Objective Data Collection: 17.6 of 18 (97.78%)
Correct Incorrect
Partially correct Missed
Assessed Vitals 0.8 of 1 point
Temperature (1/5 point) Blood Pressure (No point)
Normothermic Normotensive
Hyperthermic Hypertensive
Hypothermic Hypotensive
Heart Rate (1/5 point) Respiratory Rate (1/5 point)
No abnormal findings No abnormal findings
Tachycardia Tachypnea
Bradycardia Bradypnea
Oxygen Saturation (1/5 point)
No abnormal findings
Hypoxemia
Assessed IV Bag 1 of 1 point
Appropriate Fluid (1/3 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)
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, 3/20/2019 Focused Exam: End of Life | Completed | Shadow Health
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) Dressing (1/2 point)
No visible abnormal signs Dry and Intact
Erythema Moist dressing
Infiltration
Assessed Urine Quality 1 of 1 point
Clarity Of Urine (1/3 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
Eyelids (1/4 point) Conjunctiva And Lens (1/4 point)
No visible abnormal findings No visible abnormal findings
Ptosis Sclera - injection
Swelling Sclera - icterus
Lesion Lens opacification
Allergic shiners
Pupillary Reaction (1/4 point)
No visible abnormal findings (PERRL)
Unequal
Irregular
Miosis
Mydriasis
Non-reactive to light
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