Health Screening and History of an Adolescent or Young Adult Client - Essay Example

• Chief Complaint: Breathing difficulties, coughs, chest wheezing, and breathing sounds
• Past Chronic illnesses: Breathing problems
• Past Injuries/Accidents: None
• Past Hospitalization: She was once admitted into a hospital for 4 days in 2011 for persistent ineffective coughs, chest wheezing, and fever.
• Past Operations: None
• Childhood Illness: Measles

1. Family History:

• Alcoholism: None
• Allergies: Sister is allergic to penicillin antibiotics
• Asthma: Paternal Grandfather
• Blood Disorders: none
• Breast Cancer: paternal Grandmother and aunt
• Cancer (Other): None
• Cerebral Vascular Accident: None
• Diabetes: None
• Heart Disease: Maternal grandfather passed away due to heart attack
• High Blood Pressure: None
• Immunological Disorders: None
• Kidney Disease: None
• Mental Illness: None
• Neurological Disorder: None
• Obesity: Yes
• Seizure Disorder: None
• Smoking: Yes
• Tuberculosis: None
• Gravida: N/A

1. Behavioral Health History

• Activities: Academics
• Hobbies: Swimming, reading, music

1. Review of Systems

Body System

Condition

Respiratory

breathing problems characterized by ineffective coughs and breathing sounds

Cardiovascular

Difficulty in breathing and chest pains

Head, eyes, ears, nose and throat

Hoarse voice and problem swallowing

Genitourinary

Normal

Central nervous system

Normal

Nursing Diagnosis

1. Actual Nursing Diagnosis

            Based on the clinical history of the patient, the actual nursing diagnosis of the patient is ineffective airway clearance as evidenced by ineffective coughs. Ineffective airways clearance often occurs when an individual is unable to clear respiratory tract secretions or remove obstructions from the track to maintain the patency of the airway. The rationale for the diagnosis of this condition on the client is particularly based on a number of defining characteristics of the condition as shown in their clinical history (Ackley and Ladwig, 2006). For example, the client has a past health history of persistent ineffective coughs characterized by the production of sputum, Dyspnea, and abnormal breathing sounds.

Ineffective airway clearance is an important clinical condition that is normally characterized by the inability of an individual to effectively clear the respiratory tract obstructions and secretions. If not checked, this condition may develop into serious breathing problems and other related complications. One of the environmental factors that may have predisposed the patient to the condition is her smoking habit. Maintaining a clear and patent airway is critically important in every individual. In most cases, coughing is the primary mechanism through which people normally clear their airway.

However, according to Carlson (2008), there are cases when a patient may suffer from ineffective airway clearance due to factors such as respiratory muscle fatigue, respiratory surgical trauma, and neuromuscular weakness among others. On the other hand, factors such as dehydration and anesthesia are also widely known to affect the normal functions of mucociliary systems. Additionally, conditions that result in increased production of airway secretions such as chemical irritants, pneumonia, and bronchitis increase the risk of the condition.

2. Wellness Nursing Diagnosis

With regard to her wellness nursing diagnosis, the client has shown readiness to improve the management of the recommended therapeutic regimen. This judgment is particularly passed on the visible indications of the patient that she is willing and has the potential to actively get involved in improving her current condition (Gordon, 1994). For example, despite her history of unhealthy lifestyles such as smoking, the client has clearly shown her willingness to effectively participate in her own treatment by quitting smoking.

The client particularly wants to achieve greater physical wellness in their lives by and getting actively engaged in healthy life practices such as routine exercises, a healthy diet, and other weight management practices (Pesut and Herman, 2009). Some of the appropriate nursing interventions that can be recommended to the client to help her accomplish some of the therapeutic goals of her condition include teaching her to adopt effective coughing practices, learning how to use postural drainage to remove the respiratory secretions from the tract, avoiding potential allergens, completely quitting smoking, marinating an infection-free environment and avoiding extreme fatigue.

3. Risk Nursing diagnosis

Based on the patient’s family history and previous health history, the main risk nursing diagnosis for the patient is potential pneumonia infection due to ineffective cleaning of the respiratory tract. The risk nursing diagnosis is particularly based on the fact that the patient is unable to effectively clear her airway through normal coughing. Additionally, the client has a family history of respiratory problems and allergies, and this further increases her likelihood of related infections. For example, her sister is allergic to penicillin antibiotics. The other predisposing factors such as her smoking habit, poor lifestyles, and history of immunodeficiency disorders have also increased her risk of future pneumonia infection.

Pneumonia is a serious breathing and respiratory condition that is normally caused by an infection of the lung. According to Sparks and Taylor(2001), when the body is unable to effectively clean the respiratory tract through the normal mechanisms such as coughing, the resultant accumulation of bacteria may be transferred to the alveoli through inhalation or direct spread from their site of infection. In the lungs, the pathogens usually cause pneumonia through inflammation that result from their interactions with the alveolar macrophages.

Finally, as earlier been noted, some of the potential ways of reducing her clinical risks to pneumonia infection include adopting effective coughing practices, learning how to use postural drainage to remove the respiratory secretions from the tract, avoiding potential allergens, completely stopping her smoking habits. Generally, without proper intervention measures, the client may quickly develop pneumonia and her current problem of ineffective airway clearance may generate serious breathing problems and other related complications.