Question

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.

Complete the assignment as outlined on the worksheet, including:

Biographical data

Past health history

Family history: Obstetrics history (if applicable) and well young adult behavioral health history screening

Review of systems

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" 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.

Answer 1

Date:

Patient name: Ms.X Age/sex:17/F

Address: XXXXXXX Date of birth: Birth place:

Marital status: unmarried Race/origin: hispanic

Occupational status: student Monthly income:if applicable

Allergies:no

Immunisation history:immunised upto date

Past medical history: no serious or chronic illnesses , but visited hospital with abdominal pain and bleeding before a year

Past surgical history: no surgeries

Current medications:If any

Menstrual history : Length of cycle - irregular cycles date of last menstruation 25.4.18, profuse bleeding

Gravida: nil Parity: Live birth: Abortions:

Family history: Any metabolic or genetic disorders in family members, consanguinity

Alcoholism :no
Arthritis:grandmother
Asthma:brother
Blood Disorders:cousin
Breast Cancer:no
Cancer (Other):no
Cerebral Vascular Accident (Stroke):no
Diabetes:no
Heart Disease:Paternal grandfather
High Blood Pressure:paternal grandfather
Immunological Disorders:no
Kidney Disease:no
Mental Illness:no
Neurological Disorder:no
Obesity:no
Seizure Disorder:no
Tuberculosis:no

Extracurricular activities:she is in school NSS team

Hobbies/interests:reading, painting

Skills:Biking

Social status : lives with parents

Educational status : Completed High School with completion of general education diploma

Job satisfaction: not applicable

Emotional status: stable

Life style : Smoking - No

Acohol consumption : no

Drug abuse : no

Present medical history : c/o fatigue , irregular menstruation

Physical examination: Anthropometric measurements : height -148cm , weight 112lbs , abdominal circumference 24cm

Blood pressure;100/60mmhg pulse: 85b/min Temperature : 37.6c Respiratory rate :16b/min

• Skin: pale in color, no presence of any foul odor, moist skin turgor , skin’s temperature normal
• Hair: no infection or odor, Full head of thick shinny hair that is shoulder length
• Nails: pale color , slow blanching

Head

• Head: shape and symmetry normal
• Skull: no masses or depression
• Face: no abnormalities
• Eyebrows: Hair distribution is symmetrical
• Eyelashes: Equal distribution
• Eyelids: no discharges , absence of any stye

Eyes: no abnormal eye movements like squint eyes, color of sclera white, no edema , no abnormal secretions,visual acquity.20/20

Ears: Hearing acquity normal , no abnormal discharges.

Nose: no nasal septal deviation,no abnormal discharges

Mouth: pale and dry tongue, uvula normal , no tooth decay , glossitis present , no gingivitis ,foul odor, artificial dentures

Neck : normal thyroid gland , symmetry of muscles of neck, no palpable lymph nodes and range of motion normal

Chest: symmetrical respiration movement , auscultation of lung sounds well heard , no exertional dyspnea

Abdomen : no scars , bowel sounds heard and normal, no irregular masses .

Genitourinary :note elimination pattern bowel and bladder habits , absence of masses, no hemorrhoids or any abscess, infection ,any abnormal discharge and foul smell .

Extremities: Perform range of motion exercises, check for deformity, symmetry , any abnormal findings.

Ineffective Tissue Perfusion r/t decreased red blood cell and hemoglobin concentration.

add iron rich foods, iron supplements

Activity Intolerance R/T fatigue

allow to take rest

Risk for deficient fluid volume r/t bleeding