In the nursing assessment of depression, it’s critical to evaluate both the physical and mental health of the patient to ensure a complete diagnosis and appropriate care planning.
Abigail Harris’s depression evaluation, conducted using Objective data collection in nursing, demonstrates a thorough approach, particularly in nursing care plans for depression.
This process ensures accurate clinical nursing depression exam and highlights the importance of mental health nursing assessments in addressing depression signs and symptoms.
Objective Data Collection in Nursing: Depression Assessment
The nursing assessment depression includes gathering objective data, which is essential in assessing the physical state and mental health of patients suffering from mood disorders, such as depression.
During this exam, Abigail’s vital signs were monitored, including temperature, blood pressure, heart rate, and respiratory rate, all of which were within normal ranges.
The assessment of blood glucose and urine quality provided further insight into her overall health, aligning with nursing clinical documentation standards that require thorough tracking of all relevant data.
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Key findings from the assessment include:
- Vitals: Normal temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation.
- IV Bag and Pump: No abnormalities, with appropriate fluid, labeling, and infusion rate, ensuring no discrepancies in the clinical procedure.
- Urine Quality: Clear urine with no signs of infection, supporting the patient’s overall health status.
- Skin Integrity: No abnormal findings, such as wounds or skin trauma, which might suggest self-harming behavior, commonly associated with depression.
Assessing Mental and Physical Health in Nursing
A clinical examination of depression includes assessing various physical and cognitive functions. Abigail’s mood and affect were observed as stable, with little fluctuation throughout the interview, suggesting a balanced emotional state. Her thought process was logical, with no disturbances in cognitive function, which is important in differentiating between types of mental health disorders.
During the depression symptoms assessment in nursing, mental and physical health are both prioritized:
- Mood & Affect: Normal, with no signs of blunted or flattened affect.
- Thought Content & Perceptual Disturbances: No delusions or hallucinations, which are crucial in differentiating depression from other psychiatric disorders like schizophrenia.
- Orientation: Abigail was oriented to person, place, time, and situation, indicating a clear understanding of reality.
Clinical Observations in Depression: A Detailed Breakdown
Objective data collection not only includes the physical symptoms of depression, such as skin trauma or motor function impairments, but also addresses psychiatric observations that affect the nursing diagnosis depression. During Abigail’s evaluation, there was no evidence of abnormal skin conditions, poor grooming, or signs of neglect, all of which can be indicative of severe depression or mental health decline.
- Mood and Affect: Abigail’s mood remained stable, and her affect was appropriate, with no signs of depressed mood or anhedonia.
- Speech and Thought Process: Speech was clear, with no signs of slurring or rapid speech, and her thought process was coherent, supporting the clinical skills nursing required for this level of assessment.
Nursing Assessment Checklist for Depression Evaluation
A depression assessment in nursing includes a comprehensive checklist that covers both physical and cognitive aspects. Abigail’s assessment included:
- Physical Health: Clear vital signs and absence of physical trauma.
- Cognitive Function: Full orientation, intact memory, and abstract thinking.
- Psychiatric Symptoms: No perceptual disturbances or suicidal ideation, indicating a normal mental health status.
The assessment of cognitive function was completed with the serial sevens test, showing Abigail could accurately perform mental tasks, confirming that she did not exhibit signs of impaired cognitive ability, which can sometimes accompany depression.
Nursing Diagnosis Depression and Treatment Planning
From the nursing assessment depression results, a clear diagnosis can be made, forming the foundation of the nursing care plans for depression. Since there were no severe mood disturbances or cognitive impairments, Abigail’s depression appears manageable with appropriate psychiatric nursing assessments and interventions focused on her well-being.
The integration of Electronic Health Records (EHR) in nursing ensures that all of Abigail’s data, including clinical observations and depression assessment in nursing, is documented and easily accessible for further treatment planning and follow-up care. This technology streamlines the process of diagnosing and tracking mental health conditions, improving care outcomes for patients with mood disorders.
Focused Exam: Depression Abigail Harris Shadow health Objective data Collection: 31 of 31 (100%)
- Correct
- Partially correct
- Incorrect
- Missed
- Normothermic
- Hyperthermic
- Hypothermic
- Normotensive
- Hypertensive
- Hypotensive
Alcohol Use Disorder Rachel Adler shadow health Documentation/Electronic Health Record
- Normal
- Tachycardic
- Bradycardic
- Normal
- Tachypnea
- Bradypnea
- Normal
- Hypoxemia
- Bag is normal saline
- Bag is not normal saline
- Bag is not labeled
- Name and dosage are correct
- Name is incorrect
- Dosage is incorrect
- Infuse rate is incorrect
- Bag is not labeled
- No visible abnormal appearance
- Cloudy
- Inappropriate color
- Crystallization
- 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
- No visible abnormal signs
- Erythema
- Infiltration
- Dry and intact
- Moist dressing
- Preprandial
- Postprandial
- <80 mg/dL
- 80-130 mg/dL
- 130-180 mg/d
- >180 mg/dL
- Normal value
- Hypoglycemic
- Hyperglycemic
- Clear
- Cloudy
- Clear
- Pale yellow
- Dark yellow
- Pink or amber
- Red or brown
- Orange
- No noticeable odor
- Foul odor
- Sweet odor
- Normal (PERRL)
- Unequal
- Irregular
- Miosis
- Mydriasis
- Non-reactive to light
- Moist and Pink
- Dry appearance
- Pale
- Moist and pink
- Dry appearance
- Redness
- Bleeding
- Discoloration
- Moist and pink
- Dry appearance
- Chapping
- Redness
- Bleeding
- Discoloration
- No abnormal findings
- Abrasion
- Laceration
- Exposed wounds or cuts
- Sore or pressure ulcer
- Focused Exam: Depression Abigail Harris Shadow health Objective data
- No abnormal findings
- Bruising
- Burn
- Ligature mark
- Scarring
- No abnormal findings
- Purpura or petechiae
- Redness
- Jaundice
- Rash
- Freckles, birthmarks, melasma, or other lesions
- No abnormal findings
- Visible masses (warts, cysts, or tumors)
- Varicosities
- Striae
- Moles or skin tags
- No abnormal findings
- Excessive dry or flaking skin
- Excessive hair growth
- No bruit
- Bruit
- No bruit
- Bruit
- 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 palpable abnormalities
- Nodules
- Enlarged
- Irregular
- None reported
- Tenderness reported
- Able to perform without difficulty; no tremor
- Tremor
- Performed with difficulty
- Unable to perform
- Able to perform without difficulty; no tremor
- Tremor
- Able to perform without difficulty; no tremor
- Tremor
- Performed with difficulty
- Unable to perform
- 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)
- No tenting
- Tenting
- Less than 2 seconds
- Greater than 2 seconds
- No hesitancy
- Hesitancy or multiple attempts to start
- Stepping foot passes stationary foot
- Stepping foot does not pass stationary foot
- Steps clear floor
- Steps do not clear floor completely
- Right and left step length equal
- Right and left step length unequal
- Steps are continuous
- Discontinuity between steps
- No deviation of path
- Some path deviation or use of walking aid
- Significant path deviation
- 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
- Heels set apart
- Heels almost touching while walking
- Less than or equal to 12 seconds (normal mobility)
- Greater than 12 seconds (increased likelihood of falls)
- Direct eye contact
- Indirect or no eye contact
- Upright posture without tension or rigidity
- Bent or hunched posture, tension, or rigidity
- Clean clothing, appropriate to age, fit, season and occasion
- Dirty, disheveled, or inappropriate to age, fit, season, or occasion
- 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
- Remote and immediate memory intact
- Remote or immediate memory not intact
- Demonstrates abstract thinking with similarities test
- Demonstrates concrete thinking with similarities test
- 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
Comprehensive Assessment: Abigail Harris’s Depression Evaluation
Objective Data Collection: 31 of 31 (100%)
– Assessed Vitals
– Temperature: Normal
– Blood Pressure: Normal
– Heart Rate: Normal
– Respiratory Rate: Normal
– O2 Saturation: Normal
– Assessed IV Bag
– Appropriate Fluid: Normal saline
– Appropriate Label: Correct name and dosage
– Fluid Appearance: No visible abnormal appearance
– Assessed IV Pump
– Infusion Rate: IV pump is infusing IV fluid at the ordered rate
– Assessed IV Site
– Insertion Site: No visible abnormal signs
– Dressing: Dry and intact
– Assessed Blood Glucose
– Timing: Preprandial
– Level: 80-130 mg/dL
– Assessment: Normal value
– Assessed Urine Quality
– Clarity of Urine: Clear
– Color of Urine: Pale yellow
– Odor: No noticeable odor
– Inspected Eyes
– PERRL: Normal (PERRL)
– Inspected Mouth
– Oral Mucosa: Moist and pink
– Gums: Moist and pink
– Lips: Moist and pink
– Inspected Skin
– Wounds or Sores: No abnormal findings
– Signs of Skin Trauma: No abnormal findings
– Color or Appearance: No abnormal findings
– Masses or Texture: No abnormal findings
– Skin Characteristics and Hair Growth: No abnormal findings
– Auscultated Carotids
– Right: No bruit
– Left: No bruit
– Auscultated Breath Sounds
– Breath Sounds: Clear in all areas
– Adventitious Sounds: No adventitious sounds
– Auscultated Heart Sounds
– Heart Sounds: S1 and S2 audible
– Extra Heart Sounds: No extra sounds
– Rate and Rhythm: Regular rate and rhythm
– Palpated Thyroid
– Observations: No palpable abnormalities
– Tenderness: None reported
– Tested Fine Motor Skills
– Observations at Rest (Arms and Hands at Patient’s Side): Able to perform without difficulty; no tremor
– Observations With Held Posture (Forward Extension Of Patient’s Arms): Able to perform without difficulty; no tremor
– Observations With Movement (Nose To Finger Test): Able to perform without difficulty; no tremor
– Tested Grip Strength
– Strength: Active movement against full resistance without fatigue (normal)
– Tested Skin Turgor
– Skin Turgor: No tenting
– Tested Capillary Refill
– Capillary Refill Time: Less than 2 seconds
– Tested Gait
– Initiation of Gait: No hesitancy
– Step Length: Stepping foot passes stationary foot
– Step Height: Steps clear the floor
– Step Symmetry: Right and left step length equal
– Step Continuity: Steps are continuous
– Path: No deviation of path
– Trunk: No sway, no flexion of knees or back, no use of arms or walking aid for stability
– Walking Stance: Heels set apart
– Time to Complete Test: Less than or equal to 12 seconds (normal mobility)
– Assessed General Appearance
– Eye Contact: Direct eye contact
– Posture: Upright posture without tension or rigidity
– Clothing: Clean clothing, appropriate to age, fit, season, and occasion
– Grooming: Demonstrates an appropriate level of grooming
– Assessed Attitude Toward Medical Staff
– Attitude Toward Medical Staff: Generally open and cooperative
– Assessed Speech
– Rate: Demonstrates appropriate or expected rate of speech
– Volume: Demonstrates appropriate or expected speech volume
– Articulation: No appreciable issues with articulation
– Assessed Mood and Affect
– Mood: Stable mood with little or no fluctuation throughout the interview
– Affect: Full or balanced (normal)
– Assessed Thought Process
– Thought Process: No presence of thought process disturbances
– Assessed Thought Content
– Thought Content: No presence of thought content disturbances
– Perceptual Disturbances: No presence of perceptual disturbances
– Confirmed Orientation
– To Person: Oriented to person
– To Place: Oriented to place
– To Time: Oriented to time
– To Situation: Oriented to situation
– Assessed Serial Sevens
– Serial Sevens: Able to complete the series
– Assessed Memory
– Memory: Remote and immediate memory intact
– Assessed Abstract Thinking
– Abstract Thinking: Demonstrates abstract thinking with similarities test
– Assessed
Visuospatial Ability
– Visuospatial Ability: Visuospatial ability intact for interlocking shapes test
– Assessed Insight
– Insight: Demonstrates full awareness of illness and willingness to seek treatment
– Assessed Judgment
– Judgment: Demonstrates good judgment
This comprehensive assessment provides a detailed overview of Abigail Harris’s physical and mental well-being, ensuring a thorough evaluation of her condition.
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