Assignment 2: NURS 6512N Digital Clinical Experience (DCE): Health History Assessment

Assignment 2: NURS 6512N Digital Clinical Experience (DCE): Health History Assessment

Assignment 2: NURS 6512N Digital Clinical Experience (DCE): Health History Assessment

SUBJECTIVE DATA:

Chief Complaint (CC): “I got a scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”

History of Present Illness (HPI): Ms. Jones claimed that one week ago, she was walking on stairs outside when she tripped and fell, causing her right ankle to twist and the ball of her foot to scrape. She went to the emergency room of the nearby hospital, where she received negative results from the x-rays and was given tramadol for the pain she was experiencing. She has been cleaning the wound twice. She has been treating the wound with an antibiotic medication and bandaging it. She adds that the pain and swelling in her ankle have subsided, but that the bottom of her foot is becoming increasingly uncomfortable. She describes the pain as throbbing and sharp when she is forced to bear weights. She reports that her ankle “ached” but it is better now. After taking the most recent dose of tramadol, the level of pain has decreased to a 7 out of 10. The degree of pain when bearing weight is a 9. She says that the ball of foot has become swelled and more red over the previous two days and that yesterday, she noticed discharge pouring from the wound. She also says that the swelling has gotten worse. She claims that there is no smell coming from the wound. Her shoes appear to be too small. She has been seen wearing shoes that are without laces. Last night, she reported a temperature of 102. She denies recent illness. An increased appetite is reported alongside with an accidental weight loss of ten pounds that occurred over the course of the month. Denies making any changes to their diet or amount of physical activity.

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Medications: Acetaminophen 500 to 1000 mg PO as needed (headaches). Ibuprofen 600 mg PO twice daily as needed (menstrual cramps). Tramadol 50 mg PO BID prn (foot pain). Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing while neat cats, most recent administration: three days ago)

Allergies: Rash caused by penicillin, Allergic to cats and dust but not food or latex sensitivities. She claims that being among allergens causes her to experience runny nose, itchy and swollen eyes, and an increase in the severity of her asthma symptoms.

Past Medical History (PMH): At the age of 2 and a half, the asthma was identified. When she is in an environment with cats or dust, she utilizes the albuterol inhaler that she carries with her. Two of three times a week, she makes use of her inhaler. Three days ago, she was around cats, and she had to use her inhaler once to get some respite from the symptoms that were bothering her. Her last asthma related hospitalization was when she was in high-school. Never had an intubation. Diabetes type 2 was discovered at the age of 24. She had been taking Metformin in the past but stopped doing so three years ago, citing the fact that the drugs caused her to have gas and that “it was stressful taking pills and testing my sugar”. She does not keep an eye on her sugar levels. In the hospital’s emergency room, the patient’s sugar levels were high the week before last. No surgeries. Hematologic: Acne has been a problem for her ever since she hit adolescence and she also gets bumps on the backs of her arms if her skin is dry. Complains of a darkening of the skin on her neck as well as an increase in the hair on her face and body. She has noted that she has a few moles, but no noticeable alterations to her hair or nails.

Past Surgical History (PSH): No history of past surgery.

Sexual/Reproductive History: Menarche, age 11. First sexual encounters at the age of 18, with men, and the individual identifies as straight. I was never pregnant. Her last menstruation was three weeks ago. Her menstrual cycle has been erratic over the last year, occurring every 4-6 weeks, and she has experienced heavy bleeding lasting 9-10 days. She currently does not have a partner. When she was younger, she used oral contraceptives. She claims she did not use condoms during her sexual activity. I’ve never had an HIV/AIDS test. There is no history of previous sexually transmitted infections or evidence of STIs. Four years have passed since her last teste.

Personal/Social History: Never married and does not have any children. Since the age of 20, has lived on her own, and since her father passed away a year ago, they now share a home with their mother and a sister in a single family dwelling in order to support the family. Currently working as a supervisor at Mid-American Copy and Ship for a total of 32 hours per week. She was just elevated to the position of shift supervisor, which she thoroughly enjoys. She attends school on a part-time basis and is currently in her final semester of work toward obtaining a bachelor’s degree in accounting. She has her sights set on becoming an accountant for the company she currently works for. She is well off as she owns a car, a cellphone and a computer. Even though she is covered by the employer’s basic health insurance, she avoids seeking medical attention because of the out-of-pocket expenses involved. She takes pleasure in socializing with her friends, going to Bible study, being active in the ministry of her church and dancing. Tina has a solid family and social support structure and she is also involved in her local church community. She describes feeling stressed as a result of the death of her father, as well as the responsibilities of her job and education and her financial situation. She states that coping with the stress has been easy because of her family and the church. No tobacco usage. Cannabis use on an irregular basis between the ages of 15 and 21. She denies ever having used cocaine, methamphetamines, or heroine. Utilizes alcoholic beverages “when out with pals, two or three times a month.” and claims to consume no more than three drinks throughout each occasion. She consumes four beverages containing caffeine and diet soda daily. No foreign travel. No pets. She is not in an intimate relationship currently but she completed a significant monogamous relationship that lasted for three years two years ago. It is in her future intentions to start a family by getting married and having children.

Health Maintenance: The most recent Pap smear was performed in 2014. The last eye exam was conducted when she was a child. The last time she had a dental exam was a couple of years ago. PPD test was negative less than two years ago. No workout. 24-hour diet recall: She admits that she skipped her breakfast the day before and that she normally consumes baked good for breakfast, sandwich for lunch and either meatloaf or chicken for dinner. However, she did not have any of these foods yesterday. Her munchies are either usually either pretzels of French fries.

Immunization History: Regarding immunizations, a tetanus booster shot was administered during the past year; however, a flu shot and vaccine against human papillovirus were not given nor received. She states that she feels that she is up to date on all of her childhood vaccines and that she received the meningococcal vaccine while she was in college. Safety: She does not ride a bike, possesses smoke alarms at home, and always puts on seatbelt whilst driving. Does not use sunscreen. The home has firearms that once belonged to her father and are currently secured in the room used by her parents.

Significant Family History: The mother is 50 years old and has hypertension and high cholesterol. Father died in a car accident a year ago at the age of 58; he has hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, age 25), suffers from obesity Sister (Brittany, age 14) struggles with asthma Grandmother on the maternal side passed away at the age of 73 as a result of stroke; she had a history of hypertension and excessive cholesterol. Grandfather on the maternal side passed away at the age of 78 as a result of a stroke; he had a history of hypertension and excessive cholesterol. Grandmother on the father’s side is still alive and has hypertension despite being 82 years old. Grandfather on the father’s side passed away at the age of 65 from colon cancer, family history of type 2 diabetes. Negative for mental illness other malignancies, unexpected death, kidney disease, sickle cell anemia, and thyroid disorders. An uncle on the father’s side had a problem with alcoholism.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

HEAD: The patient’s head is round, symmetrical, and normocephalic; palpation reveals no nodules, masses, or depressions.

EYES: The bulbar conjunctiva was translucent with few capillaries obvious, and there is no edema or tears in the lacrimal gland. However, the patient’s vision is blurry at the moment. Eye lashes appeared to be uniformly distributed. However, the patient’s eyesight is blurry at the moment. During the test of the additional ocular muscle, both eyes moved in sync and aligned themselves parallel to one another.

EAR: The auricle membranes are spotless and are the same color as the skin on the face.

NOSE: The nose seemed straight, symmetrical, and of a single color.

THROAT: The patient denies having any pain, there being any swelling present, and having any trouble swallowing.

Neck: The patient demonstrated synchronized smooth head movement without any signs of discomfort, indicating that the neck muscles are of comparable size.

            Breasts: Patient shows no signs of pain or discomfort.

            Respiratory: The patient has a history of asthma but claims they are not having any respiratory problems. The breathing sounds were regular, and there was no evidence of discomfort

            Cardiovascular/Peripheral Vascular:  The patient states that they are not experiencing any chest pain and that they have no history of hypertension. The patient’s blood pressure is on the cusp of being dangerous. Only experiences chest pressure when she is having trouble breathing, which is otherwise painless.

            Gastrointestinal: The patient reports no discomfort in the abdomen region, and all four quadrants exhibited positive bowel sounds.

 

            Genitourinary: Denies that urinating causes any discomfort

            Musculoskeletal: The patient is experiencing discomfort in their foot

 

            Psychiatric: Denied any history of previous mental health issues.

            Neurological: Patient is alert, oriented x3

            Skin: On the foot, there was a skin break that measured approximately 2 centimeters by 1.5 centimeters and was 2.5 millimeters deep. It was draining pus. Her hands and feet each have skin that is parched and cracked.

            Hematologic: Rejects that they have any blood disorders.

            Endocrine: The patient’s blood glucose level is 238 mg/dl and they have a history of diabetes.

SAMPLE 2

Name: Irikefe Ojevwe

Section: 4

Week 4                

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA

Chief Complaint (CC): Ms. Jones presented with an open foot wound. She describes the pain as throbbing and sharp when she tries to stand. The initial injury occurred one week ago when she scraped her foot on a cement step and she has experienced a significant increase in pain in the past two days.

History of Present Illness (HPI): Ms. Jones tripped on a cement step while walking outside one week ago, scraped the ball of her foot and twisted her ankle. She visited a local ED where she was given tramadol for pain. The X-ray test at the ED showed that there were no broken bones. She had been managing her wound by using a bandage, cleansing it twice a day, and given tramadol for pain. Although her ankle got better, the pain at the bottom of her foot increased. She rated the pain as 7 out of 10 after taking a recent dose of tramadol and 9 out of 10 with weight bearing. In the past two days, her foot has become increasingly red and swollen and currently has yellow pus but no odor from the wound. She reports experiencing pain that radiates to her ankle. She has lost 10 pounds unintentionally and has increased appetite. She also reports experiencing fever last night.

Medications: • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago). Acetaminophen 500-1000 mg PO prn ( for headaches).

Allergies: allergic to dust and cats and reports experiencing itchy swollen nose, runny nose, and exacerbated asthma symptoms when exposed to allergens. Reports Penicillin allergy that caused hives in childhood; denies latex allergy.

Past Medical History (PMH): Diagnosed with asthma at two and a half years. Patient uses albuterol inhaler 2 or 3 times a week especially when exposed to allergens such as cats. She has never been intubated but has been hospitalized for asthma at age 16. Her last breathing problem occurred three days ago. Patient was diagnosed with type 2 diabetes when she was 24 and was prescribed with metformin although she stopped taking it three years ago because the medication made her feel gassy. She does not monitor her blood sugar levels stating she didn’t like taking daily pills and checking sugar. She reports staying away from sweets and drinking diet soda. She is currently not on any diabetes medication. Denies history of hypertension, does not check her blood pressure regularly.

Past Surgical History (PSH): No surgical history.

Sexual/Reproductive History: Sexual/Reproductive History: First period at age 11, identifies as heterosexual and had her first sexual encounter when she was 18. Patient has never been pregnant and experienced her last period 3 weeks ago. She is currently not sexually active. Patient has experienced irregular cycles with heavy bleeding for the past year. She has used oral contraceptives in the past and did not use condoms when she was sexually active. The patient has no history of STIs and has never tested for HIV/AIDS. Last Pap smear was four years ago.

Personal/Social History: patient has never had children or gotten married. She has lived alone since age 20 although she currently lives with her sister and mother to support them after her father’s death one year ago. She works as a supervisor at Mid-American Copy and Ship and is currently working on an accounting degree. She has basic health insurance but high out-of-pocket costs prevent her from seeking healthcare. The injury has affected her ability to walk, job performance, and prevented her from attending classes. Reports smoking marijuana up to age 20 or 21 and does not take more than 2 or 3 alcoholic drinks in a single setting. Denies tobacco use and exposure to second hand smoke.

Immunization History: Has not received HPV vaccine, influenza vaccine is not current, has received tetanus booster within the past year. She received the meningococcal vaccine while in college and is up-to-date with childhood vaccines.

Health Maintenance: last Pap smear was 4 years ago. Last dental exam was a few years ago; last eye exam was during childhood. No exercise.

Diet: reports that her last meal was dinner which consisted mashed potatoes and baked chicken the previous night. A typical daily diet would include pumpkin bread or a muffin for breakfast, sandwich for lunch, and home cooked meat and vegetables for dinner. Snacks are French fries or pretzels. Does not drink coffee and reports not adding too much salt to her food. Drinks diet soda habitually (up to 4 sodas in a day).

Significant Family History:

Family members, including father, mother, maternal grandmother, and maternal grandfather have a history of hypertension and elevated cholesterol. Her sister is asthmatic and her brother is overweight. Her father and paternal grandfather have a history of type 2 diabetes.

 

Review of Systems

General: Denies any frequent or recent illness; reports occasional fatigue and recent fever-related chills. Denies night sweats and reports typical sleeping patterns.

HEENT: Reports occasional headaches but denies current headache, has no history of head injury. Denies any ear problems, change in hearing, ear pain, ear discharge, ringing, or tinnitus. Reports change in vision and infrequent itchy eyes. Denies eye pain, double vision, eye redness, dry eyes, discharge, crusting, or wateriness. Last eye exam was during childhood. Reports blurry vision that occurs occasionally.

Reports infrequent nose problems, occasional sneezing around dust and cats. Denies change in smell. Denies nosebleeds, sinus problems, and reports infrequent runny nose.

Denies mouth problems, mouth pains, mouth sores, gum problems, tongue problems, jaw problems, or change in sense of taste. No known dental issues although the last dental visit was years ago.

Neck: denies sore throat, voice changes, frequent throat problems, general neck problems, difficulty swallowing, neck pain, swollen glands, or history of lymph node problems.

Breasts: Denies general breast problems, breast lumps, breast pain, nipple changes, and nipple discharge. Reports doing self-breast exams but has no past mammograms.

Respiratory: Denies current breathing problems, wheezing, chest tightness, pain while breathing, and coughing.

Cardiovascular/Peripheral Vascular: Denies chest pain or discomfort, palpitations, irregular heartbeat, easy bruising, circulation problems, vascular diseases. No edema apart from the foot swelling from the infection.

Gastrointestinal: Denies nausea, vomiting, stomach pain, heartburn, indigestion, GERD, changes in bowel movements, constipation, diarrhea or loose stool, bloody or tarry stool, and flatulence.

Genitourinary: Denies dysuria, hematuria, flank pain, incontinence, and history of bladder or tract infection. Reports nocturia, polyuria and normal vagina discharge.

Musculoskeletal: Denies muscle pain, joint pain, muscle weakness, joint swelling, back pain, history of fractures or breaks.

Psychiatric: Patient has never been diagnosed with mental illness; denies history of depression or suicidal ideation or attempts.

Neurological: Denies dizziness, vertigo, or lightheadedness, vision disturbances, numbness or tingling, coordination, loss of sensation, history of seizures, and problems with balance or disequilibrium. Denies memory loss and recent loss of consciousness.

Skin: Reports changes to neck skin (discoloration), moles, acne, excessive body and facial hair, and occasional dry skin. Denies body sores apart from the foot wound, dandruff, nail abnormalities, and rashes. Patient rarely uses sunscreen.

Hematologic: Denies history of anemia and sickle cell anemia.

Endocrine: Denies history of kidney disease and thyroid problems.

(DCE): Health History Assessment
A comprehensive health history is essential to providing quality care for patients across
the lifespan, as it helps to properly identify health risks, diagnose patients, and develop
individualized treatment plans. To effectively collect these heath histories, you must not
only have strong communication skills, but also the ability to quickly establish trust and
confidence with your patients. For this DCE Assignment, you begin building your
communication and assessment skills as you collect a from a volunteer
"patient."
Photo Credit: Sam Edwards / Caiaimage / Getty Images
To Prepare
 Review this week’s Learning Resources as well as the Taking a Health History media

program, and consider how you might incorporate these strategies. Download and
review the Student Checklist: Health History Guide and the History Subjective Data
Checklist, provided in this week’s Learning Resources, to guide you through the
necessary components of the assessment.

 Access and login to Shadow Health using the link in the left-hand navigation of the

Blackboard classroom.
 Review the Shadow Health Student Orientation media program and the Useful Tips and
Tricks document provided in the week’s Learning Resources to guide you through
Shadow Health.
 Review the Rubric, provided in the
Assignment submission area, for details on completing the Assignment.

Complete the following in Shadow Health:
Orientation
 DCE Orientation (15 minutes)
 Conversation Concept Lab (50 minutes)
Health History
 Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many
times as necessary prior to the due date to achieve 80% or better, but you must take all
attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
No Assignment submission due this week but will be due Day 7, Week 4.
Grading Criteria
To access your rubric:
Week 4 Assignment 2 DCE Rubric

What’s Coming Up in Module 3?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
In Module 3, you will examine advanced health assessments using a system focused
approach.
Next week, you will specifically explore how to assess the skin, hair, and nails, as well
as how to evaluate abnormal skin findings while conducting health assessments. You
will also complete your first Lab Assignment: Differential Diagnosis for Skin Conditions
as well as complete your in the simulation tool,
Shadow Health.
Week 4 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in Seidel’s Guide to
Physical Examination as well as other media, as required, prior to completing your Lab
Assignment. There are several videos in varied lengths. Please plan ahead to ensure
you have time to view these media programs to complete your Assignment on time.
Next Module

Also Read:

Learning Resources

Required Readings (click to expand/reduce)
Note: To access this week’s required library resources, please click on the
link to the Course Readings List, found in the Course Materials section of
your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel’s guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.
 Chapter 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection,
palpation, percussion, and auscultation. This chapter also explores special
issues and equipment relevant to the physical exam process.

 Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational
age, and pubertal development. The authors also differentiate growth
among the organ systems.

 Chapter 5, “Recording Information”  (Previously read in Week 1)
This chapter provides rationale and methods for maintaining clear and
accurate records. The text also explores the legal aspects of patient
records.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Student checklist: Health history guide. In Seidel’s guide to
physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line:  Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Centers for Disease Control and Prevention. (2018). Childhood overweight
and obesity. Retrieved from http://www.cdc.gov/obesity/childhood

This website provides information about overweight and obese children.
Additionally, the website provides basic facts about obesity and strategies
to counteracting obesity.

Chaudhry, M. A. I., & Nisar, A. (2017). Escalating health care cost due to
unnecessary diagnostic testing. Mehran University Research Journal of
Engineering and Technology, (3), 569.

This study explores the escalating healthcare cost due the
unnecessary use of diagnostic testing. Consider the impact of
health insurance coverage in each state and how nursing
professionals must be cognizant when ordering diagnostics for
different individuals.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

 Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom
Analysis”

This chapter walks you through the diagnostic process, which includes analyzing your symptoms and then generating and testing a hypothesis. The authors describe how developing clinical judgment takes time and experience to become an excellent clinician.

H. Gibbs and K. Chapman-Novakofski (2012). Examining nutrition literacy: Paying close attention to the assessment and skills that clients require. Health, vol. 4, no. 3, pp. 120–124.
Nutrition literacy is the subject of this study. The authors look at how much attention nutrition professionals pay to health literacy and the skills and knowledge required to understand nutrition education.

B. C. Martin, W. T. Dalton, S. L. Williams, D. L. Slawson, M. S. Dunn, and R. Johns-Wommack (2014). Misperceptions about weight status and health risk behaviors among middle school children. 116–123 in Journal of School Health, vol. 84, no. 2. doi:10.1111/josh.12128
Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., and Johns-Wommack, R., in Journal of School Health, Vol. 84/Issue 2, weight status misperception as related to chosen health risk behaviors among middle school students. Blackwell Publishing owns the copyright for 2014. Reprinted with Blackwell Publishing’s permission via the Copyright Clearance Center.

Noble, H., & Smith, J. (2015) Issues of validity and reliability in qualitative
research . Evidence Based Nursing, 18(2), pp. 34–35.

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide
to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance
Center.

This History Subjective Data Checklist was published as a companion to
Seidel’s Guide to Physical Examination (8th ed.) by Ball, J. W., Dains, J.
E., & Flynn, J.A. Copyright Elsevier (2015). From
https://evolve.elsevier.com
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.
 Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Week 1)
 Chapter 5, "Pediatric Preventative Care Visits" (pp. 91 101)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Shadow Health Nursing Documentation Tutorial (Word
document)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Optional Resource
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 3, "The Physical Screening Examination"

 Chapter 17, "Principles of Diagnostic Testing"
 Chapter 18, "Common Laboratory Tests"
Required Media (click to expand/reduce)

Taking a Health History

How do nurses gather information and assess a patient’s health?
Consider the importance of conducting an in-depth health assessment
interview and the strategies you might use as you watch. (16m)
Accessible player