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.
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 client.
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 grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the
assignment criteria and expectations for successful completion of the assignment.
Content
25.0 %Develop Three Nursing Diagnoses for the Client Based on Health History and Screening (Actual, Wellness, Risk For) Provides less than three complete nursing diagnoses (Actual, Wellness, and Risk
For) based upon the information collected in the health history and screening, with or without rationale. Provides three complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) based upon
the information collected in the health history and screening. Rationale absent. Provides three complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and includes rationale based upon the
information collected in the health history and screening. Interrelates the three complete and accurate nursing diagnoses (Actual, Wellness, and Risk For) and provides rationale based upon the information
collected in the health and history screening. Interrelates the three complete and accurate nursing diagnoses (Actual, Wellness, and Risk For), provides rationale based upon the information collected in the
health and history screening, and integrates each diagnosis into a recommended wellness plan for the patient.
25.0 %Include All Components of the Health History (Biographical, Past Heath, Family, Symptoms) Using Appropriate Medical Acronyms and Abbreviations Provides incomplete medical history with or
without use of appropriate medical acronyms and abbreviations. Provides all components of the health history based upon the information collected in the health history. Appropriate medical acronyms and
abbreviations are absent or inconsistent. Provides all components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations. Provides all
components of the health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses. Provides all components of the
health history (biographical, past health, family, symptoms) using appropriate medical acronyms and abbreviations, and relates information to the diagnoses and integrates into treatment plan.
30.0 %Benchmark D5: Holistic Patient Care Competency 5.1: Understand the human experience across the health-illness continuum Health screening and diagnosis do not demonstrate understand of the
human experience across the health-illness continuum. Health screening and diagnosis suggest minimal understanding of the human experience across the health-illness continuum. Health screening and diagnosis
demonstrate understanding of the human experience across the health-illness continuum. Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness
continuum. Health screening and diagnosis are integrated in an understanding of the human experience across the health-illness continuum and provide specific suggestions for treatment across this continuum.
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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