Health History and Screening of an Adolescent or Young Adult Client

Health History and Screening of an Adolescent or Young AdultClient

Biographical Data

Patient/Client Initials: Gordon Mcklain

Phone No:

Address: 45633310

Birth 24/10/1987

Age: 28

Sex: Male

Birthplace: Kansas City Hospital

Marital Status: Single

Race/Ethnic Origin: African American

Occupation: IT technician

Employer: Self Employed

Financial Statu : Though the patient in question is self employed and has medicare insurance, he is also well off with the support of his family thus able to meet the health lifestyle required for hypertension patient.

Source and Reliability of Informant: The information was provided by the patient and is reliable as there records.

Past Use of Health Care System and Health Seeking Behaviors: The patient has frerquently visited Kansa City Hospital

Present Health or History of Present Illness: The patient suffers from hypertension

Past Health History

General Health: “I have been suffering from hypertension since childhood, as far as am concerned I have kept myself in good health inregard to my health.” Patient.

Allergies: The patient has no known allergies at this point.

Reaction:

He reacts well to hypertension medicine no side effects incidents

Current Medications: Thiazide diuretics Acebutolol

Last Exam Date: june 6 2015

Immunizations: Varicella, tetanus, diphtheria, pertussis and influenza vaccines.

Childhood Illnesses: The patient has only suffered from hypertension condition only since as major illness: Since child the patient has only suffered from Malaria and hypertension

Serious or Chronic Illnesses: The patient does not suffer from any serious or chronic illness apart from hypertension

Past Health Screening. The patient has been screen for chronic disease before and hypertension associated illness.

Past Accidents or Injuries:

The patient has never been involved in any accident or injured himself.

Past Hospitalizations: At the age 12 the patient was hospitalized in Kansa City Hospital

Past Operations: Never had an operation

Family History

(Specify which family member is affected.)

Alcoholism (ETOH use/abuse): N/A

Allergies: N/A

Arthritis: N/A

Asthma: N/A

Blood Disorders: N/A

Breast Cancer:N/A

Cancer (Other): N/A

Cerebral Vascular Accident (Stroke): N/A

Diabetes: N/A

Heart Disease: N/A

High Blood Pressure: Fathers suffers from hypertension

Immunological Disorders: N/A

Kidney Disease: N/A

Mental Illness: N/A

Neurological Disorder: N/A

Obesity: N/A

Seizure Disorder: N/A

Tuberculosis: N/A

Obstetric History (if applicable)

Gravida: N/A

Term:N/A

Preterm: N/A

Miscarriage/Abortions: N/A

Course of Pregnancy : 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? The patient is an active church member

How would you describe your community? The patient describes the community as essential family that is important in his life any especially supportive of his condition.

Hobbies, skills, interests, recreational activities? Reading watching fiction movies and playing basket ball

Military service: Yes___ No___

If yes, overseas assignment? Yes___N/A_ No_N/A

Close friends or family members who have died within past 2 years? None

Number of relatives or close friends in this area? Around 10

Marital status: Single__ MarriedDivorced_Separated_ In serious relationship Length of time_

Environmental Content and Questions:

Do you live alone: Yes No

When did you last move: N/A

Describe your living situation: patient lives with his family that takes care of him.

Number of years of education completed:16

Occupation

If employed, how long: N/A

Are you satisfied with this work situation: The patient indicates signs of job satisfaction as he is self employed.

Do you consider your work dangerous or risky? The patient considers his job safe

Is your work stressful? Since he is self employed the job he does he considers it as stress free as their no one to boss him.

Over the past 2 years have you felt depressed or hopeless? The patient indicates some feelings of depression

Biophysical Content and Questions

Have you smoked cigarettes? Yes___ No

How much?

Less than ½ pack per day__N/A___ About 1 pack per day?__N/A More than 1 and ½ packs per day___N/A___

Are you smoking now? Yes___N/A No__N/A__ Length of time smoking? N/A__

Have you ever smoked illicit drugs? Yes__ No_

If yes, for how long? __N/A_ Do you smoke these now? Yes___N/A___ No __N/A

Do you ingest illicit drugs of any kind? Yes__ ___ No__

If so, what drugs do you use and what is the route of ingestion?N/A_

How long have you used these drugs _N/A

Review of Systems

(Include both past and current health problems. Comment on all present issues.)

General Health State: The patient experiences fatigue when walking or standing for long hours, he has lost wait in a span of 3 months. The patient complains of weak limbs and numbness.

Skin: Patient skin is well pigmented, has no history of skin diseases and it appears to be well oiled and moisture.

Health Promotion : The patient use Obagi skin care products.

Hair: The air seems perfectly okay and their no noticeable loss of hair.

Health Promotion: The patient shaves his air and oils chis hair .

Nails: The nails are in perfect health colour.

Health Promotuion. The patient has kept himself in proper diet and close medical check ups.

Head : The client experience some acute headaches

Eyes:The patient has not experienced significant eye prolems.

Health Promotion : The patient were glass to enhance reading with easy, his last vision check up was in Kansa City Hospital 6 June 2015. Also eats diet that enhance vision.

Ear : The ears are in perfect health.

Health Promotion: The Patient works in a noise free environment, he had recents check ups in Kansa hospital 6 june 2015. Cleans his eyes with a moist cloth and mineral oil.

Nose and Sinuses: The patient is in perfect nose and sinuses condition, he has no pain discharge, nasal obstructions or allergies or associated change in smell.

Health Promotion: The patient cleans the nose with warm-salted water.

Mouth and Throat: The patient has no incidence throat and mouth related illiness or tongue.

Health Promotion: The patient brushing his teeth twice a day in the morning and before going to sleep. His last dental check up was in 2014 Dec 16.

Neck: The patient has no history of neck pain or associated illness.

Neurologic System :The patient has not had any episodes of neurologic disorders

Health Promotion :The patient is playful, likes to read, play basket ball and active church member plus self employed practioneer in IT

Endocrine System: The patient has not had an incidence related to endocrine system.

Health Promotion: The patient avoids food that can lead to diabetes or affecting the sugar levels. Last result for glocuse level was 132mg/dl.

Breast and Axilla:The patient axilla and breast are healthy and the patient has never had any surgery in relation to the axilla and breast.

Health Promotion: The patient does not perform any check ups in regard to axilla wether self or physician initiated.

Respiratory System : The patient experience no pain associated with respiratory system expect chest pains.

Health Promotion: The patient has avoided instances that will affect his respiratory system and had frequent check ups the last one was in august 26 2015

Cardiac System: The patient has had episodes of chest, and suffers from arteriosclerosis.

Health Promotion (last cardiac exam):The patien has a kept a health diet, the last cardiac exam was in jan 14 2015.

Peripheral Vascular system: The patient legs and variscose veins sometime swell.

Health Promotion:He controls the condition by wearing medical recommended shoes and avoid making himself to stand or siting for long hours. In addition to proper diet, he exercises.

Hematologic System: The patient has a healty mucous membrane, shows no signs of swelling in the lymph. He has no records of reaction towards toxic agents or radiation as has never been exposed.

Health Promotion The patient had knowledge to treat every fluid as infectious, thus handling it with care.

Gastrointestinal System : The patient has no previous problem with his gastrointestial system.

Health Promotion: The patient is under diet for Heart and high blood pressure promotion foods.

Musculoskeletal System: The patient has had pains in his legs and points to having problems frequently associated with bones weakness.

Health Promotion : Moderate exercise to avoid overworking the bones and use of calcium enhancer medicine.

Urinary System: The patient indicates to have had episodes of blood in his urine.

Health Promotion: the patient regular visits medical clinic for frequent check up.

Male Genital System :The patient indicates to have no history of genital problems and confirms his condition to be medically fit.

Health Promotion: The patient is aware of genital associated problems,the patient regular performs testicular self exam.

Female Genital System: N/A

Health Promotion: N/A

Sexual Health:

The patient is currentlty not sexually active and has no history of sexual transmitted diseases

Health Promotion: The patients has always practiced safe sex in his instance in life he ever had an intercourse use of condom

NursingDiagnoses

Acutepain related to hypertension as evidenced by vasoconstricted veins.

Tointervene as early as possible to enable recovery of constrictedveins.

Providesupport and reduce pain

Readinessfor self care r/t reduced swelling of legs and varicose vein due toexcercises and medical check up. To encourage the patient to keeppracticing the self care practice as they will enhance his health.

Riskfor decreased cardiac output due to unmonitored patient conditions.

Tokeep be aware what measure need to be undertaken t avoid theoccurrence of that risk.

Reference

NandaNursing diagnosis for hypertension

Retrieved fromnandanursingdiagnosis.blogspot.co.ke/2011/10/nanda-nursing diagnosisfor .html.

NursingDiagnosis AORN JOURNAL by JC Rothrock 1984

What is Thrree-part nursing diagnosis? (n.d.). Retrieved from

http://acceleratednursing.roseman.edu/blog/three-part-nursing-diagnosis/

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