The assessed individual is a 19-years-old female with Caucasian cultural background.
General Health
The perceived general health is average for age, and the wellness checkup in March has not revealed any chronic diseases. Nevertheless, the quality of sleep is a concerning parameter, with only six hours of sleep on average and sleep-related issues. It is a potential topic of concern because having trouble falling asleep and other sleep disorders could indicate more severe complications.
Medications
The individual is currently not taking any medications – no concern.
Women Only
The individual is neither pregnant nor planning pregnancy in the near future. However, she has never undergone a test for breast cancer, which is advisable.
Lifestyle
The individual uses e-cigarettes daily – the amount of nicotine consumed is unspecified. Nevertheless, she has tried to quit smoking but failed in doing so, which could indicate the early stages of nicotine addiction. The only form of physical activity is walking for approximately 30 minutes four times per week, which is insufficient. It is a potential topic of concern because the Centers for Disease Control and Prevention (CDC) recommends at least 150 minutes of moderate physical activity per week in addition to workout sessions (“How much physical activity,” 2022). Considering the assessed individual is sitting for approximately 30 hours per week, more physical activity is highly encouraged.
The nutrition quality is average, with no particular emphasis on healthy or junk food. The individual is mostly eating at home, with only 3-4 times eating out per month. The diet consists of a variety of foods with no apparent shortages of proteins, carbohydrates, fats, or vitamins, and the individual does not drink soda. The concerning exceptions in the individual’s nutrition are occasional junk food, an unspecified amount of coffee consumed per day, and lunch skips. While the diet could be improved, there is no apparent topic of concern in nutrition. Substance abuse is seemingly a more relevant problem with daily smoking, occasional alcohol, and marijuana. The individual consumed marijuana three times in the past 30 days, which could indicate unhealthy coping strategies. Lastly, the individual recognizes some issues in her lifestyle, including nutrition and a lack of physical activity.
Mental Well-Being
Perceived mental well-being is relatively unstable, with multiple instances of stress, a need for emotional support, and a single depression episode per two weeks. The stated coping strategies include sleep, painting, tv, and shopping; although the quality of sleep is lacking, and the individual does not mention substances as coping methods.
Access to Preventative Services
The individual has access to preventative services and has never skipped prescribed care.
Education
The individual receives health information from providers, family, and nursing school and is satisfied with current knowledge.
Topic of Concern: Substance Abuse Coping
There are several potential topics of concern, including sleep disorders, a lack of physical activity, and mental health issues. However, subjectively, the risk of increased substance abuse is the most pressing problem. There is conflicting evidence on whether these issues suggest that the individual will inevitably progress to more dangerous substances (Scheier & Griffin, 2021). However, the individual demonstrates several associated risk factors – failure to quit smoking, a lack of healthy coping mechanisms, and episodes of stress and depression. The research shows that substance abuse, specifically alcohol and marijuana, in addition to revealed risk factors, can lead to the usage of more dangerous drugs and the development of psychiatric disorders (Scheier & Griffin, 2021).
Moreover, it is a particularly relevant problem because the individual has few healthy coping strategies and is currently being emotionally supported by family and friends. In case the individual experiences acute stress due to financial or social reasons, she might rely on unhealthy coping mechanisms, such as alcohol and marijuana. Hence, the most pressing topic of concern in the health assessment is the increased risk of substance abuse as an ineffective coping strategy.
Nursing Diagnosis
Substance Abuse: Ineffective coping related to inadequate support system or coping skills.
References
How much physical activity do adults need? (2022). Centers for Disease Control and Prevention. Web.
Scheier, L. M., & Griffin, K. W. (2021). Youth marijuana use: a review of causes and consequences. Current Opinion in Psychology, 38, 11-18. Web.