Benchmark Assignment – Health Screening and History of an Adolescent or Young Adult Client

Order Description

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.

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

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors.

Complete the assignment as outlined on the worksheet, including:
1.Biographical Data
2.Past Health History
3.Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening
4.Review of Systems
5.Include all components of the health history
6.Use correct acronyms or abbreviations when indicated
7.Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one “Risk For” nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client.
8.Using the three nursing diagnoses you have identified, develop a wellness plan for the adolescent/young adult client

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:    Phone No:
Address:
Birth Date:    Age:    Sex:
Birthplace:                                                          Marital Status:
Race/Ethnic Origin:
Occupation:    Employer:
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

Source and Reliability of Informant:

Past Use of Health Care System and Health Seeking Behaviors:

Present Health or History of Present Illness:

Past Health History
General Health: (Patient’s own words)

Allergies: (include food and medication allergies)

Reaction:

Current Medications:

Last Exam Date:    Immunizations:

Childhood Illnesses:

Serious or Chronic Illnesses:

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:

Past Hospitalizations:

Past Operations:

Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse):
Allergies:
Arthritis:
Asthma:
Blood Disorders:
Breast Cancer:
Cancer (Other):
Cerebral Vascular Accident (Stroke):
Diabetes:
Heart Disease:
High Blood Pressure:
Immunological Disorders:
Kidney Disease:
Mental Illness:
Neurological Disorder:
Obesity:
Seizure Disorder:
Tuberculosis:
Obstetric History (if applicable)
Gravida:    Term:    Preterm:    Miscarriage/Abortions:
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):

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?

How would you describe your community?

Hobbies, skills, interests, recreational activities?

Military service: Yes_______ No_______
If yes, overseas assignment? Yes________ No_________

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

Number of relatives or close friends in this area?

Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________Length of time_________

Environmental Content and Questions:

Do you live alone?  Yes________ No ________

When did you last move?

Describe your living situation?

Number of years of education completed?

Occupation?
If employed, how long?
Are you satisfied with this work situation?
Do you consider your work dangerous or risky?
Is your work stressful?

Over the past 2 years have you felt depressed or hopeless?

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No________

How much?
Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______

Are you smoking now? Yes_______ No________ Length of time smoking?______________

Have you ever smoked illicit drugs? Yes__________ No_________

If yes, for how long? ___________ Do you smoke these now?  Yes__________ No __________

Do you ingest illicit drugs of any kind? Yes_________ No__________
If so, what drugs do you use and what is the route of ingestion?_________
How long have you used these drugs_________________

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 ):

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):

Health Promotion (Sun exposure? Skin care products?):

Hair (recent loss or change in texture):

Health Promotion (method of self-care, products used for care):

Nails (change in color, shape, brittleness):

Health Promotion (method of self-care, products used for care):

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):

Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):

Health Promotion (methods for cleaning nose):

Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):

Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):

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):

Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):

Health Promotion (last blood glucose test and result, diet):

Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):

Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):

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.):

Health Promotion (last chest x-ray, smoking cessation):

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):

Health Promotion (last cardiac exam):

Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or  ulcers):

Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):

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):

Health Promotion (use of standard precautions when exposed to blood/body fluids):

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):

Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):

Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):

Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):

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 Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):

Health Promotion (performs testicular self-exam):

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):

Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):

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):

Health Promotion (safe-sex practices):

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.

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

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

Solution

Health Screening and History of an Adolescent or Young Adult Client

Health Screening and History of an Adolescent or Young Adult Client

Student Name: Makayla Weaverling	Date:11/12/2017
Biographical Data
Patient/Client Initials: CB	Phone No: 814-327-6895
Address: 426 Connecticut Road Osterburg PA 16667
Birth Date: April 22,1996	Age: 21	Sex: M
Birthplace:    Johnstown,PA	Marital Status: Single
Race/Ethnic Origin:  White/Caucasian
Occupation: Mechanic	Employer: Stuckey Subaru
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)  CB lives within his means. Adequate income for lifestyle and no current health concerns. Health insurance is provided by parents. CB is not on any form of disability.
Source and Reliability of Informant:  Per individual and information is reliable.
Past Use of Health Care System and Health Seeking Behaviors:  Flu, Stitches, Oral surgery
Present Health or History of Present Illness:  No illnesses noted.
Past Health History
General Health: (Patient’s own words)  I feel good. I don’t really have any health concerns. I’m not sick and don’t have any diseases.
Allergies: (include food and medication allergies)                   No known allergies,	Reaction:  N/A
Current Medications:  Not on any current medications
Last Exam Date: 5/24/17	Immunizations:  Up to date.
Childhood Illnesses: Flu, nothing serious. No chicken pox or anything else
Serious or Chronic Illnesses:  No serious or chronic illnesses
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:  Four wheeler accident 2012, stitches in neck.
Past Hospitalizations:  Emergency room visit for stitches.
Past Operations:  Oral surgery.
Family History (Specify which family member is affected.)
Alcoholism (ETOH use/abuse): none
Allergies: Mom
Arthritis: grandmother
Asthma:none
Blood Disorders: none
Breast Cancer: none
Cancer (Other): Pap- lung cancer
Cerebral Vascular Accident (Stroke): none
Diabetes: none
Heart Disease: none
High Blood Pressure: step father
Immunological Disorders: none
Kidney Disease: none
Mental Illness: none
Neurological Disorder: none
Obesity: aunt diana
Seizure Disorder: none
Tuberculosis: none
Obstetric History (if applicable)
Gravida: N/A	Term: N/A	Preterm: N/A	Miscarriage/Abortions: N/A
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?  Car groups How would you describe your community?  Slow, not much going on, safe place to live Hobbies, skills, interests, recreational activities? Working on cars, playing XBOX   Military service: Yes_______ No__X_____       If yes, overseas assignment? Yes________ No_____X____   Close friends or family members who have died within past 2 years? Yes, close friend last spring   Number of relatives or close friends in this area?  50+     Marital status:  Single______ Married________Divorced_________Separated_________                           In serious relationship___X_____  Length of time____2.5years_____

Environmental Content and Questions:   Do you live alone?  Yes________ No __X______   When did you last move? February 2017   Describe your living situation? Live with girl friend in parents house.   Number of years of education completed? 14 years   Occupation? Mechanic        If employed, how long? 9 months        Are you satisfied with this work situation? NO        Do you consider your work dangerous or risky? Yes        Is your work stressful? Yes   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?N/A Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______   Are you smoking now? Yes_______ No____N/A____ Length of time smoking? ______________   Have you ever smoked illicit drugs? Yes__________ No___N/A______   If yes, for how long? ____N/A_______ Do you smoke these now?  Yes__________ No ____N/A______   Do you ingest illicit drugs of any kind? Yes_________ No___NO_______ 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 ):  Weight 145 maintained since high school No symptoms listed above

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):  No skin diseases, pigmentation issues, moles, dryness or moisture, no pruritis, bruising, rashes, or lesions.   Health Promotion (Sun exposure? Skin care products?):  Exposed to sun daily encouraged to use sun screen everyday no matter what.

Hair (recent loss or change in texture): no change in amount or texture of hair   Health Promotion (method of self-care, products used for care):  Uses Axe or suave body products and hair care

Nails (change in color, shape, brittleness) : No change in nails   Health Promotion (method of self-care, products used for care): Clips nails as needed

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):  No head related problems.

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts): Only issue is glasses have been prescribed. Doesn’t wear them.    Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection): Encouraged to wear glasses and sun protection.

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo): No ear issues    Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears): encouraged to use ear plugs when in environments with loud noise.

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):  No problems Health Promotion (methods for cleaning nose):  Encouraged to blow nose and keep clean.

Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):  Teeth intact, none missing. No issues Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):  CB brushes teeth twice daily, flossing was encouraged, no dentures required. Dental exam scheduled for next week.

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):  Bubble on right mid neck. No issue. No doctor consult.

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):  No neurological problems Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):  Plays mind game on phone.

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):  No endocrine issues. No heat or cold intolerance Health Promotion (last blood glucose test and result, diet): Last blood glucose unknown

Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):  No problems Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products): Doesn’t preform self breast exam. Encouraged to.

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.):  No history of any lung issues personally. No chest pain or other respiratory symptoms Health Promotion (last chest x-ray, smoking cessation): See family doctor yearly for check up

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):  No cardiac related issues. Health Promotion (last cardiac exam): See family doctor yearly

Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or  ulcers):  No issues Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose): Shouldn’t cross legs, good posture, supportive shoes, change position frequently.

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):  No issues here Health Promotion (use of standard precautions when exposed to blood/body fluids): Personal protection of in contact with blood or body fluids

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):  No GI issues Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives): Provided information on a healthy diet

Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):None noted     Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion): Encouraged to participate in exercise daily even if its just walking.

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):  No issues Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises): Preventative measures for UTI explained.

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):  No male genital issues Health Promotion (performs testicular self-exam):  Encouraged to perform testicular exam

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):  N/A Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products): N/A

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):  Participates in sexual intercourse. Health Promotion (safe-sex practices):  Encouraged to use condoms, contraceptive use, and STD prevention

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:

Readiness for enhanced nutrition- CB doesn’t eat healthy

Disturbed sleep patter- CB stated he may sleep 2-16 hours. Sometimes sleeping during the day and sometimes at night

Deficient fluid volume- doesn’t drink enough fluids and feel parched

One “actual” nursing diagnosis with rationale for choice of this diagnosis.

 Imbalanced nutrition- less than body requirements- according to CB BMI he is underweight for his size and weight.  

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

 Readiness for enhanced health management- CB was unaware of the need for yearly doctor visits, but feels he now knows they are important and has made an appointment

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

 Risk for trauma- related to reckless behavior while using fourhweeler

Wellness plan:

Physical wellness plan is to set goals such as walking more and being more active. CB has plans to get a fitbit and reach goals set on the fitbit app to becoming healthier and improve his physical wellness.

Nutritional wellness goals are to increase intake of healthy foods and decrease on unhealthy foods such as little Debbie and candy. CB has a my plate web address to help guide him through healthy food decision making and portioning.

Mental wellness goals are to set aside time to just relax and not worry about any pressing issues. CB is aware of deep breathing techniques when he feels stressed as well as coping mechanisms such as going for a walk and listening to music.

Spiritual wellness goals are to meditate. He is new to this idea but feels it will give him inner peace. He is planning to set a goal to meditate at least 2-3 time weekly.

To make sure he meet and achieves his wellness plan he has each goal written down with a weekly reflection space beside each goal so he can track his progress and see where changes may need to be added.