The purpose of this assignment is to complete a comprehensive health screening and history on a young adult client. In order to complete this assignment, you will need to select an adolescent or young adult client on whom to perform the health screening and history. If you do not work in an acute setting, you may “practice” these skills with a patient, community member, neighbor, friend, colleague, or loved one.
The first step of this assignment is to complete the “Health History and Screening of an Adolescent or Young Adult Client” worksheet. This worksheet will guide you through the process of gathering the necessary information for the health screening and history.
The worksheet includes several sections that need to be completed. The first section is the biographical data, which includes basic information about the client such as their name, age, gender, and contact information. It is important to gather accurate and up-to-date information in this section.
The second section of the worksheet is the past health history. This section requires you to gather information about the client’s past medical history, including any chronic conditions, surgeries, or hospitalizations they may have had. It is important to be thorough in this section and ask the client specific questions about their past health experiences.
The third section of the worksheet is the family history. This section includes two sub-sections: the obstetrics history (if applicable) and the well young adult behavioral health history screening. The obstetrics history is relevant if the client is a female and includes information about any pregnancies, deliveries, or complications related to childbirth. The well young adult behavioral health history screening includes questions about the client’s mental health history, including any diagnoses or treatments they may have received.
The fourth section of the worksheet is the review of systems. This section requires you to gather information about the client’s current physical health status by asking specific questions about each body system. It is important to be thorough in this section and ask the client about any symptoms or concerns they may have experienced.
The fifth section of the worksheet is the all components of the health history. This section requires you to summarize all the information gathered in the previous sections into a complete health history. It is important to organize this information in a logical and coherent manner.
The sixth section of the worksheet is the three nursing diagnoses for this client. In this section, you will need to identify three nursing diagnoses for the client based on the information gathered in the health screening and history. These diagnoses should include one actual nursing diagnosis, one wellness nursing diagnosis, and one “risk for” nursing diagnosis. It is important to provide a rationale for the choice of each nursing diagnosis based on the client’s health history.
The seventh section of the worksheet is the wellness plan for the adolescent/young adult client. In this section, you will need to develop a comprehensive plan for promoting the client’s overall wellness based on the nursing diagnoses identified in the previous section. This plan should include specific interventions and goals for each nursing diagnosis.
In order to complete this assignment, it is important to format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. While APA format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines.
In conclusion, this assignment provides an opportunity to practice and demonstrate your skills in completing a comprehensive health screening and history on a young adult client. By following the instructions provided in the worksheet and presenting your findings in a clear and organized manner, you will be able to successfully complete this assignment.
