Directions: In this assignment, you will be completing a comprehensive health screening and history on a young adult. 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” worksheet. 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. All components of the health history 6. Three nursing diagnoses for this client based on the health history and screening (one actual nursing diagnosis, one wellness nursing diagnosis, and one “risk for” nursing diagnosis) 7. Rationale for the choice of each nursing diagnosis. 8. A wellness plan for the adolescent/young adult client, using the three nursing diagnoses you have identified. Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Use correct acronyms or abbreviations when indicated. 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. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Rubric: Benchmark – Health Screening and History of an Adolescent or Young Adult Client 1 Unsatisfactory 0.00% 2 Less than Satisfactory 75.00% 3 Satisfactory 79.00% 4 Good 89.00% 5 Excellent 100.00% 80.0 %Content 20.0 % Include All Components of the Health Screening and Health History (Biographical Data, Past Health History, Family History, Review of Systems) Does not provide health history and/or screening. Provides some components of the health screening and history in an incomplete form. Provides all components of the health screening and history in a complete form. Provides all components of the health screening and history in detail and relates information to the diagnoses. Provides all components of the health screening and history in extensive detail and relates information to the diagnoses and integrates into treatment plan. 30.0 % Develop Actual Nursing, Wellness, and ?Risk For? diagnoses for the Client Based on Health History and Screening Does not provide nursing diagnoses. Provides incomplete nursing diagnoses (Actual, Wellness, and Risk For) based upon the information collected in the health screening and history, and review of systems. Rationale absent. Provides complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and includes rationale based upon the information collected in the health screening and history. Interrelates complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and provides rationale based upon the information collected in the health screening and history, and review of systems. Interrelates complete and accurate nursing diagnoses (Actual, Wellness, and Risk For), provides rationale based upon the information collected in the health screening and history, and review of systems, and integrates each diagnosis into a recommended wellness plan for the patient. 20.0 % Wellness Plan Does not provide wellness plan. Provides incomplete wellness plan based upon the diagnoses developed. Provides complete and accurate wellness plan based upon the diagnoses developed. Provides all components of the wellness plan in detail and relates information to the diagnoses. Provides all components of the wellness plan in extensive detail and relates information to the diagnoses. 10.0 % Use Appropriate Medical Acronyms and Abbreviations Medical acronyms and abbreviations are absent. Medical acronyms and abbreviations are incorrectly used. Medical acronyms and abbreviations are used and generally consistent. Medical acronyms and abbreviations are used and appropriate. Medical acronyms and abbreviations are sophisticated and used appropriately. 10.0 %Organization and Effectiveness 10.0 % Mechanics of Writing (Includes spelling, punctuation, grammar, and language use) Surface errors pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Some mechanical errors/typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Writer is clearly in command of standard, written, academic English. 10.0 %Format 10.0 % Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment) No reference page is included. No citations are used. Reference page is present. Citations are inconsistently used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and style is usually correct. In-text citations and a reference page are complete. The documentation of cited sources is free of error. 100 % Total Weightage

 
 

Directions:

In this assignment, you will be completing a comprehensive health screening and history on a young adult. 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” worksheet.

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. All components of the health history
  6. Three nursing diagnoses for this client based on the health history and screening (one actual nursing diagnosis, one wellness nursing diagnosis, and one “risk for” nursing diagnosis)
  7. Rationale for the choice of each nursing diagnosis.
  8. A wellness plan for the adolescent/young adult client, using the three nursing diagnoses you have identified.

Format the write-up in a manner that is easily read, computer-generated, neat, and without spelling errors. Use correct acronyms or abbreviations when indicated.

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.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

 

 

Rubric:

Benchmark – Health Screening and History of an Adolescent or Young Adult Client

  1
Unsatisfactory
0.00%
2
Less than Satisfactory
75.00%
3
Satisfactory
79.00%
4
Good
89.00%
5
Excellent
100.00%
80.0 %Content  
20.0 % Include All Components of the Health Screening and Health History (Biographical Data, Past Health History, Family History, Review of Systems) Does not provide health history and/or screening. Provides some components of the health screening and history in an incomplete form. Provides all components of the health screening and history in a complete form. Provides all components of the health screening and history in detail and relates information to the diagnoses. Provides all components of the health screening and history in extensive detail and relates information to the diagnoses and integrates into treatment plan.  
30.0 % Develop Actual Nursing, Wellness, and ?Risk For? diagnoses for the Client Based on Health History and Screening Does not provide nursing diagnoses. Provides incomplete nursing diagnoses (Actual, Wellness, and Risk For) based upon the information collected in the health screening and history, and review of systems. Rationale absent. Provides complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and includes rationale based upon the information collected in the health screening and history. Interrelates complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and provides rationale based upon the information collected in the health screening and history, and review of systems. Interrelates complete and accurate nursing diagnoses (Actual, Wellness, and Risk For), provides rationale based upon the information collected in the health screening and history, and review of systems, and integrates each diagnosis into a recommended wellness plan for the patient.  
20.0 % Wellness Plan Does not provide wellness plan. Provides incomplete wellness plan based upon the diagnoses developed. Provides complete and accurate wellness plan based upon the diagnoses developed. Provides all components of the wellness plan in detail and relates information to the diagnoses. Provides all components of the wellness plan in extensive detail and relates information to the diagnoses.  
10.0 % Use Appropriate Medical Acronyms and Abbreviations Medical acronyms and abbreviations are absent. Medical acronyms and abbreviations are incorrectly used. Medical acronyms and abbreviations are used and generally consistent. Medical acronyms and abbreviations are used and appropriate. Medical acronyms and abbreviations are sophisticated and used appropriately.  
10.0 %Organization and Effectiveness  
10.0 % Mechanics of Writing (Includes spelling, punctuation, grammar, and language use) Surface errors pervasive enough that they impede communication of meaning. Inappropriate word choice and/or sentence construction used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or word choice are present. Some mechanical errors/typos are present, but are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used. Prose is largely free of mechanical errors, although a few may be present. A variety of sentence structures and effective figures of speech are used. Writer is clearly in command of standard, written, academic English.  
10.0 %Format  
10.0 % Research Citations (In-text citations for paraphrasing and direct quotes, and reference page listing and formatting, as appropriate to assignment) No reference page is included. No citations are used. Reference page is present. Citations are inconsistently used. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and style is usually correct. In-text citations and a reference page are complete. The documentation of cited sources is free of error.  
100 % Total Weightage    

 

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