Health_History_and_Screening_as_a_Young_Adult

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. Submit this resource with your assignment to the instructor by the end of Module 3. |Student Name: Naomi Coleman |Date: July 24, 2012 | |Biographical Data | |Patient/Client Initials: E.K. |Phone No: 727-563-4536 | |Address: 3719 39th Street N., Saint Petersburg, Florida 33713 | |Birth Date: 06/26/1984 |Age: 28 |Sex: Female | |Birthplace: Saint Petersburg, Florida |Marital Status: Single | |Race/Ethnic Origin: Caucasian | |Occupation: Unemployed |Employer: Not Applicable | |Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance' Employment disability') | | | |Patient does not have adequate income to provide for the lifestyle she would like for her and her children. Since she does not have a job, she| |does not have health insurance or any other benefits that may come with being employed. Her boyfriend is employed but the couple has five | |children with one on the way and her boyfriend only carries medical insurance for himself through his work. The children are all covered | |through Medicaid. At this time, the patient has Pregnancy Medicaid but will lose this as soon as she delivers and only issues involved with | |the pregnancy are covered at this time. | |Source and Reliability of Informant: | | | |Informant is the patient and the information given is reliable. | |Past Use of Health Care System and Health Seeking Behaviors: | | | |The patient first became pregnant at fifteen years of age and has been on Pregnancy Medicaid when pregnant. When patient is not pregnant, she | |does not have any health insurance and treats herself when she becomes sick. Patient briefly had health insurance when employed but did not | |see a doctor on a regular basis. | |Present Health or History of Present Illness: | | | |Patient is presently 27 weeks pregnant. On a recent doctor’s visit, her OB/GYN did lab work and found the patient to be severely anemic and | |has started the patient on Iron pills. He has also scheduled her to be tested for Gestational Diabetes. Patient believes she has carpal tunnel| |syndrome in both hands and is in regular pain from this. Patient is severely constipated at times but has not told the doctor about this. | |Past Health History | |General Health: (Patient’s own words) | | | |“I know I am not in the best of health. I don’t really take good care of myself. I have had cryosurgery done on my cervix for early stages of | |cancer. I have had a total of six pregnancies, some of them very close together. Other than the cryosurgery, I have not had much else happen. | |But, I am very tired all of the time, even when I am not pregnant. I also believe I have carpal tunnel syndrome in both hands and they hurt | |very badly.” | |Allergies: (include food and medication allergies) |Reaction: | |NKA |Not Applicable | |Current Medications: | | | |Daily Prenatal Vitamin (Patient does not always take.) Iron supplement (Patient does not always take.) | |Last Exam Date: July 17, 2012 |Immunizations: Current | | | | | | | |Childhood Illnesses: Asthma | | | |Serious or Chronic Illnesses: Asthma | | | |Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) | |Not Applicable | |Past Accidents or Injuries: | | | |Not Applicable | |Past Hospitalizations: | | | |Delivering babies | |Past Operations: | | | |Cryosurgery, Tonsillectomy | |Family History | |(Specify which family member is affected.) | |Alcoholism (ETOH use/abuse): Not Applicable | |Allergies: Self | |Arthritis: Not Applicable | |Asthma: Self | |Blood Disorders: Not Applicable | |Breast Cancer: Maternal and Paternal Grandmothers, Maternal Aunt | |Cancer (Other): Not Applicable | |Cerebral Vascular Accident (Stroke): Not Applicable | |Diabetes: Brother | |Heart Disease: Not Applicable | |High Blood Pressure: Father | |Immunological Disorders: Not Applicable | |Kidney Disease: Not Applicable | |Mental Illness: Mother | |Neurological Disorder: Not Applicable | |Obesity: Self, Father, Sister | |Seizure Disorder: Not Applicable | |Tuberculosis: Not Applicable | |Obstetric History (if applicable) | |Gravida: Six |Term: Four |Preterm: One |Ab/incomplete: Zero | |Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby’s weight, baby’s condition):| |Pregnancy #1: 38 weeks, January 1, 2001, Vaginal, 14 hours, No complications, 6lbs, 5oz., Great condition. Pregnancy #2: 36 weeks, January 14,| |2003, Vaginal, 11 hours, Baby born and tested positive with Group B Strep, Mother had very high blood pressure and had to be given Mg, 6lbs, 1| |oz., Fair condition. Pregnancy #3: 39 weeks, May 3, 2005, Vaginal, 8 hours, No complications, 7lbs, 3 oz., Great condition. Pregnancy #4: 40 | |weeks, May 23, 2010, Vaginal, 5 hours, No Complications, 8lbs, Great condition. Pregnancy #5: 39 weeks, May 25, 2011, Vaginal, 5 hours, No | |Complications, 8lbs, 3 oz., Great condition. Pregnancy # 6: Patient currently pregnant, due October 26, 2012. | | | | | | | | |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' Not | |Applicable | | | |How would you describe your community' I live in a close knit community, the same neighborhood I grew up in. It is very safe and clean. My | |father and brothers live on the same block as I do. | | | |Hobbies, skills, interests, recreational activities' I love to read, true crime stories and romance and I like to watch movies. I also enjoy | |spending time with my family. | | | |Military service: Yes_______ No___X____ | |If yes, overseas assignment' Not Applicable | | | |Close friends or family members who have died within past 2 years' My daughter passed away two years ago at 36 days old from SIDS. | | | |Number of relatives or close friends in this area' I have at least twenty family members in my area. My father, mother, three siblings, my | |children and significant other, and a handful of aunts, uncles, and cousins. | | | | | | | |Marital status: Single__X____ Married________Divorced_________Separated_________ | |In serious relationship__Yes______ Length of time__12 years_______ | |Environmental Content and Questions: | | | |Do you live alone' Yes________ No ___X_____ | | | |When did you last move' Three years ago. | | | |Describe your living situation' “I live with my boyfriend, who is the father of all six of my children, 4 boys, and am currently pregnant. We | |live in a two bedroom house, so it is very cramped at times. We do have a large yard where we hang out at a lot.” | | | |Number of years of education completed' 9th grade. | | | |Occupation' Not Applicable | |If employed, how long' Not Applicable | |Are you satisfied with this work situation' Not Applicable | |Do you consider your work dangerous or risky' Not Applicable | |Is your work stressful' Not Applicable | | | |Over the past 2 years have you felt depressed or hopeless' Yes. | | | | | |Biophysical Content and Questions | | | |Have you smoked cigarettes' Yes___X____ No________ | | | |How much' | |Less than ½ pack per day_____ About 1 pack per day'___X___ More than 1 and ½ packs per day______ | | | |Are you smoking now' Yes_______ No____X____ Length of time smoking' 3 years | | | |Have you ever smoked illicit drugs' Yes_____X_____ No_________ | | | |If yes, for how long' A couple of months. 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' Not Applicable | |How long have you used these drugs' Not Applicable | | | | | | | | | |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): “I am currently 27 weeks pregnant and weigh 246 lbs which is a huge weight gain for me from my pre-pregnancy | |weight of 190lbs. I am always fatigued. I feel very depressed still due to the death of my daughter. I often feel overwhelmed taking care of 4| |boys, with one on the way and miss my daughter so much. I have not had any counseling because I do not want it. I do have a lot of weakness. I| |believe that is because I am so tired. I do not experience any sweats, 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): Not applicable. | | | | | |Health Promotion (Sun exposure' Skin care products'): Patient uses 50 SPF sunscreen when in the sun or she will burn. | | | |Hair (recent loss or change in texture): Not applicable | | | |Health Promotion (method of self-care, products used for care): Patient washes her hair on a daily basis. Patient blow dries her hair on a | |daily basis. | |Nails (change in color, shape, brittleness): Nails have become more brittle since the patients last 2 pregnancies. | | | |Health Promotion (method of self-care, products used for care): Patient does not do anything with nails except paint with color nail polish | |sometimes. | |Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo): Patient has been experiencing more headaches | |recently. Frequency of headaches is at least 2-3/week. She also is dizzy when experiencing these headaches. | | | |Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge,| |glaucoma or cataracts):Not Applicable | | | |Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection): Patient does not wear | |contacts or glasses/sunglasses. She cannot remember her last vision check. | |Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo): Not Applicable | | | | | |Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears): Patient uses Q-Tips. | |Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, | |change in sense of smell): Patient does have frequent sinus pain, seasonal allergies, and frequent colds. | | | |Health Promotion (methods for cleaning nose): Patient just blows her nose when feeling congested. Other than this, she does not “clean” her | |nose. | |Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, | |tonsillectomy, alteration in taste): Patient has had a tonsillectomy. She also has a toothache right now. | | | |Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.): Patient brushes| |at least once daily but does not floss on a regular basis. Patient believes her last dental check-up was when she was around 15 years of age. | |Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter): Not Applicable | | | |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):Patient is severely depressed due to the death of her daughter 2| |years ago. | | | |Health Promotion (activities to stimulate thinking, exam related to mood changes/depression): Patient has been examined for depression and | |diagnosed following her daughter’s death but she refuses to go to counseling. | |Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold): Patient is about to | |undergo testing for Gestational Diabetes. | | | |Health Promotion (last blood glucose test and result, diet): Patient not sure of result of blood glucose test at doctor’s office. Patient’s | |diet is not good. She states she does not eat nutritional foods, drinks a lot of soda, and eats for comfort. | |Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery): Not applicable | | | |Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products): Patient does | |perform breast self-exam but admits not a regular basis. Patient has never had a Mammogram. | |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.): Patient has smoked for the past 3 years off and on. | |Patient does not smoke when she is pregnant. Patient is often short of breath and believes this is due to her asthma which she is not | |currently being treated for. She does not even have an inhaler. | | | |Health Promotion (last chest x-ray, smoking cessation): Patient has not had a chest X-Ray recently and cannot remember f she ever has. Patient| |stopped smoking “cold turkey”. | |Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina): Not Applicable | | | |Health Promotion (last cardiac exam): Not Applicable | |Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent | |claudication, thrombophlebitis or ulcers): Patient does have numbness and tingling in both hands. She also has swelling in both ankles since | |her pregnancy. | | | |Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose): Patient does not | |wear support hose and she does sit for long periods of time. She states she does not feel like doing much. | |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): Not Applicable | | | |Health Promotion (use of standard precautions when exposed to blood/body fluids):Patient states she does use standard precautions when exposed| |to bodily 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): Patient states she does not have a good appetite but eats a lot. She does feel nauseous at times,| |especially when preparing meat. She experiences a lot of heartburn. Patient does not have regular or frequent bowel movements and is severely | |constipated. Patient does have hemorrhoids and experiences rectal bleeding a lot. When patient does have a bowel movement, it is frequently a | |loose bowel movement and has a lot of mucous present. | | | |Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives): Patient uses Tums for heartburn and has recently tried | |Metamucil for the constipation but has not felt any difference at this time. | |Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness):Not | |Applicable | | | |Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion): Patient does not exercise on a regular basis. | |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): Patient states at times she | |experiences a hesitancy or straining when trying to urinate. Urine color ranges from bright to dark yellow. | | | |Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel excercises): Patient does do the | |Kegel exercises. | |Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia): Not Applicable | | | |Health Promotion (performs testicular self-exam): Not Applicable | |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): Patient was 12 years old when she had her first menses. Last | |menstrual cycle was in December 2011. Patients’ menstrual history is very scattered. She does not have a period on a regular basis and often | |goes months or more without a period. She does have moderate pain when menstruating and in between menstruating experiences some white/yellow | |discharge at times. | | | |Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products): Have not had a regular gynecological | |exam except for her six week checkup after her last baby and the checkup when finding out she was pregnant with this baby. | |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): Patient is currently involved in a relationship that included intercourse on a | |regular basis. Patient does not use any contraceptives and has never had an STD. Both the patient and her significant other are monogamous. | | | |Health Promotion (safe-sex practices): Patient has a very hard time using or remembering to take contraceptives. She states this is why she | |has been pregnant so many times. Patient states that after her 4th child, her first daughter was born, they requested her tubes to be tied and| |the Dr. refused due to her age. Then, the patients’ daughter passed away and patient wanted to try for another child. | 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. Actual Nursing Diagnosis: Altered Nutrition: Intake exceeds the body’s needs. Rationale for this diagnosis: Patient was overweight prior to pregnancy and still is even at this stage of her pregnancy and patient states she eats for comfort and does not pick nutritional foods. One wellness nursing diagnosis with rationale for choice of this diagnosis. Wellness Nursing Diagnosis: Readiness for Enhanced Sleep. Rational for this diagnosis: Patient states that she does not get enough sleep for her or the baby and is ready to start trying to get more by getting at least 8 hours of sleep per night and taking a nap during the day when feeling the need. One “risk for” nursing diagnosis based on the health screening with rationale for choice of this diagnosis. Risk For Diagnosis: Risk for Impaired Parent/Infant/Child Attachment. Rationale for this diagnosis: This is due to the fact that the mother is severely depressed and not getting counseling. She still misses her daughter and states she feels guilty for having this child when her daughter died. She is also not taking care of herself physically which could alter her mental capacities.