Grand Canyon Week 3 Benchmark Assignment – Health Screening and History Latest 2015 October

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:Biographical DataPast Health HistoryFamily History: Obstetrics History (if applicable) and Well Young Adult Behavioral Health History ScreeningReview of SystemsInclude all components of the health historyUse correct acronyms or abbreviations when indicatedDevelop 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.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.You are not required to submit this assignment to Turnitin.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:

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):

Health Promotion (methods for cleaning nose):

Mouth and Throat (mouth pain, sore throat, bleeding gums,
toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness,
tonsillectomy, alteration in taste):

Health Promotion (Daily dental care – brushing, flossing.
Use of prosthetics – bridges, dentures. Last dental exam/check-up.):

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender
lymph nodes, goiter):

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):

Health Promotion (activities to stimulate thinking, exam
related to mood changes/depression):

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):

Breast and Axilla (pain, lump, tenderness, swelling, rash,
nipple discharge, any breast surgery):

Health Promotion (performs breast self-exam – both male and
female, last mammogram and results, use of self-care products):

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.):

Health Promotion (last chest x-ray, smoking cessation):

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):

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):

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):

Health Promotion (nutrition – quality/quantity of diet; use
of antacids/laxatives):

Musculoskeletal System (history of arthritis, joint pain,
stiffness, swelling, deformity, limitation of motion, pain, cramps or
weakness):

Health Promotion (mobility aids used, exercises, walking,
effect of limited range of motion):

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, Kegelexercises):

Male Genital System (penis or testicular pain, sores or
lesions, penile discharge, lumps, hernia):

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):

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):

Health Promotion (safe-sex practices):

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 “actual” nursing diagnosis with rationale for choice of
this diagnosis.One wellness nursing diagnosis with rationale for choice of
this diagnosis.One “risk for” nursing diagnosis based on the health
screening with rationale for choice of this diagnosis.

 

 

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