Teen Health Assessment

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: Mary Koke | Date: December 6th, 2012 | Biographical Data | Patient/Client Initials: A.K. | Phone No: 222-555-1234 | Address: 123 Smith St. | Birth Date: September 8,1999 | Age: 13 yrs. | Sex: Male | Birthplace: Racine, WI | Marital Status: Single | Race/Ethnic Origin: Caucasian | Occupation: Student | Employer: too young to work | Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)Patient is supported financially by parents. Health insurance is through the father’s place of work. | Source and Reliability of Informant:Information provided by patient and patient’s biological mother. Both sources appear competent and reliable. | Past Use of Health Care System and Health Seeking Behaviors:Patients has seeked health care system for general health maintenance only. | Present Health or History of Present Illness:Patient appears to be in good health with signs or symptoms of illness or disease present. Alert, orientated, and without pain. | Past Health History | General Health: (Patient’s own words)“Good” | Allergies: (include food and medication allergies) No known Allergies | Reaction:Does not apply since patient does not have allergies | Current Medications:Patient does not take any medications. | Last Exam Date:May 2012, physical. | Immunizations:Current and up to date | Childhood Illnesses:Patient does not have any childhood illnesses. | Serious or Chronic Illnesses:Patient does not have any serious or chronic illnesses. | Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)Information provided below | Past Accidents or Injuries:No accidents or injuries experienced by patient. | Past Hospitalizations:No past hospitalizations experienced by patient. | Past Operations:Patient has not had any operations. | Family History(Specify which family member is affected.) | Alcoholism (ETOH use/abuse): No family history. | Allergies: Some seasonal allergies experienced by biological mother. | Arthritis: No family history. | Asthma: No family history. | Blood Disorders: No family history. | Breast Cancer: No family history. | Cancer (Other): No family history. | Cerebral Vascular Accident (Stroke): No family history. | Diabetes: Biological grandmother on mother’s side Type 2 diabetic. | Heart Disease: No family history. | High Blood Pressure: No family history. | Immunological Disorders: No family history. | Kidney Disease: No family history. | Mental Illness: Biological grandfather on mother’s side has occasional periods of depression related to loss of work. | Neurological Disorder: No family history. | Obesity: No family history. | Seizure Disorder: No family history. | Tuberculosis: No family history. | Obstetric History (if applicable) | Gravida: | 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? “None” Patient is not involved in any activities besides attending school at this time. How would you describe your community? “Big city”. Patient resides in a city with a population of around 100,000 people. Hobbies, skills, interests, recreational activities? “Playing guitar, hanging out with friends and playing video games”. Military service: Yes_______ No__N/A Patient not old enough for service_____ If yes, overseas assignment? Yes________ No_________ Close friends or family members who have died within past 2 years? No close friends or family members have died in past 2 years. Number of relatives or close friends in this area? Large extended family within same city. 50+ family members within 10mile radius. Marital status: Single___X___ Married________Divorced_________Separated_________ In serious relationship________ Length of time_________ | Environmental Content and Questions: Do you live alone? Yes________ No _X _Patient lives with parents, 1 brother, and 1 sister______ When did you last move? 8 years ago (age 5 years old) Describe your living situation? “Live with my parents”. Patient lives with biological parents and siblings in single family dwelling. Number of years of education completed? “In 7th grade”. Patient is a 7th grader, currently in middle school. Occupation? If employed, how long? N/A Patient too young to work. Are you satisfied with this work situation? N/A Do you consider your work dangerous or risky? N/A Is your work stressful? N/A Over the past 2 years have you felt depressed or hopeless? “No”. Patient did not express any feelings of depression or hopelessness or display any signs. | Biophysical Content and Questions Have you smoked cigarettes? Yes_______ No___X Patient states not having tried cigarettes___ 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 Patient states not having used any illicit drugs.__ If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________ Do you ingest illicit drugs of any kind? Yes_________ No___X Patient states not having used any illicit drugs.____ 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 ):Patient’s current weight is 112lb. No reports of weight loss or gain outside of expected growth pattern. No complains of fatigue, malaise, weakness, sweats, night sweats, or chills). | Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash or lesion):Patient’s skin is warm, soft, and intact. Color is consistent throughout, light in color. Good turgor. No bruises or lesions. Small amount of acne on forehead. Health Promotion (Sun exposure? Skin care products?):Patient states being out in sun often during summer months using sun block only occasionally. Acne cream used on forehead daily. Patient reminded about sun safety and to use sun block. | Hair (recent loss or change in texture):Patient has skinny, fine, light-brown hair with no sparse areas. No reports of changes in loss or texture. Health Promotion (method of self-care, products used for care):Patient states using “whatever shampoo is in the shower” for washing hair. Mom states patient uses regular shampoo, nothing special. | Nails (change in color, shape, brittleness):Patient has a slight curve to fingernail surface. Edges are smooth and rounded. Nails beds appear pink in color with no spots, dryness, or brittle edges. Health Promotion (method of self-care, products used for care):Patient states only using a nail clipper occasionally and hand washing. | Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):Skull is symmetrical, no complaints of pain or history of headaches, 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):Eyes are equally round in shape. Sclera of eyes are white, pupils round, equal, and reactive. Patient has 20/20 vision (per recent eye appt). No complaints of changes in vision, decreased acuity, blurred vision, 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):Patient just had vision check within last month. Uses sunglasses when outdoors. No glasses or contacts needed. | Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):Patient’s ears are equal in size and position. Ear drum clean of discharge and ear drum shiny. No history of earaches, infections, discharge, tinnitus, or vertigo. Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):Patient has not experienced any hearing loss, hearing aids, or damage from noise exposure. | Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):Nose is symmetric, in the midline, and in proportion to other facial features. (Jarvis, 2008) Nasal passages are patent, with no obstructions. No swelling, discharge or signs of blood. Health Promotion (methods for cleaning nose):Patient only uses tissues 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):Patient’s oral cavity is pink in color, with no sores, or signs/symtoms of infection. Teeth are present and intact with minimal discoloration. Tongue is pink in color. Throat is pink in color, patent, and shows no s/s of infection. Patient denies any mouth pain, sores, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, or alterations in taste.Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):Patient states brushing teeth with fluoride toothpaste approximately two times a day, most days, but flosses only occasionally. No use of prosthetics, bridges, or dentures. Last dental exam/check-up was 5 months ago (June 2012). | Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):Patient’s neck has full range of motion. No presence of lymph nodes or swelling. Denies pain. | 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):Patient is alert and orientated x3. Speaks clear English. Comprehends and answers questions appropriately. Able to move all four extremities with no spastic movements. Hand grips equal and strong bilaterally. Tactile sensations intact. Ambulates with a steady gait. General mood happy, enjoys life. Patient denies any history of seizure disorder, syncopal episodes, CVA, motor function or coordination disorders/abnormalitites, paresthesia, mood change, depression, memory disorder, or history of mental health disorders.Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):Patient enjoys video games, chess, checkers, and cards. Patient and mother state that patient has not had any mood or depression that needs further exams at this time. | Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):Patient is not a diabetic and does not display symptoms of hypo/hyperglycemia. Denies intolerance to heat and cold, changes in skin pigmentation or texture, excessive sweating, relationship between appetite and weight, abnormal hair distribution, nervousness, or tremors. Health Promotion (last blood glucose test and result, diet):Patient has not had recent blood sugar test. Diet consists of high amount of carbs, minimal fruits and vegetables, and high amounts of sugars. Family eats healthy meals together in the home 4x a week on average, whereas snacks and sugar items are being consumed at school and mostly outside the home. | Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):Does not apply.Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):Does not apply. | 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.):Patient denies any shortness of breath or difficulty breathing. Lung sounds clear in all bases. Free of congestion or cough. Chest expansion equal bilaterally. No pain or discomfort. No history of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough, sputum, hemoptysis, toxin or pollution exposure. Health Promotion (last chest x-ray, smoking cessation):No recent chest x-ray. Patient and mother not sure of last chest x-ray. No need for smoking cessation program since patient is not a smoker. | Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):Apical impulse not visible. No thrills present upon palpation of the precordium. Heart rate 85bpm, steady, and regular. S1 and S2 audible. No extra heart sounds or murmurs heard. Patient denies any history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, or angina.Health Promotion (last cardiac exam):Patient and mother unsure of last cardiac exam. Patient has had regular well visits throughout childhood. | Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers):Temperature of skin on extremities is warm. Tactile sensation of hands and present and consistent throughout. Skin is appropriate for ethnicity and evenly toned. No areas of redness, warmth, or pain upon movement to extremities. No unusual changes in skin color.Patient does not display and denies any coldness, numbness, tingling, swelling of leg/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):Patient states that he does not cross legs. | 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):Denies any bleeding disorders, excessive bruising, and swelling of lymph nodes, blood transfusions, or exposure to toxic agents or radiation. No previous abnormal lab results during childhood well visits. Health Promotion (use of standard precautions when exposed to blood/body fluids):Informed about safety precautions when exposed to blood and/or body fluids. | Gastrointestinal System (appetite, food intolerance, dysphagia, heartburn, indigestion, pain [with eating or other], pyros is, nausea, vomiting, history of abdominal disease, gastric ulcers, flatulence, bowel movement frequency, change in stool [color, consistency], diarrhea, constipation, hemorrhoids, rectal bleeding):Appetite excellent. No difficulty chewing, swallowing, or digesting food or drink. Denies heartburn or indigestion. No pain, pyrosis, nausea, vomiting, hx of abdominal disease, gastric ulcers, diarrhea, constipation, hemorrhoids, or rectal bleeding. Bowel sounds present and active in all four quadrants. Denies any intolerance or allergies to foods. Bowel movements are regular, formed stools approximately every other day.Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):General is high in carb, sugars, and fats. Patient states eating healthy family dinners 4x a week, but admits to consuming high amounts of carbohydrates, sugar, and fatty snacks and foods outside of family meals. Patient advised as to proper nutrition requirements for teenage boy. | Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):Patient able to walk, sit, squat, and bend with full range of motion. Denies any presence or history of arthritis, joint pain, stiffness, swelling, deformities, limitation of motion, pain, cramps, or weakness.Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):No mobility aids used. Exercise is minimal: school gym class and occasional basketball outside. | 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):Patient urinates multiple times daily, no recent or history of cloudiness, strong odor, or blood present in urine. No pain or discomfort associated with urination.Patient denies any pain, discomfort, or changes in urinary frequency, urgency, nocutria, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history or 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):Denies pain to male genitals. Pubic hair present. No pain, lesions, sores, discharge, lumps, or hernias. Health Promotion (performs testicular self-exam):Patient states that he does not perform testicular self-exams. Education provided. | 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):Does not apply.Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):Does not apply. | 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):Patient denies being in current relationship, having had intercourse, or other sexual activity. Health Promotion (safe-sex practices):Education provided. |
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.

Nursing Diagnosis - Imbalanced Nutrition: Less than body requirements r/t food choices poor in nutritional value.

This patient doesn’t have any present problems at this time that have actual signs or symptoms. The area that needed the most improvement was nutrition. Interventions that help improve food choices and education are important for preventing negative effects of poor nutrition. The above example is more of a risk for example than an actual.

If the teen was experiencing any signs or symptoms (overweight) related ingesting large quantities of junk food, an actual nursing diagnosis could be:

Imbalanced Nutrition: more than body requirements

Evidence of this would be that the teen is overweight.

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

Nursing Diagnosis- Potential for enhanced self-esteem by increasing positive thoughts about self. (Fiu.edu, n.d.)

Since this patient is a 13 year old boy it is important to help prevent problems of depression and suicidal thought by making sure that the teen’s self-esteem remains positive and healthy. Interventions to help the teen increase self-esteem are important for his mental and social health.

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

Nursing Diagnosis-Risk for Constipation due to diet low in fiber.

This teen has poor eating habits which cause a lack of fiber and puts the teen at risk for constipation.

Work Cited

Fiu.edu. (n.d.). Transition to professional nursing examples of wellness diagnoses.
Retrieved from: http://chua2.fiu.edu/faculty/phillips/NUR3055/TransWellDx.htm

Jarvis, C. (2008). Physical examination and health assessment. (5th ed.) St. Louis: Saunders.

Health Screening and History of an Adolescent or Young Adult Client Grading Criteria | | | | Possible Points | Points Earned | Instructor’s Comments | Biographical Data: *Information is complete. *All sections complete or indicate “not applicable.” *Information is appropriate, demonstrating understanding of the questions. * No errors in spelling or grammar. | 10 Point | | | Past Health History: *Information is complete. *All sections complete or indicate “not applicable.” *Information is appropriate, demonstrating understanding of the questions. * No errors in spelling or grammar. | 20 Points | | | Family History: *Information is complete. *All sections complete or indicate “not applicable.” *Information is appropriate, demonstrating understanding of the questions. * No errors in spelling or grammar. (Including Obstetrical History, if indicated) | 20 Points | | | Well Young Adult Behavioral Health History Screening: *Information is complete. *All sections complete or indicate “not applicable.” *Information is appropriate, demonstrating understanding of the questions. * No errors in spelling or grammar. | 20 Points | | | Review of System: *Information is complete. *All sections complete or indicate “not applicable.” *Information is appropriate, demonstrating understanding of the questions. Fully addresses health promotion measures for client. * No errors in spelling or grammar. | 40 Points | | | Nursing Diagnoses: *Develops three appropriate nursing diagnoses for client based on health history and screening. * Includes rationale for each chosen nursing diagnosis for client. *Includes one “actual” nursing diagnosis; one “wellness” nursing diagnosis, and one “risk for” nursing diagnosis. *Each nursing diagnoses is each appropriate to the client. | 40 Point | | | TOTAL POINTS | 150 Points | | Total______%/100x150 =_______ | | | |