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Sample Essay on Health Screening

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Sample Essay on Health Screening
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: Mike Williamson

Date: 2/25/2017

Biographical Data

Patient/Client Initials:MW

Phone No:+145688456

Address: 455

Birth Date:20/12/1996

Age:21

Sex: male

Birthplace:                                ohio                       

Marital Status: Single

Race/Ethnic Origin:         White    

Occupation: student

Employer:N/A

Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)

MW has health insurance  and does not suffer from any form of disbaliity. His income is not adequate enough to cater for all of his lifestyle needs.The major heath issue of great concern is his weight

 

Source and Reliability of Informant:

 

Primary information from the patient

Past Use of Health Care System and Health Seeking Behaviors:

MW has severally been admitted in various healthcare setting due to his condition

 

Present Health or History of Present Illness:

Type 2 Diabetes mellitus

 

Past Health History

General Health: (Patient’s own words)

 

Suffers from Diabetes Type 2

Allergies: (include food and medication allergies)                 

None

 

Reaction:

None

 

Current Medications:

Metformin

 

Last Exam Date:

3/09/ 2016

Immunizations:

All childhood immunizations

 

 

Childhood Illnesses:

None

 

Serious or Chronic Illnesses:

Type 2 Diabetes Mellitus

 

Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)

None

Past Accidents or Injuries:

None

 

Past Hospitalizations:

 

3 times after diagnosis with type 2 Diabetes Mellitus

Past Operations:

None

 

Family History

(Specify which family member is affected.)

Alcoholism (ETOH use/abuse): father and mother

Allergies: none

Arthritis: none

Asthma: none

Blood Disorders: none

Breast Cancer: neone

Cancer (Other):

Cerebral Vascular Accident (Stroke):

Diabetes: father and mother

Heart Disease: father

High Blood Pressure: mother

Immunological Disorders: none

Kidney Disease: none

Mental Illness: none

Neurological Disorder: one

Obesity: father and mother

Seizure Disorder: none

Tuberculosis: none

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):

N/A

           
             

 

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?

Community  programs

How would you describe your community?

Supportive of the needs of its members

 

Hobbies, skills, interests, recreational activities?

Watching television and travelling

Military service: Yes_______ No___no ____

      If yes, overseas assignment? Yes________ No_no ________

 

Close friends or family members who have died within past 2 years?

None

Number of relatives or close friends in this area?

Ourextendd family

 

 

Marital status:  Single___yes ___ Married________Divorced_________Separated_________
                         In serious relationship________  Length of time_________

 

Environmental Content and Questions:

 

Do you live alone?  Yes________ No _____X___

 

When did you last move?

Never moved

Describe your living situation?

 MW lives together with his parents

Number of years of education completed? 12 years eight in junior school

High school four years

Occupation? Not employed

       If employed, how long? Not employed

       Are you satisfied with this work situation?N/A

       Do you consider your work dangerous or risky?N/A

       Is your work stressful?N/A

 

Over the past 2 years have you felt depressed or hopeless?

 

Yes

 

Biophysical Content and Questions

 

Have you smoked cigarettes? Yes__X_____ No________

Yes

How much?

Less than ½ pack per day_____ About 1 pack per day?___X___ More than 1 and ½ packs per day______

About one pack

Are you smoking now? Yes_____X__ No________ Length of time smoking? ______four years________

Yes, for four years

Have you ever smoked illicit drugs? Yes____X______ No_________

Yes

If yes, for how long? ______tvaries _____ Do you smoke these now?  Yes_____X_____ No __________

Two years

Do you ingest illicit drugs of any kind? Yes__X_______ No__________

Yes , marijuana

If so, what drugs do you use and what is the route of ingestion?___Ingestion ______

Mostly drugs that are ingested ie marijuana

How long have you used these drugs ___________

 

Two years

 

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 ):

Overwiht

 

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):

 

Colr change due to obesity

Health Promotion (Sun exposure? Skin care products?):

Skin care products

 

Hair (recent loss or change in texture):

Black no change

Health Promotion (method of self-care, products used for care):

 

Nails (change in color, shape, brittleness):

Change in color

Health Promotion (method of self-care, products used for care):

                          Self care

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):

Dizziness

 

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts):

Glaucoma

Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection):

Glaucoma check

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo):

 

Eareaches

Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears):

Methods of cleanng ears

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell):

Nasal  obstructions

Health Promotion (methods for cleaning nose):

Cleaning nose

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

Dysphagia

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

Dental 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):

Mood change

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

Exam related to depression

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold):

History of insulinresistance

Health Promotion (last blood glucose test and result, diet):

Glucose tests

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

n/A

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

 

 

 

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):

N/A

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):

Numbness  and feet discoloration

Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose):

Avoiding sitting an dtanding for long periods

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):

N/A

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):

Increased appetite

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

Check on food consumption

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

N/a

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):

N/A

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):

Noe

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):

N/A

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):

None

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.

 

The actual diagnosis will involve the treatment of Diabetes Type 2 meelitus. MW seems to suffer from the above disease and therefore it is necessary that certain conditions are addressed such as the use of drugs substance which may affect the bioavalibility  of the drugs used to reduce the effects of Metformin (Donath & Shoelson, 2011). In has been shown in the past studies that the use of Metformin reduces effects associated with the regulating  blood glucose. At the same time, it is necessary that numbness of the foot be checked and regular walking activity be carried out to reduce the effets neurologic effects associated with the disease codnition

One wellness nursing diagnosis with rationale for choice of this diagnosis.

 Since MW suffers from Type 2 Diabetes Mellitus should be advised to engage in physical activity and regulated diets that willreduce the effect of the disease condition. Physical activity and balanced diets have been mentioned to reduce the effects of diabetes (International Diabetes Federation Guideline Development Group, 2014). Since the parents of MW also exhibit some of the above metioned condition it is necessary that they also support their child during the treatment process as join in some of the wellness activity. It has been previously shown that the increased physical activity and support from close relatives as well as balanced diets play a key role in the reducing the effects of the forementioned condition.

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

 The abuse of specific drugs as noted in the screening process may have a negative effect on the treatment of the above condition. Use of alcohol and the other drugs has a negative effect on the treatment process. At the same time , the condition might be somewhat genetically related due to certain indications from both the mother and father. Type 2 diabetes is largely a lifestyle disease through genetics has been mentioned to play a role in some of the symptoms (Ali, 2013).  Both the mother and father seem to be geneticallt affected by the condition increasing the risk tha some gentic factors might be at play.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Ali, O. (2013). Genetics of type 2 diabetes. World Journal of Diabetes, 4(4), 114–123. http://doi.org/10.1159/000439418

Donath, M. Y., & Shoelson, S. E. (2011). Type 2 diabetes as an inflammatory disease. Nature Reviews. Immunology, 11(2), 98–107. http://doi.org/10.1038/nri2925

International Diabetes Federation Guideline Development Group. (2014). Global guideline for type 2 diabetes. Diabetes research and clinical practice (Vol. 104). http://doi.org/10.1016/j.diabres.2012.10.001

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