Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Objective Data Collection: 21 of 21 (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
Inspected Eyes
1 of 1 point
Pupillary Reaction (1/2 point)
Normal
Unequal
Irregular
Miosis
Mydriasis
Non-reactive to light
Accommodation (1/2 point)
Normal constriction and dilation
Unequal or no pupillary constriction
Unequal or no pupillary dilation
Inspected Injury
1 of 1 point
Left Hand (1/4 point)
Normal
Swelling
Redness
Bruising
Rash
Left Wrist (1/4 point)
Normal
Swelling
Redness
Bruising
Rash
Right Hand (1/4 point)
Normal
Swelling
Redness
Bruising
Rash
Right Wrist (1/4 point)
Normal
Swelling
Redness
Bruising
Rash
Inspected Upper Extremities for Self-harm or Abuse
1 of 1 point
Observations (1/3 point)
No visible evidence of self-harm or abuse
Evidence of self-harm
Evidence of abuse
Wounds Or Scars (1/3 point)
No visible wounds or scars
Wound visible
Scar visible
Location Of Visible Abnormality (1/3 point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand
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 Radial Arteries
1 of 1 point
Right: Vibration (1/4 point)
No thrill
Thrill
Right: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Left: Vibration (1/4 point)
No thrill
Thrill
Left: Amplitude (1/4 point)
0 Absent
1+ Diminished or barely palpable
2+ Expected
3+ Increased
4+ Bounding pulse
Tested Capillary Refill
1 of 1 point
Right Hand (1/2 point)
Less than 2 seconds
Greater than 2 seconds
Left Hand (1/2 point)
Less than 2 seconds
Greater than 2 seconds
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 Abstract Thinking
1 of 1 point
Abstract Thinking (1/1 point)
Demonstrates abstract thinking with similarities test
Demonstrates concrete thinking with similarities test
Assessed Memory
1 of 1 point
Memory (1/1 point)
Remote and immediate memory intact
Remote or immediate memory not intact
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
Judgment (1/1 point)
Demonstrates good judgment
Judgment poor or impaired judgment
Rachel Adler Alcohol Use Disorder shadow health Objective Data Collection
Objective Data Collection: 21 of 21 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
- Normal
- Tachycardic
- Bradycardic
-
BUY A PLAGIARISM-FREE ESSAY HERE
- 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
-
BUY A PLAGIARISM-FREE ESSAY HERE
- 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
