Analysis and Identification of Problem

Please read the following case study and complete the questions below.

Daniel is a 16 year old boy who is an identical twin. He and his brother Jeff are very close and do most things together. While Daniel excels at sports he believe his brother is much better at most everything. Daniel, his brother, and their two sisters live with their parents in the Midwest. Recently Daniel has been feeling more tired than usual. He thought it was because of his schedule and school work, which he is fairly good at. He gets mostly Bs, but his grades have been slipping of late. One day he fainted while getting ready for a game. His coach called his parents to let them know Daniel was taken to the Emergency Room. While there the doctor decided to admit Daniel to the hospital for observation. At the time he was running a slight fever, his breathing was shallow, and he was sweating. He was also very sleepy and his blood pressure was high. He did have some abnormal laboratory work, but his doctor was not too concerned at present. Daniel also stated that he felt achy.

 

You are assigned to take care of Daniel today and when you walk into his room, his mother and brother Jeff are there. Daniel appears to be sleeping. In your written assignment, respond to the following questions applying the nursing process:

 

Assessment: What type of objective and subjective data can you collect with what you know? How will you collect these data? What further evidence do you need?

 

Analysis and Identification of the Problem: What do you believe Daniel’s problem(s) are? What might be the nursing diagnoses? Use the following for identification.

 

Planning: Identify two goals and one nursing intervention for each, based on your nursing diagnoses.

While you will not be able to implement or evaluate, how well do you think your nursing interventions might help with Daniel’s care.

Additional Resource

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales

Assessment: Objective Data:

1. Daniel’s fainting episode at the game.
2. Slight fever, shallow breathing, sweating, and high blood pressure while in the Emergency Room.
3. Abnormal laboratory work.
4. Daniel feeling achy.
5. Decreasing academic performance (grades slipping).

Subjective Data:

1. Daniel feeling more tired than usual.
2. Daniel’s belief that his brother is better at most things.

To collect these data, I would:

1. Review the available medical records and laboratory results.
2. Observe Daniel’s physical appearance, noting any signs of distress or discomfort.
3. Interview Daniel and his family to gather subjective information about his symptoms, changes in behavior, and any recent stressors.
4. Assess Daniel’s vital signs, including blood pressure, temperature, and respiratory rate.
5. Speak with Daniel’s coach and teachers to understand any recent changes in his sports performance and academic abilities.

Further evidence needed: To make a more accurate assessment, it would be beneficial to know the specific details of the abnormal laboratory work, conduct a thorough physical examination, and obtain a detailed medical and family history. Additionally, obtaining information about Daniel’s diet, exercise routine, sleep patterns, and any recent illness or exposure to infections would be helpful.

Analysis and Identification of the Problem: Based on the assessment, Daniel’s problems may be:

1. Fatigue, fainting, fever, and abnormal laboratory work suggest a possible underlying medical condition.
2. Decline in academic performance and feelings of inadequacy compared to his twin brother indicate possible emotional distress and self-esteem issues.

Nursing Diagnoses:

1. Potential Nursing Diagnosis: Impaired Physical Mobility related to fainting episodes and fatigue.
2. Potential Nursing Diagnosis: Ineffective Coping related to feelings of inadequacy compared to his twin brother and declining academic performance.

Planning: Goal 1: Improve Physical Mobility Nursing Interventions:

1. Monitor vital signs regularly to identify any changes in blood pressure or other signs of physical distress.
2. Collaborate with the medical team to ensure appropriate diagnostic tests are conducted to identify the cause of fainting and other physical symptoms.

Goal 2: Enhance Coping Mechanisms Nursing Interventions:

1. Conduct therapeutic communication with Daniel to explore his feelings of self-worth and inadequacy.
2. Encourage Daniel to engage in individual counseling or support groups to address his emotional concerns.

Effectiveness of Nursing Interventions: The nursing interventions outlined above have the potential to support Daniel’s care. Regular monitoring of vital signs can help identify any acute changes in his condition, while collaboration with the medical team ensures comprehensive medical assessment and diagnosis. Implementing therapeutic communication and providing opportunities for counseling or support can assist Daniel in processing his emotions and developing healthier coping mechanisms. However, the effectiveness of these interventions will depend on the accurate diagnosis of Daniel’s underlying medical condition and his willingness to engage in emotional support and counseling. Evaluation of his progress over time would be necessary to determine the effectiveness of these interventions.