Health History and Screening of an Adolescent or Young Adult ClientSave 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: Aisha Date: 13/09/2018
Patient/Client Initials: W.L. Phone No:
Address: 2125 Chestnut ST, Massachusetts
Birth Date: August, 5, 1997 Age:21 Sex: Male
Birthplace: Tifton, Georgia Marital Status: Single
Race/Ethnic Origin: White/ Caucasian
Occupation: Unemployed Employer: N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Client is not employed so he does not have an income. However, health insurance is provided by his parents. Client is still looking for opportunities to make an income. The client does not have any disabilities or any healthcare concerns and lives with his biollogical parents in Chestnut, Massachusetts.
Source and Reliability of Informant:
Information is reliable since it was provided by the client.
Past Use of Health Care System and Health Seeking Behaviors:
Stitches, minor primary care services which include outpatient services.
Present Health or History of Present Illness:
Client has a major depression due to the lack of financial income and has epilepsy.
Past Health History
General Health: (Patient’s own words)
I feel healthy as i have continously managed my epileptic condition, i usually work out, and have a good diet.
Allergies: (include food and medication allergies)
No known allergies
Phenobarbital, 2 doses per day of 60mg – 180mg.
Last Exam Date:
Immunizations are up to date.
Flu, chicken pox, and measles.
Serious or Chronic Illnesses: Epilepsy.
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Regular HIV screening.
Regular dental check ups.
Past Accidents or Injuries:
Deep cut on the left leg from a fight in school and injuries due to epileptic falls.
Admission to the hospital due to previous epileptic attacks.
Stitches on the left leg to address a deep cut due to a fight in school.
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Father.
Blood Disorders: None.
Breast Cancer: None.
Cancer (Other): Father, lung cancer.
Cerebral Vascular Accident (Stroke): None.
Heart Disease: None.
High Blood Pressure: Mother.
Immunological Disorders: None.
Kidney Disease: None.
Mental Illness: None.
Neurological Disorder: Uncle.
Seizure Disorder: 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?
Sporting activvities which include running and biking activities. Also a member of the local community church and participates in community development programs funded by the church.
How would you describe your community?
Safe, concerned about the needs of other members, and very friendly.
Hobbies, skills, interests, recreational activities?
Sporting activities like jogging, biking, and travelling.
Military service: Yes_______ No___X____
If yes, overseas assignment? Yes________ No____X_____
Close friends or family members who have died within past 2 years?
Number of relatives or close friends in this area?
Relatives are scattered all over due to employment opportunities but the close family members and friends are within Massachusetts.
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?
In 2010 due to father’s job transfer.
Describe your living situation?
Lives with both parents, four sblings who are two sisters and two brothers. The brothers are aged 30 and 25 respectively with the sisters 18 and 15 years old.
Number of years of education completed?
Completed high school education in 2013.
Graduated from college with a BSN in 2017.
If employed, how long? N/A
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?
Yes, I have been depressed due to my search for job opportunities and my father’s alcohol use problem and lung cancer.
Biophysical Content and Questions
Have you smoked cigarettes? Yes_______ No____X____
Less than ½ pack per day__N/A___ About 1 pack per day?___N/A___ More than 1 and ½ packs per day___N/A___
Are you smoking now? Yes_______ No____X____ Length of time smoking?______N/A________
Have you ever smoked illicit drugs? Yes__________ No____X_____
If yes, for how long? ___N/A________ Do you smoke these now? Yes__________ No ____X______
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?____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 ):
Body weight: 60 kgs
Weight loss due to stress of unemployment.
No fatigue, any form of weakness, night sweats or chills.
Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):
Normal skin colour.
No history of skin disease.
No history of rashes or lesions.
Health Promotion (Sun exposure? Skin care products?):
Application of sun screan daily on face and body.
Skin moisturizer using body lotion daily after taking a shower.
Hair (recent loss or change in texture):
No hair loss or change in texture.
Hair on head intact.
Health Promotion (method of self-care, products used for care):
Daily washing and using hair products to keep the hair soft and moistureized.
Nails (change in color, shape, brittleness):
Nails are thick, short, and well cleaned.
Health Promotion (method of self-care, products used for care):
Regular trimming of the nails and manicure.
Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):
Headaches are rare.
No history of head injury.
Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):
No history of vision problems which may include eye pain, swelling, or redness.
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
Regular eye checkups.
Last checken in August, 2016.
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):
Ear ache due to an infection as a child in 2002.
Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
Regularly cleans his ears using ear muffs.
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):
No history of nose bleeding.
Health Promotion (methods for cleaning nose):
Nose blowing to remove any external agents.
Nasal sprays to address the occassional flu.
Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste):
No history of mouth infection, sores, or bleeding gums.
Teeth are white and clean.
Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.):
Daily brushing of the teeth.
Regular dental check ups
Last dental check up was on June 13, 2015.
Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter):
No issues within the neck region.
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):
Depression due to lack of employment opportunity.
Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):
Active in sporting activities and travelling to ease the mind and change his environment.
Epileptic medications to prevent seizures.
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):
Healthy diet and exercise.
Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery):
No breast lumbs, swelling, or discharge.
Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products):
Rugular breast screening to detect any issues.
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.):
Normal breathing and no allergies.
No history of smoking or asthma.
Health Promotion (last chest x-ray, smoking cessation):
Regular exercise which improves the breathing system.
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):
Active most of the time to keep adequate blood flow.
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 history of excessive bleeding or reactions to certain toxic agents.
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):
No ingestion problems.
No heart burn or gastric ulcers.
Presence of hemorrhoids and rectal bleeding.
Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):
Adequate water to help in addressing the hemorrhoids and rectal bleeding.
Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):
No joint pain or muscle weakness.
Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion):
Regular exercise to strengthen the muscles.
Active in sporting activities.
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):
Daily drinking of adequate water.
Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia):
No penile problems.
Health Promotion (performs testicular self-exam):
Regular self examination.
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):
Occasionally involved in sexual activities.
No history of sexually transmitted diseases.
Health Promotion (safe-sex practices):
Use of contaceptives to prevent sexual transmitted diseases.
Sexual intercourse with only one partner.
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
Based on this health history and health screening, the client is having a major depression which is neurological disorder which has been cuased by problems in the nervous system (Leahy, Holland, ; McGinn, 2012). This has been caused by the lack of employment and constant worry about his father’s alcohol problem and lung cancer. Depression has also been attributed to epilepsy which the client is suffering from (Louis, O’Brien, ; Ficker, 2015). Epilepsy has been indicated to affect the mood of patients due to seizures which affect the brain. The client has also lost weight in previous months (Louis, O’Brien, & Ficker, 2015).
One Wellness Nursing Diagnosis With Rationale For Choice Of This Diagnosis
A wellness nursing diagnosis is readiness for health inprovement through the counselling process (Townsend & Morgan, 2018). The client expresses the desire to keep fit by involving himself in regular exercise and sporting ativities. The client also eats a good diet which is important in the overal impovenent of the health status of the cllient (Townsend & Morgan, 2018). However, to adequately address the major depression that he is haviing, it important for the patient to start counselling sessions to address his current situation which may negatively impact the client over time (Townsend & Morgan, 2018).
One “Risk For” Nursing Diagnosis Based On The Health Screening With Rationale For Choice Of This Diagnosis
A risk nursing diagnosis is the risk of developing substance use disorder (Leahy, Holland, & McGinn, 2012). The patient is at a high rish of developing substance use disorder due to a family history of his father being an alcoholic and depression which are risk factors to substance use disorders (Leahy, Holland, & McGinn, 2012). If the patient is not helped in addressing depression, he is vulnerable to follow the behaviour of his father who has developed lung cancer due to the drug problems that he is having (Leahy, Holland, & McGinn, 2012).
Leahy, R. L., Holland, S. J., & McGinn, L. K. (2012). Treatment plans and interventions for depression and anxiety disorders. New York: Guilford Press.
Louis, E. K. S., O’Brien, T. J., ; Ficker, D. M. (2015). Epilepsy and the interictal state: Co-morbidities and quality of life. Malden, MA: Wiley-Blackwell.
Townsend, M. C., ; Morgan, K. I. (2018). Pocket guide to psychiatric nursing. Philadelphia, PA: F.A. Davis Company.