Adolescent health screenGCU

Health History and Screening of an Adolescent or Young Adult Client

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Student Name: Date: January 28, 2014
Biographical Data
Patient/Client Initials: Phone No: N/A
Address:
Birth Date: Age: 12 Sex: f
Birthplace: Upland, CA. Marital Status: Single
Race/Ethnic Origin: Caucasian
Occupation: Student Employer:N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Insurance provided by parent

Source and Reliability of Informant:
Informant: Client, Reliable

Past Use of Health Care System and Health Seeking Behaviors:
Routine exams and vaccinations

Present Health or History of Present Illness:
Present health is good

Past Health History
General Health: (Patient’s own words)
“I only get sick when my little brother brings something home”

Allergies: (include food and medication allergies)
NKA
Reaction:

Current Medications:

N/A
Last Exam Date: 8/2013 Immunizations:
8/2013

Childhood Illnesses:
UTI

Serious or Chronic Illnesses:

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

None
Past Hospitalizations: none Past Operations: none Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Maternal grandfather
Allergies:Mother and brother-seasonal; maternal grandmother- penicillin
Arthritis:N/A
Asthma: Maternal Aunt
Blood Disorders:N/A
Breast Cancer:Maternal great grandmother
Cancer (Other): Bladder- maternal grat uncle
Cerebral Vascular Accident (Stroke):Paternal grandfather
Diabetes:Maternal grandfather
Heart Disease:N/A
High Blood Pressure:Father
Immunological Disorders:N/A
Kidney Disease:N/A
Mental Illness:N/A
Neurological Disorder:N/A
Obesity:N/A
Seizure Disorder:N/A
Tuberculosis:N/A
Obstetric History (if applicable)
Gravida:N/A Term: Preterm: Ab/incomplete:
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? Softball, GATE, Science club, and Soccer

How would you describe your community?
“It’s nice. Sometimes it gets boring but I like it here.”
Hobbies, skills, interests, recreational activities?
“I like making crafts like bracelets and I also like to make things out of colorful duct tape.”
Military service: Yes_______ No_x______ If yes, overseas assignment? Yes________ No_________

Close friends or family members who have died within past 2 years?
N/A
Number of relatives or close friends in this area?

“Most of my family and all my friends live around me. I only have two uncle that live far away {San Diego}”.

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?
“My mom moved 3 years ago and my dad moved 2 years ago.”
Describe your living situation?

Number of years of education completed?
6
Occupation? Student 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?
No

Biophysical Content and Questions

Have you smoked cigarettes? Yes_______ No___x_____

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___x______

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

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?_________
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 ):

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

Seasonal dryness
Health Promotion (Sun exposure? Skin care products?):
Does not wear sunscreen

Hair (recent loss or change in texture):
No change
Health Promotion (method of self-care, products used for care):
Washes hair 4 times a week but conditions daily
Nails (change in color, shape, brittleness):
No change
Health Promotion (method of self-care, products used for care):
Wears nail polish
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):
Dizziness when drinks coffee

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):
Recent change in glasses prescription
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
Wears glasses at all times
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):
No history of aches or infections

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
Uses q-tips for daily cleaning
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):
Within normal limits
Health Promotion (methods for cleaning nose):
Blows nose when congested.
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):
Within normal limits
Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):Brushes once to twice a day, but does not floss. Sees dentist q 6mo.

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

Within normal limits
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):
Within normal limits
Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):
In accelerated programs at school (GATE)
Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):
Within normal limits
Health Promotion (last blood glucose test and result, diet):
No history of glucose testing. Admits to eating candy 3-4 times a day.
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):
Within normal limits
Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):
Does not perform self breast exams
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.):
Within normal limits
Health Promotion (last chest x-ray, smoking cessation):
No history of chest x-ray, has never smoked
Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):
Within normal limits

Health Promotion (last cardiac exam):
No history of cardiac exam
Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):
Within normal limits

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

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):
Within normal limits

Health Promotion (use of standard precautions when exposed to blood/body fluids):
No exposure 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):
Occasional diarrhea. BM once to twice per day
Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):
Admits to poor diet consisting of processed and fast food. Home cooked meals consumed 3 times a week.
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):
Within normal limits

Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):
Exercise achieved in PE at school and softball practice.
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):
Within normal limits

Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises):Wipes front to back to prevent UTI

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):
N/A
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):
No menses. Within normal limits

Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):
No gynecologic check-up history or feminine products used.
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):
Not sexually active
Health Promotion (safe-sex practices):
Will be starting sexual education course in school in two weeks.
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.

Imbalanced nutrition; less than body requirements R/T consumption of fast/processed foods daily AEB adolescent’s statements. Consumption of fast food in adolescents has increased rapidly since the 1970’s and it is estimated that 75% of American adolescent eat fast food 1 or more times per week (Ebbeling, et. al, 2004). Fast food has been linked to childhood obesity and T2DM. These processed meals contain little nutritional value, are not balanced, and provide empty calories. As with this adolescent, fast food is a inexpensive option for a quick meal. As a child of divorced parents, her mother works and is often in need of a quick and low cost meal for her and her children.

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

Readiness for enhanced nutrition R/T improving food choices AEB adolescent’s desire to change diet and recent diagnosis of grandfather’s T2DM. Family history of T2DM is a major contributing risk factor in the development of the disease (Valdez, 2009). Adolescents are at an age where they can make their own food choices but lack the ability to acquire funds to purchase food. While discussing her diet, the adolescent stated that there are healthier food options she could make, even if they come from a fast food establishment.

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

Risk for impaired skin integrity R/T lack of sun screen use and UV exposure AEB frequent sun burns. “Extended sun exposure in childhood and adolescents increases the probability of skin cancer in adulthood” (Saridi, et. al, 2013). While discussing sun exposure and the dangers of skin cancer, she stated “That’s an older person’s problem.” A lack of education of the dangers and the “It won’t happen to me” attitude are contributing factors in her noncompliance with sun protection.

Ebbeling, C., et al. (2004). Compensation for energy intake from fast food among overweight and lean adolescents. Journal of the American Medical Association, 2004;291(23):2828-2833. doi:10.1001/jama.291.23.2828. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=198947

Saridi, M. ,et. al, (2013). Knowledge and attitudes to sun exposure among adolescents in Korinthos, Greece. Rural Remote Health, 2009 Oct-Dec;9(4):1162. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20001166

Valdez, R., (2009). Detecting Undiagnosed Type 2 Diabetes: Family History as a Risk Factor and Screening Tool. Journal of Diabetes and Science Technology, 2009 July; 3(4): 722–726. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769984/