NSG435V GCU Health History and Screening

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NSG435V GCU Health History and Screening Health History and Screening of an Adolescent or Young Adult Client

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Student Name: Jennifer R Romero	Date: 2/9/2014
Biographical Data
Patient/Client Initials: JFM	Phone No: 562-761-9145
Address: 11004 Kentucky Ave Whittier, CA 90603
Birth Date: 3/23/1993	Age: 20	Sex: Female
Birthplace:   Whittier CA	Marital Status: Single
Race/Ethnic Origin: Hispanic
Occupation: Full Time College Student at Cal State Los Angeles	Employer: Caregiver for little brother w/ Autism
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?)   She lives with Both Parents and is dependent under mothers insurance plan. Both parents financially support her.
Source and Reliability of Informant:   Patient and mother are the Reliability of Source.  Pt. is A/Ox4
Past Use of Health Care System and Health Seeking Behaviors:   None
Present Health or History of Present Illness:   Abdominal/pelvic pain intense cramps, and abnormal bleeding with menstrual cycle.
Past Health History
General Health: (Patient’s own words)   ‘Good exercises 3-4 x’s/week”
Allergies: (include food and medication allergies)                  NKDA	Reaction: N/A
Current Medications: Percocet 5/325 1 Tab PO q 4-6 hrs. PRN pain.PRN Benadryl and Claritin for Seasonal Allergy.
Last Exam Date: 1/14/2014	Immunizations: IUTD= Immunizations up to date
Childhood Illnesses:   NONE
Serious or Chronic Illnesses:   NONE
Past Health Screening (see “Well Young Adult Behavior Health Assessment History Screening” below) Yearly Physical Exam with Pap and Breast exam
Past Accidents or Injuries: NONE
Past Hospitalizations: ER visits for abdominal/pelvic pain, and abnormal bleeding. Out pt. sx for bilateral eat tubes @ the age of 7
Past Operations: NONE
Family History (Specify which family member is affected.)
Alcoholism (ETOH use/abuse): FATHER
Allergies: MOTHER ALLERGIC TO PENCILLIN
Arthritis: MATERIAL GRANDMOTHER
Asthma: NONE
Blood Disorders: PATER
Breast Cancer:  FIRST COUSIN
Cancer (Other): NONE
Cerebral Vascular Accident (Stroke): NONE
Diabetes:  FIRST COUSIN DM II
Heart Disease: PETERNAL GRANDFATHER
High Blood Pressure: PATERNAL GRANDFATEHR
Immunological Disorders:  PATERNAL GRANDMOTHER
Kidney Disease: PATERNAL GRANDFATEHR
Mental Illness: BIPOLAR and DEPRESSION FATHER
Neurological Disorder: ALTHIZMERS PATERNAL GRANDMOTHER
Obesity: MOTHER HAD GASTRIC SLEEVE 4/2012
Seizure Disorder: NONE
Tuberculosis: BROTHER WITH POSTIVE TB TEST 1/2014
Obstetric History (if applicable) N/A
Gravida: N/A	Term: N/A	Preterm: N/A	Ab/incomplete: N/A
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? Full Time College Student Cal State L.A.Attends Church Weekly.   How would you describe your community? Safe, Very family Oriented. Hobbies, skills, interests, recreational activities? Reading, Vacationing, out door activities like biking, hiking and going to the beach.   Military service: Yes_______ No___X___       If yes, overseas assignment? Yes________ No___X_____   Close friends or family members who have died within past 2 years?   Paternal Grandmother   Number of relatives or close friends in this area?   Entire Family lives within 1 hr. of each other Los Angeles and Inland Empire.   Marital status:  Single_____ Married________Divorced_________Separated_________  In serious relationship____X____ Length of time___2 years______

Environmental Content and Questions:   Do you live alone?  Yes________ No ___X____   When did you last move? 2000 moved to a bigger house to accommodate the growing family   Describe your living situation? Lives with both parents, 3 siblings= brothers ages 25, 21, 8 and her Maternal Grandmother.   Number of years of education completed? Completed High School with completion of general education diploma in 2011, Full Time College Student at Cal State LA possible graduate May 2016, with BSN.   Occupation?        If employed, how long? 3 months        Are you satisfied with this work situation? No“I just care for my 8 year old brother who was diagnosed with a mild form of Autism, I attend weekly outings and help him with homework”.        Do you consider your work dangerous or risky? NO        Is your work stressful? NO   Over the past 2 years have you felt depressed or hopeless? NO

Biophysical Content and Questions   Have you smoked cigarettes? Yes_______ No____X____   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_______ No________ Length of time smoking? __________N/A____   Have you ever smoked illicit drugs? Yes__________ No___X______   If yes, for how long? ______N/A_____ Do you smoke these now?  Yes__________ No __________   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 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 ): 112 lbs.  No weight gain or loss. Denies fatigue, malaise, weakness, night sweats and chills

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritis, excessive bruising, rash or lesion):   Skin intact and moist with a clear completion. No moles, pigment changes or color changes in skin.No bruising or dryness noted.     Health Promotion (Sun exposure? Skin care products?): Skin moisturizers daily face, oil of OlayUses sunscreen on a daily basis.  Moistures skin with lotion after each shower.

Hair (recent loss or change in texture): No: Full head of thick shinny hair that is shoulder length.   Health Promotion (method of self-care, products used for care): Daily washing and grooming.

Nails (change in color, shape, brittleness): Nails are thick, long and very well manicured. As a young child she states she was “a nail bitter”.   Health Promotion (method of self-care, products used for care): Grooms and trims both nails and cuticles her self.

Head (unusual headaches, frequency of headaches, head injury, dizziness, syncope or vertigo):   Frequent monthly headaches with menstrual cycle.Denies Head injury, syncope, and vertigo

Eyes (difficulty or change in vision, decreased acuity, blurring, blind spots, eye pain, diplopia, redness or swelling, watering or discharge, glaucoma or cataracts): 20/20 vision. Denies vision changes, eye pain, redness, swelling, and glaucoma.   Health Promotion (wears glasses or contacts and reason, last vision check, last glaucoma check, sun protection): Yearly eye exams. Last exam March 2013.

Ears (earaches, infections, discharge and its characteristics, tinnitus or vertigo): Childhood ear aches/ swimmers ear, Denies discharge, tinnitus, and/or vertigo   Health Promotion (hearing loss, hearing aid use, environmental noise exposure, methods for cleaning ears): Childhood ear “tube placement surgery” — outpt. Uses Q tips to clean the outer ears on a nightly basis

Nose and Sinuses (discharge and its characteristics, frequent or severe colds, sinus pain, nasal obstruction, nosebleeds, seasonal allergies, change in sense of smell): Seasonal Allergies   Health Promotion (methods for cleaning nose): Nasal Saline Spray (Ocean Spray)Blows noseOTC Meds Benadryl and or Claritin PRN.

Mouth and Throat (mouth pain, sore throat, bleeding gums, toothache, lesions in mouth, tongue, or throat, dysphagia, hoarseness, tonsillectomy, alteration in taste): NONEDenies mouth pain, sores, horseness, bleeding gums, toothache, and dysphagia.   Health Promotion (Daily dental care – brushing, flossing. Use of prosthetics – bridges, dentures. Last dental exam/check-up.): Teeth are all intact no loose or missing teeth, teeth are straight, white and clean.Daily Dental care bruises and flosses teethTeeth cleaning and exam every 6 monthsLast Dental exam and cleaning June, 2013

Neck (pain, limitation of motion, lumps or swelling, enlarged or tender lymph nodes, goiter): NONE

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): NONE WNL   Health Promotion (activities to stimulate thinking, exam related to mood changes/depression): Full Time College Student studying for her BSN.

Endocrine System (history of diabetes or insulin resistance, history of thyroid disease, intolerance to heat or cold): NONE   Health Promotion (last blood glucose test and result, diet): Consumes a healthy diet mainly fruits and vegetables with lean meats and fish.

Breast and Axilla (pain, lump, tenderness, swelling, rash, nipple discharge, any breast surgery): Tenderness to bilateral breast with monthly menses.Denies lumps, swelling, rash, nipple discharge and surgery.   Health Promotion (performs breast self-exam – both male and female, last mammogram and results, use of self-care products): Performs monthly breast self-examsObtains yearly breast exam within her yearly GYN check up. N/A for mammograms

Respiratory System (History of lung disease, smoking, chest pain with breathing, wheezing, shortness of breath, cough – productive or nonproductive. Sputum – color and amount. Hemoptysis, toxin or pollution exposure.):   NONELungs clear bilaterally through out all lung fields, Resp. even/unlabored, No SOB noted, No cough or productive phlegm on exam.Positive for Seasonal Allergies watering eyes, and running nose and non-productive cough “dry Cough”.Denies smoking, chest pain, asthma, wheezing, Health Promotion (last chest x-ray, smoking cessation): NONE

Cardiac System (history of cardiac disease, MI, atherosclerosis, arteriosclerosis, chest pain, angina): NONE WNLDenies CP, MI, Angina   Health Promotion (last cardiac exam): N/A

Peripheral Vascular System (coldness, numbness, tingling, swelling of legs/ankles, discoloration of hands/feet, varicose veins, intermittent claudication, thrombophlebitis or ulcers): NONE+ CMS to all extremitiesDenies N/T to all extremities   Health Promotion (avoid crossing legs, avoid sitting/standing for long lengths of time, promote wearing of support hose): Avoids standing for long periods of time and she gets up and moves around every “few hours when in class to avoid Blood Clots”

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): NONEDenies excessive bleeding, swelling of lymph, and painNegative for PRBC   Health Promotion (use of standard precautions when exposed to blood/body fluids): N/A

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): Great appetiteDenies heart burn, N/V, abdominal distension, gastric ulcers, IBS, change in stool, hemorrhoids and rectal bleeding Health Promotion (nutrition – quality/quantity of diet; use of antacids/laxatives):

Musculoskeletal System (history of arthritis, joint pain, stiffness, swelling, deformity, limitation of motion, pain, cramps or weakness): Full active ROMDenies arthritis, joint pain and swelling, along with cramps and muscle weaknessNo deformities noted   Health Promotion (mobility aids used, exercises, walking, effect of limited range of motion): Very active works out at the gym 3-4x’s/weekFull active ROM x 4 extremities

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): NONEDenies all urinary disease.     Health Promotion (methods used to prevent urinary tract infections, use of feminine hygiene products, Kegel exercises): Daily feminine hygiene.

Male Genital System (penis or testicular pain, sores or lesions, penile discharge, lumps, hernia): N/A Health Promotion (performs testicular self-exam): N/A

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): Started menses @ age 12.LMP 1/20/2014Menorrhagia with corpus ovarian cyst and sever abdominal cramping/pain Health Promotion (last gynecological checkup, pap-smear and results, use of feminine hygiene products): Last pap-smear 12/1013WNL

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):   Health Promotion (safe-sex practices):   Practicing abstinence until marriage.

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.

Iron Deficiency Anemia

1. Ineffective Tissue Perfusion r/t decreased red blood cell and hemoglobin concentration.

The outcome will be that JFM will be taking iron as pills or shots and adding iron to her diet; along with calcium to correct the anemia. If not corrected different treatments and tests will preformed to look for other causes of your anemia, such as new bleeding or difficulty absorbing iron from pills (Nanda Nursing Interventions, 2012).

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

Activity

• Activity Intolerance R/T acute pain and uterine contractibility and hypersensitivity.

The out come will be that JFM will learn relaxation techniques, visualization, guidance, imagination and deep breathing exercises to reduce pain and distraction from the pain (Dobson, R, 2008).

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

1. Risk for deficient Fluid Volume/Bleeding.

Outcome JFM will have to keep track of her periods by writing down the dates of your periods and how heavy the flow is by counting how many pads or tampons she use daily/weekly how often she changes her tampon and/or pad if more than 2 hours or if she passes clots the size of a quarter or larger, that is heavy bleeding she will need to contact her doctor (Centers for Disease and Prevention CDC, 2013).

References:

Centers for Disease and Prevention CDC, 2013. Heavy Menstrual Bleeding Blood Disorders in Women. Retrieved from Web. 5 Feb. 2014. http://www.cdc.gov.

Dobson, R, (2008). Could the Pill Cure Agony of serve period pain. Article. Daily Mail 28, Oct. 2008. http://eds.a.ebscohost.com.library.gcu.edu:2048.

JFM, personal Communication/Interview February 3, 2014.

Nanda Nursing Interventions, 2012. Nursing Diagnosis and Interventions For Menstrual Disorders. 25 July 2012. Retrieved from web. 5 Feb. 2014. www.nanda-nursinginterventions.com