- No thrill
- Thrill
- 0 Absent
- 1+ Diminished or barely palpable
- 2+ Expected
- 3+ Increased
- 4+ Bounding pulse
- Less than 2 seconds
- Greater than 2 seconds
- Less than 2 seconds
- Greater than 2 seconds
- Direct eye contact
- Indirect or no eye contact
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
- Clean clothing, appropriate to age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
- 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
- Demonstrates abstract thinking with similarities test
- Demonstrates concrete thinking with similarities test
- Remote and immediate memory intact
- Remote or immediate memory not intact
- 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
- Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
