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

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.

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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.

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

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.

Targeted Questions

The nurse should ask the patient the following targeted questions:

  1. What are your beliefs and attitude towards the use of medicines for the management of hypertension?
  2. What interventions do you use to manage the symptoms of hypertension?
  3. What do you think are some of the factors that hinder you from adhering to the treatment prescribe for the management of hypertension?
  4. What is the nature of your typical diet in a day?
  5. Do you think that you have adequate support in your society that enables you to manage effectively your condition?


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.

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. Hypertension69(3), 421–427.

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 Journal53(1).

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 Reports21(6), 45.


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Elderly abuse is not only infliting physical pain on the elderly. There was a 90 year old man who was admitted to the hospital where I work last month. His children exhausted his inheritance including estate, and Medicaid program. Before he was brought to the hospital, his children and other family members visited him daily to check on him. They instilled a video camera in his home. The camera that was instilled became their nightmare. One day the patient needed to get up, he could not reach his walker, his children refused to help him, while trying to reach his walker he fell down and broke his ribs. This patient was brought to the hospital, few days later he died. It was through the video that the government found out what really happened to the patient, now the government is after his children

Feb 25, 2022, 11:22 PM


Replies to Mayreth Gonzalez Pena

Hi Mayreth,

Thank you for sharing the experience. Elderly patients get financially exploited by their family members. According to the study performed by (Conrad et al., 2019) cross-sectional data were collected on 948 cases with yes/no substantiation decisions where 357 cases had no abuse in elder mistreatment investigations. Hypotheses were tested using odds ratios, bivariate, and multiple linear regression analyses including a control for victim vulnerability. Of 948 alleged victims, 42 (4.4%) exhibited signs of substance use problems. Among the 323 alleged perpetrators, 87 (26.9%) were reported to have substance use problems. Substance use problems by alleged perpetrators were associated with financial exploitation, physical abuse, and emotional abuse.



Conrad, K. J., Liu, P. J., & Iris, M. (2019). Examining the Role of Substance Abuse in Elder Mistreatment: Results from Mistreatment Investigations. Journal of interpersonal violence34(2), 366–391.


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: Never married and does not have any children. Since the age of 20, has lived on her own, and since her father passed away a year ago, they now share a home with their mother and a sister in a single family dwelling in order to support the family. Currently working as a supervisor at Mid-American Copy and Ship for a total of 32 hours per week. She was just elevated to the position of shift supervisor, which she thoroughly enjoys. She attends school on a part-time basis and is currently in her final semester of work toward obtaining a bachelor’s degree in accounting. She has her sights set on becoming an accountant for the company she currently works for. She is well off as she owns a car, a cellphone and a computer. Even though she is covered by the employer’s basic health insurance, she avoids seeking medical attention because of the out-of-pocket expenses involved. She takes pleasure in socializing with her friends, going to Bible study, being active in the ministry of her church and dancing. Tina has a solid family and social support structure and she is also involved in her local church community. She describes feeling stressed as a result of the death of her father, as well as the responsibilities of her job and education and her financial situation. She states that coping with the stress has been easy because of her family and the church. No tobacco usage. Cannabis use on an irregular basis between the ages of 15 and 21. She denies ever having used cocaine, methamphetamines, or heroine. Utilizes alcoholic beverages “when out with pals, two or three times a month.” and claims to consume no more than three drinks throughout each occasion. She consumes four beverages containing caffeine and diet soda daily. No foreign travel. No pets. She is not in an intimate relationship currently but she completed a significant monogamous relationship that lasted for three years two years ago. It is in her future intentions to start a family by getting married and having children.

Health Maintenance: The most recent Pap smear was performed in 2014. The last eye exam was conducted when she was a child. The last time she had a dental exam was a couple of years ago. PPD test was negative less than two years ago. No workout. 24-hour diet recall: She admits that she skipped her breakfast the day before and that she normally consumes baked good for breakfast, sandwich for lunch and either meatloaf or chicken for dinner. However, she did not have any of these foods yesterday. Her munchies are either usually either pretzels of French fries.

Immunization History: Regarding immunizations, a tetanus booster shot was administered during the past year; however, a flu shot and vaccine against human papillovirus were not given nor received. She states that she feels that she is up to date on all of her childhood vaccines and that she received the meningococcal vaccine while she was in college. Safety: She does not ride a bike, possesses smoke alarms at home, and always puts on seatbelt whilst driving. Does not use sunscreen. The home has firearms that once belonged to her father and are currently secured in the room used by her parents.

Significant Family History: The mother is 50 years old and has hypertension and high cholesterol. Father died in a car accident a year ago at the age of 58; he has hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, age 25), suffers from obesity Sister (Brittany, age 14) struggles with asthma Grandmother on the maternal side passed away at the age of 73 as a result of stroke; she had a history of hypertension and excessive cholesterol. Grandfather on the maternal side passed away at the age of 78 as a result of a stroke; he had a history of hypertension and excessive cholesterol. Grandmother on the father’s side is still alive and has hypertension despite being 82 years old. Grandfather on the father’s side passed away at the age of 65 from colon cancer, family history of type 2 diabetes. Negative for mental illness other malignancies, unexpected death, kidney disease, sickle cell anemia, and thyroid disorders. An uncle on the father’s side had a problem with alcoholism.

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.


  1. Ibuprofen 600mg orally three times each day for menstrual cramps.
  2. Acetaminophen 500-100 mg orally, as needed for headaches.
  3. Tramadol 50 mg orally twice a day if foot pain persists.
  4. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.


  1. There are no documented latex or food sensitivities.
  2. Penicillin hypersensitivity
  3. Establishes dust and cat allergies
  4. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated. When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.

Past Surgical History (PSH): None

Sexual/Reproductive History: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. No reported history of STIs. The patient claims to have never had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.

Personal/Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.

Immunization History: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a teenager.

Health Maintenance: No physical activity. She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped breakfast and had a lunch of a sandwich and chicken or steak for dinner. She brings mostly French fries or pretzels as snacks. Smoke detectors have been put in her home. She admits to wearing a seatbelt in the automobile but denies riding a bike. He denies wearing sunblock. Her father’s firearms are still in the house, but they are locked up in their parents’ room.

Significant Family: The mother, who is 50, has high cholesterol. Her Father died in an automobile accident when he was 58 years old. Diabetes and hypertension were present. Her sister suffers from asthma. Brother has no medical issues. At the age of 73, her maternal granny passed away after a stroke. At the age of 78, her maternal grandfather passed away after a stroke. At the age of 65, her paternal grandfather passed away from colon cancer. Her paternal grandmother is still living. There is no history of addiction, mental health problems, headaches, malignancies, or thyroid problems.

Review of Systems:

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

General: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.

HEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.

Neck: There are no lymphatic problems or inflammation around the neck.

Breasts: There is no nipple discharge or soreness in the breasts.

Respiratory: No breathlessness, chest pain, or tightness.

Cardiovascular/peripheral: There are no blood clots in the cardiovascular or peripheral systems.

Gastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.

Gastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.

Genitourinary: The patient’s periods are irregular.

Musculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.

Neurological: There is no tingling or dizziness.

Skin: Acne-free skin with no chin hair.

Hematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.

                Endocrine: Denies heat or cold intolerance.

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