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

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

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

SUBJECTIVE DATA:

Chief Complaint (CC): ‘My right foot hurts’

History of Present Illness (HPI): The patient in the case study comes to the clinic with complains of a painful, swollen, red, warm scrape on her right foot for the last two days. The patient thought it would heal on its own but has been worsening over time. The patient reports that the pain worsened over the last two days. The patient sustained the injury a week ago while going down the back steps when she tripped and twisted her ankle. She also scrapped her foot on the edge of the step. The patient went to the ER an hour after falling because of the strained ankle. The x-ray performed was normal. She was prescribed pain medications. The patient rates the pain 7/10 in the pain rating scale. She reports that the scrape is infected and worsening. The patient describes the pain as throbbing. It is associated with sharp pain when weight is applied.

The pain radiates to the ankle. The patient reports that the affected foot is non-weight bearing. The patient reports that the wound drains pus, white in color, for the last two days. She has been treating the wound at home by cleaning twice daily and bandaging it. She has been cleaning it with soap, water, and some peroxide if irritated. She has also been applying Neosporin ointment twice daily. The problem has affected her functioning ability since she has missed her work because of the pain. She has also missed her class two days ago. Besides the current problem, she reports losing 10 pounds unintentionally, being thirsty, experiencing oliguria and polyphagia for the past month.

Medications: She currently uses Proventil inhaler if symptoms of asthma persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management.

Allergies: She develops asthma symptoms when she is near cats. She is also allergic to dust and develops asthma symptoms with intensive physical activity. She is also allergic to penicillin.

Past Medical History (PMH): The patient was diagnosed with diabetes type 2 at the age of 24 years. She is also asthmatic since the age of two and half years. Her last asthmatic attack was when she was in high school. She developed breathing problems three days ago at her cousin’s place.  She has a history of using Metformin, which she took it three years ago. The patient has history of five hospitalizations when she was 16 years because of asthma.

She has a history of using nebulizer. She manages asthma by avoiding triggers but uses Proventil inhaler if symptoms persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management. She has also been using tramadol 100 mg three times a day for pain for the last two days. She takes Advil when her cramps het bad and Tylenol for headache.

Past Surgical History (PSH): The patient denies any history of surgeries

Sexual/Reproductive History: The patient denies history of sexually transmitted infections

Personal/Social History: The patient is a student currently finishing her bachelor’s degree in accounting. She lives with her mother and her sister. She is worried about her right foot. The patient denies barriers in accessing healthcare. Her family and church are her social support systems.

Immunization History: The patient believes that she received her childhood immunizations. She did not get her flu shot this year. Her tetanus booster was a year ago.

Health Maintenance: The patient reports that she started watching her sugar and avoiding regular soda after she found out that she is diabetic. She only drinks diet coke. She rarely checks her sugars, with the last time being a month ago. She does not understand the meaning of blood glucose numbers. She rarely checks her blood pressure. She stopped taking Metformin because of its side effects and feeling overwhelmed remembering to take the pills and checking her blood sugar. Her typical breakfast comprises muffin or pumpkin bread obtained from a nearby café. Her typical lunch is a meal she usually picks from a nearby campus or subway to get turkey sandwich.

Her typical dinner is meatloaf, pasta, casseroles, and chicken. Her typical snacks include pretzels and French fries. She does not pay attention to the amount of salt she eats. She drinks about four-diet coke daily. She last took alcohol three weeks ago. She drinks alcohol once or twice a week during night outs. She is exposed to second-hand smoke from her friends. Her last eye and dental examination was when she was a child. She reports doing self-breast examination a couple times. She has never undergone mammography.

Significant Family History: Her mother has high cholesterol and diabetes. Her deceased father had type 2 diabetes, high cholesterol, and hypertension. Grandfather had colon cancer, diabetes, and hypertension. Paternal grandmother has high cholesterol and hypertension. Her sister is asthmatic. Her brother and father are overweight. Her uncle has alcohol addiction problem.

Review of Systems:

Vital signs: Height 170 cm, weight 90kg, BMI 31, Random blood glucose 238, Temperature 101.1F, O2 saturation 99%

General: The patient reports fatigue, fever and chills last night. She denies night sweat or suicidal thoughts.

HEENT: She denies headache, head injuries, changes in hearing, ringing ears, ear pain, and ear discharge. She denies changes in vision, double vision, itchy eyes, watery eyes, and dry eyes. She reports eye pain when she reads for too long. She reports occasional rhinorrhea. She denies sinus pain, changes in sense of smell, nosebleeds, or dental problems. She denies changes in sense of taste, dry mouth, mouth pain, mouth sores, or tongue problems.

Neck: She denies dysphagia, sore throat, lymphadenopathy, voice changes, or neck pain.

Breasts: She denies breast problems, such as pain, lumps, nipple changes, or nipple discharge.

Respiratory: The patient denies wheezing, chest tightness, dyspnea, cough, or chest pain.

Cardiovascular/Peripheral Vascular: The patient denies palpitations, easy bruising, edema, circulation problems, or vascular diseases.

Gastrointestinal: The patient denies nausea, vomiting, stomach pain, changes in bowel movements, heartburn, constipation or diarrhea.

Genitourinary: The patient denies dysuria, urgency, frequency, or history of sexually transmitted infections.

Musculoskeletal: The patient reports right ankle sprain, which is non-weight bearing. She denies fractures.

Psychiatric: The patient denies depression, anxiety, or stress.

Neurological: The patient denies ataxia, numbness, tingling, loss of balance, and difficulties in coordinating movement.

Skin: The patient denies rash. She reports swollen right foot with a wound draining pus.

Hematologic: The patient denies easy bruising or prolonged bleeding

Endocrine: The patient denies heat or cold intolerance. She reports unintentional weight loss, polydipsia, polyphagia, and polyuria.

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.

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 experience at the age of 18, which encounters were with men, and the individual identifies as straight. Never pregnant. It’s been three weeks since her last menstruation. During the last year, her menstrual period has been quite erratic, occurring every 4-6 weeks and she has had heavy bleeding that lasts 9-10 days.

She does not have a partner currently. She used oral contraceptives when she was younger. She claims that she did not use condoms when she was sexually active. Never had an HIV/AIDS test done. No record of previous sexually transmitted infections or signs of STIs. When she was last teste, four years have elapsed.

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Personal/Social History:She has never married and has no children. She has lived on her own since the age of 20, and since her father died a year ago, they now share a home with their mother and a sister in a single family dwelling to support the family. Currently working 32 hours per week as a supervisor at Mid-American Copy and Ship. She was recently promoted to shift supervisor, a position she thoroughly enjoys.

She goes to school part-time and is currently in her final semester of work toward a bachelor’s degree in accounting. She aspires to be an accountant for the company where she currently works. She is prosperous because she owns a car, a cellphone, and a computer. Despite the fact that she is covered by her employer’s basic health insurance, she avoids seeking medical attention due to the out-of-pocket costs. She enjoys socializing with her friends, going to Bible study, being involved in her church’s ministry, and dancing.

Tina has a strong family and social support network, and she is active in her local church community. She describes feeling stressed as a result of her father’s death, as well as the demands of her job and education, as well as her financial situation. She claims that her family and the church have helped her cope with the stress. There will be no smoking. Cannabis use between the ages of 15 and 21 on an irregular basis. She claims she has never used cocaine, methamphetamines, or heroin.

Alcohol is consumed “when out with friends, two or three times a month,” with no more than three drinks consumed per occasion. She drinks four caffeine-containing beverages and diet soda every day. No international travel. Pets are not permitted. She is not currently in an intimate relationship, but two years ago she ended a significant monogamous relationship that lasted three years. She plans to start a family in the future by marrying and having children.

Assignment 2: Digital Clinical Experience (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 health history 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 Week 4 DCE Health History Assessment Rubric, provided in the
Assignment submission area, for details on completing the Assignment.

DCE Health History Assessment:
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 DCE: Health History Assessment 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

To go to the next module:
Module 3

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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 introduces the diagnostic process, which includes performing
an analysis of the symptoms and then formulating and testing a
hypothesis. The authors discuss how becoming an expert clinician takes
time and practice in developing clinical judgment.

Gibbs , H., & Chapman-Novakofski, K. (2012). Exploring nutrition literacy:
Attention to assessment and the skills clients need. Health, 4(3), 120–124.
This study explores nutrition literacy. The authors examine the
level of attention paid to health literacy among nutrition
professionals and the skills and knowledge needed to
understand nutrition education.

Martin, B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., &
Johns-Wommack, R. (2014). Weight status misperception as related to
selected health risk behaviors among middle school students. Journal of
School Health, 84(2), 116–123. doi:10.1111/josh.12128
Credit Line: Weight status misperception as related to selected health risk behaviors among middle school students by Martin,
B. C., Dalton, W. T., Williams, S. L., Slawson, D. L., Dunn, M. S., & Johns-Wommack, R., in Journal of School Health, Vol.
84/Issue 2. Copyright 2014 by Blackwell Publishing. Reprinted by permission of Blackwell Publishing 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

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort.

She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided.

She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.

Medications:

1. Ibuprofen 600mg orally three times each day for menstrual cramps.
2. Acetaminophen 500-100 mg orally, as needed for headaches.
3. Tramadol 50 mg orally twice a day if foot pain persists.
4. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.

Allergies:

1. There are no documented latex or food sensitivities.
2. Penicillin hypersensitivity
3. Establishes dust and cat allergies
4. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms.

She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being in