Focused Exam Depression Completed Shadow Health

5/23/2021 Focused Exam: Depression | Completed | Shadow Health Focused Exam: Depression Results | Turned In Your Results Overview Objective Data Collection: 27.72 of 31 (89.42%) Transcript Subjective Data Collection Objective Data Collection Correct Incorrect Partially correct Missed Education & Empathy QSEN Competencies Documentation SBAR Reflections Assessed Vitals Temperature (1/5 point) 0.8 of 1 poin Blood Pressure (No point) Normothermic Normotensive Hyperthermic Hypertensive Hypothermic Heart Rate (1/5 point) Hypotensive 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 1/6 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 point Level (1/3 point) Preprandial <80 mg/dL Postprandial 80-130 mg/dL 130-180 mg/d >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 2/6 5/23/2021 Focused Exam: Depression | Completed | Shadow Health Discoloration 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 Color Or Appearance (1/5 point) Scarring 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 point Left (1/2 point) No bruit No bruit Bruit Bruit Auscultated Breath Sounds Breath Sounds (1/2 point) 1 of 1 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 point 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 point Tenderness (1/2 point) No palpable abnormalities None reported Nodules Tenderness reported Enlarged Irregular 3/6 5/23/2021 Focused Exam: Depression | Completed | Shadow Health Tested Fine Motor Skills Observations At Rest (Arms And Hands At Patient's Side) (1/3 point) 1 of 1 point 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 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 Initiation Of Gait (1/9 point) No hesitancy Hesitancy or multiple attempts to start Step Height (1/9 point) Steps clear floor Steps do not clear floor completely Step Continuity (1/9 point) 1 of 1 point Step Length (1/9 point) Stepping foot passes stationary foot Stepping foot does not pass stationary foot Step Symmetry (1/9 point) Right and left step length equal Right and left step length unequal 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) 4/6 5/23/2021 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) Direct eye contact Indirect or no eye contact Clothing (1/4 point) Clean clothing, appropriate to age, fit, season and occasion Dirty, disheveled, or inappropriate to age, fit, season, or occasion 0.75 of 1 poi Posture (No point) Upright posture without tension or rigidity Bent or hunched posture, tension, or rigidity 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 point 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 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 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 1 of 1 point To Place (1/4 point) Oriented to place 5/6 5/23/2021 Focused Exam: Depression | Completed | Shadow Health Not oriented to person To Time (1/4 point) Not oriented to place 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 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 0 of 1 point Abstract Thinking (No 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 Comments 6/6