Abigail Harris Shadow health Depression Focused Exam
Objective Data Collection for Depression: Abigail Harris Shadow Health
Assessed Vitals
– Temperature: Normothermic
– Blood Pressure: Normotensive
– Heart Rate: Normal
– Respiratory Rate: Normal
– O2 Saturation: Normal
Assessed IV Bag
– Appropriate Fluid: Bag is normal saline
– Appropriate Label: Name and dosage are correct
– Fluid Appearance: No visible abnormal appearance
Assessed IV Pump
– Infusion Rate: IV pump is infusing IV fluid at the ordered rate
Assessed IV Site
– Insertion Site: No visible abnormal signs
– Dressing: Dry and intact
Assessed Blood Glucose
– Timing: Preprandial
– Level: 80-130 mg/dL
– Assessment: Normal value
Assessed Urine Quality
– Clarity Of Urine: Clear
– Color Of Urine: Pale yellow
– Odor: No noticeable odor
Inspected Eyes
– PERRL: Normal (PERRL)
Inspected Mouth
– Oral Mucosa: Moist and Pink
– Gums: Moist and pink
– Lips: Moist and pink
Inspected Skin
– Wounds Or Sores: No abnormal findings
– Signs Of Skin Trauma: No abnormal findings
– Color Or Appearance: No abnormal findings
– Masses Or Texture: No abnormal findings
– Skin Characteristics And Hair Growth: No abnormal findings
Auscultated Carotids
– Right: No bruit
– Left: No bruit
Auscultated Breath Sounds
– Breath Sounds: Clear in all areas
– Adventitious Sounds: No adventitious sounds
Auscultated Heart Sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds
– Rate And Rhythm: Regular rate and rhythm
Palpated Thyroid
– Observations: No palpable abnormalities
– Tenderness: None reported
Tested Fine Motor Skills
– Observations At Rest: Able to perform without difficulty; no tremor
– Observations With Held Posture: Able to perform without difficulty; no tremor
– Observations With Movement: Able to perform without difficulty; no tremor
Tested Grip Strength
– Strength: 5 – Active movement against full resistance without fatigue (normal)
Tested Skin Turgor
– Skin Turgor: No tenting
Tested Capillary Refill
– Capillary Refill Time: Less than 2 seconds
Tested Gait
– Initiation Of Gait: No hesitancy
– Step Length: Stepping foot passes stationary foot
– Step Height: Steps clear floor
– Step Symmetry: Right and left step length equal
– Step Continuity: Steps are continuous
– Path: No deviation of path
– Trunk: No sway, no flexion of knees or back, no use of arms or walking aid for stability
– Walking Stance: Heels set apart
– Time To Complete Test: Less than or equal to 12 seconds (normal mobility)
Assessed General Appearance
– Eye Contact: Direct eye contact
– Posture: Upright posture without tension or rigidity
– Clothing: Clean clothing, appropriate to age, fit, season, and occasion
– Grooming: Demonstrates an appropriate level of grooming
Assessed Attitude Toward Medical Staff
– Attitude Toward Medical Staff: Generally open and cooperative
Assessed Speech
– Rate: Demonstrates appropriate or expected rate of speech
– Volume: Demonstrates appropriate or expected speech volume
– Articulation: No appreciable issues with articulation
Assessed Mood and Affect
– Mood: Stable mood with little or no fluctuation throughout the interview
– Affect: Full or balanced (normal)
Assessed Thought Process
– Thought Process: No presence of thought process disturbances
Assessed Thought Content
– Thought Content: No presence of thought content disturbances
– Perceptual Disturbances: No presence of perceptual disturbances
Confirmed Orientation
– To Person: Oriented to person
– To Place: Oriented to place
– To Time: Oriented to time
– To Situation: Oriented to situation
Assessed Serial Sevens
– Serial Sevens: Able to complete the series
Assessed Memory
– Memory: Remote and immediate memory intact
Assessed Abstract Thinking
– Abstract Thinking: Demonstrates abstract thinking with similarities test
Assessed Visuospatial Ability
– Visuospatial Ability: Visuospatial ability intact for interlocking shapes test
Assessed Insight
– Insight: Demonstrates full awareness of illness and willingness to seek treatment
Assessed Judgment
– Assessed Judgment: Demonstrates good judgment
Focused Exam: Depression Abigail Harris Shadow health Objective data
Objective Data Collection: 31 of 31 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
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- 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
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- 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
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- 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
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- 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
