Shadow Health Assignments
Focused Exam: Depression Abigail Harris Shadow health Objective data
Objective Data Collection: 31 of 31 (100%)
Assessed Vitals
1. Temperature
– Normal body temperature
– Elevated body temperature
– Low body temperature
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2. Blood Pressure
– Normal blood pressure
– High blood pressure
– Low blood pressure
3. Heart Rate
– Normal heart rate
– Fast heart rate
– Slow heart rate
4. Respiratory Rate
– Normal respiratory rate
– Rapid breathing
– Slow breathing
5. O2 Saturation
– Normal oxygen saturation
– Low oxygen saturation
Assessed IV Bag
1. Appropriate Fluid
– Bag contains normal saline
– Bag contains a different fluid
– Bag is not labeled
2. Appropriate Label
– Correct name and dosage on label
– Incorrect name on label
– Incorrect dosage on label
– Incorrect infusion rate on label
– Bag is not labeled
3. Fluid Appearance
– No abnormal appearance
– Cloudy fluid
– Inappropriate color
– Crystallization
Assessed IV Pump
– IV pump is infusing IV fluid at the ordered rate
– IV pump is infusing IV fluid at a slower rate than ordered
– IV pump is infusing IV fluid at a faster rate than ordered
Assessed IV Site
1. Insertion Site
– No abnormal signs
– Redness at insertion site
– Infiltration at insertion site
2. Dressing
– Dressing is dry and intact
– Dressing is moist
Assessed Blood Glucose
1. Timing
– Before a meal
– After a meal
2. Level
– Below 80 mg/dL
– 80-130 mg/dL
– 130-180 mg/dL
– Above 180 mg/dL
3. Assessment
– Normal blood glucose level
– Low blood glucose level
– High blood glucose level
Assessed Urine Quality
1. Clarity Of Urine
– Clear urine
– Cloudy urine
2. Color Of Urine
– Clear urine
– Pale yellow urine
– Dark yellow urine
– Pink or amber urine
– Red or brown urine
– Orange urine
3. Odor
– No noticeable odor
– Foul odor
– Sweet odor
(Note: The headings, titles, and specific details are preserved, while the rest of the text has been paraphrased in simpler language.)
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Focused Exam: Depression Abigail Harris Shadow health Objective data
Objective Data Collection: 31 of 31 (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
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