Focused Exam Depression Completed Shadow Health PDF

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Summary

oBJECTIVE DATA FOR DCE MENTAL HEALTH...

Description

5/23/2021

Focused Exam: Depression | Completed | Shadow Health

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Focused Exam: Depression Results | Turned In NU309 - Mental Health Nursing - May 2021, (2021_summer_c16_term)__nu309km1 Return to Assignment (/assignments/493115/)

Your Results

Reopen (/assignment_attempts/9883359/reope Lab Pass (/assignment_attempts/9883359/lab_pass.

Overview

Objective Data Collection: 27.72 of 31 (89.42%)

Transcript Subjective Data Collection Objective Data Collection

Correct

Incorrect

Partially correct

Missed

Education & Empathy

Assessed Vitals

0.8 of 1 poin

QSEN Competencies Documentation SBAR Reflections

Temperature (1/5 point)

Blood Pressure (No point)

Normothermic

Normotensive

Hyperthermic

Hypertensive

Hypothermic

Hypotensive

Heart Rate (1/5 point)

Respiratory Rate (1/5 point)

Normal

Normal

Tachycardic

Tachypnea

Bradycardic

Bradypnea

O2 Saturation (1/5 point) Normal Hypoxemia

Assessed IV Bag Appropriate Fluid (1/3 point)

1 of 1 point

Appropriate Label (1/3 point)

Bag is normal saline

Name and dosage are correct

Bag is not normal saline

Name is incorrect

Bag is not labeled

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

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5/23/2021

Focused Exam: Depression | Completed | Shadow Health

Assessed IV Site Insertion Site (1/2 point)

1 of 1 point

Dressing (1/2 point)

No visible abnormal signs

Dry and intact

Erythema

Moist dressing

Infiltration

Assessed Blood Glucose Timing (1/3 point)

1 of 1 poin

Level (1/3 point)

Preprandial

180 mg/dL

Assessment (1/3 point) Normal value Hypoglycemic Hyperglycemic

Assessed Urine Quality Clarity Of Urine (1/3 point)

1 of 1 point

Color Of Urine (1/3 point)

Clear

Clear

Cloudy

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 Oral Mucosa (1/3 point)

1 of 1 point

Gums (1/3 point)

Moist and Pink

Moist and pink

Dry appearance

Dry appearance

Pale

Redness Bleeding Discoloration

Lips (1/3 point) Moist and pink Dry appearance Chapping Redness Bleeding

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Inspected Skin Wounds Or Sores (1/5 point)

1 of 1 point

Signs Of Skin Trauma (1/5 point)

No abnormal findings

No abnormal findings

Abrasion

Bruising

Laceration

Burn

Exposed wounds or cuts

Ligature mark

Sore or pressure ulcer

Scarring

Color Or Appearance (1/5 point)

Masses Or Texture (1/5 point)

No abnormal findings

No abnormal findings

Purpura or petechiae

Visible masses (warts, cysts, or tumors)

Redness

Varicosities

Jaundice

Striae

Rash

Moles or skin tags

Freckles, birthmarks, melasma, or other lesions Skin Characteristics And Hair Growth (1/5 point) No abnormal findings Excessive dry or flaking skin Excessive hair growth

Auscultated Carotids Right (1/2 point)

1 of 1 poin

Left (1/2 point)

No bruit

No bruit

Bruit

Bruit

Auscultated Breath Sounds

1 of 1 poin

Breath Sounds (1/2 point)

Adventitious Sounds (1/2 point)

Clear in all areas

No adventitious sounds

Diminished in some areas

Wheezing

Absent in some areas

Fine crackles Stridor Rhonchi Rales

Auscultated Heart Sounds Heart Sounds (1/3 point)

1 of 1 poin

Extra Heart Sounds (1/3 point)

S1 and S2 audible

No extra sounds

S1, S2, and S3 audible

Gallops

S1, S2, and S4 audible

Murmur

S1, S2, S3, and S4 audible

Friction rub Valve clicks

Rate And Rhythm (1/3 point) Regular rate and rhythm Arrhythmia

Palpated Thyroid Observations (1/2 point)

1 of 1 poin

Tenderness (1/2 point)

No palpable abnormalities

None reported

Nodules

Tenderness reported

Enlarged Irregular

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Tested Fine Motor Skills Observations At Rest (Arms And Hands At Patient's Side) (1/3 point)

1 of 1 poin

Observations With Held Posture (Forward Extension Of Patient's Arms) (1/3 point)

Able to perform without difficulty; no tremor

Able to perform without difficulty; no tremor

Tremor

Tremor

Performed with difficulty Unable to perform 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 poin

Skin Turgor (1/1 point) No tenting Tenting

Tested Capillary Refill

1 of 1 poin

Capillary Refill Time (1/1 point) Less than 2 seconds Greater than 2 seconds

Tested Gait Initiation Of Gait (1/9 point)

1 of 1 point

Step Length (1/9 point)

No hesitancy

Stepping foot passes stationary foot

Hesitancy or multiple attempts to start

Stepping foot does not pass stationary foot

Step Height (1/9 point)

Step Symmetry (1/9 point)

Steps clear floor

Right and left step length equal

Steps do not clear floor completely

Right and left step length unequal

Step Continuity (1/9 point)

Path (1/9 point)

Steps are continuous

No deviation of path

Discontinuity between steps

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

Walking Stance (1/9 point) Heels set apart Heels almost touching while walking

No sway, but flexion of knees or back or arms spread out while walking for stability Observable sway or use of walking aid Time To Complete Test (1/9 point)

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Focused Exam: Depression | Completed | Shadow Health Less than or equal to 12 seconds (normal mobility) Greater than 12 seconds (increased likelihood of falls)

Assessed General Appearance Eye Contact (1/4 point)

0.75 of 1 po

Posture (No point)

Direct eye contact

Upright posture without tension or rigidity

Indirect or no eye contact

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

0 of 1 poin

Attitude Toward Medical Staff (No point) Generally open and cooperative Generally suspicious, guarded, or evasive

Assessed Speech Rate (No point)

0.67 of 1 poi

Volume (1/3 point)

Demonstrates appropriate or expected rate of speech

Demonstrates appropriate or expected speech volume

Excessively slow or rapid rate of speech

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 Mood (No point) Stable mood with little or no fluctuation throughout the interview Frequent and appreciable mood changes throughout the interview

0.5 of 1 poin

Affect (1/2 point) Full or balanced (normal) Expansive affect (excessively cheerful affect characterized b contagious laughter or smiling) Blunted or flat affect (little to no variation of expression regardless of conversation topic)

Assessed Thought Process

1 of 1 poin

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 Thought Content (1/2 point) No presence of thought content disturbances Presence of delusions, obsessive or intrusive thoughts, or suicidal or homicidal ideation

1 of 1 point

Perceptual Disturbances (1/2 point) No presence of perceptual disturbances Presence of auditory or visual hallucinations

Confirmed Orientation To Person (1/4 point) Oriented to person

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1 of 1 poin

To Place (1/4 point) Oriented to place

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Focused Exam: Depression | Completed | Shadow Health Not oriented to person

Not oriented to place

To Time (1/4 point)

To Situation (1/4 point)

Oriented to time

Oriented to situation

Not oriented to time

Not oriented to situation

Assessed Serial Sevens

1 of 1 poin

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

0 of 1 poin

Abstract Thinking (No point) Demonstrates abstract thinking with similarities test Demonstrates concrete thinking with similarities test

Assessed Visuospatial Ability

1 of 1 poin

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

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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