NURS 6512 Assignment 2 Digital Clinical Experience (DCE): Health History Assessment
NURS 6512 Assignment 2 Digital Clinical Experience (DCE): Health History Assessment
NURS 6512 Assignment 2 Digital Clinical Experience (DCE) Health History Assessment
SUBJECTIVE DATA:
Chief Complaint (CC): ‘My right foot hurts’
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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.
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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.
Hypertension is one of the health problems in the elderly populations. Hypertension increases the risk of health problems that include heart failure, stroke and renal failure. The risk for hypertension in the elderly populations is attributed to factors that include obesity, physical inactivity, smoking and alcohol abuse. Therefore, this essay examines the factors associated with hypertension, sensitive issues and targeted questions for EB, who has hypertension.
Hypertension is associated with a number of socioeconomic factors. One of them is ethnicity. The risk of hypertension is increased in individuals from ethnic minorities such as African Americans in the US. The client in the case study is black, which increases her risk for developing hypertension. The other socioeconomic factor is income. The level of income influences the affordability of care that the patient needs. Level of income also determines the patient’s ability to utilize health promotion interventions in the community that can be explored for optimum health and management of hypertension (Kanwar et al., 2019).
The presence of social support for the client in the case is another socioeconomic factor influencing the health of the client in the case study. Since the client is single, she might be lacking the social and emotional support she needs for the optimum management of hypertension. Therefore, the lack of social support might have predisposed the patient to poor adherence to the treatment regime for the hypertension. The last socioeconomic factor that influences the management of hypertension and risk factors in the patient is level of knowledge or awareness.
The effective management of hypertension requires the adept understanding of the patient on its management. The patient in the case study appears to have low level of understanding about the management of hypertension (Ahammed et al., 2020). Therefore, there could be an effect of level of education or awareness on the management of the disease.
There exist lifestyle factors that predispose the patient to hypertension and its poor management. The risk for hypertension is elevated in individuals who engage in minimal physical activity. There is also the enhanced risk for the disease in obesity and engaging in unhealthy dietary habits such as high intake of salt, alcohol and fats (Diaz Keith M. et al., 2017). Therefore, it is important to educate the patient about the lifestyle and behavioral modifications that are needed for the effective management of hypertension and its complications.
The nurse should consider sensitive issues in assessing the client. One of the sensitive issues is her values and beliefs related to the medical management of hypertension. The nurse should elicit information from the client concerning her attitude towards conventional management of hypertension. African American patients place more emphasis on the use of alternative and complementary medicine in disease management than conventional methods.
The nurse should therefore obtain information concerning her attitude, values
and beliefs concerning the medical management of hypertension. This will aid in the determination of barriers to the effective management of hypertension. The other sensitive issue that the nurse should explore in patient assessment is the lifestyle and behavioral interventions that the patient uses for managing hypertension.
As shown above, the effective management of hypertension requires interventions that include living healthy lifestyle such as engaging in moderate physical activities, minimizing salt intake in diet, alcohol intake and smoking (Galiè et al., 2019). Consequently, the patient should be educated on the interventions that are effective for the management of hypertension.
NURS 6512 Assignment 2 Digital Clinical Experience (DCE): Health History Assessment
Targeted Questions
The nurse should ask the patient the following targeted questions:
- What are your beliefs and attitude towards the use of medicines for the management of hypertension?
- What interventions do you use to manage the symptoms of hypertension?
- What do you think are some of the factors that hinder you from adhering to the treatment prescribe for the management of hypertension?
- What is the nature of your typical diet in a day?
- Do you think that you have adequate support in your society that enables you to manage effectively your condition?
References
Ahammed, B., Maniruzzaman, Md., Talukder, A., & Ferdausi, F. (2020). Prevalence and Risk Factors of Hypertension Among Young Adults in Albania. High Blood Pressure & Cardiovascular Prevention. https://doi.org/10.1007/s40292-020-00419-5
Diaz Keith M., Booth John N., Seals Samantha R., Abdalla Marwah, Dubbert Patricia M., Sims Mario, Ladapo Joseph A., Redmond Nicole, Muntner Paul, & Shimbo Daichi. (2017). Physical Activity and Incident Hypertension in African Americans. Hypertension, 69(3), 421–427. https://doi.org/10.1161/HYPERTENSIONAHA.116.08398
Galiè, N., Channick, R. N., Frantz, R. P., Grünig, E., Jing, Z. C., Moiseeva, O., Preston, I. R., Pulido, T., Safdar, Z., Tamura, Y., & McLaughlin, V. V. (2019). Risk stratification and medical therapy of pulmonary arterial hypertension. European Respiratory Journal, 53(1). https://doi.org/10.1183/13993003.01889-2018
Kanwar, M., Raina, A., Lohmueller, L., Kraisangka, J., & Benza, R. (2019). The Use of Risk Assessment Tools and Prognostic Scores in Managing Patients with Pulmonary Arterial Hypertension. Current Hypertension Reports, 21(6), 45. https://doi.org/10.1007/s11906-019-0950-y
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Adolescent pregnancy is viewed as a high-risk situation because it poses serious health risks for the mother and the baby. Describe various risk factors or precursors to adolescent pregnancy. Research community and state resources devoted in adolescent pregnancy and describe at least two of these resources. Research the teen pregnancy rates for the last 10 years for your state and community. Has this rate increased or decreased? Discuss possible reasons for an increase or decrease.
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Adolescent pregnancy is seen as high-risk, as it causes serious risks for both mother and baby. Some of these risk factors include children being born pre-term, have lower birth weight, and higher neonatal mortality. Mothers tend to have greater rates of post-partum depression and are less likely to initiate breastfeeding [1, 2]. May 25, 2016. According to the CDC all sectors of the population communitywide should all make an effort to address teen pregnancy prevention.
From 2010Campa to 2015, nine state-and community-based organizations and five national organizations were funded by cooperative agreement, Teen Pregnancy Prevention. The state- and community-based grantees, in turn, provide training and technical assistance to youth-serving organizations and partners. National resource, National Campaign to Prevent Teen and Unplanned Pregnancy. Its mission is promoted through, Raising awareness through affiliation with the media, policy makers, and influential leaders.
Promote discussion about prevention of teed and unplanned pregnancy and Develops and distributes materials including pamphlets and online information. State resource, Human services help people find stability, and can include everything from providing for basic needs like food and shelter with the goal of promoting self-sufficiency.
Over the last ten years, California’s females ages 15-19 increased by 15% between 2000 and 2016 the number of births in this population decreased by 61%. Although reasons for the decline are not totally clear, evidence suggests these declines are due to more teens abstaining from sexual activity, and more teens who are sexually active using birth control than in previous years.
References
Parenting in the digital age
https://cdc,gov> teen pregnancy
Centers for Disease Control and Prevention
WWW.Humanservicesedu.org
Health History Assessment
Health risk assessment is an important component in nursing practice. Health risk assessment enables nurses to identify the factors contributing to a patient’s health problem alongside the associated risks. The information for health risk assessment is obtained when performing a comprehensive health history taking from the patients.
Health history taking entails the use of both subjective and objective assessments to understand the experiences of a patient with a disease. Subjective assessment entails the information that the patient gives concerning the condition while the nurse obtains objective data through further clinical investigations (Ball et al., 2019).
Effective interviewing techniques are important in obtaining the information that is needed from the 76-year-old black male with disabilities living in an urban setting. One of the interviewing techniques that I will use in obtaining information from the client is the use of open-ended questions. I will use open-ended structured questions to enable the patient to provide detailed information concerning his health problem.
Open-ended questions will also enable the identification of additional factors that influence the experiences of the patient with the disease. The other approach to interviewing the patient that I will embrace will be asking questions that are specific to the condition of the patient. The questions that are asked should relate to the presenting complaint of the patient to ensure that adequate and objective information related to the health problem is achieved as possible.
The other interviewing technique that I will embrace in the assessment of the patient in the case study is promoting privacy during the assessment. I will ensure that the environment where the assessment takes place is free from interruptions (Slade & Sergent, 2021). Privacy is important in the assessment process, as it builds the confidence in the patient.
The use of effective communication techniques will also be important in obtaining relevant information related to the disease from the patient. I will utilize a number of communication techniques in the process. One of the communication techniques will be active listening. Active listening enables the acquisition of information related to the critical issues that affect the disease process. I will also establish rapport to build confidence in the patient. Building rapport also sets the tone of the interview alongside promoting honesty in communication with the patient.
The other communication technique that I will use in patient assessment is empathy. Empathy is a communication technique where the nurse places himself in the situation of the patient. Empathy is important in history taking and patient assessment because it allows the patient to feel that the nurse understands his experiences, thereby openness and honesty in his self-expression (Ball et al., 2019). Therefore, the effective use of the above communication techniques will enable the acquisition of accurate data that relates to the patient’s health status.
An effective tool that can be used in assessing the patient in the case study is pain-rating scale. The pain rating scale can be used to assess the subjective pain rating of the patient to determine the interventions that should be embraced. The following is a category of questions that I will ask the patient with the aim of understanding his health problem.
- Please tell me what brings you to the hospital today?
- How long have you had the problem?
- Can you describe the characteristics of the problem such as location, relieving factors and precipitating factors?
- What are some of your values and beliefs that I should be aware of when planning the plan of care for your health problem?
- Do you think you have adequate support in your family and society that will enable you to manage the disease effectively?
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s Physical Examination Handbook: An Interprofessional Approach. Elsevier.
Slade, S., & Sergent, S. R. (2021). Interview Techniques. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK526083/
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.”
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
TO PREPARE
- Review this week’s Learning Resources as well as the Taking a Health Historymedia 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 Orientationmedia 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 (Required, you will not be able to access the Health History without completing the requirements).
- DCE Orientation (15 minutes)
- Conversation Concept Lab (50 minutes, Required)
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 total score of 80% or better(includes BOTH DCE and Documentation), but you must take all attempts by the Week 4 Day 7 deadline.
SUBMISSION INFORMATION
No Assignment submission due this week but will be due Day 7, Week 4.
DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT
In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCE
TO PREPARE
- Review this week’s Learning Resources as well as the Taking a Health Historymedia program in Week 3, 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.
- Review the DCE (Shadow Health) Documentation Template for Health History found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Shadow Health Student Orientationmedia 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.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE HEALTH HISTORY ASSESSMENT:
Complete the following in Shadow Health:
Orientation
- DCE Orientation (15 minutes)
- Conversation Concept Lab (50 minutes, Required)
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 a total of 80% or better (this includes your DCE and your Documen