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. Julio Molina demonstrates several distinct symptoms of Type-1 Diabetes Mellitus, including his extreme thirst, excess urination and temporary episodes of blindness. One wellness nursing diagnosis with rationale for choice of this diagnosis. Julio leads an athletic lifestyle, but considering the likelihood that he suffers from undiagnosed diabetes, this ostensibly healthy choice may be inhbiting his body’s ability to recover. One “risk for” nursing diagnosis based on the health screening with rationale for choice of this diagnosis. Julio is at risk for a number of complications related to his suspected diagnosis of Type-1 diabetes, including heart disease, diabetic retinopathy (loss of peripheral vision or visual acuity), obesity and a greater risk for amputation of limbs later in life.
Health History And Screening of an Adolescent or Young Adult Client
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Biographical Data
Patient/Client Initials: Julio Molina
Phone No: XXX-XXX-XXXX
Birth Date:1/28/1999
Age:15
Sex: Male
Birthplace: Tucson, AZ
Marital Status: Single
Race/Ethnic Origin: Mexican-American
Occupation: Student
Employer: N/A
Financial Status: (Income adequate for lifestyle and/or health concerns. Is there a source of health insurance? Employment disability?) Patient is a freshman in high school and thus has no income, however, his parents have health insurance which covers Julio.
Source and Reliability of Informant: Information obtained directly from the patient.
Past Use of Health Care System and Health Seeking Behaviors: Patient visits a general health care clinic during instances of poor health and illness.
Present Health or History of Present Illness: Patient exhibits no signs of serious illness, however, he has reported excess thirst and urination, random bouts of fatigue/muscle soreness/headache, and occasional issues with his eyesight.
Past Health History
General Health: (Patient's own words)
"I feel fine for the most part, but every so often I have trouble seeing, almost like I am going blind. During the day, I find myself becoming very thirsty no matter how much water or Gatorade I drink, and this leads to me using the restroom much more often than normal. Also, my muscles are sore sometimes and I feel tired even when I got a good night's sleep, and I get terrible headaches."
Allergies: (include food and medication allergies)
None reported.
Reaction:
N/A
Current Medications: Aspirin for the muscle soreness and headaches.
Last Exam Date: 4/24/1998
Immunizations:
Current and full.
Childhood Illnesses: None reported.
Serious or Chronic Illnesses: None reported.
Past Health Screening (see "Well Young Adult Behavior Health Assessment History Screening" below)
Past Accidents or Injuries: None reported.
Past Hospitalizations: None reported.
Past Operations: None reported.
Family History
(Specify which family member is affected.)
Alcoholism (ETOH use/abuse): Grandparents on both sides
Allergies: N/A
Arthritis: Fraternal grandmother and uncle on father's side
Asthma: N/A
Blood Disorders: Low blood sugar/both parents
Breast Cancer: N/A
Cancer (Other): N/A
Cerebral Vascular Accident (Stroke):
Diabetes: Mother, Uncle and multiple cousins
Heart Disease: N/A
High Blood Pressure: N/A
Immunological Disorders: N/A
Kidney Disease: Multiple members of family on both sides
Mental Illness: N/A
Neurological Disorder: N/A
Obesity: Multiple members of family on both sides
Seizure Disorder: N/A
Tuberculosis: N/A
Obstetric History (if applicable)
Gravida:
Term:
Preterm:
Ab/incomplete:
Course of Pregnancy (length of pregnancy, delivery date, method of delivery, length of labor, complications, baby's weight, baby's condition):
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?
Patient plays soccer, basketball and baseball for his high school, participates actively in a local Catholic Church youth group, and achieves high scores in school.
How would you describe your community?
Patient's community is a urban area in Central Phoenix a few blocks away from Chase Field, where the average income is lower- to middle-class, but the neighborhood is close-knit.
Hobbies, skills, interests, recreational activities?
Military service: Yes____ No__ N/A
If yes, overseas assignment? Yes____ No
Close friends or family members who have died within past 2 years?
Number of relatives or close friends in this area?
Marital status: Single____ Married____Divorced____Separated
In serious relationship____ Length of time
Environmental Content and Questions:
Do you live alone? Yes____ No ____X
When did you last move?
Patient moved from Tucson to Phoenix when 5 years old, lived in same residence since.
Describe your living situation?
Patient lives in a medium-sized home with his parents, two brothers and a sister, all younger.
Number of years of education completed?
Patient is in the first year of high school.
Occupation? N/A
If employed, how long? N/A
Are you satisfied with this work situation? N/A
Do you consider your work dangerous or risky? N/A
Is your work stressful? N/A
Over the past 2 years have you felt depressed or hopeless?
Patient did not report any symptoms of depression.
Biophysical Content and Questions
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