Health History And Screening Of An Adolescent Or Youn 949863

Health History And Screening Of An Adolescent Or Young Adult Clientsav

Health History and Screening of an Adolescent or Young Adult Client

Paper For Above instruction

Introduction

Adolescence and young adulthood represent critical phases in human development characterized by physiological, psychological, behavioral, and social transitions. Conducting a comprehensive health history and screening during this period is essential for early detection of potential health issues, prevention, and promotion of healthy lifestyles. This paper presents a detailed health history and screening process for an adolescent or young adult client, including biographical data, past and family health histories, review of systems, and identification of nursing diagnoses with appropriate rationales. Additionally, a tailored wellness plan is formulated based on these assessments.

Biographical Data and Presenting Profile

The client is a 20-year-old college student, male, single, residing in an urban community. He reports living alone for the past two years while attending university. The client is employed part-time as a retail associate, working approximately 20 hours per week. He maintains a satisfactory academic performance and engages actively in recreational sports such as soccer and cycling. The client reports being generally healthy but confesses occasional feelings of fatigue and stress during exam periods. His last medical examination was approximately one year ago, with all routine immunizations current, including the HPV and meningococcal vaccines. He reports no recent hospitalizations, surgeries, or serious illnesses.

Past Health History and Family Background

The client reports a history of mild asthma managed with occasional inhaler use during cold seasons. He states no known food or medication allergies. His childhood illnesses included chickenpox and mumps with no lasting effects. Family history reveals that his mother has hypertension and hyperlipidemia, his father has type 2 diabetes and a history of myocardial infarction at age 55, and a maternal aunt was diagnosed with breast cancer. No family history of mental health disorders, neurological diseases, or genetic syndromes was reported.

Obstetric history is not applicable, as the client is male. His behavioral health history includes episodes of stress-related anxiety during exam periods but no formal psychiatric diagnosis or pharmacological treatment. He denies any substance use except occasional alcohol consumption. No history of smoking or illicit drug use is reported. The client remains motivated to maintain a healthy lifestyle and is aware of the importance of preventive care.

Review of Systems

General Health: Reports stable weight over the past year; no recent weight loss or gain. Occasional fatigue associated with academic stress.

Skin: No current skin lesions or rashes; reports dry skin occasionally during winter.

Hair/Nails: No recent hair loss; nails healthy with no brittleness or discoloration.

Head: No headaches or dizziness; reports minor headaches during stressful periods.

Eyes: No vision changes; wears glasses for reading; last eye exam was 12 months ago.

Ears/Nose/Throat: No tinnitus, ear infections, nasal congestion, or sore throat.

Respiratory: No current cough or shortness of breath; history of mild asthma, infrequent exacerbations.

Cardiovascular: No chest pain or palpitations; family history of cardiovascular disease.

Gastrointestinal: No abdominal pain, nausea, or bowel habit changes.

Genitourinary: No urinary issues or dysuria.

Musculoskeletal: No joint pain or swelling; active in sports.

Nervous System: No recent fainting or seizures; occasional stress-related anxiety.

Endocrine: No thyroid or diabetes symptoms.

Hematologic: No bleeding or easy bruising.

Psychosocial: Reports a supportive social environment but experiences academic stress and occasional mood fluctuations. Engages in regular physical activity and maintains balanced nutrition.

Nursing Diagnoses with Rationales

1. Actual Nursing Diagnosis: Risk for Anxiety related to academic stress and upcoming examinations as evidenced by self-reported feelings of stress and occasional headaches during stressful periods. The client’s acknowledgment of stress and physical symptoms indicates an existing pattern that could escalate into clinical anxiety if unaddressed.

2. Wellness Nursing Diagnosis: Readiness for Enhanced Health Management related to existing knowledge of healthy lifestyles, including regular exercise, vaccination status, and awareness of stress management strategies. The client displays motivation to maintain health and seeks information about wellness promotion.

3. ’Risk for’ Nursing Diagnosis: Risk for Obesity related to sedentary behavior combined with high academic workload and unhealthy eating patterns as evidenced by occasional irregular meals and sedentary study habits during exam periods. Although currently not obese, behavioral tendencies increase vulnerability.

Rationale for Diagnoses

The actual diagnosis of anxiety is supported by the client's stress-related symptoms, which, if unmanaged, may impair daily functioning. Addressing this early aligns with holistic nursing care emphasizing mental health promotion (American Psychiatric Association, 2013). The wellness diagnosis recognizes the client’s proactive health behaviors and motivation, providing an opportunity to reinforce good practices and foster self-management. The risk diagnosis of obesity pertains to behavioral risks, emphasizing the need for preventive strategies to mitigate future health complications such as metabolic syndrome (World Health Organization, 2020).

Wellness Plan

The wellness plan centers around reinforcing existing positive behaviors and addressing potential risks. For anxiety management, the plan includes teaching relaxation techniques such as progressive muscle relaxation, mindfulness, and stress management workshops. Encouraging regular physical activity, like continued participation in sports and daily exercise, will help mitigate the risk of obesity and improve mood (Sharma et al., 2014). To enhance health management, the client is advised to maintain consistent sleep patterns, balanced nutrition, and attend annual health screenings, including vision checks and immunizations. Educational interventions will focus on recognizing stress triggers and seeking social support or counseling services when needed (Mohr et al., 2012). The client will also be counseled about maintaining a balanced diet and limiting sedentary behaviors, especially during academic stress, to prevent weight gain. Integrating these strategies supports holistic health promotion tailored to his developmental stage (Hockenberry & Wilson, 2018).

Conclusion

Comprehensive health assessment in adolescents and young adults enables early identification of physical, behavioral, and psychosocial issues, thereby facilitating targeted nursing interventions. By establishing accurate diagnoses and developing customized wellness plans, nurses can promote health, prevent disease, and foster resilience among this vulnerable age group. Continuous education and support are vital for empowering young adults to adopt sustainable health behaviors that will benefit them throughout their lives.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Hockenberry, M. J., & Wilson, D. (2018). Wong’s nursing care of infants and children (11th ed.). Elsevier.
• Mohr, D. C., Rieckmann, T., & Cox, D. (2012). Health behavior change and maintenance in chronic illness. Journal of Behavioral Medicine, 35(4), 357-370.
• Sharma, M., Cockerell, O. C., & Williams, M. (2014). Preventing obesity in young adults: Strategies and challenges. Public Health Nursing, 31(6), 563-571.
• World Health Organization. (2020). Obesity and overweight. WHO Fact Sheet.