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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:

NRS-434VN-R-HealthScreeningandHistoryAdolescentAssignment-Student.docx

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. All components of the health history
  6. 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)
  7. Rationale for the choice of each nursing diagnosis.
  8. A wellness plan for the adolescent/young adult client, using the three nursing diagnoses you have identified.

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Use correct acronyms or abbreviations when indicated.

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:
© 2016. Grand Canyon University. All Rights Reserved.
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?
© 2016. Grand Canyon University. All Rights Reserved.
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 _________________
© 2016. Grand Canyon University. All Rights Reserved.
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
© 2016. Grand Canyon University. All Rights Reserved.
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 selfcare 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):
© 2016. Grand Canyon University. All Rights Reserved.
Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel
exercises):
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.
© 2016. Grand Canyon University. All Rights Reserved.
© 2016. Grand Canyon University. All Rights Reserved.
UNIVERSITY
era
Sep 25, 2018
NRS-434VN (NRS-434VN-OL191) Healt…
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Assi
Environmental Factors and Health Promotion Pamphlet: Accident Prevention and Safety Promotion for Parents and Caregivers of Infants
1
2
3
5
Unsatisfactory Less than Satisfactory Satisfactory
Good
Excellent
0.00%
75.00%
79.00%
89.00%
100.00%
75.0 %
Content
15.0 %
Explanation of
Potential Effect
Explanation of how
the selected
environmental factor
can potentially
affect the health or
safety of infants is
not given.
Explanation of how
the selected
environmental factor
can potentially
affect the health or
safety of infants is
minimal and/or
inaccurate.
Explanation of how
the selected
environmental factor
can potentially
affect the health or
safety of infants is
accurate.
Explanation of how
the selected
environmental factor
can potentially
affect the health or
safety of infants is
accurate and
supported with
detail.
Explanation of how
the selected
environmental factor
can potentially
affect the health or
safety of infants is
accurate and
supported with detail
and thoughtful
insight.
20.0 %
Recommendations
Pamphlet does not
offer
recommendations on
accident prevention
and safety
promotion as they
relate to the
selected
environmental factor
Recommendations
offered on accident
prevention and
safety promotion as
they relate to the
selected
environmental factor
and the health or
safety of infants are
Recommendations
offered on accident
prevention and
safety promotion as
they relate to the
selected
environmental factor
and the health or
safety of infants are
Recommendations
offered on accident
prevention and
safety promotion as
they relate to the
selected
environmental factor
and the health
safety of infants are
Recommendations
offered on accident
prevention and
safety promotion as
they relate to the
selected
environmental factor
and the health or
safety of infants are
3. Demographical information of the parent and child (age, gender, ethnicity, educational level).
4. Description of parent response to teaching.
5. Assessment of parent understanding.
6. Your impressions of the experience; what went well, what can be improved.
Submit Part I and Part II of the Accident Prevention and Safety Promotion for Parents and Caregivers of Infants assignment by the end of Topic 1.
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.
05.ge
Environmental Factors and Health Promotion Pamphlet: Accident Prevention and S…
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GRAND CANYON
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Adiane Perera
Sep 25, 2018
NRS-434VN (NRS-434VN-OL191) Healt… E
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ASSI
HI 1015L.
10.0 %
Examples,
Interventions, and
Suggestions
Pamphlet does not
offer examples,
interventions, and
suggestions from
evidence-based
research.
Pamphlet offers
minimal examples,
interventions, and
suggestions, or
examples are offered
but they are
inaccurate or not
from evidence-based
research.
Pamphlet offers
accurate examples,
interventions, and
suggestions from
evidence-based
research.
Pamphlet offers
accurate examples,
interventions, and
suggestions from
evidence-based
research and is
supported with
detail.
Pamphlet offers
accurate examples,
interventions, and
suggestions from
evidence-based
research and is
supported with detail
and thoughtful
insight.
10.0 %
Written Summary of
Teaching / Learning
Interaction
Summary of teaching
I learning
experience is not
offered.
Summary of teaching
/ learning
interaction is offered
but lacks detail and
is missing two or
more components.
Summary includes
student’s reflection
on teaching
experience but is
missing details of the
experience and an
assessment of
learning with the
parent.
Summary includes
demographic
information,
description of parent
response to
teaching, and
assessment of parent
understanding but
does not include
student’s reflection
on teaching
experience.
Summary includes
demographic
information,
description of parent
response to teaching,
assessment of parent
understanding, and
student’s impressions
of teaching.
20.0 %
Resources
Pamphlet does not
provide readers with
community, national,
and Web-based
Pamphlet does not
provide readers with
all the resources
indicated by the
Pamphlet provides
readers all the
resources indicated
by the assignment
Pamphlet provides
readers all the
resources indicated
by the assignment
Pamphlet provides
readers all the
resources indicated
by the assignment
3. Demographical information of the parent and child (age, gender, ethnicity, educational level).
4. Description of parent response to teaching.
5. Assessment of parent understanding.
6. Your impressions of the experience; what went well, what can be improved.
Environmental factors and Health Promionon pamphlet Accident Prevention and S…
Order now Custom written Essays, Term papers, Research
GRAND CANYON
Adiane Perera
Sep 25, 2018
NRS-434VN (NRS-434VN-OL191) Healt…
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UNIVERSITY
CALENDAR
TASKS
RESOURCES
CONNECT
REPORTS
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FM
Apply Rubrics
SS!
LAMLI ILIILL.
Resources
20.0% Pamphlet does not
provide readers with
community, national,
and Web-based
resources.
Pamphlet does not
provide readers with
all the resources
indicated by the
assignment
(community,
national, and Web-
based resources), or
resources provided
do not adequately
address selected
environmental factor
or are missing
descriptions and
contact information.
Pamphlet provides
readers all the
resources indicated
by the assignment
(community,
national, and Web-
based resources),
including brief
descriptions of
resource and contact
information.
Pamphlet provides
readers all the
resources indicated
by the assignment
(community,
national, and Web-
based resources),
including brief
descriptions of
resource and contact
information.
Qualities of
resources selected
indicate thoughtful
consideration.
Pamphlet provides
readers all the
resources indicated
by the assignment
(community,
national, and Web-
based resources),
including brief
descriptions of
resource and contact
information. Quality
of resources selected
and the
accompanying
descriptions indicate
thoughtful
consideration.
15.0 %
Organization and
Effectiveness
Presentation
5.0 %
The piece is not neat
or organized, and it
does not include all
required elements.
The work is not neat
and includes minor
flaws or omissions of
required elements.
The overall
appearance is neat,
but major elements
are missing.
The presentation is
good. The overall
appearance is neat,
with a few minor
flaws or missing
The work is well
presented and
includes all required
elements. The
overall appearance is
3. Demographical information of the parent and child (age, gender, ethnicity, educational level).
4. Description of parent response to teaching.
5. Assessment of parent understanding.
6. Your impressions of the experience; what went well, what can be improved.
Dort Il of the arrident Prevention and Safety Promotion for Parents and Caregivers of Infants assignment by the end of Topic 1.

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