Focused Exam: PTSD Nicole Diaz shadow health Objective Data

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

Objective Data Collection: 19 of 19 (100%)

 Correct

 Partially correct

 Incorrect

 Missed

 Assessed Vitals

1 of 1 point

Temperature 
(1/5 point)

 Normothermic

 Hyperthermic

 Hypothermic

ORDER SHADOW HEALTH HELP 

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 Upper Extremities

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

 Inspected Legs

1 of 1 point

Right Leg 
(1/2 point)

 No edema

 Pitting

 Non-pitting

Left Leg 
(1/2 point)

 No edema

 Pitting

 Non-pitting

 Auscultated Carotid Arteries

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

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

 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

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

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)

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

 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

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

 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)

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 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

Focused Exam: PTSD Nicole Diaz shadow health Objective Data

 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

Focused Exam: PTSD Nicole Diaz shadow health Objective Data