Shadow Health Digital Clinical Experience Sample

Subjective Data

Chief Complaint

The patient, Tina Jones, a 28-year-old female, presents within the Elsevier (acquired 2020) Shadow Health platform with a chief complaint of a foot wound. She states, "I got this scrape on my foot a while ago, and I thought it would heal up, but it's gotten worse." Maintaining HIPAA privacy standards is essential during the collection of this subjective data (American Nurses Association, 2015).

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History of Present Illness

Ms. Jones reports the wound on the plantar surface of her right foot occurred approximately 7 days prior to this assessment. She rates the pain as 4/10 on the numeric rating scale, described as throbbing. The pain is exacerbated by bearing weight. This digital clinical experience, utilizing simulation technology initially developed in 2011, requires accurate subjective data collection to formulate appropriate nursing diagnoses (Shadow Health, 2020).

Past Medical History

The patient has a confirmed history of Type 2 Diabetes, diagnosed at age 24. She also reports a history of Asthma since early childhood and Polycystic Ovary Syndrome (PCOS). Adherence to treatment regimens for these chronic conditions is a primary focus for this assessment, directly aligning with QSEN competencies for patient-centered care and safety (Cronenwett et al., 2007).

Medications & Allergies

Ms. Jones is currently prescribed Metformin 850 mg BID for diabetes management. For asthma, she utilizes an Albuterol inhaler 90 mcg/spray PRN and Fluticasone Propionate 88-110 mcg BID. She takes Yaz daily for PCOS and contraception. Over-the-counter medications include Ibuprofen 600 mg PRN for cramps and Acetaminophen 500 mg PRN for headaches. She has a known allergy to Penicillin, which causes a systemic rash. Thorough medication reconciliation is required to prevent adverse drug events (Institute for Safe Medication Practices, 2021).

Review of Systems

General: Denies recent fever, chills, or unexplained weight loss in the past 30 days. Respiratory: Reports occasional shortness of breath when exposed to triggers like cats, managed effectively with Albuterol. Endocrine: Reports increased thirst and frequent urination (polyuria and polydipsia) over the past month, indicative of poor glycemic control.

Objective Data

Vital Signs

• Blood Pressure: 128/82 mmHg
• Heart Rate: 78 bpm, regular rhythm
• Respiratory Rate: 16 breaths/min, unlabored
• Oxygen Saturation (SpO2): 99% on room air
• Temperature: 99.0°F (37.2°C)

General Survey & Skin

The patient is alert, oriented x4, and in no acute distress. The skin is warm and dry, with the exception of the right plantar surface. Examination of the right foot reveals an erythematous wound measuring exactly 3 cm by 2 cm, with mild purulent drainage and 1 cm of surrounding edema. The patient demonstrates physical guarding upon palpation of the affected area.

System-Specific Findings

Respiratory: Lungs are clear to auscultation bilaterally; no wheezing or rhonchi noted during full respiratory cycle. Cardiovascular: S1 and S2 heard clearly; no murmurs, gallops, or rubs. Capillary refill is <3 seconds in upper extremities, but slightly delayed (>3 seconds) in the right lower extremity near the wound site.

Assessment

Nursing Diagnoses

1. Impaired tissue integrity related to compromised peripheral circulation secondary to Type 2 Diabetes, as evidenced by a 3 cm x 2 cm erythematous foot wound with purulent drainage. Strict glycemic control is critical for wound healing in diabetic patients (American Diabetes Association, 2023).

2. Ineffective health maintenance related to deficient knowledge of diabetic foot care and medication adherence.

3. Risk for infection secondary to impaired skin integrity and immunosuppression associated with uncontrolled blood glucose levels (Jarvis, 2019).

Pathophysiology

Type 2 diabetes frequently leads to peripheral neuropathy and microvascular complications, which impair wound healing and increase susceptibility to infection (American Diabetes Association, 2023). The presence of the foot wound in Ms. Jones necessitates immediate intervention to prevent further complications such as osteomyelitis.

Plan

Interventions

1. Wound Care: Cleanse the right foot wound with 0.9% normal saline and apply a sterile, non-adherent dressing daily. Monitor for signs of systemic infection, such as temperature > 100.4°F.

2. Glycemic Management: Monitor blood glucose levels before meals and at bedtime. Educate the patient on the critical importance of taking Metformin 850 mg BID consistently with meals to optimize glycemic control.

Patient Education

Provide comprehensive education regarding diabetic foot care, including daily inspection of feet, wearing well-fitting footwear, and avoiding walking barefoot. Instruction must adhere to AACN Essentials for clinical practice readiness and patient education (American Association of Colleges of Nursing, 2021). Furthermore, reinforce the asthma action plan, emphasizing the correct use of Fluticasone for maintenance and Albuterol for acute exacerbations (National Asthma Education and Prevention Program, 2020).

Follow-up Care

Schedule a follow-up appointment in exactly 7 days to evaluate wound healing progress and review continuous blood glucose logs. Refer to a podiatrist if the wound demonstrates no improvement or signs of deterioration.

References

American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. AACN.

American Diabetes Association. (2023). Standards of Care in Diabetes—2023. Diabetes Care, 46(Supplement_1), S1-S291.

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., ... & Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.

Institute for Safe Medication Practices. (2021). ISMP list of high-alert medications in acute care settings. ISMP.

Jarvis, C. (2019). Physical examination and health assessment (8th ed.). Saunders.

National Asthma Education and Prevention Program. (2020). 2020 Focused Updates to the Asthma Management Guidelines. National Heart, Lung, and Blood Institute.

Shadow Health. (2020). Digital Clinical Experience student manual. Elsevier.