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
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N
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.
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 NURS 6512N
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
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N
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
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
Grid View
List View
Excellent Good Fair Poor
Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score – Do not round up on the DCE score.
56 (56%) – 60 (60%)
DCE score>93
51 (51%) – 55 (55%)
DCE Score 86-92
46 (46%) – 50 (50%)
DCE Score 80-85
0 (0%) – 45 (45%)
DCE Score <79
No DCE completed.
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
You should list these in bullet format and document the systems in order from head to toe.
36 (36%) – 40 (40%)
Documentation is detailed and organized with all pertinent information noted in professional language.
Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
31 (31%) – 35 (35%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
26 (26%) – 30 (30%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
0 (0%) – 25 (25%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
or
No documentation provided.
Total Points: 100
Name: NURS_6512_Week_4_DCE_Assignment_2_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.