Nursing Process for Daniel

Module 04 Written Assignment Nursing Process – Case Study

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.

Assessment: Objective Data:

1. Vital Signs: Collect data on Daniel’s vital signs, including his current blood pressure, heart rate, respiratory rate, and temperature.
2. Laboratory Results: Review the abnormal laboratory results to identify any specific abnormalities or trends.
3. Physical Examination: Conduct a physical examination to assess for any signs of distress, such as pallor, sweating, or any other abnormal findings.
4. Observations: Observe Daniel’s breathing pattern, skin color, level of consciousness, and overall appearance.

Subjective Data:

1. History of Present Illness: Obtain information from Daniel’s mother and brother about when his symptoms started, any recent illnesses, changes in behavior, and any significant family history.
2. Pain Assessment: Ask Daniel to describe the nature, location, and intensity of his aches and pains.
3. Fatigue Assessment: Inquire about the severity and duration of his fatigue, including any changes in sleep patterns or daily activities.

Further Evidence Needed: To gather more comprehensive data, it would be essential to:

1. Obtain a detailed medical history, including any recent illnesses or infections.
2. Perform a thorough physical assessment to identify any localized or systemic abnormalities.
3. Review Daniel’s recent school performance and daily routines to understand the impact of his symptoms on his life.
4. Assess Daniel’s medication history and any allergies.
5. Ask about any recent travel or exposure to infectious diseases.

Analysis and Identification of the Problem: Based on the assessment data, the following nursing diagnoses and problems are possible:

1. Risk for Infection related to elevated temperature, fatigue, and abnormal laboratory results.
2. Impaired Gas Exchange related to shallow breathing and high blood pressure.
3. Fatigue related to feeling tired, reduced school performance, and recent fainting episode.
4. Risk for Fluid Volume Imbalance related to sweating and elevated blood pressure.
5. Acute Pain related to reported achiness.

Planning: Goal 1: Prevent Infection Intervention 1: Administer prescribed antibiotics or antipyretics as ordered. Intervention 2: Educate Daniel and his family on infection prevention measures, such as proper hand hygiene and respiratory etiquette.

Goal 2: Improve Gas Exchange Intervention 1: Encourage deep breathing exercises and provide support for pulmonary hygiene techniques. Intervention 2: Monitor oxygen saturation and respiratory rate regularly, reporting any abnormalities to the healthcare provider.

Goal 3: Reduce Fatigue Intervention 1: Collaborate with the school to temporarily adjust Daniel’s workload to accommodate his fatigue. Intervention 2: Educate Daniel and his family on strategies to improve sleep hygiene and energy conservation.

Goal 4: Maintain Fluid Balance Intervention 1: Monitor fluid intake and output, paying attention to any significant changes. Intervention 2: Encourage adequate hydration and provide fluids as ordered.

Goal 5: Manage Pain Intervention 1: Administer prescribed pain relief medication as ordered. Intervention 2: Use non-pharmacological pain management techniques, such as positioning and relaxation exercises.

The effectiveness of these nursing interventions would depend on the underlying diagnosis and the individual response of the patient. Regular assessment and communication with the healthcare team would be essential to evaluate and adjust the care plan as needed.