Health History and Screening of an Adolescent or Young Adult Client
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| 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
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| Source and Reliability of Informant:
Primary information from the patient |
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| Past Use of Health Care System and Health Seeking Behaviors:
MW has severally been admitted in various healthcare setting due to his condition
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| Present Health or History of Present Illness:
Type 2 Diabetes mellitus
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| Past Health History | ||||||
| General Health: (Patient’s own words)
Suffers from Diabetes Type 2 |
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| Allergies: (include food and medication allergies)
None
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Reaction:
None
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| Current Medications:
Metformin
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| Last Exam Date:
3/09/ 2016 |
Immunizations:
All childhood immunizations
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| Childhood Illnesses:
None
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| Serious or Chronic Illnesses:
Type 2 Diabetes Mellitus
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| Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below)
None |
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| Past Accidents or Injuries:
None
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| Past Hospitalizations:
3 times after diagnosis with type 2 Diabetes Mellitus |
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| Past Operations:
None
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| Family History
(Specify which family member is affected.) |
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| 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 |
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| 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_________
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| 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
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| 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
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| 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
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| Hair (recent loss or change in texture):
Black no change Health Promotion (method of self-care, products used for care):
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| 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
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| 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):
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| 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):
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| Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina):
N/A Health Promotion (last cardiac exam):
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| 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):
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| 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):
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| 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):
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| 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):
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| 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):
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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