Case Study: Health History and Screening of a Young Adult Client

This case study presents a detailed health history and screening of a 23-year-old female client, CM, focusing on her biographic data, past and present health status, and relevant family history. The client's health issues, including hypertension, are explored through various assessments, such as socio-demographic and environmental factors, biophysical aspects, and a review of systems. The study identifies potential risk factors and health promotion needs, culminating in three nursing diagnoses: an actual diagnosis related to the client's hypertension, a wellness diagnosis concerning her dietary management, and a 'risk for' diagnosis regarding potential diabetes due to low blood sugar levels. The case study provides a comprehensive overview of the client's health and potential areas for nursing intervention. Desklib offers a wealth of similar solved assignments and study resources for students.

Health History and Screening of an Adolescent or Young Adult Client
Save this form on your computer as a Microsoft Word document. You can expand or shrink each
area as you need to include the relevant data for your client.
Student Name: Date:
Biographical Data
Patient/Client Initials:CM Phone No: [phone]
Address:5 Wallace Street, Fort 400 001
Birth Date: 09/06/1995 Age:23 Sex: Female
Birthplace: Mumbai India Marital Status: Single
Race/Ethnic Origin: Apatanis
Occupation: Student Employer: None
Financial Status: Depends on the parents
Source and Reliability of Informant: Very credible and ascertained by the parents
Past Use of Health Care System and Health Seeking Behaviors: Goes to the hospital on a weekly
basis
Present Health or History of Present Illness: Hypertensive
Past Health History
General Health :Apart from high blood pressure there is no other ailment
Allergies: None Reaction: None
Current Medications:Thiazide diuretics, Angiotensin-converting enzyme (ACE) inhibitors. ...
Angiotensin II receptor blockers (ARBs)and Calcium channel blockers.
Last Exam Date: 27/05/2018 Immunizations: BCG, Polio
Childhood Illnesses: None
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Serious or Chronic Illnesses: High Blood Pressure
Past Health Screening: Done once
Past Accidents or Injuries: Minor eye injury
Past Hospitalizations: None
Past Operations: None
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Father
Allergies: None
Arthritis: Grandmother
Asthma:None
Blood Disorders: None
Breast Cancer: None
Cancer (Other): None
Cerebral Vascular Accident (Stroke): None
Diabetes: Mother
Heart Disease: None
High Blood Pressure: Sister
Immunological Disorders: None
Kidney Disease:None
Mental Illness: None
Neurological Disorder: None
Obesity: Aunt
Seizure Disorder: None
Tuberculosis: None
Obstetric History (if applicable)
Gravida: Term: Preterm: Miscarriage/Abortions:
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Course of Pregnancy : Got pregnant in 2016 and gave birth to a healthy girl in the month of
October.
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?
Basketball and involved in volunteering in case of any disasters
How would you describe your community?
Supportive as it teaches on the skills and issues surrounding self and community care
Hobbies, skills, interests, recreational activities?Travelling, swimming and reading novels
Military service: No
If yes, overseas assignment? No
Close friends or family members who have died within past 2 years? Grandmother
Number of relatives or close friends in this area?13
Marital status: Single______ Married________Divorced_________Separated_________
In serious relationship________ Length of time_________
Environmental Content and Questions:
Do you live alone? No
When did you last move? Never
Describe your living situation? Live with my parents
Number of years of education completed? 15
Occupation?
If employed, how long? Not employed
Are you satisfied with this work situation? No
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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? Yes majorly because of being
hypertensive
Biophysical Content and Questions
Have you smoked cigarettes?No
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________ Length of time smoking? ______________
No
Have you ever smoked illicit drugs? No
If yes, for how long? ___________ Do you smoke these now? Yes__________ No __________
Do you ingest illicit drugs of any kind? Yes_________ No__________
If so, what drugs do you use and what is the route of ingestion?_________
How long have you used these drugs _________________
Review of Systems
(Include both past and current health problems. Comment on all present issues.)
General Health State : Weighs 83 kg which has been an increase of about 5 kilos for about 4
months
Skin: None
Health Promotion : None
Hair: None
Health Promotion: None
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Nails: Pink with white spots and very strong
Health Promotion: None
Head:None
Eyes: Gets teary when exposed to light
Health Promotion: Uses eye drops
Ears: None
Health Promotion: None
Nose and Sinuses: None
Health Promoion: None
Mouth and Throat : None
Health Promotion:None
Neck: None
Neurologic System:None
Health Promotion: None
Endocrine System:None
Health Promotion:None
Breast and Axilla:None
Health Promotion: None
Respiratory System:None
Health promotion: None
Cardiac System:None
Health Promotion: None
Peripheral Vascular System : None
Health Promotion: None
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Gastrointestinal System:None
Health Promotion :None
Musculoskeletal System:None
Health Promotion:None
Urinary System :None
Health Promotion:None
Female Genital System: Began at the age of 14. Has a cycle of 28-31days with only kower back
pqin experienced.
Health Promotion: Uses painkillers
Sexual Health:Sexually actuve
Health Promotion: Uses protection
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.
The patient suffers from high blood pressure and is currently under medication.
One wellness nursing diagnosis with rationale for choice of this diagnosis.
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The patient has been introduced to a diet program and is currently taking drugs to manage her
condition.
One “risk for” nursing diagnosis based on the health screening with rationale for choice of this
diagnosis.
The patient has a high chance of getting diabetes due to her low blood sugar level.
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