Adolescent health screenGCU

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: January 28, 2014 Biographical Data Patient/Client Initials: Phone No: N/A Address: Birth Date: Age: 12Sex: f Birthplace: Upland, CA. Marital Status: Single Race/Ethnic Origin: Caucasian Occupation: StudentEmployer: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) â€Å"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: 8/2013Immunizations: 8/2013 Childhood Illnesses: UTI Serious or Chronic Illnesses: N/A Past Health Screening (see â€Å"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/ATerm: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? â€Å"It’s nice. Sometimes it gets boring but I like it here. † Hobbies, skills, interests, recreational activities? â€Å"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? â€Å"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? â€Å"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 ? pack per day_____ About 1 pack per day? ______ More than 1 and ? 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 â€Å"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 â€Å"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. â€Å"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 â€Å"That’s an older person’s problem. † A lack of education of the dangers and the â€Å"It won’t happen to me† attitude are contributing factors in her noncompliance with sun protection.