In this assignment, you will be completing a comprehensive health screening and
ID: 246091 • Letter: I
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.
Explanation / Answer
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
Head
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