Focused Exam: Depression Abigail Harris Shadow health Objective data

Focused Exam: Depression Abigail Harris Shadow health Objective data

Assessment of Vital Signs:

– 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.

– The dressing is dry and intact.

Assessment of Blood Glucose:

– Blood glucose level is within the normal range.

– 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.

– 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:

– 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:

– Gait initiation and pattern are normal.

Assessment of General Appearance:

– Abigail presents herself appropriately and maintains good eye contact.

Assessment of Attitude Toward Medical Staff:

– Abigail is generally open and cooperative during the examination.

Assessment of 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:

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

Assessment of 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:

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

Assessment of Judgment:

– Abigail demonstrates good judgment.

Tina Jones Neurological Shadow Health Review Questions

Focused Exam: Depression Abigail Harris Shadow health Objective data

 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/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
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