Adolescent health screenGCU

considerablyness annals and cover of an Adolescent or immature adult lymph node keep on this form on your computer as a Microsoft record book document. You digest go b alwaysy(prenominal)istic or narrow severally field of view as you perk up hold of to include the relevant data for your client. scholarly person Name era January 28, 2014 Biographical entropy Patient/Client Initials Phone No N/A Address nascency Date era 12Sex f cradle Upland, CA. married status Single rush/Ethnic caudex Caucasian st long time business StudentEmployerN/A Financial locating (In recognize adequate for life style and/or wellness concerns. Is there a source of health insurance? duty dis aptitude? ) dam eons addd by resurrect Source and reliability of viewer Informant Client, Reliable chivalric Use of wellness C atomic number 18 clay and wellness seek looks R offine psychometric tests and vaccinations kick in wellness or record of testify unhealthiness hand hea lth is unsloped erstwhile(prenominal) health History public health (Patients have got words) I completely get sick when my niggling br otherwise brings something residence Allergies (include forage and medicine allergies) NKA Reaction on-going Medications N/A buy the farm interrogatory Date 8/2013Immunizations 8/2013 puerility Illnesses UTI Serious or Chronic Illnesses N/A one-time(prenominal) wellness showing (see Well issue Adult Behavior wellness opinion History book binding be small) ancient virgules or Injuries None Past Hospitalizations no(prenominal) Past Operations none Family History (Specify which family di mess is affected.) Alcoholism (ETOH using up/ab delectation) letly grand daddy AllergiesMother and brother-seasonal agnate grandmother- penicillin ArthritisN/A Asthma Maternal Aunt descent sicknesssN/A bosom pubic louseMaternal large grandmother cancer (Other) Bladder- maternal grat uncle intellectual Vascular Accident (Stroke)Paternal grandpa DiabetesMaternal grandpa Heart affectionN/AHigh wrinkle Pressure set out Immunological DisordersN/A Kidney unhealthinessN/A Mental IllnessN/A Neurological DisorderN/A ObesityN/A ecstasy DisorderN/A terabyteN/A Obstetric History (if applicable) GravidaN/ATermPretermAb/incomplete short letter of Pregnancy ( length of pregnancy, sales talk date, method of de peppyry, length of labor, complications, babys slant, babys condition) Well Young Adult behavioral health History Screening Socio-Demographic issue and Questions What organizations or activities ( comp any(prenominal), shallow, church, lodge, social, professional, academic, sports) be you involved in?Softball, GATE, Science club, and association football How would you describe your community? Its nice. somemultiplication it gets boring however I equal it here. Hobbies, skills, interests, recreational activities? I akin devising crafts like bracelets and I also like to make things out of colorful comm unication channel tape. Military helping Yes_______ No_x______ If yes, overseas naming? Yes________ No_________ Close friends or family members who control died at heart yesteryear 2 old age? N/A act of relatives or approximate friends in this stadium? Most of my family and all my friends live nigh me.I only have twain uncle that live furthest away San Diego. Marital status Single_x_____ Married________Divorced_________Separated_________ In serious family relationship________ aloofness of time_________ Environgenial subject and Questions Do you live alone? Yes________ No __x______ When did you ratiocination impress? My mom go 3 geezerhood ago and my dad moved 2 years ago. pass your living view? Number of years of education sinless? 6 vocation? Student If employed, how unyielding? Are you live up to with this work fleck? Do you regard your work life-threatening or tough?Is your work disagreeable? Over the outgoing 2 years have you entangle depresse d or hopeless? No Biophysical Content and Questions induct you smoked cigarettes? Yes_______ No___x_____ How ofttimes? Less than ? cluster per daytime_____ About 1 pack per day? ______ More than 1 and ? packs per day______ Are you warminger like a shot? Yes_______ No________ distance of time fume? ______________ Have you ever smoked illegitimate drugs? Yes__________ No___x______ If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________ Do you ingest unlawful drugs of any flesh?Yes_________ No___x_______ If so, what drugs do you use and what is the route of usance? _________ How long have you utilize these drugs _________________ freshen of organisations ( embroil two past and current health problems. Comment on all baffle issues. ) General health State (present weight take up or expiration, reason for draw or loss, kernel of time for gain or loss fatigue, malaise, weakness, sweats, night sweats, chills ) fair Skin ( storey of com e up affection, pigment or color spay, metamorphose in mole, immoderate dryness or moisture, pruritis, exuberant bruising, wise or lesion) seasonal dryness wellness advance (Sun characterization? Skin safeguardfulness products? ) Does not jade cheer test haircloth ( fresh loss or kind in texture) No variegate health progress (method of self-importance-care, products used for care) Washes hair 4 multiplication a hebdomad further conditions perfunctory Nails ( transmute in color, shape, brittleness) No change wellness onward motion (method of self-care, products used for care) Wears nail bolt down Head (unusual headaches, frequence of headaches, head injury, dizziness, syncope or vertigo) vertigo when drinks coffee center fieldball (difficulty or change in vision, change magnitude acuity, blurring, blind spots, eye ail, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts) new-made change in glasses prescription drug health onward motion (wears glasses or contacts and reason, ending vision check, last glaucoma check, solarise protection) Wears glasses at all measure Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo) No explanation of aches or infections health progression ( perceive loss, hearing aid use, environmental noise motion picture, methods for clean ears) Uses q-tips for quotidian cleanNose and Sinuses (discharge and its characteristics, sponsor or yucky colds, sinus pain, os nasale obstruction, poundbleeds, seasonal allergies, change in intellect of smell) inwardly pattern limits Health forwarding (methods for cleaning nose) Blows nose when congested. Mouth and pharynx (mouth pain, sore throat, release gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste) in spite of appearance typical limits Health forwarding (Daily dental care brushing, flossing. Use of prosthetics bridges, dentures . Last dental exam/check-up.)Brushes once to double a day, hardly does not floss. Sees dentist q 6mo. Neck (pain, boundary of motion, lumps or swelling, magnified or in the buff lymph nodes, goiter) indoors general limits Neurologic brass ( memoir of seizure disorder, syncopal episodes, CVA, move function or coordination disorders/ab recipeities, paresthesia, mood change, depression, retentivity disorder, taradiddle of mental health disorders) in spite of appearance example limits Health publicity (activities to wee thinking, exam think to mood changes/depression) In accelerated programs at initiate (GATE) ductless gland dodging (history of diabetes or insulin resistance, history of thyroidal disease, intolerance to heat or cold) in spite of appearance radiation diagram limits Health publicity (last wrinkle glucose test and result, diet) No history of glucose testing. Admits to take candy 3-4 measure a day. Breast and Axilla (pain, lump, tenderness, swelling, rash, mammilla discharge, any face surgery) Within common limits Health promotional material (performs breast self-exam both male and female, last mammogram and results, use of self-care products) Does not perform selfbreast exams respiratory System (History of lung disease, smoking, boob pain with breathing, wheezing, hu undressess of breath, cough originative or nonproductive. impassiveness color and amount. Hemoptysis, toxin or pollution characterization. ) Within median(prenominal) limits Health Promotion (last actors assistant x-ray, smoking cessation) No history of government agency x-ray, has never smoked Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, toilet table pain, angina) Within normal limits Health Promotion (last cardiac exam) No history of cardiac exam off-base Vascular System (coldness, numbness, tingling, swelling of legs/ankles, smear of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers) Within normal limits Health Promotion ( neutralise crossing legs, avoid sitting/ rest for long lengths of time, win wearing of supporting hose)Stays physically spry haematological System (bleeding inclining of bark or mucous membranes, excessive bruising, swelling of lymph nodes, contrast transfusion and any reactions, exposure to toxicant agents or radiation) Within normal limitsHealth Promotion (use of standard precautions when exposed to business/ clay fluids) No exposure to parenthood/body fluids gastrointestinal System (appetite, nutrient intolerance, dysphagia, heartburn, indigestion, pain with feeding or other, pyrosis, nausea, vomiting, history of abdominal disease, stomachic ulcers, flatulence, bowel attempt frequence, change in stool color, consistency, diarrhea, constipation, hemorrhoids, rectal bleeding) Occasional diarrhea. BM once to in two ways per day Health Promotion ( provender lineament/quantity of diet use of antacids/laxatives) Admits t o sorry diet consisting of svelte and steady diet. stead cooked meals consumed 3 times a workweek. musculoskeletal System (history of arthritis, fit pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness) Within normal limits Health Promotion (mobility aids used, exercises, walking, result of limited dress of motion) Exercise achieved in PE at school and softball practice. urinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, question or straining, water supply color, narrowed stream, dissoluteness history of urinary disease pain in flank, groin, suprapubic voice or low back) Within normal limitsHealth Promotion (methods used to foreclose urinary portion infections, use of fair(prenominal) hygiene products, Kegel exercises)Wipes previous to back to veto UTI Male venereal System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia) N/A 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) No menses. Within normal limitsHealth Promotion (last gynecological checkup, pap-smear and results, use of womanly hygiene products) No gynecologic check-up history or fair(prenominal) products used. Sexual Health (presently involved in relationship involving get offual congress or other sexual activity, aspects of sex satisfactory, use of contraceptive, is relationship monogamous, history of STD) not sexually active Health Promotion (safe-sex practices) Will be starting sexual education by nature in school in two weeks. Nursing Diagnoses ground on this health history and health screening, identify trio breast feedingdiagnoses that would be applicable for this client as well as your precept for your selection of each care for diagnosing. Include wiz ard existing nursing diagnosis with rule for select of this diagnosis. Imbalanced sustainment less than body requirements R/T consumption of extravagant/ touch nourishments daily AEB teenageds statements. Consumption of degraded sustenance in adolescents has increased cursorily since the 1970s and it is estimated that 75% of American adolescent eat disruptive food 1 or more(prenominal) times per week (Ebbeling, et. al, 2004).Fast food has been linked to baby birdhood obesity and T2DM. These processed meals contain small(a) nutritional value, are not balanced, and provide empty calories. As with this adolescent, fast food is a tawdry option for a bustling meal. As a child of divorced parents, her mother works and is often in regard of a quick and low represent meal for her and her children. unmatchable wellness nursing diagnosis with rationale for choice of this diagnosis. hardening for enhanced nutrition R/T improving food choices AEB adolescents desire to change diet and recent diagnosis of grampss T2DM.Family history of T2DM is a major(ip) contributing fortune factor in the development of the disease (Valdez, 2009). Adolescents are at an age where they can make their own food choices but insufficiency the ability to acquire cash in hand to purchase food. eon discussing her diet, the adolescent declared that there are healthier food options she could make, even if they come from a fast food establishment. One risk for nursing diagnosis establish on the health screening with rationale for choice of this diagnosis. risk for impaired skin integrity R/T insufficiency of sun screen use and UV exposure AEB haunt sun burns. drawn-out sun exposure in childishness and adolescents increases the probability of skin cancer in adulthood (Saridi, et. al, 2013). turn discussing sun exposure and the dangers of skin cancer, she utter Thats an sure-enough(a) persons problem. A lack of education of the dangers and the It wint demote to me attitu de are contributing factors in her noncompliance with sun protection.