Health Screening And History Of An Adolescent Or Young Adult Client assignment

NRS 434 Health Screening And History Of An Adolescent Or Young Adult Client

Health Screening And History Of An Adolescent Or Young Adult Client Details:

In this assignment, you will be completing a comprehensive health screening and history on a young adult. To complete this assignment, do the following:

Select an adolescent or young adult client on whom to perform a health screening and history. Students who do not work in an acute setting may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one.

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Complete the “Health History and Screening of an Adolescent or Young Adult Client” worksheet.

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Complete the assignment as outlined on the worksheet, including:

  • Review of systems
  • Biographical data
  • Past health history
  • Family history: Obstetrics history (if applicable) and well young adult behavioral health history screening
  • All components of the health history
  • Three nursing diagnoses for this client based on the health history and screening (one actual nursing diagnosis, one wellness nursing diagnosis, and one “risk for”
    health screening and history of an adolescent or young adult client
    Health Screening And History Of An Adolescent Or Young Adult Client

    nursing diagnosis)

  • Rationale for the choice of each nursing diagnosis.
  • A wellness plan for the adolescent/young adult client, using the three nursing diagnoses you have identified.

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Use correct acronyms or abbreviations when indicated.

APA format is required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

NRS 434V Week 4 Discussion 1

Using the patient information provided, respond to the following questions: (a) What cultural considerations are important for you to remember while you interview Ms. Li? (b) What is the Abuse Assessment screen? (c) If abuse is discovered, what should you do? NRS 434 Benchmark Assignment Health Screening and History of an Adolescent or Young Adult Client Essay. Health Screening And History Of An Adolescent Or Young Adult Client

Patient Information:

Patient: Sue Li

Age: 20

Ethnicity: Asian American


NRS 434V Week 4 Discussion 2

For the middle-aged adult, exercise can reduce the risk of various health problems. Choose three health issues that regular physical exercise and activity can help prevent and manage. Discuss the prevalence of each of these health problems in society today. Describe measures that you would take as a nurse to assist clients with health promotion measures to incorporate exercise and physical activity into their lives. Include the kind of activities you would recommend, the amount of exercise, and the approach you would use to gain cooperation from the client. Support your response with evidenced-based literature.

Health History and Screening of an Adolescent or Young Adult Client

Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include the relevant data for your client.
Student Name: Date:
Biographical Data
Patient/Client Initials: CBM Phone No:
Address: 777 Brockton Avenue, Abington MA 2351
Birth Date:10/10/1994 Age: 24 Sex: Female
Birthplace: Abington, MA Marital Status: Single
Race/Ethnic Origin: Asian-American
Occupation: College student at Massachusetes’ Institute of Technology Employer: Caregiver for aunt with stroke
Financial Status:
• Se stays with his parents and depends on his father’s health insurance plan. The parents give her financial support.

Source and Reliability of Informant:
• The patient is a reliable source whose Pt. is A/Ox4

Past Use of Health Care System and Health Seeking Behaviors:
• Not Applicable

Present Health or History of Present Illness: Abdominal pain/ intsene cramps, and menstral cycle with abnormal bleeding

Past Health History
General Health: (Patient’s own words)
• “Moderate exercises 2 times per week”

Allergies: (include food and medication allergies) NRS 434 Benchmark Assignment Health Screening and History of an Adolescent or Young Adult Client Essay
• NKDA Reaction:
• None
Current Medications:
• PRN Benadryl

• Claritin for Seasonal Allergy.

• Percocet 5/325 1 Tab PO q 4-6 hrs for PRN pain.

Last Exam Date:
• 10/20/2017 Immunizations:
• IUTD’s immunizations up-to-date

Childhood Illnesses:
• Dental carries
Serious or Chronic Illnesses:
• None
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
• Annual physical exam alongside Breast and Pap smear exam
Past Accidents or Injuries:
• Left leg fracture at the age of 10

Past Hospitalizations:
• ER visit for abdominal bleeding and pelvic pain

Past Operations:
• None
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): MOTHER
Asthma: NONE
Blood Disorders: PATER
Breast Cancer: MATERNAL AUNT
Cancer (Other): NONE
Cerebral Vascular Accident (Stroke): MATERNAL GRANDFATHER
Diabetes: NONE
High Blood Pressure: NONE
Immunological Disorders: PATERNAL GRANDMOTHER
Kidney Disease: NONE
Seizure Disorder: NONE
Tuberculosis: FIRST COUSIN, 7/2015
Obstetric History (if applicable)
Gravida: NONE Term: NONE Preterm:NONE Miscarriage/Abortions: NONE
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):
• N/A

Well Young Adult Behavioral Health History Screening
Socio-Demographic Content and Questions:

What organizations or activities (community, school, church, lodge, social, professional, academic, sports) are you involved in?
• Full time student at MIT, MA
• Cheerleader for the college’s football team
• Goes to chrch weekly

How would you describe your community?
• Conservative, and Safe

Hobbies, skills, interests, recreational activities?
• Dancing, reading, and watching movies

Military service: Yes_______ No____X___
If yes, overseas assignment? Yes________ No_____X____

Close friends or family members who have died within past 2 years?
• Maternal grandfather

Number of relatives or close friends in this area?

• Most of the extended family- around 7


Marital status: Single__X____ Married________Divorced_________Separated_________
In serious relationship________ Length of time_________

Environmental Content and Questions:

Do you live alone? Yes________ No ____X____

When did you last move?
• 2010, moved to a bigger home

Describe your living situation?
• I stay with both parents, alongside 4 siblings plus an aunt

Number of years of education completed?
• Finiahed high school when I acquired diploma in 2014
• Full time college student with possibility to graduate in 2020

If employed, how long?
• 1 month
Are you satisfied with this work situation?
• NO
Do you consider your work dangerous or risky?
• NO
Is your work stressful?
• NO
Over the past 2 years have you felt depressed or hopeless?
• NO


Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No____X____

How much?
Less than ½ pack per day_N/A____ About 1 pack per day?____N/A__ More than 1 and ½ packs per day____N/A__

Are you smoking now? Yes_______ No___X_____ Length of time smoking? ___X___________

Have you ever smoked illicit drugs? Yes__________ No______X___

If yes, for how long? ___N/A________ Do you smoke these now? Yes__________ No ____X______

Do you ingest illicit drugs of any kind? Yes_________ No___X_______
If so, what drugs do you use and what is the route of ingestion?____N/A_____
How long have you used these drugs ______N/A___________


Review of Systems
(Include both past and current health problems. Comment on all present issues.)
General Health State (present weight – gain or loss, reason for gain or loss, amount of time for gain or loss; fatigue, malaise, weakness, sweats, night sweats, chills ):
• 114 lbs
• Weight constant
• Denies chills, night sweats, sweats, malaise, fatigue

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):
• Sin-moist, intact, clear complexion
• Denies moles, pigment or color changes
• Lacks bruising, dryness

Health Promotion (Sun exposure? Skin care products?):
• Oil of Olay, skin moisturizers
• Daily sunscreen use
• Uses lotion to moisturize skin after showers

Hair (recent loss or change in texture):
• Denies hair loss ot texture change

Health Promotion (method of self-care, products used for care):
• Daily grooming and washing
Nails (change in color, shape, brittleness):
• Denies color change, nails are long and well-manicured

Health Promotion (method of self-care, products used for care):
• Trims and grooms the nails herself
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):
• Frequent headaches accompany menstrual cycle
• Denies vertigo, syncope, head injury
Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):
• Denies glaucoma, swelling, redness, eye pain, vision changes
• 20/20 eye vision
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
• Conducts annual eye exam
• Last checked on 8/2017
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):
• Ear arches during childhood
• Denies vertigo or tinnitus, discharge

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
• Outpatient childhood tube placement surgery
• Q tips to remove dirt from the oter ears
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):
• Experiences Seasonal allergies
• Denies discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, change in sense of smell. Health Screening And History Of An Adolescent Or Young Adult Client

Health Promotion (methods for cleaning nose):
• Uses Ocean spray
• OTC Clatrin PRN or Benadryl
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):
• Denies everything

Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):
• Daily dental care-brushing
• Denies using prosthetics
• Last dental checkup August, 2017
Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):
• Denies everything
Neurologic System (history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalities, paresthesia, mood change, depression, memory disorder, history of mental health disorders):
• Denies everything

Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):
• Doing Yoga
Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):
• Denies everything

Health Promotion (last blood glucose test and result, diet):
• Last glcose test 1/2018, 7.8 mmol/L 2 hors after a meal
• Diet, healthy, comprises frits, vegetables, lean meat
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):
• Tenderness dring menses
• Denies the rest

Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):
• Performs breast self-exam
• Last mammogram 12/10/ 2017, normal
• N/A for selfcare
Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):
• Denies everything bar non-prodctive cogh dring episodic allergies

Health Promotion (last chest x-ray, smoking cessation):
Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):
• Denies CP, Angina, MI
Health Promotion (last cardiac exam):
• N/A
Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):
• Denies N/T-all extremities
• +CMS-all extremities

Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):
• Avoids lengthy sittings
Hematologic System (bleeding tendency of skin or mucous membranes, excessive bruising, swelling of lymph nodes, blood transfusion and any reactions, exposure to toxic agents or radiation):
• BRC, negative
• Denies pain, lymph swelling, and bleeding

Health Promotion (use of standard precautions when exposed to blood/body fluids):
• N/A
Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyrosis, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):
• Heightened appetite
• Denies the rest

Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):
• Eats balanced diet
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):
• ROM, fll active
• Denies joint pain, arthritis, limitation of motion, muscle weakness

Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):
• Moderate workout in the gym
• Walking exercises
Urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence; history of urinary disease; pain in flank, groin, suprapubic region or low back): Health Screening And History Of An Adolescent Or Young Adult Client
• Denies everything

Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):
• Does Kegel exercises
Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):
• N/A

Health Promotion (performs testicular self-exam):
• N/A
Female Genital System (menstrual history, age of first menses, last menstrual cycle, frequency of cycles, premenstrual pain, vaginal itching, discharge, premenopausal symptoms, age at menopause, postmenopausal bleeding):
• Menses began at age 12
• Last menstral cycle 5/16/ 2018
• Menorrhagia alonsgside severe abdominal pain and corps ovaria cyst
Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):
• Last pap smear 12/2017
Sexual Health (presently involved in relationship involving intercourse or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD):
• Denies all

Health Promotion (safe-sex practices):
• Abstinence till marriage
Nursing Diagnoses:

Based on this health history and health screening, identify three nursing diagnoses that would be applicable for this client as well as your rationale for your selection of each nursing diagnosis. Include:

One “actual” nursing diagnosis with rationale for choice of this diagnosis. Health Screening And History Of An Adolescent Or Young Adult Client

CBM suffers from iron deficiency anemia related to ineffective tissue perfusion leading to decreased concentrations of red blood cells and haemoglobin.

The diagnosis will involve iron supplements or iron addition to the diet. The iron will be combined with calcium so as to correct the anemic condition. Shold the two supplements fail to produce the desired results, then additional tests and different treatment plans will be established. The tests may be important in determining the exact cause of the anemia including new bleeding or incapacity to absorb iron from pills by the body (Abdulmajeed et al., 2018).

One wellness nursing diagnosis with rationale for choice of this diagnosis.

Activity intolerance related to uterine contractibility, hypersensitivity, and acute pain.

CBM will need to learn relaxation techniqes , deep breathing, imagination, guidance and visalization techniques so as to redce the pain by offering distraction (Souza et al., 2014).

One “risk for” nursing diagnosis based on the health screening with rationale for choice of this diagnosis.

CBM is at risk of deficient fluid volume related to the bleeding.

She will have to monitor her periods by jotting their dates and heaviness. This will be done by counting the number of tampons or pads she tilizes weekly or daily, the frequency of chaging the tampons or pads-if it is more than 2 hours or if the shep passes large clots (Sparks & Taylor, 2014). Should these observations be made, then she is experiencing heavy bleeding and shoud contact her phsycian immediately. Health Screening And History Of An Adolescent Or Young Adult Client

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