Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

April 5, 2022
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Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

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Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

HPI

Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.

Assignment 2: 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.

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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.
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

Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N-32

Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N-32

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 copy and
paste the same Documentation Notes into your Assignment submission link below.
 Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.

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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 participate in this Assignment:
Week 4 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 4 Assignment 2 DCE Student Acknowledgement Form

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

 

Learning Resources

Required Readings (click to expand/reduce)
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 five images of different skin conditions. You will
use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
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.

Document: DCE (Shadow Health) Documentation Template for Health
History (Word document)
Use this template to complete your Assignment 2 for this week.

Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the
diagnosis of skin and nail disorders. The chapter supplies descriptions and
pictures of common skin and nail conditions.
Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from
https://web.archive.org/web/20170215015223/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/a
bsorbable_suture_chart.pdf
Ethicon, Inc. (2006). Dermabond topical skin adhesive application
technique. Retrieved from
https://web.archive.org/web/20150921174121/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/d
b_application_poster.pdf
Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from
https://web.archive.org/web/20150921171922/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/n
eedle_template.pdf
Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from
https://web.archive.org/web/20150921202525/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/s
uture_chart_ethicon.pdf
Ethicon, Inc. (2002). How to care for your wound after it's treated with
Dermabond topical skin adhesive. Retrieved from
https://web.archive.org/web/20150926002534/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/d
b_wound_care.pdf

Ethicon, Inc. (2005). Knot tying manual. Retrieved from
https://web.archive.org/web/20160915214422/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/k
not_tying_manual.pdf
Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from
https://web.archive.org/web/20170829043048/http://academicdepartments
.musc.edu/surgery/education/resident_info/supplement/suture_manuals/et
h

Required Media (click to expand/reduce)

Module 3 Introduction

Dr. Tara Harris reviews the overall expectations for Module 3. Consider
how you will manage your time as you review your media and Learning
Resources for your Discussions, Case Study Lab Assignments, DCE

Assignments, and your Midterm exam (12m).

Accessible player
Online media for Seidel's Guide to Physical Examination
In addition to this week's media, it is highly recommended that you access and
view the online resources included with the text, Seidel's Guide to Physical
Examination. Focus on the videos and animations in Chapter 8 that relate to the
assessment of the skin, hair, and nails.
Note: To access the online resources included with the text, you need to
complete the FREE online registration that is located
at https://evolve.elsevier.com/cs/product/9780323172660?role=student .
To Register to View the Content
1. Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
2. Enter the name of the textbook, Seidel's Guide to Physical Examination (name of
text without the edition number) in the Search textbox.
3. Complete the registration process.
To View the Content for this Text
1. Go to https://evolve.elsevier.com/
2. Click on Student Site.
3. Type in your username and password.
4. Click on the Login button.
5. Click on the plus sign icon for Resources on the left side of the screen.
6. Click on the name of the textbook for this course.
7. Expand the menu on the left to locate all the chapters.
8. Navigate to the desired content (checklists, videos, animations, etc.).

Note: Clicking on the URLs in the APA citations for the Resources from
the textbook will not link directly to the desired online content. Use the
online menu to navigate to the desired content.
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture,
as well as the vertical and horizontal mattress suturing techniques
Tulane Center for Advanced Medical Simulation & Team Training. (2010,
July 8). Suturing technique [Video file]. Retrieved from

Note: Approximate length of this media program is 5 minutes.
Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical
mattress, horizontal mattress [Video file]. Retrieved from

Note: Approximate length of this media program is 9 minutes.
Incision and Drainage of an Abscess (a common procedure in primary
care)
New England Journal of Medicine (NEJM). (2013, September 30). NEJM
abscess incision and drainage [Video file]. Retrieved from

q4–Vf2NYfUANEyObfeNm&index=8
Note: Approximate length of this media program is 10 minutes.
Dermablade Use for Shave Biopsies
Dermablade®. (2012, November 9). PersonnaBlades [Video file].
Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ
Note: Approximate length of this media program is 5 minutes.

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.

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