Health History and Screening of a Young Adult Client

In this assignment, you will be completing a comprehensive health screening and history on
a young adult using the nursing process and Gordon’s functional health patterns. To
complete this assignment, do the following:
Select an adolescent or young adult client on whom to perform a health screening and
history. Students who do not work in an acute setting may “practice” these skills with a
patient, community member, neighbor, friend, colleague, or loved one.
Complete the “Health History and Screening of an Adolescent or Young Adult Client,”
Format the write-up in a manner that is easily read, computer-generated, neat, and without
spelling errors.
Complete the assignment as outlined on the worksheet including:

  1. Biographical Data
  2. Past Health History
  3. Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral
    Health History Screening
  4. Review of Systems
  5. Include all components of the health history.
  6. Use correct acronyms or abbreviations when indicated.
  7. Develop three Nursing Diagnoses for this client based on the health history and
    screening. Include: one actual nursing diagnosis, one wellness nursing diagnosis, one “Risk
    For” nursing diagnosis, and your rationale for the choice of each nursing diagnosis for this
    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, which can be found in the APA Style Guide, located in the
    Student Success Center.

Health History and Screening of a Young Adult Client

In healthcare, screening is usually the first step taken when diagnosing a patient for the
first time. It is through this screening that a medical practitioner is able to identify the health

status of the client (Weir-Hughes, 2009). This paper contains a comprehensive screening and
history of a young adult with application of nursing process and Gordon’s functional health
Gordon Marjoirie (1987) proposed the functional health pattern as a good guide in
ensuring that nurses capture comprehensive information from the clients. This standardized
approach ensures effective collection of data from the clients (Koshar, 2012).
Biographical information
Steve is a young adult from the state of Illinois. He is aged 32 years and he holds a
bachelor’s degree in engineering. Steve is married and has one child. He is employed as a senior
engineer at a local water company. Apart from his own family, he has the responsibility to take
care of his parents and some of his relatives who are unemployed. Steve is an American by
nationality also a Christian. He has been in a good relationship with his family and his relatives.
His relationships at work are not bad either. Steve holds distinct values about life. He
emphasizes more on the achievement of goals he set and works harder to ensure that these goals
are achieved. He is therefore optimistic and has high self-perception. He is also a person who
likes traveling and engaging in leisure activities and in sports. Furthermore, Steve drinks and
smokes cigarettes and even though he has tried to stop but in vain.
Past Health History
Steve’s history seems good. He was diagnosed with typhoid and malaria and admitted in
hospital for five days at the age of 20. This situation was contained well and did not have any
complication. At the age of 25, Steve noticed a swelling on one of his legs. The swelling begun
as a pimple and he therefore ignored it. Its persistence compelled him to seek for medical

attention. The nurse he met did not carry out further investigation. He was treated as a usual
swelling with antibiotics. The swelling eventuality subsided and healed. After two years,
elapsed, armed robbers shot Steve his left hand at his home. During this robbery, he lost his
valuables and witnessed his wife being gang raped. This ordeal left a scar in his life. It made him
disillusioned about life. He was depressed even after being released from the hospital. Life
changed abruptly and when he realized that the situation was going out of hand he decided to
come to us for diagnosis and medication.
Family History: Obstetrics History (if applicable) and Well Young Adult Behavioral
Health History Screening
Family history is important aspect in screening a patient. Some diseases are genetically
inherited and understanding this history is essential in determining whether the client is at risk or
not. Steve comes from a large family. Four members of his extended family died last years after
suffering from cancer. Currently, he has a grandmother who is also suffering from colon cancer.
Other people in the family have also succumbed to death because of stroke and diabetes.
In ensuring that this process is well carried out, it is important for the systems to function
well. The medical practitioner is required to have requisite skills and knowledge to ensure that
the process is well carried out. It is also important for the client to provide accurate information
to ensure that the screening process becomes successful. Furthermore, resources should be in
place to enhance these screening. Equipment able to detect complications in the body should be
deployed in the facility to enhance the outcome.
Based on the health history and screening, a nurse is supposed to come up with a nursing
diagnosis. The nursing diagnosis is a clinical judgment about an individual experiences, or

responses to potential or actual health or life process (Herdman, 2009). There are various types
of nursing diagnosis. One of the diagnoses is actual nursing diagnosis and this kind of diagnosis
exists in an individual. Others include one wellness and one risk for nursing diagnosis. Actual
diagnosis in this case of Steve is that he is suffering from cancer and stress because of the life
experiences. He has cancer because of the swelling on his leg that has been expanding. His
family has various cases of people that have suffered from the disease and therefore this may be
closely related to genetics. Stress is because of the bad experiences he faced. Her wife was raped
in front of her, he was also shot, and his valuables stolen.
The risk factor in this scenario is risk for shock. Steve may not believe this screening
and he may even be caught with heart attacks when this news is conveyed to him. Therefore,
caution is required when giving out these screening results. One wellness nursing diagnosis is
that Steve should live positively. He should forget the past and believe that all shall be well.
Because of cancer, he should be ready to go through radiotherapy to kill the cancer cells before
spreading and maturing.


Herdman, T. (2009). Nursing diagnoses: definitions and classification 2009 – 2011. Wiley-
Blackwell: Singapore.

Koshar, J. (2012). N 340 Women’s Health & Illness in The Expanding Family & N345 Clinical