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

Digital Clinical Experience (DCE) allows nursing students to simulate their clinical practice in a virtual environment. This approach encompasses various tasks allowing students to apply theoretical knowledge in realistic, simulated scenarios while providing feedback on performance, all without personal interactions with patients. DCE trains the critical thinking, assessment, and decision-making skills that connect classroom learning to clinical practice. The complexities of gathering and interpreting information from a patient may present challenges to nursing students.

This guide will provide you with an example case, some helpful tips for asking the right questions, and strategies on how best to analyze responses. With this support, you'll have everything you need to succeed in your assignment and strengthen your clinical skills for the future.

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

Name:

Section: 

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 reported that one week ago, she tripped and fell while walking on stairs outside, causing her right ankle to twist and the ball of her foot to scrape. She went to the emergency room at a nearby hospital, where x-rays came back negative, and she was prescribed tramadol for pain relief. She has been cleaning the wound twice daily, using an antibiotic medication and bandaging it.

She adds that the pain and swelling in her ankle have decreased, but the bottom of her foot is becoming more uncomfortable. She describes the pain as throbbing and sharp when bearing weight. She mentions that her ankle ached but is feeling better now. After the latest dose of tramadol, the pain level decreased to 7 out of 10. Pain when bearing weight is 9 out of 10. She notes that the ball of her foot has become more swollen and red over the past two days, and yesterday, she noticed discharge coming from the wound.

She also reports that the swelling has worsened. She claims that there is no smell coming from the wound. Her shoes appear to be too small, and she has been wearing shoes without laces. Last night, she had a temperature of 102°F. She denies any recent illness. She also reports an increased appetite and an unintended weight loss of 10 pounds over the last month, with no changes to diet or physical activity.

Medications:

• Acetaminophen 500-1000 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 around cats; most recent use was three days ago)

Allergies:

• Rash caused by penicillin
• Allergic to cats and dust but not food or latex sensitivities. Claims that allergens cause runny nose, itchy and swollen eyes, and increased asthma symptoms.

Past Medical History (PMH):

• Asthma diagnosed at age 2.5 years, uses albuterol inhaler around cats or dust, typically 2-3 times per week. Last asthma-related hospitalization was in high school; never intubated.
• Type 2 diabetes diagnosed at age 24. Discontinued Metformin 3 years ago due to side effects (gas and stress). Does not monitor blood sugar. Her blood sugar was elevated in the ER two weeks ago.
• No surgeries.
• Hematologic: Acne since adolescence; bumps on the backs of her arms when skin is dry. Darkening of the skin on her neck and increased hair growth on her face and body. Several moles, no changes to her hair or nails.

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

Sexual/Reproductive History:

• Menarche at age 11.
• First sexual experience at age 18; has had encounters with men and identifies as straight.
• Never pregnant.
• Last menstruation was three weeks ago. Menstrual cycles have been erratic over the past year (every 4-6 weeks) with heavy bleeding lasting 9-10 days.
• No current partner. Used oral contraceptives when younger but did not use condoms during sexual activity.
• Never had an HIV/AIDS test. No history of sexually transmitted infections or symptoms. Last test was four years ago.

Personal/Social History:

• Never married, no children.
• Has lived independently since age 20, currently living with mother and sister in a single-family home for support after father passed away a year ago.
• Works 32 hours per week as a supervisor at Mid-American Copy and Ship, recently promoted to shift supervisor.
• Attends school part-time and is in the final semester of a bachelor’s degree in accounting.
• Plans to become an accountant for her current employer.
• Owns a car, cellphone, and computer.
• Covered by employer’s basic health insurance but avoids medical care due to out-of-pocket expenses.
• Enjoys socializing, attending Bible study, and being active in her church’s ministry.
• Describes coping with stress related to the death of her father, job responsibilities, education, and finances, aided by support from family and the church.
• No tobacco use.
• Cannabis use irregularly between ages 15-21.
• Denies use of cocaine, methamphetamines, or heroin.
• Consumes alcohol 2-3 times a month, no more than 3 drinks per occasion.
• Drinks four caffeinated or diet sodas per day.
• No foreign travel.
• No pets.
• No current intimate relationship. Ended a three-year monogamous relationship two years ago.
• Intends to marry and have children in the future.

Health Maintenance:

• Last Pap smear in 2014.
• Last eye exam as a child.
• Last dental exam a couple of years ago.
• PPD test negative less than two years ago.
• No regular exercise.
• 24-hour diet recall: Skipped breakfast yesterday, usually eats baked goods for breakfast, a sandwich for lunch, and either meatloaf or chicken for dinner. Munches on pretzels or French fries.

Immunization History:

• Tetanus booster received in the past year.
• No flu shot or HPV vaccine.
• Up-to-date on childhood vaccinations; received meningococcal vaccine during college.

Safety:

• Does not ride a bike.
• Has smoke alarms at home and always wears a seatbelt while driving.
• Does not use sunscreen.
• Home contains firearms once belonging to her father, securely stored in the room used by her parents.

Significant Family History:

• Mother, 50, has hypertension and high cholesterol.
• Father, deceased at age 58 in a car accident, had hypertension, high cholesterol, and type 2 diabetes.
• Brother, Michael, 25, has obesity.
• Sister, Brittany, 14, has asthma.
• Maternal grandmother, deceased at 73 from a stroke, had hypertension and high cholesterol.
• Maternal grandfather, deceased at 78 from a stroke, had hypertension and high cholesterol.
• Paternal grandmother, 82, has hypertension.
• Paternal grandfather, deceased at 65 from colon cancer, had type 2 diabetes.
• Uncle (paternal side) had alcoholism.
• No history of mental illness, malignancies, unexpected death, kidney disease, sickle cell anemia, or thyroid disorders.

General:

• Reports no recent weight changes, weakness, fatigue, or fever. (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. Eyelashes 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.

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 health 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.

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:

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