Health Screening and History of an Adolescent
Grand Canyon University- NRS-434V
Health Screening and History of an Adolescent
Biographical Data
L.C.R is a 13 year old Caucasian/Hispanic female. She lives with her Mother and Father and one older sister and currently residing in Chula Vista, California. She is the youngest out of three siblings. She is an 8th grader at a local middle school. Both parents have full time jobs and are able to afford and provide health care for her. She states that parents take her to see the doctor for wellness visits as per instructions of provider and as needed for any physical ailments. States that she has no issues or concerns for her present or past health.
Past Health History
View of personal health:
L.C.R states that she feels that she is “in good health and the only thing that bothers her is a cold but nothing serious.”
Immunizations:
Immunizations are up to date. Currently waiting to see provider to get flu vaccination.
Drug Allergies: NKDAMedications: Takes Motrin-PRN for occasional aches and pains.
Child Hood Illnesses:
No childhood illness that she can recall at this time. For injury in 2006, she suffered a calcaneus fracture from landing on her foot wrong. She was given a special orthotic boot that she had to wear for rehabilitation (OrthoInfo, 2015).
Past Hospitalizations:
In 2008 she was in the hospital for dog bite that lacerated her left cheek and was close to her eye. Her primary care physician required her to stay the night due to wanting to make sure that her sight was not affected.
Past Operations:
No operations are to her knowledge at this time.
Family History
| Gravida: 0 | Term: 0 | Preterm: 0 | Miscarriage/Abortions: 0 | |||
| 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? Dance three times a week performing in Ballet, jazz, contemporary and hip hop. Does not attend Church like they used to due to busy dance and work schedules. Family is Roman Catholic and attends on special occasions. Reports not having time to attend afterschool sports or club due to her Dance commitment and balancing studies. How would you describe your community? Really nice and Friendly and have known then for most of her life. Reports having a good network of friends that are responsible. Hobbies, skills, interests, recreational activities?Likes to dance, and run. Also working with her Dad and their business in a hobby. They make t-shirts and add gems to them. Military service: Yes_______ No_X__ If yes, overseas assignment? Yes________ No_________ Close friends or family members who have died within past 2 years?None Number of relatives or close friends in this area?5 Family member friends of the Mothers- 1 daughter that is close to her, similar in age. Marital status: Single__X____ Married________Divorced_________Separated_________ In serious relationship__N/A____ Length of time__N/A_______ |
| Environmental Content and Questions: Do you live alone? Yes________ No _X____ When did you last move? 9 months old from Santa Maria to Chula Vista Describe your living situation? Currently lives with parents (Dad and Mom) and an older sister Number of years of education completed? Nine years K-8th Occupation: Assist Father with family business If employed, how long? 3 years Are you satisfied with this work situation? Yes Do you consider your work dangerous or risky? No- training of equipment Is your work stressful? “It can be, but depends on the work load and orders that have to be fulfilled.” Over the past 2 years have you felt depressed or hopeless? No feelings of depression or hopelessness in the past 2 years. |
| Biophysical Content and Questions Have you smoked cigarettes? Yes_______ No_X_____ How much? Less than ½ pack per day_____ About 1 pack per day?______ More than 1 and ½ packs per day______ Are you smoking now? Yes_______ No____X____ Length of time smoking? __N/A_______ Have you ever smoked illicit drugs? Yes__________ No_X___ If yes, for how long? ___________ Do you smoke these now? Yes__________ No ___N/A______ Do you ingest illicit drugs of any kind? Yes_________ No__X__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 SystemsGeneral Health State:Sleeps an average of 7 hours a night. Feels fatigued at time from Dance and School. Eat an adequate amount of healthy foods. Tries to follow Vegan and vegetarian diet. Does consume fish for iron and protein. No unexplained weight loss or weight gain. Works out 4 time a week to stay in shape. Denies malaise, unexplained weakness, sweats, night sweats or chills. |
| Skin:L.C.R. has a small rash on the back of her arms. States that she gets it from dance and from sweating. Uses a luffa to scrub back of arms. Reports that they are dry and get irritated very easily. Has small like pustules there alsoDenies any pigment or color change, changes in moles, pruritus, excessive bruising, rash or lesions. Health Promotion:Sun block is applied when doing outing that are in the sun. Lotion is applies to rash on the back of her arms and also she makes sure to exfoliate to open up pores. |
| Hair (recent loss or change in texture): No issues or concerns. She has waist length hair, does not dye or process hair. No extreme hair loss or change in texture. Health Promotion:Showers daily and washes hair every other day or as needed. Makes sure to not use shampoo that contains high alcohol content. Uses Coconut oil as natural moisturizer. |
| Nails: Does not bite nails, Does have a habit of tearing nails instead of clipping them. Nails are not brittle or misshaped. Luna is present in all nails. Health Promotion: Paints nails occasionally and may go once a month to get them done professionally. |
| Head : Denies headaches, dizziness, or issues with syncope. Does have occasional vertigo when standing up to fast. Episode does not last longer than a noted 10 seconds. |
| Eyes:Denies change in vision, blurring, blind spots, eye pain, diplopia, redness or swelling, and watering or discharge. Denies glaucoma or cataracts.No issues or concerns at this time. Last eye exam was done last school year in the school March 2015. Health Promotion:L.C.R admits to not wearing sunglasses when exposed to the sun or bright lights. Last eye exam was march 2015 at school. |
| Ears:Patient denies earaches, infections, discharge from ears, tinnitus, and vertigo.No issues or concerns at this time Health Promotion:Has head phone in a lot and parents state that it is too loud. Cleans ears once a month. Denies hearing loss. |
| Nose and Sinuses: Reports mild seasonal allergies occasionally and nasal discharge. Denies frequent or severe colds. Denies sinus pain, nasal obstruction, nosebleeds, or change in sense of smell.Health Promotion:Blows nose when needed with a tissue and washed hands to prevent spread of germs. |
| Mouth and Throat:Sometimes when sick has issues swallowing because of sore throat. Denies mouth pain, chronic sore throat, toothaches, lesions in mouth, tongue, or throat. No chronic dysphagia, hoarseness or alterations in taste. Still has tonsils and has no issues with them. Health Promotion:Last dental exam, August 2013. Patient receives dental cleanings every six months. Brushes teeth and tongue twice daily and flosses once or twice a week. Mother reports four cavities so far and no root canals or crowns. Neck:Patient denies pain, limited motion, lumps or swelling, or neck enlargement. Neurologic System:Patient and mother denies any history of neurological disorders to include seizures, syncopal episodes, or CVA. No motor function or coordination problems, paresthesia, mood change, depression, memory disorder and any history of mental health reported. Health Promotion:Patient reports being an avid reader. Enjoys board games especially if they relate to memory. Board games enjoyed such as Recall (memorization of hidden items) and The World (geography game). Endocrine System:Mother denies history of diabetes, thyroid disease, or intolerance to heat or cold. Health Promotion:School physical which included lab values were obtained in September 2013. Mother recalls glucose level at 92 and TSH level at 1.5 from September’s lab results. Mother reports serving a well-balanced diet to include vegetables and fruits. Breast and Axilla:Denies any pain, swelling, tenderness, lumps, rash, and nipple discharge. Denies any chest or axillary surgery. Health Promotion:Patient reports never performing breast self-exam. Respiratory System:Patient reports asthma. Experiences 1 – 2 attacks per week. Patient denies history of other lung disease, chest pain with breathing, sputum, or hemoptysis. Patient does report wheezing, shortness of breath, and cough associated with his asthma. Patient and mother denies toxin or pollution exposure. Health Promotion:Last chest x-ray for school physical, August 2013. Patient reports getting the flu vaccine every fall. Cardiac System:Mother denies history of cardiac disease. No history of MI, atherosclerosis, arteriosclerosis, chest pain, or angina. Health Promotion:Last ECG obtained for school physical, August 2013. Peripheral Vascular System:Patient denies coldness, numbness, tingling, swelling of legs/ankles or hands. He denies any discoloration of hands or feet. Denies any claudication, thrombophlebitis or ulcers, and varicose veins. Health Promotion:Patient and mother verbalizes understanding of not crossing legs. Patient expresses that he is active and does not sit for long periods of time. Hematologic System:Patient denies any bleeding tendency other than an occasional small bleed while flossing teeth. Mother expresses that she has not seen any excessive bruising, swelling of lymph nodes. Patient has never had a blood transfusion. Denies exposure to toxic agents or radiation. Health Promotion:Patient reports good hand hygiene by washing hands or using a hand sanitizer when needed. Patient is not routinely exposed to blood or body fluids. Gastrointestinal System:Patient and mother reports good appetite with no change in eating habits. Patient denies food intolerances, dysphagia, heartburn, indigestion, pain with or without eating, pyrosis, nausea, vomiting, flatulence, diarrhea, constipation, hemorrhoids or rectal bleeding. Reports no history of abdominal disease, gastric ulcers, or change in stool of color or consistency. Patient reports bowel movements 1 – 2 daily with no straining. Health Promotion:Mother states that she prepares and patient eats well balanced meals with vegetables and fruits and limits red meat consumption. Reports only an occasional antacid and laxative use. Musculoskeletal System:Patient reports lingering left leg stiffness, ongoing slight pain, weakness, and limited range of motion from previous fracture and fixation of left tibia fracture. Patient reports that his left leg still is not as strong as his right leg. No history of arthritis, swelling, or cramps of musculoskeletal system. No other problems reported of his musculoskeletal system. Health Promotion:Patient reports occasional use of physical therapy exercises for left leg prescribed by his doctor when he remembers. He also wants to start muscle training to strengthen his left leg. Urinary System:Patient denies urinary problems. He denies any change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, change in color, narrowed stream, or incontinence. Denies history of any urinary disease, pain in flank, groin, suprapubic region or lower back. Health Promotion:Patient states an understanding of staying hydrated and expressed signs of dehydration such as dark urine color. Male Genital System:Patient reports no penile or testicular pain, sores, lesions, penile discharge, lumps or hernia. Health Promotion:Patient denies ever performing a testicular self-exam. Female Genital System:N/AHealth Promotion:Sexual Health:Patient denies being sexually active or ever having a STD. Health Promotion:Patient expresses the wish to stay abstinent from sex. He does express an understanding of contraceptives and condom use as well as potential of sexually transmitted diseases from sexual encounters. Nursing Diagnoses:Actual Nursing Diagnosis:“Ineffective therapeutic regimen: management individual” (Weber, 2005, p. 1) related to “lack of understanding of the implications of not following the prescribed treatment plan” (Nursing Diagnosis, n.d., no. 1). The rationale for choosing this nursing diagnosis is the patient’s reported lingering left leg stiffness, ongoing slight pain, weakness, and limited range of motion from previous fracture and fixation of left tibia fracture. Patient reports weakness of left leg. Patient reports only occasional use of physical therapy exercises when he remembers as prescribed by his doctor. Also, patient has not started any type of strength training for this leg. Desired outcomes to include:Expected outcomes include that the patient will demonstrate the probability of effective management of the therapeutic regimen as evidenced by: 1. Willingness to learn about and participate in the ongoing treatment plan as prescribed by his doctor. 2. Patient states ways that he will achieve physical therapy exercises into his weekly or daily habits. 3. Patient states understanding of the implications of not fulfilling his physical therapy exercises. Interventions include:A. Encourage patient to participate in treatment plan.B. Seek clarification of physical therapy exercises from doctor. C. Assist patient to identify ways to incorporate physical therapy into his daily or weekly schedule. D. Include mother in explanations and teaching sessions and encourage support. E. Reinforce behaviors suggesting compliance of physical therapy exercises. (Nursing Diagnosis, n.d.) Wellness Nursing Diagnosis:“Health-seeking behaviors” (Weber, 2005, p. 1) related to “lack of awareness of environmental hazards affecting personal health” (Martucci & Gulanick, n.d., para. 5). The rationale for choosing this nursing diagnosis is the patient’s knowledge deficit related to sun exposure. Patient only occasionally uses sun screen with SPF of 30 when he remembers or parents insist. He wears a baseball cap occasionally when in the sun. Patient wears sunglasses but unsure if they contain UV protection. Expected outcomes include that the patient will demonstrate increased sun protection as evidenced by: 1. Willingness to learn out possible sun exposure risks to skin and eyes. 2. Patient identifies and states understanding sun exposure risks. 3. Patient engages in sun protection activities. Interventions include:A. Encourage patient to participate in treatment plan.B. Seek clarification of sun exposure risks.C. Assist patient in identifying reduced sun exposure strategies. D. Include mother in explanations and teaching sessions and encourage support. E. Use of a variety of teaching methods(Martucci & Gulanick, n.d.)Risk Nursing Diagnosis:“Risk for chronic pain” (Weber, 2005, p. 4) related to “pain resulting from medical problems” (Gradishar, Muzio, Filipski & Klopp, n.d., para. 2). The rationale for choosing this nursing diagnosis is that the patient reports lingering ongoing slight pain which has lasted more than six months. His surgery was fourteen months ago. Expected outcomes includes that the patient will demonstrated decreased or eliminated pain as evidenced by: 1. Willingness to seek medical treatment for prolonged pain. 2. Follows medical treatment regimen 3. Expands physical therapy treatment by Physical Therapist or self-treatment if ordered by doctor. 4. Patient verbalizes adequate relief or elimination of pain. Interventions include:A. Encourage patient to see medical treatment for prolonged pain. B. Teach purpose, benefits, and techniques of medical treatment regimen. C. Assist patient with scheduling physical therapy either with a Physical Therapist or self-treatment if ordered by doctor. D. Instruct patient to report any continued pain. (Gradishar, Muzio, Filipski & Klopp, n.d.) ReferencesGradishar, D., Muzio, L., Filipski, A. & Klopp, A. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick39.htmlMartucci, S. & Gulanick, M. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick27.htmlNursing Diagnosis. (n.d.). Retrieved from http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=338Weber, J. R. (2005). Retrieved from http://jxzy.smu.edu.cn/jkpg/UploadFiles/file/TF_06928152357_nursing%20diagnoses%20grouped%20by%20functional%20health%20patterns.pdfHealth Promotion:Dental checkup in Aug. States that she has no cavities. Brushes teeth twice a day and after meals. Used to have braces and is very dedicated to her oral care. |
| Neck:L.C.R denies pain, limited motion, lumps or swelling, or neck enlargement |
| Neurologic System:Denies any history of neurological disorders to include seizures, syncopal episodes, or CVA. No motor function or coordination problems, paresthesia, mood change, depression, memory disorder and any history of mental health reported. Health Promotion (activities to stimulate thinking, exam related to mood changes/depression):Relaxes before doing homework by cat napping and listening to music to clear mind. Then sets a time to get task started |
| Endocrine System:L.C.R denies history of diabetes, thyroid disease, or any sensitivity or intolerance to heat or cold.Health Promotion):Follows a Vegan and vegetarian diet and does not consume a high carb/sugar diet. |
| Breast and Axilla):Denies pain, swelling, tenderness, lumps, rash, and nipple discharge. No history of surgery. Health Promotion:L.C.R. states that she does not know how to do breast exams and does not perform them. |
| Respiratory System:Patient denies history of other lung disease, chest pain with breathing, sputum, or hemoptysis, wheezing, or shortness of breath. L.C.R. confirms with mother and denies toxin or pollution exposure. Health Promotion:Last x-ray was 3 years ago for school physical. |
| Cardiac System:Denies history if cardiac disease, MI, atherosclerosis, chest pain or angina. Health Promotion (last cardiac exam): States that she never had an EKG done or had a cardiac exam |
| Peripheral Vascular System:L.C.R. reports no coldness, numbness, tingling or discoloration of extremities. Denies any claudication, thrombophlebitis or ulcers, and varicose veins. Denies swelling. No issues or concerns at this time.Health Promotion:Crosses legs when sitting. Does not feel the need to wear support hose. Is active and does not sit for long lengths of time. |
| Hematologic System: L.C.R. states that she has no problem stopping the bleeding when she gets cuts. No bruising or swollen lymph nodes. Has never had a blood transfusion. Denies exposure to toxic agents or radiation.Health Promotion:Is not exposed to bodily fluids. |
| Gastrointestinal System:L.C.R states that she has a good appetite. Tries to follow a Vegan and Vegetarian diet whenever possible. Denies food intolerances, dysphagia, heartburn, indigestion, pain with or without eating, pyrosis, nausea, vomiting, flatulence, diarrhea, constipation, hemorrhoids or rectal bleeding. Reports no history of abdominal disease, gastric ulcers, or change in stool of color or consistency. Patient reports bowel movements at least once daily with no straining. No issues or concerns at this time.Health Promotion:Follows a Vegan and Vegetarian diet. Does not eat past 800pm. Drinks water throughout the day to stay hydrated. |
| Musculoskeletal System:No mobility aids used. Has no difficulty walking. Gait is stable .No issues or concerns at this time. Health Promotion: L.C.R .states that when she feels tense from working out or dance she will take time to stretch those muscles. She is very active and does yoga for core strengthening along with her dance routines. |
| Urinary System:No issues or concerns at this time. Health Promotion:She knows how to clean after restroom use and to wipe front to back. To prevent UTI’s L.C.R drink cranberry juice and changes out of damp or sweaty clothing. Uses sanitary pads during menstrual cycle and knows to change them every 3 hours or as needed. |
| Female Genital System:LMP: September 15th, 2015. Menstrual cycle every 28 days with no pain or discomfort. No vaginal itching or discharge or concerns at this time. Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products):L.C.R has not had a geological pap-smear done being that she is not sexually active. She uses sanitary pads during menstrual cycle and knows to change them every 3 hours or as needed. |
| Sexual Health: Is not in a relationship. Is knowledgeable about birth control but choose not to take it. No history of STD’s. Health Promotion:Not sexually active, is not on birth control. Practices abstinence. |
|---|
Nursing Diagnosis
Impaired skin integrity related to scrubbing the back of arms as evidence by rough and dry skin on the posterior side of upper arms.
L.C.R. has bumps on the back of her arms. She admits to” using a luffa to the back of her arms to keeping the pores open.” Writer noticed that she also has dry skin that is rough, dry and little pustule bumps that are irritated.
Readiness for enhanced spiritual being related to desire for enhanced satisfying philosophy of life as evidence by expressing wanting that connection with spiritual leaders
L.C.R. states that she remembers going to church as a little girl with her family. Being Roman Catholic she states that they do not require you to go all that often. With her busy dance schedule and other family activities she states that they are not able to go very often and she misses it.
At risk for decreased or damaging eye sight related to not using sun protection for eyes when in bright lights or sun exposure.
L.C.R even admits that she needs to use eye protection when out in the sun. Her father was even in the passing and making jokes about how she needs to wear and “not just because they are cool.”
Goal: Inform patient about the benefits for using eye protection.
Intervention:
Have parents encourage her to wear sun glasses when outside.
Buy sun glasses that block out 100% UV rays
Educate patient and parents on symptoms of worsening eye sight from sun damage. Squinting, dry eyes, and headaches.
Wellness plan
Given L.C.R is a very active lady she needs to think about things and apply herself. Writer also took the time to educate the parents on the importance of health check and prevention. The writer went over the risks and concerns or using such an abrasive cloth to scrub her arms. L.C.R was encouraged to see provider for the rash. Educated L.C.R on not using harsh soaps on the skin and to quit scrubbing with a luffa as to not cause any more skin damage until seen by a provider (Jarvis, 2015).
For the spiritual well-being L.C.R was encouraged to speak with her parents about attending church more often. Wad educated on the new apps that they have on phone and how they can be like having church in your pocket. Also educated on that they are online broad casting on many websites that she can watch when she has the time.
L.C.R. agrees that eye protection is very important. Writer showed her pictures of eyes that are damaged due to over exposure of the sun. Also that she does not need eye glasses now but over exposure can change that. The risks are very high. L.C.R agrees that she needs to get sun glasses. Writer educated her on having more than one pair and that she can place them in different places as to remember to put them on. Also making sure that they are UV resistant (Rick Daniels, Leslie Nicoll ,2011).
References
Rick Daniels, Leslie Nicoll (2011) Contemporary Medical-Surgical Nursing. Retrieved from https://books.google.com/books?id=wUAJAAAAQBAJ&pg=PA1095&lpg=PA1095&dq=nursing+diagnosis+for+sun+exposure+to+eyes&source=bl&ots=eq7yswsU3G&sig=pNKViNMKP4jb0h7WzeVFC-RajgA&hl=en&sa=X&ved=0CCQQ6AEwAWoVChMIlq-lxefNyAIVVNdjCh0KvwXU#v=onepage&q=nursing%20diagnosis%20for%20sun%20exposure%20to%20eyes&f=falsehttps://books.google.com/books?id=wUAJAAAAQBAJ&pg=PA1095&lpg=PA1095&dq=nursing+diagnosis+for+sun+exposure+to+eyes&source=bl&ots=eq7yswsU3G&sig=pNKViNMKP4jb0h7WzeVFC-RajgA&hl=en&sa=X&ved=0CCQQ6AEwAWoVChMIlq-lxefNyAIVVNdjCh0KvwXU#v=onepage&q=nursing%20diagnosis%20for%20sun%20exposure%20to%20eyes&f=false
Jarvis, C. (2012). Physical Examination and Health Assessment,7th Edition. St. Louis, MO: Elsevier.
Orhto Info (2015) Calcaneus (Heel Bone) Fractures. Retrieved from http://orthoinfo.aaos.org/topic.cfm?topic=A00524
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