COMPLETE THE “HEALTH HISTORY AND SCREENING OF AN ADOLESCENT OR YOUNG ADULT CLIENT” WORKSHEET.Assignment Benchmark Assignment – Health Screening and History of an Adolescent or Young Adult Client
View Rubric Due Date: Dec 17, 2015 23:59:59 Max Points: 150
Details:
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.
Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors.
Complete the assignment as outlined on the worksheet, including: 1.Biographical Data 2.Past Health History 3.Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History Screening 4.Review of Systems 5.Include all components of the health history 6.Use correct acronyms or abbreviations when indicated 7.Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one “Risk For” nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this client. 8.Using the three nursing diagnoses you have identified, develop a wellness plan for the adolescent/young adult client.
While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
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:
Biographical Data
Patient/Client Initials: Phone No:
Address:
Birth Date: Age: Sex:
Birthplace: Marital Status:
Race/Ethnic Origin:
Occupation: Employer:
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)
Source and Reliability of Informant:
Past Use of Health Care System and Health Seeking Behaviors:
Present Health or History of Present Illness:
Past Health History
General Health: (Patient’s own words)
Allergies: (include food and medication allergies)
Reaction:
Current Medications:
Last Exam Date: Immunizations:
Childhood Illnesses:
Serious or Chronic Illnesses:
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
Past Accidents or Injuries:
Past Hospitalizations:
Past Operations:
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse):
Allergies:
Arthritis:
Asthma:
Blood Disorders:
Breast Cancer:
Cancer (Other):
Cerebral Vascular Accident (Stroke):
Diabetes:
Heart Disease:
High Blood Pressure:
Immunological Disorders:
Kidney Disease:
Mental Illness:
Neurological Disorder:
Obesity:
Seizure Disorder:
Tuberculosis:
Obstetric History (if applicable)
Gravida: Term: Preterm: Miscarriage/Abortions:
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?
How would you describe your community?
Hobbies, skills, interests, recreational activities?
Military service: Yes_______ No_______
If yes, overseas assignment? Yes________ No_________
Close friends or family members who have died within past 2 years?
Number of relatives or close friends in this area?
Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________ Length of time_________
Environmental Content and Questions:
Do you live alone? Yes________ No ________
When did you last move?
Describe your living situation?
Number of years of education completed?
Occupation?
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?
Biophysical Content and Questions
Have you smoked cigarettes? Yes_______ No________
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_________
If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________
Do you ingest illicit drugs of any kind? Yes_________ No__________
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 ):
Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):
Health Promotion (Sun exposure? Skin care products?):
Hair (recent loss or change in texture):
Health Promotion (method of self-care, products used for care):
Nails (change in color, shape, brittleness):
Health Promotion (method of self-care, products used for care):
Head (unusual headaches, frequency of headaches, head injury, 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):
Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):
Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):
Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):
Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):
PLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING TERM PAPERS TODAY AND GET AN AMAZING DISCOUNT
