Develop three Nursing Diagnoses for this client based on the health history and screening. Include: one actual nursing diagnosis,
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
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?
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