Feb 23, 2024 NURS 6512 Health History Assessment
NURS 6512 Health History Assessment
NURS 6512 Health History Assessment
SUBJECTIVE DATA:
The patient is Tina Jones 28 years of age who came to the facility in regards to a scrape on her foot that is not healing as expected that she got due to an accident. She does not live alone but together with her sister and her mother. She is a student who is studying bachelor in accounting. Furthermore, she is working at company known as Mid- American Copy & Ship as a supervisor.
In terms of a relationship she does not have a boyfriend and reports she has not been sexually active for about 2 years. Apart from those she lives with her family further consists of a brother, a maternal grandmother and paternal grandparents. She lost her father due to a road accident and reports that her maternal grandfather also passed away.
Chief Complaint (CC): Pain on her foot due to a scrape that has persisted and won’t heal on its despite wound care.
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History of Present Illness (HPI):
Patient has come into the facility due to a scrape on her foot that isn’t healing normally despite appropriate interventions and is also giving her pain. She ranks the pain at 7 out of a scale of 1-10 and reports the pain is aggravated by when she attempts to stand while her pain medication tramadol provides partial relief. The wound was a result of scrapping it on a cement step the previous week.
After that she did go to the emergency room and has been taking tramadol pills as part of pain management. Her wound care consists of using bandages together with neosprin. She is not able to engage in activities of daily living as before as her ability to walk has been impaired thus limiting her in tasks she could perform.
Medications:
90 micrograms inhaler taking 2 puffs per required need for asthma treatment
50 mgs tramadol taken orally two pills three times daily
Patient was prescribed metformin but is no longer compliant with that medication
Allergies:
Patient reports she is allergic to cats that causes wheezing, sneezing and itchy eyes
Patient reports she is allergic to dust that causes wheezing, sneezing and itchy eyes
Patient reports she is allergic to penicillin that in her childhood caused hives.
Past Medical History (PMH):
Patient reports she has been previously diagnosed with asthma
Patient reports she has been previously diagnosed with diabetes type 2
Patient reports she is not compliant with her diabetes medication that she last took 3 years ago and her management involves not taking sweets and diet soda.
Patient reports she does not regularly monitor her glucose levels.
Patient reports her last asthma attack was in high school.
Patient reports exacerbation 3 days ago
Patient reports she uses an inhaler for her asthma per required need.
Patient reports dust, cats and running up the stairs can trigger her asthma.
Past Surgical History (PSH):
Patient has not had a surgical procedure before.
Sexual/Reproductive History:
Patient reports her last sexual activity was about 2 years ago, she is not currently in a relationship and has had 3 previous sexual partners.
Patient reports not to be under any current form of contraception.
Patient reports previous condom and oral birth control use.
Personal/Social History:
Patient reports to take alcohol though when her friends are around.
Patient reports previous marijuana use that she no longer takes.
Patient reports an increase in appetite.
Patient reports not to have stress
Patient denies to take tobacco.
Patient denies caffeine consumption.
Immunization History:
Patient reports to have had all her childhood vaccines and is up to date with current vaccines she is supposed to take.
Health Maintenance:
Patient reports that she is no longer compliant with her diabetes medication and
NURS 6512 Health History Assessment
her management from the condition involves not taking sweets and drinking diet soda instead of regular.
Patient reports to manage her pain due to the scrape in her foot she takes tramadol pain pills and wound care that involves bandages applied with neosprin.
Patient reports asthma management that involves use of an inhaler per required need and staying away from her asthma triggers.
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):
Patient reports a family history of high cholesterol and high blood pressure from her parents, maternal as well as paternal grandparents.
Patient reports a family high history of diabetes that her father had.
Patient reports that her sister had been diagnosed with asthma
Review of Systems
General: Patient reports an occurrence of weight loss, fever and fatigue.
HEENT: Patient reports occasional headaches, blurry vision but reports no ear pain, nosebleeds or sore throat
Neck: Patient reports no neck problems
Breasts: Patients reports having regular breast exams with no problems noted.
Respiratory: Patient reports at the time no wheezing, chest tightness or pain while breathing.
Cardiovascular/Peripheral Vascular: Patient reports no palpitations or edema.
Gastrointestinal: Patient reports no nausea or vomiting.
Genitourinary: Patient reports increased urine frequency though no blood in the urine
Reproductive: Patient reports irregular periods.
Musculoskeletal: Patient reports no swelling of joints, no back pain and no pain in the joints
Psychiatric: Patient denies having suicidal ideations.
Neurological: Patient denies having seizures, tingling or feeling dizzy.
Skin: Patient reports having acne, dry skin at times, excessive hair in the body and moles.
Hematologic: Patient reports not having excessive bleeding.
Endocrine: Patient reports not having issues in her thyroid.
Health assessment of the skin, hair and nails can reveal other underlying health condition of the patient. It is believed that the physical assessment skills are core to early detection of changes in the patient’s conditions (Douglas et al., 2016). The case in point is Mr. Jeremiah Jergens who is 54 years old. The patient complains of small raised patches on the lower back that have an itching sensation.
History of Present Illness (HPI)
The patient reports to the healthcare facility and presents a case where he has a large cluster of raised patches on the lower back. The patches are thick and red in coloration. The patient notes that he first observed the patches four years ago. This came about after he had just recovered from the throat infection. Additionally, he mentions of a feeling of itchiness and the patches feel tender and flaky. He also mentions that the patches bleed when he scratches them off. This condition makes him embarrassed because of how the skin looks like and is not comfortable at removing his shirt off especially when he visits the beach.
The patient reports of stiffened joints at the knees and fingers and the back during the morning hours but they become flexible after some movement. In order to relieve the pain at the joints he uses Tylenol, while also using Benadryl ointment for the itching sensation. However, he notes that the medication is not very effective because he feels minimal improvement after using the medication. The discomfort at the morning is rated at 7/10 but it reduces and in the day he rates it at 4/10.
Medication
The patient current medication includes; Tylenol 500mg PO taken once daily in the morning, Benadryl Extra Strength topical ointment, Aspirin 325mg PO once daily, Atenolol 75mg PO twice daily, men’s multivitamin once daily and Epi-pen.
Allergies
The patient presents allergic reactions on exposure of penicillin which triggers skin rushes. This is a mild allergic reaction and can be easily managed by use of antihistamine (Patterson & Stankewicz, 2020). He also experiences anaphylactic shock on exposure to salmon. Additionally, he experiences lip itching when exposed to peaches.
Past Medical History (PMH)
The patient reports of having suffered from chicken pox at the age of 5 years. In the recent years, from age of 50 years he has had a recurrent streptococcal pharyngitis. The patient also reports of a history of morbid obesity. People with morbid obesity have reported physical and physiological conditions coupled with reduced quality of life (Yazdani et al., 2020).
Past Surgical History (PSH)
The patient reports of having a tonsillectomy at the age of about seven years, appendectomy at the age of 23 years old, vasectomy at age of 32 years old and recently he underwent a gastric bypass surgery at the age of 52 years old.
Sexual/ Reproductive History
Mr JJ is heterosexual and he underwent a vasectomy operation at age of 32 years old.
Personal/ Social History
The patient has a long history of smoking that spans over 31 years. He smoked an average of 2.5 packets per day. However, he ceased the smoking habit for the past eight months. He is a social drinker who occasionally consumes alcohol during social outings. The patient denies abusing any hard drugs or substances. Mr JJ reports of an improved diet with healthy eating habits since he underwent a gastric bypass surgery and exercising five days a week. He reports of enjoying a number of physical activities like hiking and riding his motorcycle. The patient also mentions that he spends some time at the beach with his five grandchildren.
Immunization History
He received all the required immunizations from the early age. He accepts to take the influenza and pneumococcal immunization today.
Significant Family History
The patient reports maternal family history of diabetes and hypertension. The mother was diagnosed with diabetes at her late 30s.His maternal grandparents, mother and brother were diagnosed with hypertension in their late 30s. The patients paternal grandfather and father were diagnosed with arthritis in their late 40s. The father was also diagnosed with psoriasis. His two daughters and grandchildren are healthy.
Lifestyle
Mr. JJ has been married for the past 32 years. They have travelled a lot in the country on their motorcycle and RV. He bought a home in the suburbs 28 years ago. He retired from the US marine 25 years ago and entitled to an annual benefit $ 75,000. He is also entitled to a social security benefit.
Therefore, he has no financial problem. His firstborn daughter has 2 children of ages five and twelve. They live in a rented basement. Since his gastric bypass surgery, he has had an improved diet with less of meat but more of vegetables. He has lost about 143lbs of his body weight. This has improved his blood pressure condition and currently only take one blood pressure medication down from the two medication of five days a week.
He regularly does exercise at the YMCA grounds. He attends church twice a week for Bible study that is; Mondays and Thursdays. He is socially active, with good relationship with friends and family. Additionally, he is tasked with the responsibility of leading the marriage ministry to guide the newlyweds.
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.
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 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 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.
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 Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 4
Complete your Health Assessment DCE assignments in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
Complete the Code of Conduct Acknowledgement.
Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Grading Criteria
To access your rubric:
Week 4 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 4
To submit your Lab Pass:
Week 4 Lab Pass
To submit this required part of the Assignment:
Week 4 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement:
Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
Assignment 3 (Optional) Practice Assessment: Skin, Hair, and Nails Examination
Advanced practice nurses are required to have the skills and knowledge necessary to perform many different physical assessments and health examinations. In this course, you will demonstrate your abilities in this area by conducting various optional examinations on a volunteer “patient.”
In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due in Week 9, it is recommended that you practice conducting an assessment of the skin, hair, and nails this week.
Note: This is an optional practice physical assessment.
To Prepare
Arrange an appropriate time and setting with your volunteer “patient” to perform a skin, hair, and nails examination.
Download and review the Skin, Hair, and Nails Student Checklist and Key Points, provided in this week’s Learning Resources, and review the Seidel’s Guide to Physical Examination online media.
Optional Lab Assignment
Perform the skin, hair, and nails examination, covering all of the areas listed in the checklist.
What’s Coming Up in Week 5?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you examine how to properly assess the head, neck, eyes, ears, nose, and throat in order to form accurate diagnoses as you complete your Case Study Assignment of the Skin, Hair, Nails, and HEENT. You will once again complete a DCE related to a Focused Exam for cough. Make sure to plan ahead with your Please plan your time accordingly.
Week 5 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Case Study Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these videos and animations to complete your Assignment on time.
Next Week
To go to the next week:
Week 5
Week 4: Assessment of the Skin, Hair, and Nails
Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in
skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.
This week, you will explore how to assess the skin, hair, and nails, as well as how to evalua
te abnormal skin findings.
Learning Objectives
Students will:
Apply assessment skills to diagnose skin conditions
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
Analyze dermatologic procedures to include skin biopsy, punch biopsy, suture insertion and removal, nail removal, skin lesion removal
Learning Resources
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NURS 6512 Health History Assessment
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 9, “Skin, Hair, and Nails”This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
This section explains the procedural knowledge needed prior to performing various dermatological procedures.
Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
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 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (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.
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 Weeks 1 and 3)
VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals
This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282.
Document: Skin Conditions (Word document)
This document contains images of different skin conditions. You will use this information in this week’s Discussion.
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