Health History and Screening of an Adolescent or Young Adult Client

The health of a family is a vital part of how that family interacts with one another and how each individual of the family will function in society, later teaching their children about a healthy lifestyle or lack thereof. The family health assessment helps to identify risk factors and potential dysfunction (Edelman, 2014) I interviewed a single parent family home about their health and how they perceive it. This family is an all-male family, an athletic seventeen year old boy getting ready for his senior year, a twenty year old young man, and a hardworking, dedicated, overweight father.

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has

Skin (history of skin disease, pigment or color change, change in mole, excessive dryness or moisture, pruritus, excessive bruising, rash

The general health of the patient is currently being compromised due to present illness mentioned above, but is stable. L.H. reports his usual health to be, “normal and not too crazy like this”. Patient has some fatigue noted while conducting daily activities; No recent weight change, fever or sweat. The skin noted to some discoloration on upper right side of back. There is no pruritus, rash or lesions present. Bruises noted bilateral on arms. Patient reported taking baby aspirin as daily medication. His hair is greying and thinning with no hair loss.

no problems with mobility noted, patient ambulates w/o assistance, ROM of joints intact, patient pt able to rotate feet,

The couple is very happy with their great partnership. The mother enjoys as being caregiver. She takes care of the home, make sure everything is neat and organized. She plans everything, and ensure that her husband has no worries in regard to home life. She expressed that she always try to be spontaneous and keep their relationship fresh so it does not get stagnant. Sexuality

Substance abuse: Youth stated she has been substance free since admitted to CCIS in February 2017. Youth denied smoking cigarettes and substances in the

She has also been taking Minocin for rosacea, 50 mg twice weekly. She has been on higher doses of Tetracycline in the past with out problem.

A comprehensive family assessment provides a foundation to promote family health (Edelman & Mandle, 2011). 1987 Marjorie Gordon purposed 11 functional health patterns to use for guidance in order to facilitate nurses to have a frame work for the family assessment in. Gordon’s 11 functional health patterns help organizes basic family assessment information. This standardized format will guide nurses to complete the family assessment using system approaches, which will identify a patient’s

A progress note from Dr. Chweyah, dated 06/26/2017, indicated that the claimant presented for follow-up of gout, muscle weakness, and weight loss. He had ongoing weakness of the legs with knee pain. He stated that her weight drop had stopped. His current weight was 210 pounds. Objective findings showed a pulse rate of 105 with a blood pressure of 92/60. His BMI was 28.56. He was diagnosed with an acute pain in both knees, muscle weakness in the legs, chronic gout, and weight loss. A referral to neurology and medications were recommended.

There is pain with lumbar flexion and extension. There is no aberrant behavior. The patient feels that he can perform increased activities of daily living with his current medications.

A family consists of a group of interacting individuals related by blood, marriage, cohabitation, or adoption who interdependently perform relevant functions by fulfilling expected roles. (Edelman, Kudzma, & Mandle, 2014, p. 150)

HPI: S.J. is a 67 y/o Caucasian male with a history of left hip pain for two years. He has difficulty walking due to left hip pain and utilizes a cane, can walk five blocks, climbs stairs leading with the right leg. He denies any surgeries on the left lower extremity. He sought physical therapy, but he does not feel that it is improving his pain but does believe it is improving his strength. He is scheduled for a left total hip arthroplasty due to the progression of severe osteoarthritis of the left hip as confirmed by a pelvic x-ray and MRI of the lower extremity without contrast. S.J. has taken various medications that are listed on the current medication section of this note.

He still does have significant amount of residual back pain. Also, he does get still intermittent pain and numbness in the legs, left side worse than the right side. He also gets bilateral knee pain. He continues to have some bladder incontinence episode urgency. He does feel depressed as well. Treatments to date include anti-inflammatory medications, physical therapy, epidural injection performed in May 2015, spinal surgery in 2011, L4-L5 laminotomy with good improvement, and left L5-S1 laminotomy on 4/20/16 with improvement postoperative. Physical examination revealed that the patient has been able to discontinue the use of cane. There is pain to palpation over the L5-S1 area. Range of motion is limited. The patient has flexion of 60% of normal and extension of 40% of normal. Motor strength is 5-/5 in the left lower extremity, especially in the gastrocsoleus and extensor hallucis longus. Sensation is slightly diminished in the L5 distribution bilaterally, left worse than the right. Deep tendon reflexes is 2+ at the bilateral knee and 1 + at the bilateral ankle. Plan notes physical therapy of 2 x/ week to strengthen muscles, stabilize the spine and reduce pain; Flector patch 1.3% to be applied one patch to the back every 12 hours as necessary for

Using Gordon’s functional health patterns to assess a family will guide the nurse in developing a comprehensive nursing assessment that is holistic in nature. Gordon’s functional health patterns are founded on 11 principles that are incorporated within the nursing practice. These 11 principles serve as a framework for a thorough nursing assessment in which to build a holistic and individual family care plan (Grand Canyon University, 2011). The author has developed family-focused questions for each of the 11 principles and utilized these questions as a tool to assess her own family. This paper will summarize the family assessment that was performed by the author and discuss two wellness nursing diagnoses that